Pain is one of the major prehospital symptoms in trauma patients and requires prompt management. Recent studies have reported insufficient analgesia after prehospital treatment in up to 43% of trauma patients, leaving significant room for improvement. Good evidence exists for prehospital use of oral transmucosal fentanyl citrate (OTFC) in the military setting. We hypothesized that the use of OTFC for trauma patients in remote and challenging environment is feasible, efficient, safe, and might be an alternative to nasal and intravenous applications.This observational cohort study examined 177 patients who were treated with oral transmucosal fentanyl citrate by EMS providers in three ski and bike resorts in Switzerland. All EMS providers had previously been trained in administration of the drug and handling of potential adverse events.P < 0.0001). Multiple linear regression analysis showed a significant absolute reduction in pain, with no differences in all age groups and between genders. No major adverse events were observed.OTFC caused a statistically significant and clinically relevant decrease in the level of pain by a median of 3 (IQR 2 to 4) in NRS units (Prehospital administration of OTFC is safe, easy, and efficient for extrication and transport across all age groups, gender, and types of injuries in alpine environments. Side effects were few and mild. This could provide a valuable alternative in trauma patients with severe pain, without the delay of inserting an intravenous line, especially in remote areas, where fast action and easy administration are important. Pain is one of the major prehospital symptoms in trauma patients and requires prompt management. Early pain treatment following injury can improve long-term outcomes, while untreated pain can facilitate higher post-traumatic stress disorder (PTSD) rates and worsen outcomes . NeverthThere are various reasons for this failure, such as a lack of adequately skilled rescuers and long EMS response times due to mountainous terrain in remote areas. In Switzerland, with outdoor activities such as skiing and mountain biking resulting in > 76,000 injured patients per year, the need for sufficient prehospital analgesia is considerable –5. InadeUse of an oral lozenge containing transmucosal fentanyl citrate (OTFC) has been identified as a possible strategy to address this need and has been used by the military since the 1990s, predominantly within the U.S. special operations community , 7. In aThis observational cohort study examined patients who were treated with OTFC from July 2020 to May 2022. Reporting of the study conforms with the STROBE statement for the reporting of observational cohort studies. The local ethics committee evaluated and approved the study and waived written informed consent .All patients with severe pain, defined as a score of ≥ 4 on a numeric rating scale (NRS), with 0 defined as absence of pain and 10 being the maximum imaginable pain, who did not have i.v. access were included. If there was evidence of altered consciousness, alcohol consumption or noticeable abnormal vital signs, administration of OTFC was deemed to be contraindicated. Head trauma (GCS < 15) was an absolute contraindication for OTFC. Further OTFC contraindications were known allergy to the drug or its additives, patient refusal, or age < 14 years. Major adverse events were defined as apnea and severe bradypnea requiring ventilation as an expression of overdosing.All EMS providers, including ski patrol rescuers, EMS paramedics, and prehospital emergency physicians, received theoretical and practical instruction about OTFC. Specifically, they were instructed about the mechanisms of action, indications and contraindications, as well as potential side effects. The study group consisted of trauma patients predominantly participating in recreational sport in the Ski and Bike resort Lenzerheide and St. Moritz (Switzerland), Ski World Cup , Mountainbike World cup , Bike Park and MTB Stage Races .The medication used is OTFC 600/800 mcg . The single dose was 600 mcg oral fentanyl for the first 65 patients. This amount was later changed to 800 mcg.The original dose of 600 mcg was chosen according to the buccal absorption equivalent of about 20% of intravenous fentanyl. When employing this route of medication, the onset is nearly as fast as that of intravenous fentanyl, as there is no hepatic first pass effect.Because of limited availability, the dose was changed to 800 mcg lozenges. There is hardly any uptake of the drug via the intestines . Each EMData collection was performed by the medical provider using an app-based online protocol with predefined endpoints, prospectively recording the data in Table t-test was used in case of normally distributed data, and a Wilcoxon matched-pairs signed rank test was used in case of not normally distributed data. To find differences between two unpaired groups, Student’s t-test was used in case of normally distributed data , and a Mann–Whitney test was used in case data were not normally distributed. To find differences between multiple unpaired groups , a one-way ANOVA and subsequent Tukey–Kramer multiple comparisons post-hoc test with a single pooled variance was used in case of homoscedastic data with normally distributed residuals. In case of heteroscedastic data with normally distributed residuals, a Brown-Forsythe and Welch ANOVA with subsequent Dunnett’s T3 multiple comparisons post-hoc test, and with individual variances computed for each comparison (n > 50 / group) was used. In case of not normally distributed residuals, a Kruskal–Wallis test with a subsequent Dunn’s multiple comparisons test was applied. To show the connection between pre-therapeutics NRS and effectiveness of therapy, simple linear regression analysis was used. Furthermore, a multiple linear regression with NRS-reduction as dependent and gender, age group and initial NRS as main effects was calculated, whereas male gender as well as the age group < 20 years old was used as reference. Statistical analyses were performed using IBM SPSS Statistics  and GraphPad Prism . Significance was accepted at P < 0.05 (two-sided for t-tests and exact for Mann–Whitney tests).Patient characteristics are summarized and presented in tables. Continuous variables were summarized by mean ± standard deviation if normally distributed, or by median and the interquartile range if skewed. To increase the quality of data analysis, each set of data was tested for normal distribution  and for homogeneity of variance (Levene’s test) before statistical analyses. To find differences between paired groups , a paired P < 0.0001) for the main subgroups, while in the thorax, abdomen and spine, subgroup pain reduction was 3 (IQR 2 to 5) in NRS units (P < 0.001).During the observation period, a total of 177 patients  were treated with OTFC  or relative values  were evaluated Table .Table 2PMultiple linear regression analysis showed that absolute reduction in pain was only dependent of initial pain but independent from sex or age group. Out of 177 patients, 137 (77.4%) were transported by GEMS and thus did not receive any further anaesthetics; 40  were transported by HEMS. Twenty-six of these patients (14%) received an i.v.-line with further analgesia and sedation after hand-over to a HEMS physician based on the severity of the injuries . The OTFC was well tolerated overall, with only a few mild side effects such as vertigo in 10 (5.6%) and/or nausea in 8 (4.5%), out of a total of 15 patients (8.4% of 177). Breathing remained unaffected in 173 patients (97.9%), with one case of mild bradypnea (0.5%) and 3 cases of tachypnea (1.6%). No major adverse events occurred, such as overdosing that would have to be reversed by administration of the carried naloxone or supported by BVM ventilation.We found OTFC to be an effective, safe and feasible strategy for pain relief in civilians treated in remote prehospital environments. Following thorough instruction, lozenges were successfully administered by EMS personnel without any major adverse events. The NRS scale was chosen as being the easiest and most well-established pain score used over the past years by our rescue personnel. In triage algorithms and treatment guidelines, pain scores are used to determine treatment priority and pain management. The verbal rating scale (VRS) or numerical rating scale (NRS) are such validated quick and easy pain scores for measuring pain and are commonly used to quantify subjective pain perception. The observed reduction in pain of 3 (IQR 2 to 4) NRS points was equal or even superior to other analgesia strategies in remote terrain—such as methoxyflurane with a 2.9-point NRS reduction—and is consistent with the findings for OTFC in a military setting , 10–12. Although there are different ways of successfully distributing strong analgesia without establishing an i.v. line, such as nasal administration of fentanyl, ketamine or nalbuphine , 10, 12,In a hostile alpine environment, surrounding conditions can play a significant role in keeping the prehospital scene time as short as possible. The OTFC lozenge can be given to patients as soon as the EMS team is on the scene, no matter whether the team member is a first responder, paramedic or physician, and allows prehospital teams to deliver rapidly effective, potent analgesia without requiring i.v. access. This is a significant time advantage in dangerous, resource-limiting environments such as remote alpine slopes, where there may be cold, snow and risk of avalanches or falling rocks. Using effective, non-i.v.-line-dependent analgesia may contribute to even faster extraction without further delay.Delivering fentanyl in a solid state significantly reduces the risk of ampule breakage and thus injuries. There is no freezing at very low temperatures, and it is ready to use almost immediately. In our trauma cohort, the lozenges were predominantly used in winter sport accidents, where reaching these patients and establishing early i.v. access can be challenging due to the harsh environmental conditions.Our study has several limitations. First is the limited area of distribution and the limited number of patients pooled from several alpine resorts offering winter sports and mountain biking. The main injuries affected both the upper and lower extremities, as expected, as we treated a limited range of injuries occurring in alpine sports such as skiing, mountain biking and backcountry hiking. Although our findings were consistent in our study, the majority of patients were relatively young to middle-aged, with few pre-existing illnesses. Compared to the cohort in the military studies , our medPrehospital OTFC administered in a hostile alpine environment is safe, easy, and efficient for different types of injuries, means of extrication and transport in all age groups and gender; side effects were few and mild. This could provide a valuable alternative without the delay of an intravenous line in trauma patients with severe pain, especially in remote areas, where fast action and easy administration are important.


Little is known about how COVID-19 has impacted the diagnosis of neck and low back pain in outpatient practices in Germany. Thus, this study aimed to compare the number of new diagnoses of neck and low back pain in German general and orthopedic practices between 2020 and 2021 and 2019. This retrospective study included patients aged ≥ 18 years with at least one visit to one of 915 general and 145 orthopedic practices in Germany in March – December 2019 , March – December 2020 , or March – December 2021 . The number of patients newly diagnosed with neck and low back pain per general and orthopedic practice was compared between March – December 2020 and March – December 2019, and between March – December 2021 and March – December 2019 using Wilcoxon signed-rank tests. Analyses were conducted in general and orthopedic practices separately and were also stratified by sex and age. There was a decrease in new diagnoses of neck and low back pain in general and orthopedic practices between 2020 and 2019, and between 2021 and 2019. This decrease reached statistical significance for neck pain in general practices in 2020 (−12.4 %) and 2021 (−6.1 %), and for low back pain in general practices in 2020 (−9.3 %). Similar findings were obtained in sex- and age-stratified analyses. The COVID-19 pandemic had a negative impact on the diagnosis of neck and low back pain in general and orthopedic practices in Germany. More data from other settings and countries are warranted to confirm or refute these results. As of DDespite this international effort, healthcare systems have been rapidly overwhelmed , and thiTherefore, this study aimed to compare the number of new diagnoses of neck and low back pain in general and orthopedic practices in Germany between 2020 and 2021  and 2019 . It was hypothesized that the number of patients newly diagnosed with neck and low back pain significantly decreased in 2020 and 2021 compared with 2019. If the hypothesis of the study is confirmed, this decreasing trend would suggest that a substantial proportion of neck and low back pain cases would have been undiagnosed, potentially undermining the management and treatment of these musculoskeletal conditions in the German general population.22.1This study used data from the Disease Analyzer database (IQVIA). This database has been described in detail elsewhere . The Dis2.2This retrospective study included all patients aged ≥ 18 years with at least one visit to one of 915 general and 145 orthopedic practices in Germany in March – December 2019, March – December 2020, or March – December 2021. Only practices continuously delivering data between April 2018 and December 2021 were included. Patients had to have no diagnosis of neck (ICD-10 code: M54.2) and low back pain (ICD-10 code: M54.5) prior to the study period of interest .2.3The diagnosis of neck and low back pain was exclusively based on ICD-10 codes. For neck pain, the ICD-10 code was M54.2, including all types of cervicalgia except those due to intervertebral cervical disc disorder. For back pain, the ICD-10 code was M54.5, including all types of low back pain except lumbago with sciatica and lumbago due to intervertebral disc displacement.2.4The number of patients newly diagnosed with neck and low back pain per general and orthopedic practice was compared between March – December 2020 and March – December 2019, and between March – December 2021 and March – December 2019 using Wilcoxon signed-rank tests. Analyses were conducted in general and orthopedic practices separately and were also stratified by sex and age. P-values < 0.05 were considered statistically significant. Analyses were performed using SAS 9.4.2.5German law allows the use of anonymous electronic medical records for research purposes under certain conditions. According to this legislation, it is not necessary to obtain informed consent from patients or approval from a medical ethics committee for this type of observational study that contains no directly identifiable data.3There were 2,161,520 patients followed in general practices and 680,625 patients followed in orthopedic practices in March – December 2019. Respective numbers were 2,169,874 and 640,305 for March – December 2020, and 2,550,751 and 663,668 for March – December 2021. The overall difference in the number of patients newly diagnosed with neck and low back pain per practice is displayed in 44.1This retrospective study, including 915 general and 145 orthopedic practices from Germany, revealed that the number of patients newly diagnosed with neck and low back pain per practice decreased in March – December 2020 and March – December 2021 compared with March – December 2019. This decrease reached statistical significance for both neck and low back pain in general practices in March – December 2020 versus March – December 2019. These findings were corroborated in the sex- and age-stratified analyses. To the best of the authors’ knowledge, this is the first study to have investigated the impact of the COVID-19 pandemic on the diagnosis of neck and low back pain in primary care and specialized practices.4.2The present results are in line with previous studies conducted in hospital settings. For example, it was observed in four hospitals in Italy that the number of visits for acute low back pain to emergency and outpatient departments decreased by 87.2 % in March – April 2020 compared with the same period in 2019 . AnotherThere are at least two hypotheses to explain the results of this study. First, a substantial body of research has shown that healthcare systems have been overwhelmed in the first months of the COVID-19 pandemic. One study of more than 500 general practices from Ireland found that the median number of face-to-face consultations decreased from 26 in February 2020 to 8 in June 2020 . Another4.3Based on this study, the number of new diagnoses of neck and low back pain decreased in general and orthopedic practices in Germany in 2020 and 2021 compared with 2019. This decrease is of particular concern, because other bodies of research have found high rates of self-reported musculoskeletal pain in the general population since the beginning of the pandemic . Further4.4The strengths of this study are the number of patients and practices included in the analyses, as well as the use of data collected until December 2021. Nonetheless, the study results should be interpreted in light of its limitations. First, patients may have been diagnosed with neck and low back pain in other settings , and the findings may thus not be extrapolated to the German population. Second, the diagnosis of neck and low back pain relied exclusively on ICD-10 codes, and data on the severity of pain and the duration of symptoms were unavailable. Third, no information is available in the Disease Analyzer database on education level, employment, and income, although it is possible that the impact of COVID-19 on the diagnosis of neck and low back pain is different between patients with high and those with low socioeconomic status.5Statements and declarationsThis study, using data from general and orthopedic practices in Germany, found that the number of new diagnoses of neck and low back pain has decreased since the beginning of the COVID-19 pandemic. The present findings suggest that a considerable proportion of people with neck and low back pain may have been undiagnosed, and this decreasing trend could have long-lasting deleterious effects on the management of these musculoskeletal disorders in this country. More data are warranted to confirm or refute these results in other countries.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


The aim of this study was twofold: (i) to measure the bite force of healthy adults and patients with tooth pain and (ii) to evaluate the influence of bite force and age on tooth pain and both genders. It is hypothesized that patients with tooth pain would have lesser bite forces as compared to healthy individuals.Two groups of participants were, the first group comprised 18 healthy adults , while the second group comprised 18 patients with tooth pain , recruited from the Faculty of Dentistry, Universiti Teknologi MARA. Their maximum bite forces were recorded using the Prescale system that consists of pressure‐sensitive films and a precalibrated scanning device. Logistic regression models were used using bite force and age on dichotomous responses of tooth pain status and gender.p ≤ .05).The mean bite force of patients with tooth pain was 684.77 ± 501.13 N, which was lesser than 798.33 ± 492.16 N of the healthy adults. The reduced gender logistic regression model on gender with age was found to be statistically significant (Even though the mean bite force was smaller in the group with dental pain, this difference was not statistically significant. This study was designed to measure the bite forces of patients with clinical tooth pain and healthy individuals. It is hypothesized that patients with tooth pain would have lesser bite forces as compared to healthy individuals. The meaSome factors that affect bite force measurements have been reported, such as craniofacial morphology, age, gender, periodontal support of teeth, signs, and symptoms of temporomandibular disorders (TMD) and pain, as well as dental status  to measure the bite force of healthy adults and patients with tooth pain and (ii) to evaluate the influence of bite force and age on tooth pain in both males and females. It is hypothesized that the bite force of patients with tooth pain would be lesser than those of healthy adults.22.1An oral examination was performed to verify that participants fulfilled the study inclusion criterion, that is, the presence of at least 20 natural teeth in the mouth. A thorough extra and intraoral examination was performed to verify that participants fulfilled the study inclusion criterion, that is, the presence of at least 20 natural teeth in the mouth. For extraoral examination, inspection and palpation were conducted by the operator on patients’ facial and neck regions. Any abnormalities like swelling, infection, or wound were noted. For intraoral examination, patients were lying supine on the dental chair and consent for oral examination was gained verbally. The oral inspection was performed using a mouth mirror and the obvious periodontal problem was checked using a periodontal probe.Thirty‐six participants were recruited for this study. The first group consisted of 18 eligible participants who were all students with ages ranging from 19 to 23 years . They were recruited from the Faculty of Dentistry, Universiti Teknologi MARA (UiTM) to serve as healthy controls. All these participants met the eligibility criteria for the study, which were asymptomatic from the pain of dental origin. Exclusion criteria for the asymptomatic participants were subjects with systemic diseases that affect jaw functions, developmental anomalies, TMDs, periodontal disease, or any history of jaw injury, trauma, or neoplastic disease. Participants who were undergoing orthodontic treatment were also excluded.The second group involved 18 consecutive patients who were all adults with ages ranging from 19 to 36 years . Exclusion criteria for the patients were the same as the asymptomatic participants. All cases were recruited through the UiTM dental centre and diagnosed by the orofacial pain specialist who made a clinical judgment that the pain was of dental origin. Participants who need to have immediate treatment for their pain were excluded. The pain intensity was not evaluated.This study was approved by the Research Ethics Committee of UiTM , and all subjects were provided written informed consent as part of the study protocol.2.2Their maximum bite forces were recorded using the Prescale system that consists of pressure‐sensitive films  and a precalibrated scanning device . All subjects were asked to bite on the film for 3 s with maximal bite force at their intercuspal positions. Before the measurement, subjects were seated comfortably on a dental chair in a natural unsupported posture looking forward, to the greatest extent possible, with the Frankfort horizontal plane parallel to the floor. The subjects were then asked to occlude repetitively in an intercuspal position to ensure that the teeth were in maximal contact when they bit on the pressure‐sensitive film, which is a horseshoe‐shaped disposable sheet . All subjects were then asked to bite three times on the films for 3 s with a maximum bite force. There was a time interval of 5 min in each biting. The average bite force was calculated from the two readings obtained.The procedures were repeated three times where the mean bite forces of each subject were calculated and recorded. The system has been well documented by Matsui et al.  and Chon2.3t test (p < .05). Two logistic regression models were performed using bite force and age as continuous predictor variables, respectively. The first model used gender, while the second model utilized the presence of tooth pain as binary responses. A likelihood ratio test (LRT) was used to compare nested models. This test yields a χ2 value and a p value. If two nested models are compared and the LRT produces p ≤ .05, then the model being compared fits the data better than the base model. The gender and presence of tooth pain were dichotomized into 0 = female and 1 = male and 0 = no pain and 1 = pain, respectively, for both models.Data were analysed using RStudio, PBC version 0.97.551‐©2009–2012 Inc. software,. Mean bite force was compared between the two groups by using the 33.1p = .201). Also, there was no significant difference in bite force of each group according to gender .The bite force of healthy adults ranged from 86.40 to 1758.60 N; the mean (SD) bite force was 798.33 ± 492.16 N. The bite forces of the patients with tooth pain ranged from 119.0 to 1648.40 N, while the mean bite force (SD) was 684.77 ± 501.13 N (Table p ≤ .05) as compared to all other full models and reduced gender/pain logistic regression models. The percentage of gender–age model's area under the curve is 72%  was found to be statistically significant with a coefficient estimate of .05 . Previous studies concurred with the present finding. Bakke et al. (Gender is also known to be another factor that affects the occlusal force. In general, present results showed that the bite force decreases significantly with aging women as compared to aging men (e et al.  have repe et al. , 2001 haSubsequently, males possess a higher mean occlusal force than the females in both groups, although the differences were not statistically significant. This result is consistent with the study carried out by Dean et al. , in whicBite force during chewing is not only correlated with maximal strength of the masticatory muscles but is also probably controlled by other factors such as pain thresholds (Mohl et al., In the present study, all participants had 20 or more teeth, including their posterior teeth. Arnold  reportedThere are several occlusal force measurement devices available in the market such as the Photocclusion® and T‐scan system®. The photocclusion system manages to record the color patterns of the occlusal contact, but quantitative measurement of this device was difficult and the sheet was rigid (Amsterdam et al., There was a limitation in this study. The pain intensity and psychological status that would be able to influence the bite force were not evaluated. The future study could have these evaluations as well.5From the results, even though the mean bite force was smaller in the group with dental pain, this difference was not statistically significant.Yoshinobu Shoji conceived and planned the experiments. Yoshinobu Shoji and Rostam Iffendi Bin Idris carried out the experiments. Yusmiaidil Putera Mohd Yusof contributed to the interpretation of the results and helped shape the analysis. Somsak Mitrirattanakul supervised the findings of this study. All authors discussed the results and provided critical feedback to the final manuscript.The authors declare no conflicts of interest.


Pain after cardiac surgery is both multifocal and multifactorial. Sternotomy, sternal retraction, internal mammary dissection, posterior rib dislocation or fracture, potential brachial plexus injury, and mediastinal and pleural drains all contribute to pain experienced in the immediate postoperative period. Ineffective pain management can result in systemic and pulmonary complications and significant cardiac consequences.This study compared the effectiveness of regional anesthesia techniques for perioperative pain management in cardiac surgery patients at our clinic. The effects of different analgesic methods, in terms of contributing to recovery, were examined.The records of 221 patients who had undergone coronary bypass surgery were evaluated retrospectively. The extubation rate in the operating room was 91%. No patient received balloon pump support, and 20 patients were transferred to the cardiovascular intensive care unit while intubated. Regional anesthesia was performed on two of these 20 patients, but not on the remaining 18. Examination of intraoperative and postoperative opioid consumption revealed significantly lower levels among patients receiving regional anesthesia. The most effective results among the regional anesthesia techniques applied were achieved with double injection erector spinae plane block.Regional anesthesia techniques severely limit opioid consumption during cardiac surgery. Their importance will gradually increase in terms of rapid recovery criteria. Based on our study results, double injection of the erector spinae plane block seems to be the most effective technique in cardiac surgery. We therefore favor the use of fascial plane blocks during such procedures.Trial Numbers The study is registered with ClinicalTrials (NCT05282303). Ethics committee registration and approval were Granted under Number 2021.464.IRB1.131. Definitive coronary bypass, traditionally performed via median sternotomy, can be associated with a significant level of surgical soft tissue and bony injury during the dissection phase. Significant pain is experienced after cardiac surgery, with 30–75% of patients reporting moderate-to-severe acute pain. Post-sternotomy patients may develop chronic pain syndrome. Higher levels of pain and greater analgesic requirements in the immediate postoperative period correlate strongly with the development of chronic pain syndrome. Pain after cardiac surgery is both multifocal and multifactorial. Sternotomy, sternal retraction, internal mammary dissection, posterior rib dislocation or fracture, possible brachial plexus injury, and mediastinal and pleural drains all contribute to pain experienced in the immediate postoperative period. A shift in pain modulation also occurs in the peripheral and central nervous systems in the hours and days following surgery. Some changes are derived from DNA methylation and the subsequent gene expression of proteins that modulate opioid analgesia. In other cases, the inflammatory cascade induces gene-driven expression of inflammatory pain modulators in the spinal cord. Pain management schemes must take into account the cause, location, and timing of pain foci in order to achieve maximal success , 2.Ineffective pain management can lead to systemic and pulmonary complications and significant cardiac consequences. Tachycardia and hypertension attacks, occurring as a secondary response to pain, increase myocardial oxygen consumption and may cause hemodynamic impairment .Increasing restrictions on human and financial resources in the health care system have also encouraged the use of regional anesthetic techniques as part of an opioid-sparing, multimodal pain regimen during pediatric and adult cardiac surgery for early extubation, reducing postoperative complications, minimizing the length of ICU and hospital stay, and reducing the overall cost of perioperative care. Growing advocacy for minimal or opioid-minimizing enhanced recovery protocols in perioperative settings has also been observed. All these factors have led to the adoption of multimodal analgesia in perioperative care. Neuraxial and peripheral nerve blocks are essential components of multimodal analgesic protocols , 5. ThorThis study was conducted to compare the effectiveness of regional anesthesia techniques for perioperative pain management in patients undergoing cardiac surgery at our clinic. It also examined the effects of different analgesic methods, in terms of contributing to recovery.This study was approved by the Koç University Clinical Research Ethics Committee (2021.464.IRB1.131). Patients who underwent coronary artery bypass grafting (CABG) surgery at the VKV American Hospital, Turkey, between January 2015 and May 2020 were reviewed retrospectively. Patients with a history of cerebrovascular events, scheduled carotid surgery, or emergency CABG surgery were excluded from the study. Demographic data from the preoperative evaluation forms and operation types from the surgery reports were recorded. Intraoperative anesthesia follow-up forms were assessed, and the use or otherwise of regional anesthesia and the type and extent of opioid use during the operation were examined. Postoperative transfer forms to the cardiovascular intensive care unit (CICU), intensive care follow-up forms, and departmental ward record follow-up forms were examined. Pain scores (NRS) during rest and coughing, vital signs, mobilization, and initiation of respiratory exercises were recorded for postoperative respiratory complications.Patients with a history of cerebrovascular events, Alzheimer's disease, or dementia, with inadequate cognitive functions, a history of chronic pain, or in receipt of long-term opioid therapy were excluded from the study.Statistical analysis was performed on using IBM SPSS Statistics for Windows version 25.0 . The normality of distribution of continuous variables was investigated using the Shapiro–Wilk test. Descriptive statistics were expressed as means and standard deviations for normally distributed variables. The Mann–Whitney U test was applied in the comparison of two dependent, non-normally distributed groups, and the paired sample t-test in the comparison of two independent, normally distributed groups. Statistical significance was set at a two-sided p value lower than 0.05.The records of 229 patients who underwent coronary artery bypass surgery between January 2015 and March 2020 were reviewed. Five patients were found to have been admitted under emergency conditions, with three patients having a history of cerebrovascular disease. The records of 221 patients who met the study criteria were thus finally subjected to retrospective analysis. Demographic data and operational characteristics are shown in Table The operational characteristics are listed in Table Anesthesia was induced with propofol and fentanyl. In terms of fentanyl dosages, 157 patients received 50 µg, 21 received 75 µg, and 43 patients received 100 µg. There was no difference in terms of the regional anesthesia techniques. Inhalation anesthesia was employed in all cases, and remifentanil was used for intraoperative analgesia. No difference was observed in terms of the remifentanil doses.In terms of analgesia methods, regional analgesia was used in 179 cases. The distribution of the regional analgesia methods is shown in Fig. Intraoperative opioid consumption is shown in Table Opioid consumption after 24 h is shown in Table Analysis of the patients’ starting times for receipt of breathing exercises showed that all began at the postoperative 6th hour, according to the intensive care follow-up forms. No difference was observed in TriFlo deep breathing start times among the patients who underwent regional anesthesia. Length of stay in the ICU, time to first mobilization, and time to discharge were significantly lower among the patients receiving regional anesthesia (p < 0.05). No positive contribution of regional anesthesia, a recovery criterion, was observed at discharge.  opioids. However, this practice has changed due to “fast-tracking” or the expectation of tracheal extubation shortly after admission to the ICU. Regional anesthetic techniques may help reduce acute postoperative pain and the potential development of chronic pain by reducing sensitization from noxious surgical injury and opioid-induced hyperalgesia. The use of neuraxial techniques in cardiac surgery with full heparinization and hemodynamic instability remains controversial. Fascial plane chest wall blocks are growing in popularity as an alternative, owing to their simplicity and perceived low complication risks, when thoracotomy or sternotomy are required. The wider implementation of minimally invasive surgical approaches over the last two decades and novel techniques in ultrasound-guided regional anesthesia have meant that it is now not unusual to achieve intraoperative conditions permitting extubation in the operating room , 9. RegiThe thoracic intercostal nerves (T1–T11) are primarily responsible for sensory innervation of the chest wall. Each spinal nerve exits an intervertebral foramen and divides into a dorsal and ventral ramus, which communicates with the sympathetic trunk via the white and gray rami. The dorsal rami supply the muscles, bones, joints, and skin of the mid-back. The ventral rami run together with blood vessels, initially between the pleura and endothoracic fascia, and then between the internal and innermost intercostal muscles, innervating the lateral and anterior chest walls. The medial (C8–T1) and lateral (C5–C7) pectoral, long thoracic (C5–C7), and thoracodorsal (C6–C8) nerves originate from the brachial plexus for motor innervation to the muscles of the chest wall, but also carry sensory nerve fibers . InnervaThe benefits of neuraxial blockade include lower opioid requirements, lower pain scores, fewer pulmonary complications, lower incidences of stroke and myocardial ischemia, less vestigial stress response, a lower incidence of kidney failure, lower infection rates, shorter ICU stays, lower anesthesia costs, and earlier discharge. Peripheral blocks contribute significantly to hemodynamic stability, high safety profiles, opioid sparing, and improved cough , 11, 12.Fascial plane block selection is important for analgesia in all surgeries. Correct fascial plane block, surgical selection, and multimodal analgesia management are the most important steps toward success. Various blocks are employed for postoperative pain reduction after cardiac surgery, including bilateral pectoralis I/II (PEC I/II), erector spinae (ESB), serratus anterior plane (SAPB), and paravertebral (PVB) blocks . The carThe PECS II block is used when a local anesthetic is injected between the pectoralis minor and serratus anterior muscles, typically along the fourth rib. It blocks the anterior divisions of the thoracic intercostal nerves, long thoracic nerve, and thoracodorsal nerve . In a 20Parasternal nerve blocks target the anterior and posterior intercostal nerves located below each rib, lateral to the sternum. In order to perform a parasternal block, a local anesthetic is injected between the pectoralis major and external intercostal muscles. The anterior branches of the intercostal nerve penetrate these two muscles and innervate the internal mammary area. Infiltration of the local anesthetic in this area should therefore block the anterior branches of the intercostal nerves , 16–18. The ESPB is a fascial plane block performed by injecting local anesthetic deep into the fascial plane of the erector spinae muscle overlying the transverse processes of the thoracic vertebrae . ESPBs hIn addition to studies reporting effective results in cardiac surgery, others have suggested that ESPB is not effective for sternotomy pain .ESPB does not relieve chest pain around the sternum during cardiac surgeries in our clinic. The first complaint among patients undergoing ESPB was severe pain around the sternum, and we did not therefore use classic ESPB on a frequent basis. We described different modifications of the ESPB for the purpose of increasing its transition to the paravertebral area. Using this technique, known as DIESBP, we observed a dramatic decrease in sternal pain during cardiac surgery , 27. In In conclusion, fascial plane blocks reduce opioid consumption. Different fascial plane blocks are used in cardiac surgery, and published studies generally describe effective results. Analgesic methods that allow extubation in the operating room are considered effective in cardiac surgery. The most important issue is selecting the appropriate fascial plane block. The major concern with fascial plane blocks is that they have different outcomes. Different effects from the same block can be observed in one type of operation performed by the same practitioner. Fascial planes must be well understood. The deep fasciae of the chest wall  are usually formed by a single layer of undulated collagen and elastic fibers adhering to the underlying muscles. The presence of varying numbers sublayers in the thoracolumbar fascia has been previously described. The middle thoracolumbar fascia contains three sublayers. It is not usually possible to determine the number of fascial layers, and to clearly differentiate between them, using current ultrasound technology. It is also still unclear whether there is an optimal choice of layer for local anesthetic injection, or whether this will affect the spread of medication or clinical outcomes , 28. ThiRegional anesthesia techniques significantly reduce opioid consumption during cardiac surgery. The importance of fascial plane blocks in terms of rapid healing criteria in cardiac surgery is growing rapidly. Fascial plane blocks occupy a particularly important place in terms of significantly reducing opioid consumption and also supporting extubation in the operating room. According to the study's findings, DIESBP was the fascial plane block providing the most effective analgesia in cardiac surgery We think more extensive, randomized, controlled studies are needed to determine the most effective techniques in terms of fascial plane blocks.The principal limitation of this study lies in its retrospective nature. The patients’ pain scores were determined using a uniform scale. Pain follow-ups were carried out by intensive care and pain nurses. The commencement of the breathing exercises was based on the operability of the device, patient compliance, and nursing support. Mobilization and length of ICU stay are recovery criteria, although it is controversial whether or not they determine early recovery.


As we stand upright, perceptual afferences are crucial to successfully help generating postural motor commands. Non-Specific Low Back Pain patients frequently demonstrate a lack of proprioceptive acuity, often translating into postural control deficiencies. For the first time, to our knowledge, we studied the postural effects of proprioceptive manipulations in orthograde posture on Non-Specific Low Back Pain patients. Using static posturography recordings, we computed sway speed, speed variance, and the main direction of sway. We also addressed the patient’s subjective feedbacks after being manipulated. Five minutes after the proprioceptive manipulations, our results revealed decreased speed and speed variance outcomes, but the main direction of sway was not modulated. Furthermore, after the proprioceptive manipulations, the patients also self-reported improved clinical outcomes. These findings provide new knowledge opening new fields of research as well as potential treatment strategies in Low Back Pain patients. Humans navigate and act upon their environment upright. Therefore, orthograde posture is the primary interface between perception and action. Postural control is the foundation on which general human motor control is based2, as balance needs to be dynamically adjusted for movements to be precise and accurate. Furthermore, erect posture also serves as a fundamental reference frame around which the motor output is controlled and organized2. Indeed, the control of axial and proximal musculature provides stabilizing support for increased distal motor skill performances3. Moreover, as we move, the ongoing changes in the body’s geometry generate dynamical shifting of the center of mass. Such changes need pre-established modulatory control by Anticipatory Postural Adjustments (APAs)4, to avoid instabilities or falls5. Such adjustments derive from cortical internal models regularly updated through multisensory integration processes where vision, somatosensory, proprioception as well as vestibular information are bound within the central nervous system7.Human motor behavior depends on sensory inputs processing and motor outputs. Sensory acuity is primordial to execute precise motor tasks, and motor signals impact sensory integration while voluntarily moving8. Non-Specific Low Back Pain (NSLBP) patients, for instance, often demonstrate postural control deficiencies9. Non-Specific Low Back Pain is defined as “pain that cannot be attributed to a recognizable pathology, ”10, and much debate is still ongoing on how to treat such an issue given the various approaches used clinically11.People experiencing Low Back Pain demonstrate motor control changes12. Moreover, with NSLBP, proprioception is reweighted in such a way that the ankle information gain increases while the lumbar information gain decreases accordingly14. Altogether, these weighting mechanisms modulate integrative processes inducing plastic changes not only at the dorsal horn of the spinal cord but also at the cortical level15.Acute NSLBP modifies the way proprioceptive cues are integrated. Patients with NSLBP have less lower-back proprioceptive acuity and awareness16. Second, the reweighting mechanisms implicated in the emergence of NSLBP could, through the neurological plastic changes, help to transition from acute pain states to more chronic ones15.If maintained, such modulatory processes could have important consequences. First, because of the reweighting proprioceptive mechanisms, the wrongly modulated internal models could impact the APAs. With altered postural control, NSLBP patients could be more prone to instabilities and fallsIn this context, facilitating proprioceptive integration and improving postural control in NSLBP patients could not only be potentially beneficial for their recovery but could also avoid patients from evolving towards more chronic painful states.17. Intriguingly, such a system uses proprioceptive manipulative techniques while the patient stands erect in their functional orthograde posture. Yet, to our knowledge, such a system has never been scientifically evaluated and thus published in an international peer-reviewed journal. No formal physiotherapy-specific graduate programs  are available in France. This could potentially explain why such a system was left unresearched to this day, even though thousands of French physiotherapists use it daily in their practice. Thus, for the first time, to our knowledge, the study described in this paper investigated whether such manipulations modulate postural control in NSLBP patients.A French manual therapy system claims to modulate motor control in general and postural control more specifically9 could be modulated with such manipulations. Second, we also wanted to address how the patients subjectively felt after they had been manipulated. Given these proprioceptive manipulations are used as treatment techniques in France, we hypothesized (1) improved postural control and (2) that the patients would report positive feedback about how they felt after the manipulations.The aim of this study was twofold. First, the study was meant to investigate whether the known altered postural control in LBP patientsAfter a referral from their primary physician, we asked patients with an NSLBP medical diagnosis if they would be willing to participate in the current study. Men and women aged 20 to 60 years diagnosed with acute (less than 3 months) NSLBP with or without leg pain were recruited for the study. To avoid any preconceived bias, we excluded patients who had already been treated with the techniques evaluated in the current work. In cooperation with the patients’ general practitioner and based on their medical record, exclusion criteria were set as follows: (1) history of lumbar surgery, known rheumatic, neurologic, inflammatory disorder, and mental disease, (2) pregnancy or suspicion of pregnancy, (3) suspicion of infection, malignancy, osteoporosis, fracture, (4) patients with any sort of medication, (5) known vestibular and visual diseases, and (6) overt loss of somatic sensation.The sample size was calculated using the PWR package in R. Assuming two-tailed testing, a level of significance of α = 0.05, a power of 0.8, and a value of d set at 0.8, a minimum of 33 participants was needed. Given these criteria, forty-two patients were recruited for the study  “Would you mind telling us what you have specifically experienced during the manipulations?” and (2) “Is there anything about the treatment you would like to tell us right now?”. Then, right before the second recording, the physiotherapist asked: “Is there anything you would like to tell us about the treatment before we proceed to the second measurement?”. Finally, the physiotherapy asked this last question: “Is there anything you would like to tell us about the treatment before we end this session?”.The study was conducted in compliance with the protocol “Good Clinical Practices” and the Declaration of Helsinki principles. In accordance with French law, all participants gave their verbal and written consent to participate after being informed about the study protocol, and their confidentiality and anonymity were always preserved. The participation in the study did not modify usual rehabilitation.20, the cut-off frequency was determined with a residual analysis, which was done using a customized Matlab program. Sway characteristics were also computed using a customized Matlab program. Classically sway variables are analyzed on orthogonal antero-posterior (AP) and medio-lateral (ML) axes independently. However, AP-ML analyses are known to be biased by biomechanical factors21 such as foot positions and the patients’ feet were constrained to a 30° angle. Secondly, AP and ML data are not independent as balance is controlled by coordinating the body in space in both dimensions simultaneously22. Therefore, we favored planar sway analyses over AP-ML one-dimensional analyses. Among classical sway variables, the path length  is reported as the more sensitive and reliable outcome24. Thus, we computed path length as the total sum of the distances between each point in the AP-ML plane  accounting for the largest part of the COP time-series’ variance. θ, the angle between the ML axis and the PC1 axis was computed to describe the main direction of sway  were used to describe the main direction of sway. A Watson-Williams two-sample test was used to investigate the effect of the manipulations on the direction of the sway29.We performed all linear statistical analyses using R version 3.3.22 = 0.31)   = 4.285, p = 0.0001, R19) Fig. A and aft19) Fig. B directiDuring the treatment, participants reported feeling their vertebrae moved under the therapist’s finger (36%), and that their tendons and muscles vibrated (58%) as “guitar strings” as the technique was respectively applied to the spinal segments, the ankles, and the feet. Participants also reported increased sweating (28%), and dizziness (42%). These sensations lasted after the manipulations up to two minutes for one patient but were shorter than a minute for the rest of the patients reporting such feedback. All side effects were gone at the end of the 5 min resting period. After the manipulations, patients reported less pain (72%), being freed in their motion (62%), and having less tension in their lower back (78%). These sensations lasted until the patient stepped out of the clinic.The primary aim of this pilot study was to gain insight into whether proprioceptive manipulations modulate postural control in NSLBP patients when standing upright. We found that after the proprioceptive manipulations, COP speed and speed variance were significantly decreased, whereas sway mainly stayed oriented antero-posteriorly.35. Second, published evidence also underlines the test–retest reliability of COP measurements is high39. Third, participants stood in a non-changing environment, eyes open on a flat hard surface. Therefore, the task did not represent any difficulty for a learning effect to account for the effect sizes we found for both speed and speed variance. Thus, given that (1) the performance measure is reliable, (2) the measured variables usually remain stable over time, and (3) the only alteration between the two measurements were the manipulations, we can hypothesize that, all other things being equal, the statistical differences herein could likely be due to the proprioceptive manipulations. Indeed, whatever caused these changes had to be sufficiently relevant to provide such effect sizes and nothing significant besides the manipulations occurred between the two measurements. Nonetheless, randomized placebo-controlled clinical trials will have to further investigate these effects.One could first point out that such decrease could be due to a learning effect as the experimental conditions were not randomized. Yet, this is probably unlikely. First, published postural data do not show statistical differences in COP outcomes during randomly repeated trials even when sensory stimulations are provided32. In our study, we manipulated the lumbar spine, ankles, and feet within the same session. This is a limitation as we cannot untangle whether the decreased COP speed found herein could have resulted from spine, feet, or ankles manipulations alone or their combination. This distinction will have to be evaluated in future protocols.Such results contrast with previous evidence showing that isolated ankles, feet, and lumbar manipulations, when the patients are lying down, do not seem to modulate COP speed24. It is also considered as a good postural biomarker as decreased COP speed reflects a more efficient postural control system overall40. Evidence shows that compared to healthy controls, NSLBP patients have increased AP body sway43. Moreover, chronic NSLBP patients often express higher COP speed measures45. Therefore, decreasing COP speed in acute NSLPB patients, as seen in our results, could be an interesting starting point in their rehabilitation process. This first point also raises the question of whether these proprioceptive techniques could help avoid translating NSLBP patients from acute to more chronic pain states. This could only be answered by future protocols, and we reckon that such research would be worth investigating.Compared to other COP parameters, the COP speed shows the highest reliability and sensitivity26. Increased speed variance has been related to increased body stiffening26. Thus, since speed variance was decreased after the proprioceptive manipulations, one could hypothesize that these manipulations could have impacted muscle activation by decreasing their tonic activity. Back pain patients responding to spinal manipulations show significant lumbar stiffness reduction46. Such a mechanism implies stiffening of the trunk and could potentially be linked to lumbar pain and altered postural control15. Interestingly, our results show not only a decrease in speed variance, but patients also self-reported less pain, less muscle tension, and a feeling of freedom in their capacity to move. The use of new methodological methods such as High-Density Electromyography (HDEMG) could help in providing answers on whether these proprioceptive techniques modulate muscles’ activation when patients experience low back pain47. Indeed, HDEMG has shown to be effective in giving a more precise representation of muscle behavior both spatially and temporally than more classical EMG recordings48.Our results also show a significant decrease in the speed variance after we applied the proprioceptive manipulations. Published data underline a strong correlation between the speed variance and the activation of the overall postural muscles regardless of the amount of backward or forward body swayGiven that these proprioceptive manipulations are used in a clinical context, our secondary aim, in this pilot study, was to investigate how the patients subjectively felt. An important number of patients reported less pain after the manipulations. However, this point needs to be taken with a grain of salt. Considering the presumed effect on pain, it is worth noticing that our study was not intended to focus on pain levels. Pain is a very complex field of research and several uncontrolled parameters in our protocol could have inflated the responses in favor of decreased pain levels. For instance, placebo effects or a willingness to please the therapist cannot be underestimated. Yet, on the other hand, without being specifically questioned about their pain level, the patients freely and undirectedly self-reported their pain had been reduced. Therefore, future protocols could more precisely investigate and focus on the effects of the proprioceptive techniques on pain.Taken together, five minutes after the proprioceptive manipulations were applied on patients standing up, our results show a better postural control. Such impact cannot be related to any biomechanical effect given (1) the low nature of the forces applied to the spinal processes, the ankles and the feet, (2) that no mechanical lever was used to manipulate the anatomical structures, (3) the fact that these techniques were not biomechanically oriented  and (4) that these techniques were done upright when the antigravity muscle tone is not inhibited, thus considerably restraining the body parts movements. Therefore, our results are more likely due to other processes. Although only speculative at this point, there is a need to provide potential underlying mechanisms.52. Because these illusionary movements would not be generated by any self-produced motor command, they could be perceived as an externally generated balance perturbation53. Therefore, the techniques could be interpreted and integrated as exafferent information54 perturbating the ongoing postural control myogenic commands. Given that exafferent information is perceived as much stronger than reafferent cues55, the system could have been forced to find an appropriate motor solution to maintain proper balance. Indeed, postural control modulations, more specifically in the AP direction, are recorded immediately after vibrations are applied to muscles engaged in upright postural motor demands56. Altogether, the induced illusional movements tricking the brain into readjusting postural control online could have favored the emergence of new or alternative postural strategies.The patients reported feeling their body parts moving. Although we did not monitor for actual spinal and other movements, this is not likely due to biomechanical mechanisms given the nature of the techniques, the force applied, and the fact that muscle tone fighting against gravity would have avoided such movements. A more rational explanation could be that such perception of movement is generated by the brain being tricked by the somatosensory influx integration within the cortex. Apart from feeling spinal movements, the patients also reported feeling their body parts vibrating as the techniques were applied. Vibrations and kinesthetic cues applied to the skin and muscles have the capacity to induce spatial movement illusions54. Such cerebellar bimodal neurons explicitly respond to passive body motions57 and, in turn, play a major role in warranting accurate and proper posture and the maintenance of balance by sending strong neurological motor projections to the spinal cord58 and the vestibular nuclei59. Interestingly, such rFN neurons are also linked to vestibulo-autonomic function58, which could also explain why a subgroup of patients reported increased sweating and dizziness60. Illusionary passive perceived motions are often integrated and perceived as real physiological movements52. Furthermore, based on sensory inputs, the cerebellum is thought to play a crucial role in motor control by fine-tuning motor commands through internal models61. Therefore, by inducing a virtual perception of motion, the proprioceptive afferences could have updated the cerebellar models online, providing in return the motor commands needed to regulate the ongoing postural demands.We propose several different hypotheses that could explain such recalibration of postural strategies. First, so-called bimodal neurons encode both proprioceptive and vestibular information within the rostral Fastigial Nuclei (rFN) of the cerebellum14. This has been linked to a reorganization of the somatosensory cortex14. The result could therefore also emerge from a mechanism inverting the reweighting from the ankle to the lumbar spine, therefore normalizing the proprioception gains, and thus postural control.Second, the techniques were applied at the lumbar spine but also the ankles and the feet. When standing on a stable surface, NSLBP patients rely more on ankle proprioception than on their back muscles proprioception to maintain proper postural control62. Interestingly, low back pain patients with postural control deficits demonstrate modulations of cortical maps within their motor cortices63.Third, such strategies could also likely originate in cortical networks involving the motor cortex, given its important contribution to postural control12, often associated with body schema disruptions64. Here again, skin and muscles vibrations and/or cues can also modulate the labile body schema representations49. Interestingly, tactile manipulations are positively reweighted when being upright while deficits emerge when lying down65.Fourth, patients with NSLBP have less low back proprioceptive acuity and awareness66. Moreover, such networks are thought to link together more specifically the intraparietal sulcus, the premotor cortex, the sensorimotor cortex, the extrastriate body area, and the temporoparietal cortex. All five cortical areas are known to bind visual, somatosensory, and vestibular signals69 all implicated in postural control70.Thus, the manipulations given in an orthograde posture could have optimized the integration of the proprioceptive cues. If so, they could have modulated and/or updated the cortical networks and maps in relation to embodiment mechanisms which are linked with how one’s body is perceived in space15. Such rehabilitation program considers targeting cortical networks integrating the primary motor cortex to fine-tune trunk muscle activations to help refine the motor control of the spine15. Whether the techniques in the present study reorganize cerebellar models and/or sensorimotor cortical maps, will have to be investigated in future protocols.Motor control training is currently promoted to modulate sensorimotor neuroplasticity to improve LBP72. Yet, training patients often required multiple sessions per day over days or even weeks to improve postural adjustments73. We only investigated the postural post-effects 5 min after we applied the techniques and unfortunately no follow-up of these patients was done. Therefore, we do not know the mid-and long-term effects of such manipulations which will have to be investigated in the future. Furthermore, although our results could be seen as encouraging, only randomized placebo-controlled clinical trials will provide more thorough answers as to which extent these proprioceptive techniques help the patients. Nonetheless, if future randomized placebo-controlled clinical trials were to show improved results through time, these techniques could help in gaining recovery time. If so, then perhaps these manipulations could avoid translating patients from acute lumbar to more chronic states which are ruining patients’ lives and economically burdening our societies75.Rehabilitation strategies implementing motor control regimens have proved to be efficient in helping NSLBP patients65. Thus, the singularity of the orthograde posture context could potentially open new therapeutic perspectives. If confirmed, with more thorough protocols, these results could also potentially be the beginning of a manual therapy paradigm shift combining simultaneously manual proprioceptive cues bound online with regulatory motor control commands. Given the postural effects, the techniques will also have to be tested on different populations. Indeed, they could provide an interesting solution for a broad range of patients such as the elderly, people experiencing dizziness and instabilities as well as mild traumatic brain-injured patients all experiencing postural and balance difficulties. Continuing investigating the effects of these proprioceptive techniques could, if proven effective, provide a cost-effective alternative not only for patients with musculoskeletal disorders76 but also for individuals with a broader range of dysfunctions.Future studies will also have to investigate the underlying mechanisms. Tactile and proprioceptive cues are more easily integrated in the upright posture than when lying downFor the first time, to our knowledge, we investigated and showed improved withing-group postural stability after proprioceptive techniques were used. Contrary to more traditional manual therapies, such techniques were not applied on patients lying supine or prone, but in their physiological orthograde functional posture which requires not only simultaneous postural and motor commands but also online multisensory integration processes.


Background: The aim of this retrospective uncontrolled article is to illustrate a technique of neurotomy of the sensitive branches of S1 S2 S3 in RFA that appears to result in a better success rate and longer-lasting pain relief. Methods: 40 patients were treated, 26 females and 14 males, with an average age of 74 (92–55). After the examination, the patients underwent an ultrasound-guided diagnostic block of the affected sacroiliac joint. Only patients who presented pain relief greater than 60% after the diagnostic block were candidates for the RFA procedure. The procedure was always performed in the operating room on an outpatient basis. After obtaining the best fluoroscopic visualization of the joint to be treated, two RFA cannulae were placed starting from the lower medial margin parallel to the SIJ to perform a bipolar RFA along the entire medial margin of the SIJ. Lidocaine 2% and hypertonic saline 2 mEq/mL were used for each RFA level. Patients were followed-up at 3, 6, 12, 18, and 24 months by evaluating the NRS and SF-12. Results: Patients reported extreme satisfaction with the procedure performed and reported a significant improvement in NRS and SF-12 at FU visits. No adverse events occurred. Conclusions: Bipolar RFA treatment of the sacroiliac joint with the use of a hypertonic saline solution appears to improve the success of the method and its durability. We are inclined to believe that the use of hypertonic saline may significantly increase the lesion area and result in a greater effect on the sensory branches. Sacroiliac joint dysfunction (SIJ) is a very common cause of refractory lower back pain, although often underestimated and undiagnosed. Sacroiliac joint pain is estimated to account for 20 per cent of all causes of lower back pain. SIJ pain is commonly felt in the gluteal region but may also affect the lower extremities and/or the lumbar region. The sacroiliac joint, a diarthrodial joint, connects the sacrum and ilium. It is a very stable joint due to the presence of anterior, interosseous, and posterior ligaments. The posterior sensory innervation of the SIJ comes from the dorsal branches of L5 S1 S2 S3 with components that can also come from L4 and S4. During the physical examination, patients with sacroiliac joint problems show at least one  of the following symptoms: lower back pain (below L5), pelvic/gluteus pain, hip/inguinal pain, discomfort in a sitting position (inability to sit for long periods of time or sitting on one side only), or pain when moving from a sitting to a standing position. Differential diagnosis to exclude other causes of pain: an absence of pathologies referable to the lumbar spine and hip. In an upright position, the patient should indicate the point where they feel pain, and experience pain at the groove of the sacroiliac joint and on the weight-bearing side following the one-legged balance test. Patients may have pain upon palpation of the sacroiliac joint, present positivity on provocation tests for at least three out of five tests , and have a significant reduction of pain after SIJ diagnostic block . The aimThis 40-patient retrospective observational cohort study considered RFA treatments of the SIJ performed at 2 pain therapy units. All procedures were performed by the authors, taking into consideration the cases treated from 2019 to 2021. In total, 40 patients were treated, 26 females and 14 males, with an average age of 74 (92–55). All patients experienced sacroiliac pain, confirmed by clinical examination, with an average NRS of 8.2. Patients had lower back pain that lasted longer than 3 months, presenting positive provocation tests for at least 3 out of 5 tests, and were not responding to conventional medical treatments. Autoimmune pathologies were excluded by performing serological tests. No other possible causes for back pain have been identified. Exclusion criteria were coagulopathies, systemic infections or infections at the site of the procedure, pregnancy, ages of less than 18 years, severe psychological disorders, allergies to local anesthetics, and senile dementia. After the examination, the patients underwent an ultrasound-guided diagnostic block of the affected sacroiliac joint with 2 ccs of 2% lidocaine. Only patients who presented pain relief greater than 60% after the diagnostic block were candidates for the RFA procedure. Informed consent forms were collected for both the procedure of the diagnostic block and the neurotomy in the RFA. The RFA procedure was always performed using a Boston Scientific G4 Radiofrequency Generator, in the operating room on an outpatient basis, and under constant fluoroscopic vision. The skin was prepped and draped. The patients were treated in the prone position and landmarks were identified under fluoroscopic guidance. In most of the cases, the RFA was performed under conscious sedation or without any sedation. After obtaining the best fluoroscopic visualization of the joint to be treated, 2 RFA all-in-one electrode, cannula and injection tubes, 100 mm 20 G AT 10 mm, were placed starting from the lower margin parallel to the SIJ with a distance between the needles of 0.81 cm to perform a bipolar RFA along the entire medial margin of the SIJ (average of 5 treatment levels) moving the distal cannula cranially for each level . A motorp-value < 0.05. Patients reported extreme satisfaction with the procedure performed and reported a significant improvement in their quality of life. Furthermore, they reported that they would repeat the procedure in case of recurrence of pain symptoms. No adverse events occurred.All patients were followed-up with FUs at 3, 6, 12, 18, and 24 months by evaluating the NRS and SF-12. In total, 4 patients completed the FU at 3 and 6 months. All 40 patients who underwent RFAs reported excellent pain relief at 3- and 6-months FUs (over 80% reduction in NRS) and stopped taking analgesic medications. The mean NRS value at 3 months was 1.3, at 6 months 1.5. A total of 36 (90%) patients completed FUs at 12, 18 and 24 months. At the 12-month FU, 4 (11%) of 36 patients reported good pain relief (40% to 50% reduction in NRS), while the remaining 32 (80%) patients reported excellent pain relief (over 80% reduction in NRS). The mean NRS value at 12 months was 2.3. At the 18-month FU, 10 (27.7%) of 36 patients reported good pain relief (40% to 50% reduction in NRS), while the remaining 26 (72.2%) patients reported constant excellent pain relief (over 80% reduction in NRS). The mean NRS value at 18 months was 3.2. At the 24-month FU, 17 (47.2%) of 36 patients reported good pain relief (40% to 50% reduction in NRS), while the remaining 19 (52.7%) patients reported excellent pain relief (over 80% reduction in NRS). The mean NRS value at 24 months was 3.4 . PatientChronic pain syndromes of the sacroiliac joint are very often underestimated, and the data in the literature regarding pain relief after RFA treatments, performed with different techniques, generally report a 50% ,8 improvBipolar RFA treatment of the sacroiliac joint with the use of hypertonic saline solution appears to improve the success of the method and its durability. This is probably due to the increased lesion area with a greater possibility of involving most of the sensory components that innervate the SIJ. This modality of an RFA carried out along the entire medial margin of the sacroiliac joint has determined in treated patients a more lasting pain relief than reported in the literature, has an absence of side effects, and can also be performed on elderly and frail patients The limitation of this study is that it is a retrospective observational cohort study. These data will need to be confirmed by further studies.


The authors claim: “The winning article documents the ongoing harms done to Canadians with chronic pain in the wake of the 2017 Canadian Guideline for Opioid Therapy and Chronic Non-Cancer Pain that introduced strict dose limits for people taking opioids, fostered a climate of fear among prescribers, and opened a Pandora’s Box of anguish and helplessness among patients” (p. 121). The commentary also fails to place the challenges faced by people living with pain in the context of strong public criticism of prescribing practices, actions by several Canadian provincial medical regulatory bodies, and guidelines arising from the United States, in particular the Centers for Disease Control and Prevention (CDC)2 and the U.S. Department of Veterans Affairs and Department of Defense,3 all stridently calling for reduced use of opioids for chronic pain. Temporally, the reduction in opioid prescribing predates  the release of the 2017 guideline.4The commentary of Dr. Katz and Ms. Waisman5 interviewed 22 participants, all of whom were selected based on their report of having been stigmatized by the opioid epidemic. The authors identified five themes, including opioid tapering as a standardized response from providers; some participants reported being pressured by their physicians to taper against their wishes or tapered more quickly than they wished. The article concluded: “Opioid guidelines are essential to inform clinical practice, but they should be interpreted in the context of a comprehensive provider–patient interaction in which the patient’s preferences, feelings, and values are addressed” (p. 75).The referenced article6This recommendation is exactly consistent with the 2017 Opioid Guideline, which concludes with the statement: “… tapering efforts should be individualized and should consider patients’ values and preferences” (p. E665).The relevant recommendation in the Canadian guideline (Recommendation #9) suggests tapering opioids to the lowest effective dose for patients with chronic noncancer pain who are using ≥90 mg morphine equivalents of opioids per day. This recommendation was a weak one based on low-quality evidence that suggested reducing opioid dose may decrease the risk of unintentional overdose and in consideration of risks associated with opioid tapering including withdrawal. A weak recommendation means that though most informed patients would choose the recommended course of action, an appreciable minority would not. With weak recommendations, clinicians should recognize that different choices will be appropriate for individual patients, and they should help patients arrive at decisions consistent with their values and preferences. The final decision to attempt a trial of opioid tapering rests with the patient. This recommendation is accompanied with the following remark: “Some patients are likely to have a substantial increase in pain or decrease in function that persists for more than one month after a small dose reduction; tapering may be paused and potentially abandoned in such patients” (p. E662).The 2017 Guideline was particularly cognizant of the potential harms associated with inappropriate opioid tapering for two reasons:(1) As we wrote in our 2016 commentary, a year before the Canadian guideline was published:7The CDC [guideline] provides a strong recommendation to avoid increasing the dosage of opioids to 90 morphine milligram equivalents (MMEs) or more per day for patients with chronic noncancer pain. In a major omission, the guideline fails to address clearly how clinicians should manage patients currently prescribed dosages that are in excess of 90 MME per day. … Overly aggressive adoption of the CDC guideline may lead to harm if physicians try to abruptly transition patients already receiving opioids at high doses to much lower doses. Harms could include withdrawal reactions, uncontrolled pain, anxiety for patients and loss of trust in their physicians. Such consequences could leave patients desperate. There is already preliminary evidence that in British Columbia, where the CDC guideline recommendations have been adopted as standards of practice, some patients have sought illicit opioids in the wake of reduced prescribing by physicians. With the profusion of counterfeit fentanyl in Western Canada, the consequences could be fatal (p. 1210).(2) Our exploration of patient values and preferences identified the following:8Our focus group interviews revealed that some patients using long term opioid therapy for chronic non-cancer pain were concerned about adverse consequences of opioid withdrawal that may result from efforts to wean or discontinue their opioid use. For those using high doses of opioids in whom weaning is undertaken, we continue to place a high value on societal considerations of minimizing the risk of rare serious adverse events, but we also place a high value on avoiding severe suffering, increased pain, and functional limitation that may accompany opioid reduction. We also place a high value on patient autonomy under these circumstances (p. 1).10The 2017 Opioid Guideline did not introduce strict dose limits for people taking opioids. The Guideline did encourage clinicians to approach patients prescribed high-dose opioid therapy to consider a voluntary trial of tapering that, in patients who elected to proceed, could be paused or discontinued based on their response. A growing body of evidence indicates that voluntary, supported opioid tapering can help most people who live with chronic pain who are prescribed high-dose opioid therapy substantially reduce their dose without increased pain or decreased function.


Bipolar electrocautery tonsillectomy has been the preferred technique for many otolaryngologists, yet coblation tonsillectomy is gaining popularity in the current practice. This study aims at comparing both techniques in terms of pain, bleeding, and healing.p < 0.001). The difference in pain duration was statistically longer for the bipolar group. The incidence of postoperative hemorrhage—both reactionary and secondary—was statistically higher in the bipolar group. Coblation tonsillectomy showed statistically shorter duration of healing (p < 0.001).A total of 120 patients were randomly divided into two equal groups. Overall mean pain score associated with coblation tonsillectomy was statistically less than that caused by bipolar electrocautery throughout the follow-up period (Coblation tonsillectomy is associated with less pain severity and shorter pain duration, fewer bleeding incidents, and more prompt healing. Tonsillectomy is the most common surgical procedure in the setting of pediatric otolaryngology practice. The procedure is mainly carried out to treat disorders of sleep and recurrent attacks of acute tonsillitis; however, these are not the only indications . The ind2 laser ..11].2.Postoperative bleeding (reactionary and secondary): the incidence of bleeding incidents was recorded for both groups.3.Healing : each time, the tonsillar bed was checked for healing and the disappearance of the white healing membrane. The guardians were informed on the appearance of the whitish membrane and were also instructed to perform daily monitoring of their patients. The exact day of complete disappearance of the white membrane was determined accordingly.On each visit, the guardian chose the suitable picture that expressed the patient mood and pain level, and then the pain scale—between 0 and 10—would be scored according to guardian’s choice. On the last visit, the overall pain scale was scored over 40 . A score of 40 represented the worst pain scale. The duration of pain was also recorded as well.t-test. P-values less than 0.05 were considered as statistically significant. Student’s t-test was used to compare between two means. Again, as these measures were taken over time, a repeated measures analysis was used to assess the correlation of these items over time.The averages per patient over time were used as the main outcome measures using the Wilcoxon signed-rank test and Wong-Baker FACES rating scale for each value and each group. Data were coded and entered using the Statistical Package for the Social Sciences (SPSS) version 28 . Data was summarized using mean and standard deviation. Comparisons between groups were done using unpaired Comparison between both groups regarding patients’ demographics:This study included 120 patients divided into 2 equal groups. Group A included patients who underwent coblation tonsillectomy, and group B included patients who underwent bipolar electrocautery tonsillectomy. Data assessed included age, sex, postoperative pain severity and duration, postoperative bleeding, and healing at 1st week, 2nd week, 1st month, and 3rd month after the procedure.2.Comparison between both groups regarding postoperative pain severity and duration Tables  and 3:The mean age of the study population was 7 years. Both groups showed similar demographic distribution without statistical significance Table .2.ComparP-value = 0.001). The overall mean pain score was significantly less in group A (P= 0.0001), while the duration of pain was significantly longer in group B .3.Comparison between both groups regarding the incidence of postoperative bleeding:According to Wong-Backer FACES score, pain score for each visit in group A (coblation) ranged between (8–10), (3–8), (0–5), and (0–1) with mean pain scores (mean ± standard deviation): 9.32 ± 0.62, 5.62 ± 1.19, 2.10 ± 1.24, and 0.22 ± 0.42 on the 1st, 2nd, 3rd, and 4th visits respectively. In group B (bipolar), the score for each visit ranged between (9–10), (7–10), (2–9), and (0–6) with mean pain scores (mean ± standard deviation): 9.97 ± 0.18, 9.03 ± 0.71, 6.13 ± 1.91, and 1.75 ± 1.90 on 1st, 2nd, 3rd, and 4th visits, respectively. Mean pain score on each interval in group A was less than group B with a significance level of . Table Comparison between both groups regarding the duration of healing as indicated by the complete disappearance of the whitish healing membrane: the duration of healing for patients in group B was significantly longer than those in group A , two after 48 h (reactionary), one after 4 days (secondary), and one after 1 week (secondary). All of them were admitted to the hospital, and the bleeding was controlled by conservative methods. None of them needed reoperation.Our current report aimed at comparing the outcome of coblation versus bipolar electrocautery tonsillectomy. The outcome parameters were the occurrence of postoperative bleeding, duration of healing , postoperative pain severity, and pain duration.The use of coblation in surgical practice is mainly dependent on chemical rather than thermal effect. This principle paved the way for the safe use of coblation during tonsillectomy procedures to reduce postoperative pain severity and duration .In the current report, the difference in pain severity between both groups was statistically significant on each of the follow-up visits; however, on the first visit, the difference in the mean pain scores did not reflect a meaningful clinical difference. The authors have also found that the overall mean pain score and pain duration were significantly better for the coblation group. This comes in agreement with what has been previously reported by Omrani and associates . PolitesThese findings were opposed by the results reported by Hasan et al . This diIn the present study, it was found that coblation tonsillectomy had better performance than bipolar tonsillectomy in terms of postoperative hemorrhage. The bipolar group had 4 patients who developed reactionary hemorrhage and two who suffered from secondary bleeding. No cases in the coblation group had any postoperative bleeding events. This difference was both statistically and clinically significant. A study by Belloso and associates agreed with our report with emphasis that this difference in postoperative hemorrhage was especially significant for the pediatric population . AnotherThe difference in the incidence of postoperative bleeding events in our study can be explained by the fact that coblation tonsillectomy produced less pain with improved swallowing ability and better oral intake in the early postoperative period. This privilege has its impact on the reduction of operative bed infection which can lead to serious hemorrhagic consequences.In our study, the healing of the operative bed was more prompt for the coblation group. This is indicated by the complete disintegration of the whitish healing membrane and complete epithelialization of the operative bed. This advantage was statistically significant when compared against the bipolar group. This comes in agreement with what has been reported by Timms and Temple in 2002  and by MIn contradiction to this finding, a study by Rakesh and associates found that healing was significantly longer on the coblation group up to 1 week after the procedure. Follow-up after 3 weeks showed no difference between coblation versus dissection tonsillectomy .The faster healing offered by coblation tonsillectomy is best explained by the fact that coblation produces less thermal heat during the dissection and hence less tissue trauma. This leads to faster recovery, less granulation tissue formation, and less scarring. Coblation device usually produces heat between 45 and 85 °C, while bipolar devices usually produces head around 300 and 400 °C , 22.This study was affected by the effect of the outliers on the means of the outcomes. The mean tends to skew towards the outlier. To preserve the integrity of the data in this study, outliers were included and not excluded despite the fact that this may lead to contamination of the results . In the The main strength of this study is stemmed from its prospective nature. Effective randomization adds to its strength. The duration of the follow-up period is not only sufficient to judge early outcomes like pain severity but is also adequate to evaluate postoperative pain duration, postoperative hemorrhage, and healing of the operative bed.The main drawback of this study is the relatively small sample size. This can be explained by the timeframe of the conduction of the study which was during the COVID-19 pandemic. Major healthcare resources were mainly directed to isolation and advanced care facilities. Many patients willingly agreed to postpone elective procedures to further save more resources to counteract the pandemic. Also, the relatively short duration of the study—7 months—have also contributed to this shortage in the number of patients. Another drawback is the method of assessment of healing, which was mainly dependent on the guardians’ observations of the white healing membrane. This is also explained by the fact that identifying the exact date of complete separation of the membrane needed examination of the patients by the surgeon every day, something that is practically unfeasible. For this, the researchers had to educate the guardians of the shape and characteristics of the white healing membrane and gave them information and training on each visit on how to observe its existence and to accurately document its disappearance. Another drawback is the lack of proper matching of the indication for tonsillectomy for both groups. This drawback also entails the lack for control for both groups regarding the extent of the procedure, i.e., whether tonsillectomy was performed alone or in combination with adenoidectomy. It is to be emphasized that usually for younger pediatric population, the procedure of tonsillectomy is usually coupled with concurrent adenoidectomy. In the current report, most of the patients had simultaneous tonsillectomy and adenoidectomy. As well, the majority of patients in our study had recurrent throat infections rather that sleep disordered breathing as the indication for the procedure. In order to confirm the diagnosis of obstructive sleep apnea, a polysomnogram is needed. In fact, the medical literature recommends against the routine use of polysomnography except in patients with syndromes affecting their craniofacial skeleton . The disOur study indicates that coblation tonsillectomy is superior to bipolar tonsillectomy with fewer postoperative bleeding incidents, shorter recovery, less pain severity scores, and shorter pain duration. This difference is of limited clinical value during the first week after surgery. These benefits should be carefully weighed against the higher cost of the coblation device.