During pregnancy and postpartum, changes in biomechanics can cause dysfunctions in the myofascial system, such as rectus abdominis diastasis, various types of pain, and pelvic floor dysfunction. These common postpartum problems seriously threaten women’s health. Myofascial therapy, as an effective means of improving biomechanics, has no unified understanding of its therapeutic effects on postpartum functional disorders. This study aims to systematically evaluate the rehabilitative effects of myofascial therapy on postpartum rectus abdominis diastasis, low back and leg pain, and pelvic floor dysfunction through a meta-analysis of published randomized controlled trials.A systematic literature search of databases in Chinese and English was performed through May 2023. The treatment methods were randomized controlled studies using myofascial therapy in the treatment of rectus abdominis separation, lumbo-leg pain, and pelvic floor dysfunction. The main outcome indicators were abdominal circumference, rectus abdominis separation distance, visual analogue pain score, pelvic floor muscle potential, ability to live daily activities, number of events, and treatment effectiveness.There were 22 studies, including 2235 patients. The result showed that compared with control group, myofascial therapy demonstrated to reduce abdominal circumference and rectus abdominis separation index, improve lumbar function significantly, and decrease urinary incontinence and pelvic organ prolapse. In the myofascial therapy group, pelvic floor muscle strength was significantly enhanced, anterior/posterior resting potential of pelvic floor muscle was significantly decreased, and pelvic floor muscle potential was enhanced. Compared with the control group, the number of patients with various types of pain and pain scores were significantly reduced after myofascial therapy. When myofascial therapy lasted <4 weeks, pain relief was greater. In the myofascial therapy group, the ability to perform daily activities was significantly improved. An analysis of the effectiveness of the treatment showed that after myofascial therapy, the patient’s symptoms improved significantly. There also saw low heterogeneity among all outcomes.The results suggested that myofascial therapy could effectively reduce rectus abdominis separation, relieve pelvic floor muscle dysfunction, enhance lumbar function, relieve pain, and improve the ability of daily living activities. All the data demonstrated that myofascial therapy had a good therapeutic effect on postpartum dysfunction. A number of postpartum disorders, such as rectus abdominis separation, abdominal circumference enlargement, pelvic leaning forward, lumbago, sacroiliac joint disorders, sacral pain, pelvic floor muscles weakness, urinary incontinence, pelvic organ prolapse, etc, are brought on by pregnancy, childbirth, and lack of rest after delivery. These conditions cannot be recovered naturally after delivery. Over time, women’s physical and mental health suffers due to impacts on significant muscle weakness, pain, which severely limited daily life abilities.,2 Long-term bad posture exacerbates biomechanical problems, including skeletal displacement to accommodate for upright walking, continual tension in the cervical, thoracic, lumbar, and abdominal muscles, and a restricted range of motion in the flexion, extension, and lateral flexion of the thoracolumbar region. On the other hand, during pregnancy, the increased progesterone destroyed the pelvic floor’s collagen fibers, resulting in decreased muscle strength for loss of protection of pelvic floor muscles and pelvic floor muscles elongated excessively. During pregnancy, the secretion of relaxin is also increased to aid in labor. Relaxin can weaken the pelvic floor support tissue by degrading collagen, which causes laxity in the ligaments surrounding the pubic symphysis and the sacroiliac joint, increases the spacing between the pubic symphysis. Laxity in the lumbar and abdominal muscles worsens pelvic pressure and puts additional strain on the pelvic floor muscles. Birth injuries, disturbance of core stabilizing mechanisms, insufficient abdominal pressure, and scarring are all possible during labor in both vaginal and cesarean deliveries. If there is insufficient rest after childbirth and excessive physical activity earlier, the body’s structure and function will be further harmed, leading to postpartum strain. The myofascial system may become over drafted as a result of these injuries. Therefore, myofascial system abnormalities can occur before, during, or after pregnancy. It will eventually cause rectus abdominis separation, dysfunction of the pelvic floor muscles, injuries to the lumbosacral and sacroiliac joints and ligaments, and injuries to the abdominal, lumbosacral, and sacroiliac muscles. Once injury occurs during the postpartum period, it is challenging on self-healing.The main causes of these injuries are disturbance of the myofascial system caused by weight and hormonal changes. During pregnancy, the center of the body leans forward to balance the increase in the weight of the abdomen, coupling with the pelvis leaning forward, the pubococcygeal bone leaning backward, and the center of gravity of the body moving backward. This causes an excessive increase in the curvature of the lumbar spine, as well as an increase in the physiological curvature of the cervical and thoracic vertebrae. The body also produces forward tension as a result of increasing mammary gland bulk, shoulder blades and glenohumeral joints migrate inward toward the chest, and kyphosis or other aberrant postures develop. Further lordosis occurs in the lower abdomen as a result of the spine adjusting to reduce pressure on the lower abdomen. According to the myofascial chain theory, the myofascial membrane serves as the body’s conduction and support system for tension, and the functional state of the local myofascial membrane directly affects the overall myofascial chain. Therefore, once the local function is abnormal, the function of the corresponding remote part will be affected along the direction of stress conduction. In order to maintain overall balance, the other tissues of the body compensate for the tension deficit in the damaged tissue, further exacerbating the dysfunction of the entire fascial chain. It will help in the treatment of dysfunction by releasing or activating local fascia, inactivating myofascial pain triggers to relieve fatigue and pain in the body, and remodeling myofascial tension. Currently, the commonly used fascia therapy methods include myofascial manipulation, myofascial pain point therapy, extracorporeal shock wave therapy, massage manipulation, acupoint application, myofascial CC point, visceral myofascial manipulation, acupuncture, shockwave therapy, etc.Myofascial chain is a tensile, integrated structure that includes ligaments, myofascial membrane, and is supported by bone. Through the chain network, each component works together to ensure the stability of the body’s structure and functionality. As an uninterrupted connective tissue, fascia has the characteristics of continuity, integrity, conduction and so on, and has the function of affecting the whole body. There is synergy between muscles and fascia to form larger interconnected anatomical chains.At present, some studies have shown that myofascial therapy was effective in musculoskeletal diseases, but there was still a lack of effective on the effect of common problems in postpartum women. The purpose of this study was to integrate the results of relevant studies and conduct a meta-analysis to clarify the influence of myofascial therapy on postpartum rectus separation, lumbago and pelvic floor muscle dysfunction, so as to provide a basis for clinical treatment.The systematic review and meta-analysis were performed according to the preferred reporting items, no ethical approval and patient consent were required. The protocol number that we registered on the PROSPERO database is CRD42022376124.Literature research included all studies on the treatment of postpartum rectus abdominis separation, pelvic floor dysfunction, and pelvic dysfunction with fascia therapy from the establishment of the database until May 5, 2023. Literature research was conducted independently by a researcher. First, titles and abstracts were selected according to inclusion and exclusion criteria. When the titles were unclear, the full text was reviewed. The following full text reading was done by 2 researchers. Differences should be resolved through discussion and agreement should be reached. We used the following keywords (using free text and MeSH search): OR ) OR (Massage manipulation)) OR (CC point)) OR .(postpartum).((((((((((((((Pelvic dislocation) OR (pubic symphysis separation)) OR (lower back pain)) OR (nonspecific low back pain)) OR (lumbago)) OR (lumbar instability)) OR (pelvic forward)) OR (sacroiliac joint disorder)) OR (tail bone pain)) OR (tailbone dislocation)) OR (sacroiliac joint pain)).(((Rectus abdominis muscle separation) OR (waist circumference enlargement)) OR )). OR ) OR (urinary incontinence)) OR (chronic pelvic pain)) OR (pelvic floor muscle dysfunction)) OR ) OR (constipation)) OR (dysuria)) OR (pelvic floor muscle weakness))).http://links.lww.com/MD/K468).Systematic searches of databases in Chinese  and English  were performed for articles published from database inception until May 5, 2023.  independently extracted the following information from each included study:Basic information about the study, including the title, first author’s name, and publication date.Characteristics of participants, including study population, sample size, age, number of pregnancies, mode of delivery, length of gestation, postpartum days, type of dysfunction, and treatment methods;Main measurement indicators, including abdominal circumference, rectus abdominis separation index, visual analogue scale (VAS), electromyography of pelvic floor, activity of daily living (ADL), Low Back Pain Rating Scale (such as Japanese Orthopaedic Association scores (JOA) and Oswestry disability index (ODI) ect), pelvic Floor muscle Dysfunction Assessment Scale, and treatment effectiveness.Any disagreement would be resolved by discussion between the 2 reviewers or consultation with the third reviewer (S Z).2I was used to monitor the extent of heterogeneity. Non-heterogeneity was considered present if P > .1 and 2I < 40%; in this case, fixed effects models were employed in the meta-analysis. The source of heterogeneity was investigated if P < .1 and 2I > 40%. Subgroup analyses were conducted according to the different study designs, study quality levels, and population characteristics when clinical or methodological heterogeneity existed between studies. A random-effects model was used when there was statistical heterogeneity between the studies but no clinical heterogeneity. If the factors contributing to heterogeneity were accurately measured and fully explained, a meta-regression analysis was performed. No meta-analysis was used, and only a general qualitative description of the results was provided when the level of heterogeneity was too high (2I > 40%), particularly when there was significant clinical or methodological heterogeneity and/or the source of heterogeneity could not be addressed by other methods. Subgroup analysis, funnel plot, and sensitivity analysis could be performed to find the cause of bias.RevMan 5.3 and Stata 15.0 were used to perform a meta-analysis. The weighted mean difference (WMD) or standardized mean difference indicated the quantitative influence of numerical or continuous factors, whereas the relative risk represented the effect size of binary variables. A 95% confidence interval (CI) was used to express each effect value. The CI was used to determine whether heterogeneity existed, and –23 5 literatures on pelvic/pubic symphysis separation,–28 and 10 literatures on pelvic floor muscle.,13,29–36 A total of 2235 patients were included in the analysis (Table http://links.lww.com/MD/K469).A total of 95,134 articles on myofascial therapy were identified through a literature search. After limiting keywords, removing duplications, animals research, experimental protocols, review/conference papers, and non-RCT articles, 22 studies were included in the final analysis       and post-resting potentials  significantly decreased, while the pelvic floor muscle tension value significantly increased   reduced and the JOA score  increased in myofascial therapy group. Lumbar radiographs also revealed that after myofascial therapy, the separation distance of the pubic symphysis was greatly reduced      compared with that when treatment ≥ 4 weeks  more  2I = 89.9%, WMD = 8.92, 95% CI )  Fig. F.2I = 0.0%, WMD = 1.14, 95% CI ), pelvic pain relief , symphysis pubis separation improvement , pelvic myofascial pain relief , sexual satisfaction , and nursing satisfaction  was significantly increased , while the number with improved rectus abdominis separation symptom , and ADL was low, and the recommendation strength was weak. Table . GRADE.Although myofascial therapy was widely used in musculoskeletal disorders, there was little evidence to support the treatment of postpartum problems. This study was the first to analyze the effects of myofascial therapy on postpartum rectus abdominis separation, pelvic floor muscle dysfunction, and lumbago through meta-analysis.Our meta-analysis showed that after myofascial therapy, the abdominal circumference of the patients was significantly reduced, the separation distance of the rectus abdominis was shortened, the thickness of the rectus abdominis was increased and the muscle strength of the rectus abdominis was increased, suggesting that after myofascial therapy, the rectus abdominis was restored to the correct biomechanical position and the elasticity of the rectus abdominis was increased.Subgroup analysis showed that the number of patients with stress urinary incontinence and pelvic organ prolapse decreased significantly after myofascial therapy. The results of the freehand muscle strength test/pelvic pressure test showed that myofascial therapy was effective in increasing the strength of patients’ pelvic floor muscles. According to Glazer assessment criteria, the anterior and posterior resting stages were normal 2 to 4 μV, and > 4 μV indicated excessive pelvic floor muscle activity. Electromyography showed a decrease in excessive pelvic floor muscle activity in the anterior and posterior resting stages.In this study, a meta-analysis was conducted on the status of patients’ lumbar function. The JOA scale selected mainly reflected patients lumbar function. The lower the score, the more obvious the dysfunction. The ODI scale shows the impact of the patient’s lower back pain on daily life, and the higher the score, the more significant the dysfunction. The results showed significant improvement in lumbar function after myofascial therapy and a significant reduction in the separation distance of the symphysis pubis on radiographs, suggesting that myofascial therapy effectively helped patients regain the correct biomechanical position.In this study, pain indicators were analyzed by dichotomous and continuous variables, respectively. The results showed that after myofascial therapy, various types of pain were significantly relieved, and the number of pain patients decreased, suggesting that myofascial therapy can reduce the sensitivity of myofascial patients.This study showed that when the symptoms of rectus abdominis muscle separation, pelvic floor muscle dysfunction or pelvic dysfunction symptoms were relieved, the patients ADL ability was also enhanced, and sexual satisfaction and nursing satisfaction were improved. Decompensated relaxation of long-term elongated abdominal muscles, coupled with increased hormones during pregnancy and childbirth, such as progesterone, relaxin, and estrogen, can relax soft tissues. It shows decreased muscle strength, decreased fascia elasticity and decompensation, resulting in separation of rectus abdominis and decreased body core stability. Restoring the elasticity of the myofascial membrane helps shorten the separated rectus abdominis. In this study, it was discovered that after receiving myofascial therapy, patients’ rectus abdominis thickness and muscular strength increased and their separation index of abdominal circumference and rectus abdominis dramatically decreased. Therefore, the main principle of myofascial therapy is to increase rectus abdominis muscular strength, reduce rectus abdominis stress, and restore myofascial suppleness.The main reason for the separation of rectus abdominis is that the abdominal muscles of pregnant women are elongated and present a state of high tension, and the fascia between the rectus abdominis on both sides becomes thinner due to stretching and gradually separates. The gradual increase of the pressure on the pelvic floor muscle in pregnant women and the excessive stretch, the damage of the pelvic floor muscle fascia during childbirth, the inflammatory factors generated in the process of postpartum pelvic floor tissue repair, and pelvic instability can all lead to postpartum pelvic floor dysfunction, and the most common symptoms are stress incontinence and pelvic organ prolapse. According to the study’s findings, myofascial therapy could significantly reduce patients’ symptoms of stress urinary incontinence and pelvic organ prolapse, increasing the pelvic floor muscle’s potential risk. Myofascial therapy might be able to increase the elasticity of the pelvic floor muscle fascia and increase the contractility of the muscle. Postpartum patients with pelvic floor dysfunction due to pain and vaginal relaxation often show indifference to the sex life, even rejection, seriously affecting the relationship between husband, and wife. Fascia manipulation, acting on myofascial pain and its related points, can effectively relieve postpartum pelvic fascia pain, increase the contraction ability of the muscles involved, and help improve sexual satisfaction.Pelvic floor muscles and bone and fascia components work together to preserve the integrity of pelvic floor function. acting as pain triggers. Studies have shown that low back pain can stimulate muscles in the post-motor myofascial chain, resulting in reduced spinal stability, leading to forward pelvis, and further aggravating low back pain. Because of the long-term load, pelvic floor muscle fascia and muscle fiber contraction and even spasm, compression of the surrounding nerve tissue, also easy to form local pain trigger points. Activation of myofascial pain trigger points leads to dilation or even dislocation of the symphysis pubis space.Postpartum symphysis pubis reduction may also be hindered by local or referred pain. In this study, we analyzed pain from a variety of angles, the results showed that with myofascial therapy, the patients’ lumbago and pelvic floor myofascial pain symptoms were significantly reduced, and separation distance was significantly shortened. It was suggested that myofascial therapy may inactivate the trigger points of myofascial pain. On the other hand, it could promote the human body to restore the correct biomechanical position and reduce the pain caused by mechanical changes.Pain is a major postpartum problem, often in the lower back and pelvic floor muscles surrounding the tissue. Histological studies have shown the presence of pain-sensing nerve endings in the lumbago fascia. which often manifest as ischemia and inflammation as well as thickening of the lumbago and dorsal muscle fasciain patients with chronic lumbago,This study conducted a meta-analysis of daily living capacity activities to assess patients quality of life, including physiological function, physiological function, physical pain, general health status, energy, mental health daily activities, sleep, etc. It was found that when patients’ rectus abdominis separation, lumbago, pubic symphysis separation, and pelvic floor muscle dysfunction symptoms improved, their ability to perform daily activities also improved.This study confirmed that myofascial therapy can reduce the tension of abnormal myofascial membrane, promote the recovery of physiological elasticity and strength of fascia and muscle tissue, and restore the correct and normal biomechanics of the body, so as to reduce the symptoms of postpartum rectus separation, pelvic floor muscle dysfunction and back pain caused by myofascial dysfunction. Other postpartum disorders such as puerperal cervical spondylosis, stenosing tendovaginitis radial styloid, flat feet, and heel pain are also associated with myofascial system disorders, and therefore, these disorders may also be treated with myofascial therapy.Postpartum dysfunction includes rectus abdominis dissociation, pelvic leaning forward, lumbago, sacroiliac joint disorders, sacral pain, pelvic floor muscle dysfunction, and stenosing tendovaginitis radial styloid. It was found that the clinical evaluation and treatment data of postpartum dysfunction were mainly in the aspects of rectus abdominis separation, pain and pelvic floor dysfunction, and other studies were few. At present, there is a lack of systematic evaluation of postpartum dysfunction. In the future, it is necessary to design a set of comprehensive evaluation methods for women’s postpartum dysfunction. In treatment, there are few studies on myofascial therapy, lack of efficacy comparison with other treatment methods, and long-term efficacy has not been reported. In the future, better randomized controlled trials with larger sample sizes and multi-centers should be designed to conduct prospective, randomized controlled trials to explore the short-term and long-term efficacy of myofascial therapy in the treatment of postpartum women with various functional disorders.In summary, myofascial therapy could reduce abdominal circumference, relieve the pain of lumbar and pelvic floor muscle fascia, improve the contractile strength of pelvic floor muscle, improve the ability of daily living activities, and play a positive role in improving postpartum health, maintaining husband and wife life, and improving the relationship between husband and wife. It is worth applying in clinic.Thanks to the Education Department of Jilin Province for providing financial support for this study. Thanks to Lijing Zhao, Lirong Guo and Bing Liang from the School of Nursing, Jilin University for their contributions to this article.Conceptualization: Shuang Zhang.Data curation: Peiqiang Peng, Hong Liu.Formal analysis: Yueting Wang, Peiqiang Peng.Funding acquisition: Wenxi He, Shuang Zhang.Investigation: Yueting Wang, Peiqiang Peng, Hong Liu.Methodology: Haitao Zhang, Haiyan Xu.Project administration: Wenxi He, Haitao Zhang.Resources: Yueting Wang, Peiqiang Peng.Software: Wenxi He, Haitao Zhang.Supervision: Shuang Zhang.Validation: Shuang Zhang.Visualization: Haitao Zhang, Haiyan Xu, Hong Liu.Writing – original draft: Yueting Wang, Hong Liu.Writing – review & editing: Yueting Wang, Peiqiang Peng.


Endoscopic submucosal dissection (ESD) is effective for the resection of colorectal intramucosal lesions. This study was performed to examine the safety and effectiveness of using dexmedetomidine (DEX) in the anesthesia regimen of patients with colorectal lesions undergoing ESD.We retrospectively examined 287 consecutive patients who underwent ESD for colorectal lesions in our institution from January 2015 to December 2021. Outcomes including the frequency of intraprocedural pain and adverse events were compared between the DEX and no DEX groups. Moreover, univariate and multivariate analyses were conducted for each clinical factor of intraprocedural pain. Intraprocedural pain was defined as patient‐reported abdominal pain or body movement during the procedure.p = 0.02). The incidence of hypotension was also significantly higher in the DEX group , but no cerebrovascular or cardiac ischemic events occurred. In the univariate analyses, the diameter of the resected specimen, procedure time, no use of DEX, and total midazolam dose was associated with intraprocedural pain. The midazolam dose and DEX administration were significantly negatively correlated and the diameter of resected specimen and procedure time were significantly positively correlated. Multivariate logistic regression showed that no use of DEX was independently associated with intraprocedural pain (p = 0.02).The incidence of intraprocedural pain was significantly lower in the DEX than in the no DEX group (7% vs. 17%, Adding DEX to the anesthesia regimen in patients undergoing colorectal ESD appears to be safe and effective for reducing intraprocedural pain. Colorectal cancer is the fourth most common cancer worldwide.The 2020 Japan Gastroenterological Endoscopy Society guidelines for sedation in endoscopy noted the usefulness of dexmedetomidine (DEX) in the sedation of patients undergoing transanal endoscopic resection.This retrospective study was conducted at the Japanese Red Cross Wakayama Medical Center, a tertiary general hospital in Wakayama, Japan. Consecutive patients in our endoscopic and pathological database who underwent ESD for colorectal lesions from January 2015 to December 2021 were eligible for enrollment. Those whose procedure was interrupted because of technical factors such as severe fibrosis were excluded. The study was performed in accordance with the principles of the Declaration of Helsinki. Institutional review board approval was obtained.Outcomes including the frequency of intraprocedural pain and adverse events were compared between the DEX and no DEX groups. Moreover, univariate and multivariate analyses were conducted for each clinical factor of intraprocedural pain. Several factors other than DEX appear to be related to intraprocedural pain in daily practice. We investigated the factors related to intraprocedural pain to confirm whether DEX was independently related to no intraprocedural pain. Based on our experience in daily practice, we considered that the presence of dementia or the patient's performance status might be associated with physical movement and that the patient's surgical history or the endoscopist's experience might be associated with abdominal pain. We therefore analyzed several factors associated with intraprocedural pain including dementia, a history of an abdominal operation, and others.The definition of intraprocedural pain during ESD was not judged by the patient's distressed expression but by the patient's direct complaint of pain. Physical movements of patients that required temporary interruption of ESD were included in the definition of intraprocedural pain. We retrospectively searched the patients’ data in their intraoperative examination records and nursing records. Patients who had at least one event of intraprocedural pain or physical activity were categorized as the pain group and those who did not were categorized as the no‐pain group. Procedure time was defined as the time from injection of normal saline or purified sodium hyaluronate to ESD completion. Intraprocedural bleeding was defined as the spurting of blood or persistent oozing that did not spontaneously arrest within 60 s or following water irrigation, requiring endoscopic hemostasis with endoclips or coagulation. Intraprocedural perforation was defined as an iatrogenic defect in the muscle layer confirmed by visualization of fatty tissue or other organs through the defect. Delayed bleeding was defined as postprocedural bleeding that required presentation to the emergency department, hospitalization, or medical intervention. Delayed perforation was defined as postprocedural perforation diagnosed by the presence of free air or fluid on abdominal computed tomography or plain radiography in a patient who had no evidence of perforation immediately after the procedure. We defined an “expert” as an endoscopist with Japanese endoscopy specialist certification and more than 10 years of experience. Other endoscopists were defined as “non‐experts.”Endoscopic resection was performed for adenomas, sessile serrated lesions, large hyperplastic polyps, intramucosal carcinoma . Slit and hole caps  of the appropriate size for the endoscope were used. All procedures were performed by a combination of expert and non‐expert endoscopists.Resected specimens were embedded in paraffin and stained with hematoxylin and eosin. Diagnoses were made by dedicated pathologists according to the Japanese Classification of Colorectal Carcinoma.p‐value of <0.05 was considered statistically significant.Statistical analyses were performed using EZR p = 0.01). Sex, hypertension, lesion location, and endoscopist experience (expert or non‐expert) also significantly differed between the groups.The study flow chart is shown in Figure p < 0.001), the incidence of intraprocedural pain , and intraprocedural perforation rate  were significantly lower in the DEX group. The rates of intraprocedural bleeding and postprocedural fever, perforation, and bleeding did not significantly differ between the groups. The incidence of hypotension was significantly higher in the DEX group . No cerebrovascular events occurred.Table p = 0.02 and p < 0.001, respectively).Table To the best of our knowledge, this is the first study to investigate the effect of adding DEX to the intravenous anesthesia regimen in patients undergoing colorectal ESD. Our findings suggest that such use of DEX reduces intraprocedural pain.Although deep sedation is typically required for esophageal or gastric ESD because of procedure‐related pharyngeal and oral discomfort and the procedure's long duration, colorectal ESD requires light or conscious sedation because it requires the patient to change their posture and breathing during the procedure.DEX is a potent and highly selective α2‐adrenergic receptor agonist that has sedative and analgesic effects that reduce the required dose of other anesthetic agents.We believe that the use of DEX in anesthesia for colorectal ESD has several merits. Even when anesthesia with DEX was titrated to maintain a Ramsay sedation score of 2 or 3, patients rarely complained of abdominal pain. They were also able to respond quickly to commands, even when they were asleep. Our univariate analyses showed that a small diameter of the resected specimen, short procedure time, use of DEX, and low total midazolam dose were associated with no intraprocedural pain. In the multivariate analysis, the use of DEX was an independent factor associated with no intraprocedural pain.However, DEX may have disadvantages as well. The use of anesthetic agents reportedly increases the risk of perforation during colorectal endoscopic resection procedures.Our study has several limitations. It was retrospective in design and was conducted in a single center. In addition, our use of patient‐reported pain and body movement during the procedure as an outcome measure was not truly objective. Furthermore, we did not assess patient or endoscopist/nurse satisfaction. However, our findings are promising and warrant confirmation in future prospective randomized studies.In conclusion, adding DEX to the anesthesia regimen in patients undergoing colorectal ESD appears to be safe and effective for reducing intraprocedural pain.The authors declare no conflicts of interest.


BackgroundOsteoporotic vertebral compression fracture (OVCF) is a common problem in old age, which causes incapacitating pain and leads to significant disability, morbidity, and mortality. Percutaneous vertebroplasty (PVP), a minimally invasive procedure, results in immediate pain relief with decreased morbidity. The primary aim of this study was to evaluate the quality of life (QOL), as denoted by the Roland-Morris Disability Questionnaire (RMDQ) score. In contrast, the secondary aims were determining pain relief using the 11-point Numeric Pain Rating Scale (NPRS) and vertebral height restoration and wedge angle measurements after PVP.MethodologyThis prospective, longitudinal, interventional study on the efficacy of PVP was conducted among patients with low back pain due to osteoporotic vertebral collapse in a tertiary care institute. Patients with OVCF were managed by PVP and followed at one week, one month, three months, and six months for improvement in QOL by the RMDQ score and pain relief using the NPRS. The pre and post-vertebroplasty wedge angle and vertebral height  at one week and six months were also compared by pre and post-vertebroplasty lateral view skiagrams.ResultsA total of 24 patients were included in this study based on the inclusion and exclusion criteria. The demographic data were comparable. The RMDQ score showed a statistically significant difference in post-PVP at one week (p = 0.044), one month (p = 0.031), three months (p = 0.022), and six months (p = 0.018). There was a statistically significant difference in the NPRS at six months compared to the pre-PVP status, showing drastic pain relief in patients after PVP. The mean wedge angle (20.5 ± 2.07) measurement was reduced with a statistically significant increase in anterior body height restoration from pre-PVP to six months. There was no significant change in height at the middle and posterior columns compared to the pre-PVP height.ConclusionsPVP is an effective, safe, minimally invasive pain and spine intervention for OVCFs with improved QOL and restoration of vertebral height. Osteoporosis is a systemic skeletal disorder characterized by low bone mass and micro-architectural deterioration, resulting in bone fragility and increased fracture risk. The World Health Organization (WHO) defines osteoporosis as having a bone mineral density (BMD) greater than 2.5 standard deviations below the young normal adult reference population at the hip or lumbar spine. Osteoporotic vertebral fracture is a common problem in old age, which causes incapacitating pain and leads to significant morbidity, disability, and mortality. It is estimated that over 200 million people have osteoporosis worldwide . Of the Bed rest and pain may lead to reduced activity and immobility, which may cause further bone loss and other problems such as atelectasis and deep vein thrombosis, thus decreasing quality of life (QOL). According to the previous literature, after about 12 weeks of conservative therapy, 85% of symptomatic patients get relief from pain and discomfort produced by these acute osteoporotic fractures. The remaining 15% of patients with chronic osteoporotic compression fractures who do not respond to conservative therapy may require open surgery or percutaneous vertebroplasty (PVP) ,5. PVP sPVP has a rare complication rate of about 1.6% to 2.8%, which includes complications associated with needle placement, infection, cement extravasation, hemorrhage, cement penetration of the nerve root foramen or spinal canal resulting in radiculopathy or spinal cord compression, and embolic events due to marrow fat or cement entering the circulation. Only a few studies have correlated the restoration of the vertebra’s height and functional outcomes after PVP. Thus, this study evaluated the QOL and functional outcomes after PVP and compared the pre- and post-vertebroplasty wedge angles and vertebral heights .This is a prospective, longitudinal, interventional study. After approval from the Institutional Ethical Committee (IEC NO. 70/19) and Clinical Trials Registry in India (CTRI/2020/08/027343), 24 OVCF patients with failed conservative care and chronic back pain (>12 weeks) who were treated with PVP from September 2019 and March 2022 were included in this study. Inclusion criteria included age between 18 and 80 years and a normal coagulation profile. Patients with a refusal of consent; those with pedicle fracture, cord compression, local  or systemic infection, concomitant hip fractures, osteoporotic vertebral collapse >90%, previous vertebroplasty, posterior vertebral body breach, and any significant compromise of the spinal canal by retropulsion bone fragment or tumor; pregnant patients; vertebral compression fracture patients with multiple myeloma and metastatic tumor; or patients with known coagulopathy were excluded  scores were generally distributed in OVCF patients treated with vertebroplasty, with a mean of 19 and a standard deviation (SD) of 5. We intended to measure a minimum reduction in the RMDQ score of 4 points that would be clinically significant. To attain these objectives, we needed to enroll a minimum of 15 patients to be able to reject the null hypothesis that the mean reduction in the RMDQ score is zero with a type I error of 0.05 and a power of 0.8.n = (Z1 − 𝖺 + Z1 − 𝛽)2 𝜎2µ1 − µ2at 95% confidence interval (CI) = 1.96Z1 − 𝛽 at 80% power = 0.84𝜎 = SDµ1, µ2 = meansµ1 − µ2 = assumed difference in mean= 15 A total of 24 patients were included in this study.After written informed consent and preoperative evaluation, all patients underwent PVP in a dedicated pain medicine operation theater. After securing intravenous access and institution of essential monitoring , all patients were placed in a prone position with pillows under the chest and pelvis to increase the lumbar lordosis. PVP was conducted under monitored anesthesia care with sedation and local anesthesia.Under fluoroscopic guidance, the target vertebra was identified in the anteroposterior (AP) view, and the entry point was marked at the superior lateral quadrant of the target pedicle. An 11-gauge bone biopsy needle (Jamshidi needle) was inserted transpedicular and advanced under AP fluoroscopic control in an antero-medio-caudal direction with rotatory hand pressure or a mallet. The Jamshidi needle path, which was parallel to the superior and inferior edges of the pedicle, was ensured by intermittent lateral fluoroscopy and advanced into the anterior third portion of the vertebra as this area is devoid of venous plexuses. In a bilateral technique, both Jamshidi needles were inserted before the cement was injected from both sides simultaneously. After satisfactory placement of Jamshidi needles, the vertebroplasty-specific cement consisting of PMMA polymer was mixed with PMMA monomer to obtain the toothpaste consistency of bone cement. Subsequently, under lateral real-time fluoroscopic control, PMMA cement was injected to ensure early detection of cement leaking into the epidural, vena cava, or disc space until it reached the posterior vertebral wall. After the cement had been injected, the Jamshidi needles were removed after confirmation in lateral view. Following needle removal, patients were advised to rest for two hours and were mobilized.Observational indexes and evaluation criteriaAfter PVP, patients were observed for two hours in the postoperative room and then made ambulatory and were discharged in the evening with instructions for the follow-up visit at one week, one month, three months, and six months. At every follow-up visit, patients were evaluated for QOL by the RMDQ  and for pain relief by the 11-point Numeric Pain Rating Scale (NPRS). Lateral static X-rays were used to measure wedge angle  and restoration of vertebral height  . Demographic data were analyzed with the difference in mean values, and the chi-square test was used for categorical variables. The demographic data were presented as mean and SD, and non-parametric data were analyzed by the chi-square test. The numerical data were analyzed by parametric and non-parametric tests based on whether they were distributed normally or non-normally. Independent Student’s t-test was used for testing RMDQ, NPRS, vertebral height , and wedge angle. P-values <0.05 were considered significant with a 95% CI in the study.A total of 24 patients were included in the study. As two patients were unable to attend the outpatient department after three months, their follow-up was done telephonically.The demographic data regarding age, sex, and duration of pain were homogenous in the study group. Of the 24 patients, 19 (79.16%) were females, and five (21.7%) were males. The mean age ± SD was 62.45 ± 9.5 years, with an age range of 50-79 years. A total of 37 collapsed vertebrae in 24 patients were treated by PVP. Out of the 37 treated vertebrae, 24 were treated by a unipedicular approach, while 13 were treated by a bi-pedicular approach  from 20.26 ± 2.91 pre-PVP which reduced to 16.39 ± 3.17 at one week (p = 0.044), 11.39 ± 2.4 at one month (p = 0.031), 8.86 ± 2.98 at three months (p = 0.022), and 8.43 ± 3.6 at six months (p = 0.018) , which reduced to 5.34 ± 1.61 (p = 0.033), 2.91 ± 1.23 (p = 0.021), 1.73 ± 1.25 (p = 0.014), 1.65 ± 1.30 (p = 0.001) at one week, one month, three months, and at six months, respectively. There was a highly statistically significant difference in the NPRS at six months, showing drastic pain relief in the patients after PVP , followed by 13.2 ± 0.29 (p = 0.033) at one week, which decreased to 12 ± 0.47 (p = 0.024) at six months. An increase in the anterior border measurement suggested a statistically significant increase in anterior vertebral height after PVP (Table The mean wedge angle 20.5 ± 2.07) measurement reduced from pre-PVP to one week (12.31 ± 1.70) and six months (11.9 ± 3.10). A statistically significant difference between one week and six months (p ≤ 0.05) showed a reduction in pain intensity with a reduction in wedge angle after PVP  were female. Previous studies also showed that women accounted for 72% of patients with OVCF . The meaPVP can be done via a bi-pedicular or unipedicular approach. The unipedicular approach has several advantages, such as being less time-consuming and having fewer complications. Of the 37 treated vertebrae, 24 (64.8%) were treated using a unipedicular approach as the PMMA flowed across the midline and adequately filled both vertebral hemispheres. The remaining 13 (35.1%) vertebral bodies were treated via a bipedicular approach . Takegami et al. [-L2. TakeThe RMDQ Table , which cThe secondary outcome measure was pain relief using the 11-point NPRS. According to numerous case series and research, pain alleviation is expected in 24 hours following PVP. Our patients also experienced statistically significant pain relief following PVP Table . Clark eSpinal radiographs  were obtained at preoperative, one week, and six months to assess vertebral body height  and wedge angle. The fractured vertebral body’s anterior, middle, and posterior vertebral height was measured in mm. In our study, the pre-PVP mean ± SD of anterior height was 09.6 ± 02.38 which increased to 13.2 ± 02.9 at one week but settled at 12 ± 04.7 at six months. The slight decrease in height from one week to six months may be due to cement dispersion with time and load on the vertebra  was reduced from preoperative to one week  and six months , showing a reduction in the intensity of pain with a reduction in wedge angle after PVP. Wedge angles can predict the outcome of PVP and are desirable to restore maximal alignment. According to some previous studies, improvement in wedge angles after PVP has been reported to be 6° and 3.5° from the pre-procedural, similar to our study . KhurjekThere was a small cement leakage in the disc in 11 (29.7%) and no cement leakage in the remaining 26 (70.3%) treated vertebral bodies (Table PVP is an effective minimally invasive intervention to improve the QOL and immediate pain relief in OVCF patients with a low complication rate. The improvement in the wedge angle and restoration of vertebral height signifies successful outcomes. A slight cement leak does not increase the chances of adjacent vertebral fracture for up to six months at least.


Both groups improved pain and depression at follow-up and reduced anxiety only during Pilates-based exercises. Therefore, only Pilates-based exercises seemed sufficient to manage patients with CNLBP.Chronic nonspecific low back pain (CNLBP) is the most common musculoskeletal condition, which can be influenced by nociceptive, psychosocial, cognitive, and affective aspects, causing vulnerabilities and impairing the individual's ability to manage pain. The association of continuous shortwave diathermy (CSWD) with Pilates-based exercises may contribute to reduce pain, depression, and anxiety in patients with CNLBP. A single-blind randomized clinical trial was performed in which 36 patients with CNLBP were divided into a control group that received placebo CSWD and an intervention group that received active CSWD. Both groups received 12 sessions of Pilates-based exercises. Pain, depression, and anxiety variables were evaluated using the McGill questionnaire, the Beck Depression Inventory, and the Visual Analog Anxiety Scale. Assessments were performed at baseline, after three and six weeks of treatment, and at the three-month follow-up. The Shapiro-Wilk test, Student's  Low back pain (LBP) is the world's most prevalent and disabling condition and is generally classified according to the duration of pain in acute (<6 weeks), subacute 6-12 weeks), and chronic (>12 weeks) ; hence, most LBPs are termed nonspecific (back pain [with or without leg pain] without a clear nociceptive specific cause). CNLBP has physical risk factors, such as prolonged standing or walking, lifting heavy weights, and psychological factors, such as depression and job dissatisfaction. High levels of depression or anxiety are consistently associated with poor outcomes  in patients with LBP ,5.Recently, studies have reported that comorbidities of depression-anxiety-chronic pain-insomnia by neurosensitization processes are similar to those of epilepsy, in which a persistent increase in neuronal reactivity occurs. Neurosensitization is the basis of a common etiology of chronic pain, depression, and anxiety disorders and can cause clinical manifestations to be increasingly spontaneous, persistent, and severe .According to the existing literature, non-pharmacological treatment of CNLBP involves interventions to help people manage health conditions effectively and maintain quality of life because it is a potential strategy to reduce pain-related disability (self-management support) . MoreovePilates and segmental stabilization of the spine aim to activate the deep and stabilizing muscles of the trunk, that is, muscles directly connected to the vertebrae and responsible for segmental spinal control, to stabilize the trunk and limb movements, thus positively impacting the management of CNLBP ,11.A network meta-analysis by Hayden et al.  pointed Therapeutic heat has also been used as a non-pharmacological treatment to decrease pain in patients ; therefoThe generation of intense heat in the body activates transient receptor potential vanilloid (TRPV1) receptors, which are abundantly expressed in the limbic system and the systemic nuclei involved in emotion management . The actOther studies have also suggested that active SWD associated with an exercise program is effective for CNLBP ,24. DespA recent systematic review on the use of SWD in chronic LBP revealed that studies lacked content; additionally, existing studies have low methodological quality with undeclared study designs and inadequate descriptions of the parameters used. The authors of the systematic review also pointed to the need for new randomized clinical trials on this subject with a special focus on detailing the prescription parameters and methodological rigor used in SWD .Therefore, this study aimed to evaluate the effect of the association between CSWD and Pilates on reducing pain, depression, and anxiety in patients with CNLBP. We hypothesized that this association is beneficial for decreasing pain, depression, and anxiety in these patients.www.randomization.com). Numbers 1 to 36 were randomly assigned to each participant after the initial evaluation in opaque and sealed envelopes. Patients were blinded about the groups and recruited from the orthopedic department of the Hospital of University of São Paulo . All participants were diagnosed with CNLBP by doctors from different sectors of the public or private service. CNLBP was diagnosed after excluding specific disorders of spinal and non-spinal origin. It is typically defined as pain below the costal margin and above the inferior gluteal folds (>12 weeks), with or without leg pain, without a clear specific nociceptive cause such as disk herniation, spinal stenosis, fracture, tumor, infection, and axial spondyloarthritis. Diagnosis is usually made through history and physical examination. Imaging tests are not routinely indicated in patients with nonspecific low back pain  randomized controlled clinical trial was conducted at the Laboratory of Clinical Physiotherapeutic Investigation and Electroneuromyography, Department of Speech Therapy, Physiotherapy, and Occupational Therapy, Faculty of Medicine of the University of São Paulo from August 2016 to August 2019. The therapist who administered the treatment was not blinded to the groups. Randomization was performed by a researcher who was not involved in data collection using a website , rheumatic disease, degenerative or inflammatory diseases, acute nonspecific LBP, ongoing physical therapy or drug treatments for musculoskeletal pain, depression, or anxiety, pregnancy, contraindication to performing physical activity according to the American College of Sports Medicine guidelines  with an emission frequency of 27.12 MHz and a continuous mode of 180 W (+/-30%). The application was performed with the patient in the supine position, with two plate-type electrodes wrapped in a towel to absorb moisture using the coplanar application method in parallel vertically placed on the right and left sides of the lumbar region, with a distance of 5-10 cm between them  Neutral Hip Position: dorsal decubitus with knees flexed and feet supported with contraction of the abdomen and pelvic floor; b) Rail Abdominal: dorsal decubitus with extended hips and legs and trunk elevation.Engagement of the arm muscles: a) Hundred: dorsal decubitus with knees flexed, feet supported, and arm swing.Stretching and strengthening of the flexor and extensor muscles of the ankles: a) Leg Stretch with Foot Movement: dorsal decubitus with one leg raised with foot flexion and extension, and the other flexed with foot supported.Strengthening of the extensor muscles of the knees: a) Single Leg Stretch I: dorsal decubitus with raised leg and knee flexion and extension, and the other knee flexed with foot supported.Strengthening of the extensor and flexor muscles of the hips: a) Bridge: dorsal decubitus with knees flexed, feet supported, and hips elevated; b) Single table top: dorsal decubitus raising and lowering one leg flexed at 90 degrees, and the other with knee flexed and foot supported; c) Single leg stretch II: dorsal decubitus raising and lowering one leg outstretched, and the other with knee flexed and foot supported.Strengthening of the adductor and abductor muscles of the hip: a) Oyster Frontal: dorsal decubitus opening and closing knees with feet supported; b) Lateral Oyster: lateral decubitus with flexed knees, moving the top knee apart and closer.Stretching of the spine: a) Hug Legs: dorsal decubitus hugging bent legs; b) Dog Stretch: four supports with glutes in the heels and spine elongated downwards.For both groups, the Pilates protocol was performed for 40 min , totaling 12 exercises with 15 slow repetitions each and a rest interval of three to five breaths. All exercises were performed individually and were supervised by the researcher ,15,27. TPilates emphasizes strengthening and activation of the deep muscles of the trunk, posterolateral and anteromedial chains of the hips and thighs, sacroiliac stabilization, flexibility of the lower limbs and spinal muscles, and overall muscles resistance ,29.All participants were instructed on appropriate postures during sleep, activities of daily living, and work. These guidelines were followed for both groups during the initial three sessions of SWD . The stuThe Brazilian version of the McGill Pain Questionnaire contains 67 words describing pain experiences organized into four categories: sensory, affective, evaluative, and mixed. The pain assessment index is calculated as the sum of the aggregated values of the words chosen within the subcategories, with the maximum score for each category being as follows: sensory=34, affective=17, evaluative=5, and mixed=11; total=67. The McGill pain questionnaire also contains a scale of pain intensity at the time of application  .Symptoms of depression and general anxiety were assessed at the beginning and at the end of treatment using the Brazilian versions of the Beck Depression Inventory (BDI)  and VisuThese tools were administered before treatment, after three and six weeks, and at three months of follow-up.The sample size was calculated considering the difference between two points on the numerical pain scale (20%) and between the active SWD and placebo, and an estimated standard deviation of three, based on data from a previous study . For a st-test and chi-squared test. The effects of time, group, and the interaction between time and group were measured using repeated measures analysis of variance (RM-ANOVA), applying Bonferroni's post hoc test for the time factor. Missing data were treated using mean imputation for the intention-to-treat analysis. The statistical software SPSS  version 15.0 for Windows was used . The significance level adopted was 5%.Descriptive statistics of the variables were performed by calculating the means±SD, and minimum and maximum values for quantitative variables and absolute and relative frequencies for categorical variables. The normality of the variables was verified using the Shapiro-Wilk test. Sociodemographic variables were compared between the groups at the pre-intervention stage using the independent Of the 36 study participants, 33 completed all the phases. Regarding sociodemographic characteristics, there were no statistically significant differences between the groups at baseline .There was no statistically significant difference between the groups for pain intensity and total pain  at baseline, three and six weeks, and three months. Both groups had an improvement in these variables throughout the treatment and at the three-month follow-up.  could benefit patients in aspects related to pain, depression, and anxiety, as intense heat activates TRPV1 receptors, which are present in the brain regions involved in emotions, such as depression and anxiety.The role of heat in improving depressive symptoms is not yet fully understood, but studies on capsaicin, which also stimulates TRPV1 receptors, have shown that it acts as an agonist of the antidepressant effects associated with amitriptyline . Lin et As the analyzed variables did not show additional improvement in CNLBP treatment with the use of CSWD, it seems that performing Pilates is sufficient to control pain, depression, and anxiety. Karasel et al.  found siAnxiety symptoms are another important aspect to be improved in patients with CNLBP. Hu et al.  recommenOur study also revealed that the application of CSWD had no significant effect on anxiety improvement. Additionally, we found that patients in both groups had moderate anxiety at the beginning of treatment, which changed to mild anxiety at the sixth week of treatment. After the 3-month follow-up, both groups returned to moderate anxiety levels, demonstrating that they managed to reduce anxiety levels only while receiving treatment.In a systematic review, Chong et al.  affirmedFinally, our study corroborates the systematic review conducted by Lemieux et al. , which fBased on the results of this study, it is suggested that a Pilates-based exercise program is sufficient to treat patients with CNLBP, without the need for the addition of CSWD.Due to the nature of this clinical intervention, there was no possibility of blinding the therapist for group allocation, given the thermal effect of CSWD. The study design did not allow for assessments by age group, which is a limitation of the study.It was concluded that active CSWD did not provide additional improvements in pain, depression, and anxiety variables in patients with CNLBP. Both groups improved pain and depression at follow-up and reduced anxiety only during Pilates exercises, thus, proving that they are sufficient for treating this condition.


Background/aimThis study investigates the degree of coexistence of cervical disc herniation and shoulder soft tissue pathology, as well as the effect of sleeping positions and orthopedic pillow use.Materials and methodsThis present study was conducted on 72 patients with shoulder/arm pain operated on for cervical disc herniation. Two groups were examined according to the presence of shoulder soft tissue pathology, four common sleeping positions, and the use of an orthopedic pillow. Preoperative and postoperative shoulder/arm visual analog scale (VAS) scores were compared.ResultsThe preoperative VAS values were 7.35, while the postoperative VAS values were 3.32. Twenty-one patients (29.2%) had a disc at the C3-4 level, a rate equal to that for the C5-6 level. Twenty-four patients (33.3%) had a disc at the C4-5 level. Thirty-two cases (44.4%) slept in a side-lying position on the same side as their disc herniation. Among those with a herniated disc at the C3-4 level, 8 (53.3%) preferred sleeping side-lying on the opposite side of the disc. In contrast, those with a herniated disc at the C4-5 level more frequently (40.6%) slept side-lying on the same side as the disc. Mean VAS scores were significantly higher in cases with shoulder soft tissue pathology and were significantly lower in the group that used orthopedic pillows (p<0.001).ConclusionShoulder soft tissue pathologies should be considered in postoperative shoulder pain. The use of orthopedic pillows is effective in preoperative and postoperative pain. Sleeping positions do not affect the shoulder/arm pain before and after the operation, but they affect the level of cervical disc herniations. Neck pain is the fourth leading reason of disability, with an annual prevalence of over 30%. Acute neck pain disappears with or without treatment most of the time. However, almost 50% of individuals continue to experience some degree of pain or frequent pain . Neck paShoulder pain has diverse reasons, such as local soft tissue, articular, or bone pathologies. Shoulder pain may be referred from the neck or shoulder that may be difficult to distinguish clinically from those localized to the shoulder . It can The types of pillows, specifically spring and rubber, have been proven effective in reducing neck pain and increasing pillow contentment in patients with chronic neck pain . AlthougStudy populationsOur study conforms to the ethical rules of the World Medical Association Helsinki Declaration and is approved by the Ethics Committee decision for clinical research. This study comprises all the patients with a single-level cervical disc herniation admitted to the Neurosurgery Clinic between June 2018 and September 2022. The data of the patients have been collected retrospectively. Patients with a single-level cervical disc herniation operated on for this cause were included in this study. Only those presented with shoulder/arm pain on one side were included in the study. Cervical disc herniations that cause bilateral pain were excluded from the study. The other chronic or rheumatological reasons, genetic spinal deformities that can cause shoulder/arm pain, were excluded. Patients not operated on for cervical disc herniation were excluded from the study. Patients with spinal deformities affecting sleeping position or patients who could not change position due to limb paralysis were not included in the study. All patients underwent a single-level anterior cervical discectomy and fusion (ACDF) operation. The criteria for surgery included arm/shoulder pain that did not resolve despite medical treatment and extruded cervical disc herniation detected by cervical magnetic resonance imagining (MRI). All patients received non-steroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants for medical treatment. As a standard conservative treatment, 400 mg of phenyramidol and diclofenac sodium 100 mg of oral therapy were given to each patient before the surgical decision for four to six weeks. A shoulder MRI was performed to determine whether there was any shoulder soft tissue pathology for differential diagnosis  values were recorded both before surgery and during the first week following cervical disc herniation surgery.Visual analog scaleVAS is a scale used for the subjective assessment of pain, allowing the person to determine the degree of pain. According to this scale, the person evaluates the amount of pain between 0 and 10. The value 0 means the absence of pain, and 10 means severe pain .Statistical analysisDescriptive statistics were expressed as frequency, percentage, mean, and standard deviation. Categorical variables were analyzed by Pearson chi-square and Fischer exact tests using 2 x 2 tables. The normality of numeric variables was tested with the Shapiro-Wilk test. The mean differences between two groups with normally distributed were compared by Student’s t-test, whereas the Mann-Whitney U test was applied to compare the not normally distributed data. Preoperative and postoperative VAS values were tested with the Wilcoxon signed rank test. The comparisons of more than two groups were tested by Kruskal Wallis variance analysis or one-way ANOVA. All statistical analyses were performed using IBM SPSS Statistics for Windows, Version 21 . p<0.05 was considered statistically significant.A total of 72 patients who presented with unilateral pain and were diagnosed with cervical disc herniation underwent single-level ACDF surgery and were included in this study. The mean age of the patients was 46.94 (±11.56), and the distribution between males and females was equal. The preoperative mean VAS values were 7.35 (±1.06) and significantly decreased after surgery to postoperative VAS values of 3.32±1.99 (p<0.001). Twenty-one patients (29.2%) had a disc at the C3-4 level, equal to the rate at the C5-6 level. Twenty-four patients (33.3%) were at the C4-5 levels. The pain was on the right side in 37 cases (51.4%). Thirty-two cases (44.4%) slept in a side-lying position on the same side as the disc. The majority of patients (62.5%) did not opt to use an orthopedic pillow. Shoulder soft tissue pathology was observed in half of the patients . The use of orthopedic pillows was higher who sleep in the side-lying position on the same side with the disc and supine position compared to other positions. No significant correlation was found between other features and sleep position (p>0.05). Although total mean preoperative VAS scores decreased after the operation, sleep positions were not significantly relevant to the differences in VAS scores.The general data were compared according to shoulder soft tissue pathology Table . The meaThe mean preoperative and postoperative VAS scores were significantly higher in the cases with shoulder soft tissue pathology than those without shoulder soft tissue pathology. The decrease in preoperative VAS scores to postoperative VAS scores was statistically significant (p<0.001). The study results indicate that there was no significant statistical variance observed among the levels of C3/4, C4/5, C5/6, and C6/7 concerning shoulder soft tissue pathology (p=0.139). The data revealed that the prevalence of shoulder pathology was higher at the C3/4 level in comparison to other levels. To achieve statistical significance, it may be necessary to conduct studies with larger sample sizes , followed by C5-6 (19%) in the literature. The least frequent level is C4-5, reported at 2% . In the C4-5 level discs can cause C5 root symptoms and usually present with shoulder/arm pain. The exact point of the pain may not be estimated because it may radiate from the neck to the arm. It may manifest with tenderness and pain along this tracing . That isShoulder/arm pain can be associated with cervical disc herniation and shoulder pathologies; therefore, a differential diagnosis is necessary. Self-reported prevalence of shoulder pain is estimated to be between 16% and 26% . PhysicaShoulder soft tissue pathologies such as rotator cuff tendon impingement, biceps tendinopathy, adhesive capsulitis, calcific tendinitis, sub-acromial bursitis, and labral tears must be kept in mind for distinction . LikewisAxial loading is an etiological factor for cervical disc herniation, as seen in workers carrying heavy weights. Presumably, biomechanics of the upper extremity may cause this dual pathology. Likewise, if the cervical muscles are not strong enough, it will increase the load on the discs and cause herniation . On the Our study determined that there were different levels of cervical disc herniation in different sleeping positions. The patients tend to lie on the contrary side of the disc at the C3-4 level. They lie on the same side of the disc at the C4-5 level. Whether the lying position causes cervical disc herniation or whether the sleeping positions of the patients change due to pain is an unknown situation. In this regard, studies on long-term sleep position changes can be conducted in the future. There was no difference between the sleep positions regarding preoperative and postoperative VAS scores. Sleeping positions do not affect the degree of shoulder/arm pain before the operation, and they do not affect the pain after the operation.On the other hand, the presence of shoulder soft tissue pathologies significantly affects pre- and postoperative pain. The pain did not decrease sufficiently in shoulder soft tissue pathology patients after cervical disc herniation operation. Therefore, the specialist should remember that if the postoperative pain after cervical disc surgeries does not decrease as desired, there is a high probability of accompanying shoulder soft tissue pathology.Improving sleep quality is effective in reducing pain according to spinal problems ,26. In aIn this study, it is understood that using orthopedic pillows does not contribute to the formation of cervical disc herniation and, therefore, the use of them is not necessary to prevent cervical disc herniation. Although an orthopedic pillow may not prevent cervical disc herniation, preoperative pain was significantly less in those using orthopedic pillows. At the same time, the postoperative pain was less in those who used orthopedic pillows. The use of orthopedic pillows has a positive effect on the difference in pain before and after the operation, while the presence of shoulder pathology has a negative effect. It is slightly effective in improving postoperative VAS scores in cases with shoulder pathology, although the difference is not statistically significant.LimitationsIn our study, personal questions about routine daily life were asked. These results were obtained by asking questions to the patients during the control. One-to-one follow-up is required for more reliable follow-up.The presence of shoulder pathologies can be confused with symptoms of cervical disc herniation and can also impact postoperative pain after cervical disc surgery. Shoulder soft tissue pathologies should be taken into account when postoperative shoulder pain doesn't decrease as expected following cervical disc surgeries. The use of orthopedic pillows is effective for both preoperative and postoperative pain but does not contribute to the causation or aggravation of shoulder pathologies or cervical disc herniations. Orthopedic pillows should be recommended to patients both before and after surgery. This study found no significant correlation between sleep position and the intensity of preoperative pain or postoperative pain levels. The influence of sleeping positions on managing patients' pain is negligible. Different sleeping postures may lead to disc herniations at distinct levels.


Background: Nonspecific lower back pain (NSLBP) is described as pain that is not caused by an identifiable, well-known disease, such as infection, tumor, osteoporosis, fracture, structural deformity, inflammatory condition, radicular syndrome, or cauda equina syndrome. Aim: The aim of this study was to determine the effect of EMG-guided trunk stabilization exercises on functional disability associated with LBP. Materials and Methods: A single-blinded pre- and post-test experimental comparative design was used for this study. Fifty individuals with chronic NSLBP were screened for inclusion criteria. Of these, forty were randomly grouped into the EMG group receiving trunk-stability exercises with electromyography biofeedback and non-EMG group receiving trunk-stabilization exercises without EMG biofeedback. Participants performed five trunk-stability exercises 3 days a week for 4 weeks. The intensity of pain, range of motion, functional disability, and balance were measured at baseline and after 4 weeks. Results: Both techniques indicated a significant effect on chronic NSLBP; however, trunk-stability exercises combined with EMG biofeedback produced better results in alleviating the intensity of pain, increasing the range of motion, and improving functional disabilities and static balance. Conclusion: The present study confirms that trunk-stability exercises with EMG biofeedback can be practiced safely, contributes to a greater boost in neuromuscular efficiency in the lumbar flexors and extensors, and is effective in modifying functional disability for patients with NSLBP. Urban society has a high rate of chronic lower back pain (LBP), which hinders people from working and limits their daily activities . This coAccording to a survey, 42.4% of people suffer from LBP each year, and 22.8% suffer from it each week. Approximately one-fifth of patients 20.6%) experienced restrictions in everyday activities because of LBP, and 14.4% reported feeling emotionally unhappy because of LBP . These b% experieSymptoms of NSLBP can include cyclic pain, buttock and thigh discomfort, morning stiffness or soreness, discomfort at the commencement of a movement, discomfort in forward flexion and returning to an upright position, increased pain with extension, side flexion, rotation, standing, walking, sitting, and activity in general, ease of pain while changing different postures, and lying down, particularly in the fetal position, to alleviate pain .Numerous activities, such as walking and sports, need trunk rotation. One of the main risk factors for lower back discomfort is trunk rotation. The latissimus dorsi, internal oblique, and transversus abdominis work ipsilaterally during rotation, whereas the external oblique, rectus abdominis, and lumbar multifidus work contralaterally . MechaniChronic lower back pain alters the lower back’s structure and surrounding tissues, leading to weakened abdominal muscles responsible for trunk stability. This causes discomfort and functional limitations. As the pain worsens, physical activity is restricted, and the muscles around the spine may atrophy, reducing in size. Spinal instability is the most prevalent biomechanical cause of lower back pain. Chronic lower back pain sufferers perceive lumbar vertebral instability as a severe problem. It causes discomfort, decreases endurance and flexibility, and restricts the lumbar range of motion . The truBalance is dependent on the interplay of the vestibular, visual, and proprioception systems . The corMuscle recruitment varies based on the activity performed. Lifting a lighter weight involves fewer muscles, while lifting a heavier weight requires more muscles to generate force. As force increases, the central nervous system becomes more stimulated, activating additional motor units and increasing their firing rate. This leads to larger EMG signal amplitudes, indicating heightened muscle activity. By using electromyography, we may exert force, make movements, and perform many other actions that let us engage with the environment. The electromyograph is a bioelectric signal that has a wide range of uses that have grown over time. Neurological problems are typically diagnosed using electromyography in clinical settings. It is widely used to evaluate individuals with neuromuscular illnesses, lower back pain, and motor control abnormalities . In addiThis was an experimental pre–post-test comparative study comparing the effects of trunk-stability exercises with and without electromyography biofeedback in patients with nonspecific chronic lower back pain.t-test with a statistical significance level of 0.05. The results of the power analysis indicated that a sample size of 40 participants was necessary to achieve statistical significance with a power of 80%: critical t = 2.02, D = 2.94, and power = 0.818.The sample size was calculated using a priori power analysis based on our primary outcome, specifically the pain level at a 6-week follow-up. This analysis utilized data from a previous study that investigated the efficacy of electromyography biofeedback training on trunk stability , resultiFifty participants, aged from 20 to 45 years, at the university campus, were screened for the inclusion criteria in the study. In this study, convenience sampling was employed to select participants based on their availability and accessibility, allowing for a quick and convenient data-collection process. Participants were eliminated if they had been diagnosed with a tumor, infection, inflammatory disease, spinal or lower limb surgery, spinal fractures, a manifestation of radiculopathy (showing signs of nerve root compression), severe osteoporosis, structural deformities such as spondylolisthesis, or an incompatibility with exercise therapy . Ten participants were excluded as they failed to comply with the inclusion criteria or declined to continue to participate. The remaining 40 participants were randomly allocated to either the non-EMG or EMG group, each containing 20 participants . A balanAll participants signed a consent form before taking part in this study. Baseline measurements were obtained for the intensity of pain using VAS, static balance through the APP-Coo test, and range of motion through modified Schober’s test . In addiThe APP-Coo test is an application that can be used on smartphones and tablets and is based on a triaxial accelerometer. It can assess both static and dynamic balance deficits . The APPThe lumbar spine’s range of motion was measured using modified Schobers’s test and the tape method was used for all other motions, i.e., flexion, extension, and lateral bending . The meaIn hospital settings, the Oswestry Lower Back Disability Index (ODI) is the most applied outcome-measure questionnaire for assessing pain in the lower back . This isThe investigator supervised the sessions, and participants were instructed to report any adverse event, whether or not it was connected to the exercises. During the trial, participants were not allowed to partake in any other physical activity. Before the trunk-stabilization exercise, all of the participants performed warmup exercises, followed by aerobic work (static bicycling for 5 min at a moderate pace) and stretching .Participants in the EMG group performed trunk-stabilization exercises after the electrodes were placed ,20. All Before the deployment of the EMG electrodes, standardized skin preparation was performed. This preparation consisted of the removal of hair, a mild abrasion with sandpaper, and the washing of the skin with an alcohol swab. The electrode–skin impedance was less than 10k Ω after this procedure. The surface EMGs of two right back muscles and four abdominal muscles, including the latissimus dorsi, rectus abdominis, external oblique and internal oblique and transversus abdominis, were measured at a sampling frequency of 1024 Hz employing hydrogel and disposable Ag/AgCl electrodes measuring 38 mm by 19 mm. In order to gather EMG data and use them as a reference for normalization, three 5-s trials of manually resisted maximal voluntary contraction (MVC) were conducted on each muscle. EMG signals from both the upper and lower rectus abdominals were recorded, along with signals from the upper rectus abdominis , lower rectus abdominis , upper back extensors , and lower back extensors  .p < 0.05. An independent t-test was used to analyze the data between two groups followed by a paired t-test to analyze the data within each group. The confidence interval was set to 95%, while the level of significance was set to p < 0.05. Descriptive statistics were used for analysis and determination of the mean and standard deviation of participants with and without EMG training.Statistical analysis was performed with the help of SPSS Version 22. Before beginning parametric tests, the assumption of normality was evaluated using a Shapiro–Wilk test. The data distribution for all variables at all levels was tested at n = 40). These participants were then equally divided into two groups based on the intervention received, each consisting of 20 participants. The non-EMG group received trunk-stabilization exercises without EMG biofeedback, while the EMG group received trunk-stabilization exercises with EMG biofeedback. A pre-assessment of different outcome variables was performed in the non-EMG group (n = 20) and the EMG group (n = 20). However, during the post-test measurement at the four-week follow-up, two participants from the non-EMG group and three participants from the EMG group did not attend; these participants were removed from the study, leaving 17 participants in the EMG group and 18 in the non-EMG group  and percentages (%) for each category within the EMG and non-EMG groups. Additionally, for these categorical variables, a chi-square test was performed to assess the level of independence between the groups. t-test was performed to compare the nominal demographic variables between the non-EMG and EMG groups, which showed no significant difference. Furthermore, the independent sample t-test test was applied on different outcome variables to compare the pre- and post-effect of trunk-stability exercises with and without EMG biofeedback in chronic lower back pain patients (An independent sample patients . There wt-test was performed to compare the pre- and post-test effects of trunk-stability exercises with and without EMG biofeedback in chronic lower back pain patients (t-test showed a significant improvement (p < 0.001) in pain as reflected by the VAS score and in function disability as obtained from the ODI% in both groups. However, the mean difference in functional disability was on the higher side (12.58 ± 8.59) in the EMG group as compared to the mean difference (8.33 ± 10.13). Regarding the range of motion, both the flexion and extension of the EMG group improved significantly (p < 0.001). In addition to this, the EMG group showed a significant improvement in static balance as measured through the APP-Coo test with closed eyes (p = 0.01) which was not observed in the non-EMG group.A paired patients . The paiFunctional disability was evaluated through the ODI score as shown in The disability levels before and after the intervention for both the non-EMG and EMG groups were determined by calculating the total score from the Oswestry Disability Index (ODI), as depicted in The aim of this study was to assess the effectiveness of trunk-stability exercises with and without electromyographic biofeedback on functional disability in patients affected with nonspecific CLBP. Additionally, the study aimed to investigate the impact of EMG biofeedback as a supplementary tool for trunk-stabilization exercise in enhancing balance, reducing pain, and increasing the lumbar range of motion. The results of this study demonstrated that combining EMG biofeedback with trunk-stability exercises resulted in better improvements in all outcome measures, including pain severity, range of motion, balance, and functional disabilities. Both groups exhibited significant improvements over the four-week intervention period. However, the EMG group exhibited significantly greater improvements compared to the non-EMG group. Furthermore, the functional impairments of patients in the EMG group improved, with all patients reporting minimal disability. The enhanced improvement observed in the EMG group can be attributed to the immediate auditory and visual feedback provided during contraction, facilitated by EMG feedback. This improvement may be associated with the patient’s increased sense of control over their pain, resulting in reduced pain levels ,22. ThusThe findings of this study revealed a significant reduction in pain in both groups following the four-week intervention. However, the group that received EMG training in addition to trunk-stabilization exercises showed more pronounced results when compared to the group that solely underwent trunk-stabilization exercises without EMG training. The enhanced outcome can be attributed to the combined effect of strengthening deep abdominal muscles, improving flexibility, and enhancing balance through EMG training. The substantial improvement observed in both groups can be attributed to increased back endurance, which subsequently reduces spinal instability and leads to pain reduction. This aligns with previous research indicating that improving endurance and promoting lumbar stability both contribute to pain reduction . AdditioThe results of this study indicate that both groups experienced improvements in their range of motion but the EMG group exhibited more significant enhancement. Abnormal or defective movement patterns during the spinal range of motion, known as a poor qualitative or quantitative range of motion, signify dynamic lumbar instability and highlight the need for stability training . Based oIndividuals with lower back pain generally exhibit reduced static balance abilities compared to healthy individuals, leading to compromised postural stability. Therefore, it is crucial to incorporate exercises that improve trunk stability to decrease shearing stress on the lower back and enable patients to achieve pelvic and trunk stability. The considerable difference observed between the two groups is a positive indication. Trunk-stability exercises are designed to enhance the body’s balance and stability. These exercises promote the simultaneous activation of abdominal muscles and the multifidus which is a fine motor muscle of the spine . By imprFrom the baseline assessment to the fourth week, there was a notable improvement in EMG amplitudes for all of the exercises, suggesting improved control over the targeted muscles. The statistical analysis revealed that the EMG group demonstrated a superior performance compared to the non-EMG group.Finally, this study supports the use of trunk-stability exercises combined with EMG biofeedback as an effective approach to improve functional disabilities, alleviate lower back pain, and address other associated symptoms. This intervention led to enhanced core stability and an improved quality of life. The findings align with a pilot study by Shaughnessy M, which demonstrated that lumbar stabilization contributes to improved quality of life and function outcomes in individuals with chronic lower back pain . AdditioThere were a few limitations of the study. Firstly, the sample size was relatively small, which may limit the generalizability of the findings. A larger and more diverse sample would enhance the statistical power and external validity of the study. Secondly, the study only included participants of a specific gender, which restricts the generalizability of the findings to the broader population. Including both genders in future research would allow for a more comprehensive understanding of the effects of the intervention across diverse populations and help to avoid potential gender-related biases or differences in treatment responses. Thirdly, the four-week intervention period might be considered short for assessing long-term effects. Extending the duration or including a follow-up period would provide insights into the sustainability of the observed improvements. In addition, core strength was not assessed and this omission hindered the evaluation of the participants’ functional abilities and potential improvements resulting from the intervention. Evaluating core strength would have provided a more comprehensive understanding of the impact of trunk-stability exercises with EMG biofeedback on overall core strength and its relevance to managing chronic lower back pain.This study concludes that combining electromyographic biofeedback with a trunk-stabilization exercise program resulted in remedying functional disabilities and, in turn, a better quality of life, better static balance, improvement in the range of motion, and a reduction in pain severity. However, further research is needed to investigate the long-term effects of this intervention.This study can be taken further by recruiting equal numbers of males and females in both the groups. The EMG-guided activity can improve the endurance, central obesity, and posture which could also be studied. Patients with lumbar radiculopathy could also be recruited in future studies.This study concludes that EMG training is superior to non-EMG training. As a result, EMG training helps with pain, range of motion, functional impairment, and static balance. EMG training gives patients audio-visual feedback on their contractions, which stimulates them to perform well. In individuals with nonspecific chronic lower back pain, EMG training can increase core strength and improve quality of life.