To compare two thoracotomy closure techniques in terms of postoperative pain and pulmonary function. Hospital dasClínicas and at the University of Mogi das Cruzes, both located in thecity of Mogi das Cruzes, Brazil. We included 30 patients (18-75 years of age)undergoing posterolateral or anterolateral thoracotomy. The patients wererandomized into two groups by the type of thoracotomy closure: pericostal suture and transcostal suture . Pain intensity during theimmediate and late postoperative periods was assessed by a visual analogic scaleand the McGill Pain Questionnaire. Spirometry variables  were determined in the preoperative periodand on postoperative days 21 and 60.  This was a prospective, randomized, double-blind study carried out in theDepartment of Thoracic Surgery of the Luzia de Pinho Melo  Pain intensity was significantly greater in the PS group than in the TS group.Between the preoperative and postoperative periods, there were decreases in thespirometry variables studied. Those decreases were significant in the PS group butnot in the TS group.  The patients in the TS group experienced less immediate and late post-thoracotomypain than did those in the PS group, as well as showing smaller reductions in thespirometry parameters. Therefore, transcostal suture is recommended overpericostal suture as the thoracotomy closure technique of choice. In this procedure, the costal periosteum and theintercostal neurovascular bundle can suffer injuries of varying degrees, resulting fromthe mechanical effects of retractors or the thermal effects ofelectrocautery.-4(-) To prevent the acute pain and respiratory changes that accompany thoracicinterventions, new approaches have been used, such as minimally invasive thoracotomy.The advent of video-assisted surgery two decades ago enabled the use of smaller accessports to the thoracic cavity and resection via small thoracotomy. This reduced theincidence of postoperative pain and the changes in pulmonary function. However, conventional techniques for thoracic surgery cannot always bereplaced by minimally invasive techniques, and, in such cases, acute and/or chronic painmay be present. There are still many resection cases requiring major posterolateral oranterolateral thoracotomy, especially in patients with tumors and in those with chronicinfectious diseases. These major surgical procedures require some precautions,especially during thoracotomy closure, because, in practice, intercostal space closureis commonly performed with sutures around the ribs, designated pericostal sutures(PSs).Most patients undergoing thoracotomy complain of pain, which is responsible for shallowbreathing, with a consequent decrease in lung volumes and capacities, as well assecretion retention and atelectasis.-8 To unction.,9 HowThoracotomy closure with PSs may cause injury due to compression of the neurovascularbundle, which courses on the lower edge of the rib, as a result of its anatomicalposition. The structure most vulnerable to trauma is the cutaneous branch of theintercostal nerve, because of its location on the costal margin. Its trauma due tocompression or crushing during the procedure of costal approximation implies pain andcutaneous paresthesia for some days or months postoperatively.(-)In an attempt to minimize pain, some thoracic surgeons are currently replacing PS withtranscostal suture (TS), which consists in passing the approximation suture throughholes drilled directly into the ribs. This technique has shown positive and promisingresults regarding decreased pain in the postoperative period.-12The objective of the present study was to compare two thoracotomy closure techniques,i.e., PS and TS, in terms of postoperative pain and pulmonary function.This was a prospective, randomized, double-blind study carried out between August of2011 and September of 2012. The study project was approved by the Research EthicsCommittee of the University of Mogi das Cruzes on November 18, 2010 .We included all patients (18-75 years of age) undergoing posterolateral or anterolateralthoracotomy through intracavitary access. The exclusion criteria were as follows: havingbone metastasis; having a history of pain caused by other comorbidities; and beingdependent on drugs, opioid analgesics, or any other substance that affects one'ssensitivity to pain. The patients were randomized into two groups by the type of thoracotomy closure: PSgroup and TS group. To that end, we used web-based randomization. In the PS group, thoracotomy closure was performed by passing the suture around thefifth rib, close to its upper border, and around the sixth rib, away from its lowerborder, and drawing them together .In the patients in the TS group, closure was performed as follows. The position for thesuture drill holes was marked on the periosteum using an electrocautery knife.Subsequently, holes were drilled into the fifth and sixth ribs using a 7-mm diameterdrill, which was rotated by a dental motor  21 and POD 60 for comparisons with the valuesobtained in the preoperative period. According to the study protocol, pain wasassessed from POD 1 to POD 10, as well as in the late postoperative period (POD 21and POD 60).  The VAS is a 0 to 10 point scale, with 0 meaning complete absence ofpain and 10 meaning the greatest level of experienced pain, with which therapists askpatients about their pain intensity. The McGill Pain Questionnaire assesses pain infour distinct domains , on the basis ofwords, designated descriptors, which patients select to describe theirpain. Patients are instructed to choose, from among 20 groups of descriptors,those that best describe their pain at the time of the assessment. The first 10 descriptors are related to the sensory dimension of pain.Descriptors 11 to 15 are related to the affective dimension of pain. Descriptor 16addresses pain in an evaluative way, whereas descriptors 17 to 20 represent a mixedclass of alternative words.To assess pain, we used a one-dimensional visual analog scale (VAS) and the McGillPain Questionnaire. The VASirpain. Patientessment. The fire words. In a stable setting, the patient sat in a comfortable position and,wearing a nose clip, performed a maximal forced expiratory maneuver, from TLC to RV.Thus, FVC, FEV1, FEV1/FVC ratio, and PEF weremeasured.Spirometry was performed in accordance with the American Thoracic Society 1995criteria and the Brazilian Thoracic Association criteria. In a steasured. The level of significance set for rejection of the null hypothesis was p< 0.05.Individual data are expressed as mean and standard error. Statistical analysis wasperformed using GraphPad Instant Software .Categorical variables  wereassessed by the chi-square test. For numerical variables (spirometry), we used theStudent's t-test to compare results between the PS and TS groups and one-way ANOVA tocompare preoperative and postoperative results within the same group. For theanalysis of pain as measured by the VAS, we used the Student's t-test, whereas, forthe analysis of pain as determined by the McGill Pain Questionnaire, we used theMann-Whitney test. The lev< 0.05.We included 31 patients, of whom 16 and 15 were randomized to the PS and TS groups,respectively. Only 1 patient in the TS group did not return for reassessment and wasexcluded from the study. The diagnosis of the patients in the PS and TS group was, respectively, as follows:adenocarcinoma, in 10 and 8 patients; epidermoid carcinoma, in 3 and 3; small cellcarcinoma, in 2 and 3; and tuberculosis sequelae, in 1 and 0. Lobectomy was the mostcommonly performed surgical procedure .The meaMean pain intensity  was calculated for each POD. In both groups,there was a reduction in pain intensity in the follow-up period. Pain intensity wasgreater for the patients in the PS group than for those in the TS group from theimmediate postoperative period, and this difference was statistically significant untilPOD 7 .  The authors of that review, searching the Cochrane Plus Library using thesearch terms "pain", "thoracotomy", and "suture", found 174 publications that linked thesurgical technique employed with postoperative pain. Of those, 11 publications met theselection criteria established for that review, and, of those 11, 6 compared thethoracotomy closure technique with post-thoracotomy pain, only 4 of which wererandomized studies. Those authors concluded that there is a need for further scientificevidence on certain technical aspects of thoracotomy closure techniques and theirrelationship with post-thoracotomy pain. In addition, they pointed out that only throughthe development of prospective randomized studies specifically comparing the differentthoracotomy closure techniques described in the literature and assessing theirrelationship with post-thoracotomy pain will it be possible to make recommendations inthis regard. However, the review made clear that a necessary aspect for reducingpost-thoracotomy pain, and that should be common to all closure techniques, is a focuson intercostal nerve preservation.Confirming the interest in the subject, during the present study, a systematic reviewwas published on thoracotomy closure techniques and their relationship withpost-thoracotomy pain. The autAmong the variables selected for the present study, pain was the one that caused themost difficulty in terms of assessment, because it is a continuous variable that isdifficult to quantify. In addition to being a symptom, it is a subjective experience andis influenced by various factors, such as environmental, emotional, behavioral, andsocial factors. Therefore, we used two standard tools (a VAS and the McGill PainQuestionnaire). Pain was assessed by a numeric pain scale and the McGill PainQuestionnaire. Those instruments were administered in the second postoperative week, aswell as in the first, second, and third postoperative months. The authors concluded thatthe patients treated with TS experienced less pain than did those undergoing PS.Although that study was not randomized, it had a consistent level of evidence torecommend the use of TS in thoracotomy closure.The largest prospective study of this subject included 280 patients undergoingposterolateral thoracotomy, divided into two groups: TS (n = 140) and PS (n =140). Pain waclosure. Seven animals underwent closure with PS close to the lower border of thelower rib, compressing the  neurovascular bundle, and 6 dogs underwent closurewith TS. Pain was assessed using pain threshold scores, which were based on parameterssuch as HR and RR, for a period of 24 h. The study showed that the animals treated withTS experienced significantly less pain. Although that experimental study used a similar methodology in terms of thesurgical technique employed, which proved of great value in preventing compression ofand injury to the intercostal nerve, its limitation was that it assessed pain only inthe immediate postoperative period.In an experimental study in dogs, pain was assessed in the immediate postoperativeperiod following thoracotomy in 13 animals. Seven ass pain. Althoug period.The present study showed, through the use of the VAS and the McGill Pain Questionnaire,that the patients in the TS group experienced less pain than did those in the PS group;these results are similar to those reported in previous studies.,17 thoracotomy closure was also performed using TS; however, there wasvariation in the technique used to open the intercostal space during access to thepleural cavity, which means that their results are not comparable to the results of thepresent study or to those of another study, in which technical variation in performing the thoracotomy involvedharvesting of intercostal muscle flaps to protect the neurovascular bundle from thechest retractor. Therefore, the assessment of pain threshold in the postoperative periodwas impaired when comparing the transcostal and pericostal closure groups because therewere different interventions.In previous studies,,,19 thr study, in whicThe use of Finochietto retractors during chest opening is known to be responsible formuch of the pain after the surgical procedure. In our study, we took this into account,which is why the same method for opening the chest wall was used in both groups, i.e.,there was no variation in the technique for opening the chest wall, as previouslysuggested by other authors.,16 comparing pain, as assessed by the McGill Pain Questionnaire, in 40patients undergoing either posterolateral thoracotomy or sternotomy. The mean number ofdescriptors used by the patients in the group undergoing posterolateral thoracotomy was16, with a mean score of 30, values that are very close to those found in the presentstudy.The present study found that the patients in the PS group used a large number ofdescriptors to characterize their postoperative pain-on average, 11 descriptors on POD1, with a mean score of 26. This has also been observed in a prospectivestudy1, and PEFon POD 21 than in the preoperative period. These results are historically expected inthe postoperative period after thoracotomy and were similar to those reported inprevious studies.Regarding pulmonary function, we observed that the patients undergoing standardthoracotomy closure (PS group) showed significantly lower FVC, FEVstudies.,21 investigated pulmonary function in 16 patients after major thoracotomy.Spirometry was performed on POD 14. The authors observed that FVC, FEV1, andPEF were significantly lower postoperatively than preoperatively. Patient recovery in terms of these variables was due to improvement inventilatory capacity, reduction of the chest wall injury caused by the surgicalprocedure, and pain relief.A previous study investiatively. Patient Spirometry was performed in the preoperative period and in the sixthpostoperative month. The FEV1, PEF, and FVC values statisticallysignificantly decreased relative to the values obtained in the preoperative period. Suchresults were expected and are related to the direct impact of surgical resection and topostoperative pain.A prospective study of 33 patients undergoing thoracic surgery evaluated the impact oflung resection on pulmonary function in lung cancer patients undergoingthoracotomy. Spiromeve pain.1, and PEF. In the PS group, inwhich pain was found to be more severe, the decreases in the spirometry values weregreater.In the present study, we expected a decrease in the spirometry variables, because thesurgical procedures involve resection of lung parenchyma. However, the proceduresperformed in both groups were quite similar, and less postoperative pain in the TS grouptranslated into a smaller decrease in FVC, FEVIn conclusion, the patients undergoing closure of a posterolateral or anterolateralthoracotomy with TS experienced a significant decrease in immediate and latepostoperative pain when compared with those undergoing closure with PS. In addition, thepatients in the TS group showed smaller reductions in the spirometry parameters.Therefore, TS is recommended over PS as the thoracotomy closure technique of choice. (-)A cirurgia torácica convencional é passível de várias complicações, pois o acesso àcavidade pleural demanda a secção dos músculos intercostais, a abertura da pleuraparietal e o afastamento das costelas. Nesse procedimento, o periósteo costal e ofeixe neurovascular intercostal podem sofrer lesões de graus variáveis decorrentes daação mecânica de afastadores ou pela ação térmica de eletrocautério.-4(-) Com o objetivo de prevenir a dor aguda e as alterações respiratóriasocasionadas pelas intervenções torácicas, novas abordagens vêm sendo praticadas, comoa toracotomia minimamente invasiva. O advento da cirurgia videoassistida nas duasúltimas décadas possibilitou a prática de acessos menores à cavidade torácica comressecções por toracotomias econômicas. Isso reduziu a incidência da dorpós-operatória e as alterações da função pulmonar. Entretanto, nemsempre as técnicas cirúrgicas convencionais torácicas podem ser substituídas pelastécnicas minimamente invasivas, e, nesses casos, a dor aguda e/ou crônica podem setornar presentes. Existem ainda muitas ressecções que exigem a prática detoracotomias posterolaterais e anterolaterais amplas, principalmente em tumores e emdoenças infecciosas crônicas. Esses procedimentos cirúrgicos amplos exigem algunscuidados, principalmente durante o fechamento da toracotomia, pois é comum, naprática, realizar-se a aproximação dos espaços intercostais por meio de suturas quecircundam as costelas, denominadas de suturas pericostais.A maioria dos pacientes submetidos a toracotomia queixa-se de dor, sendo essaresponsável pela respiração superficial, com consequente diminuição dos volumes ecapacidades pulmonares, assim como retenção de secreção e atelectasia. -8 ComAo realizar-se esse tipo de fechamento torácico, é possível que ocorra lesão porcompressão do feixe neurovascular, presente na borda inferior da costela, emdecorrência de sua posição anatômica. A estrutura mais vulnerável ao trauma é o ramocutâneo do nervo intercostal, devido a sua localização na borda costal. Seu traumapor compressão ou esmagamento durante o procedimento de aproximação costal implicaráno surgimento de dor e parestesia cutânea no período pós-operatório por alguns diasou meses.(-)Na tentativa de minimizar a dor, alguns cirurgiões torácicos atualmente vêmsubstituindo as suturas pericostais por suturas transcostais, que consistem napassagem dos fios de aproximação por furos realizados diretamente nos arcos costais.Essa técnica tem demonstrado resultados positivos e promissores quanto a diminuiçãoda dor no período pós-operatório.-12O objetivo do presente estudo foi comparar duas técnicas de fechamento detoracotomias, através de sutura pericostal (SP) ou sutura transcostal (ST), emrelação à dor pós-operatória e função pulmonar.Trata-se de um estudo prospectivo, randomizado e duplo-cego realizado entre o períodode agosto de 2011 e setembro de 2012. O projeto do estudo teve a aprovação do Comitêde Ética em Pesquisa da Universidade de Mogi das Cruzes em 18 de novembro de 2010,sob o número de processo 150/2010, CAAE 0144.0.0237.000-10.Foram incluídos no estudo todos os pacientes submetidos a toracotomiasposterolaterais ou anterolaterais com acesso intracavitário, com idade entre 18 e 75anos. Os critérios de exclusão foram os seguintes: pacientes que apresentavammetástases ósseas, pacientes com quadro doloroso prévio em decorrência de outrascomorbidades, e pacientes dependentes de drogas, analgésicos opioides ou qualqueroutra substância que afetasse sua sensibilidade à dor.web-basedrandomization. O grupo SP foi composto por pacientes submetidos afechamento torácico através de SP, e o grupo ST foi composto por pacientes submetidosa fechamento torácico por meio de ST.Os pacientes foram randomizados e distribuídos em dois grupos conforme o procedimentocirúrgico realizado. A randomização foi realizada por meio de , a aproximação costal foi realizada através de SP, queconsiste na passagem do fio de sutura contornando a quinta costela rente a sua bordasuperior e contornando a sexta costela distante da sua borda inferior, aproximando-ase fechando a toracotomia  (poliglactina 910)com cobertura  no. 1 com uma agulhacircular de 40 mm.Foram realizadas quatro perfurações equidistantes em cada costela. Os fios de suturaforam passados pelos orifícios e procedeu-se ao fechamento transcostal . Em todoAs variáveis avaliadas foram dor no período pós-operatório e função pulmonar porespirometria no 21º dia pós-operatório (DPO) e no 60º DPO para comparações com osvalores obtidos no pré-operatório. Segundo o protocolo do estudo, a avaliação da dorfoi realizada até o 10º DPO, assim como no período pós-operatório tardio (21º DPO e60º DPO). A EVA é uma escala graduada de 0 a 10, no qual o terapeuta questiona oseu paciente quanto a sua intensidade de dor, sendo que 0 significa ausência total dedor e 10 significa o nível de dor máxima sentida. O questionário de dor McGill avaliaa dor em quatro dimensões distintas , baseadoem palavras, denominadas descritores, as quais os pacientes selecionam para descreversua dor. O paciente é orientado a escolher, dentre 20 grupos de descritores,aqueles que melhor descrevem a sua dor no momento da avaliação.(13) Osprimeiros 10 descritores estão relacionados à dimensão sensorial da dor. Osdescritores 11-15 relacionam-se à dimensão afetiva da dor. O descritor 16 refere-se àdor de maneira avaliativa, enquanto os descritores 17-20 representam uma classe mistade palavras alternativas.Para a avaliação da dor, foram utilizados uma escala visual analógica (EVA)unidimensional e o questionário de dor McGill. A EVA ésua dor. O pacievaliação. OsprimeAmerican ThoracicSociety de 1995 e da Sociedade Brasileira de Pneumologia eTisiologia. Em um ambiente estável, o paciente sentava-se em posição confortável e,usando um obturador nasal, realizava uma expiração máxima forçada a partir da CPT atéo VR. Dessa forma, foram aferidos CVF, VEF1, relação VEF1/CVF ePFE.A espirometria foi realizada segundo os critérios da iologia. Em um aF ePFE.one-way ANOVA na comparaçãodos resultados antes e após a cirurgia dentro do mesmo grupo. Para a análise da dorquantificada pela EVA, utilizou-se o teste t de Student, enquanto, para a avaliaçãoda dor pelo questionário de dor McGill, utilizou-se o teste deMann-Whitney. Para a rejeição da hipótese de nulidade, adotou-se o nível designificância p < 0,05.Os dados individuais foram expressos em média e seu erro padrão. A análiseestatística foi realizada com o uso do programa GraphPad Instant . As variáveis categóricas  foram avaliadas pelo teste do qui-quadrado. Para asvariáveis numéricas (espirometria), utilizou-se o teste t de Student na comparaçãodos resultados entre os grupos SP e ST e Whitney. Para a  < 0,05.Foram incluídos no estudo 31 pacientes, sendo 16 e 14 randomizados para os grupos SPe ST, respectivamente. Somente 1 paciente do grupo ST não retornou para a reavaliaçãoespirométrica, sendo esse excluído da pesquisa. A O diagnóstico dos pacientes nos grupos SP e ST, foram, respectivamente, os seguintes:adenocarcinoma, em 10 e 8 pacientes; carcinoma epidermoide, em 3 e 3; carcinoma depequenas células, em 2 e 3; e sequelas de tuberculose, em 1 e 0. A lobectomia foi oprocedimento cirúrgico mais comumente realizado . O tempoCalculou-se a média numérica da intensidade da dor para cada DPO. Em ambos os grupos,observou-se o decréscimo da intensidade dolorosa durante a evolução. Observou-se umamaior intensidade dolorosa nos pacientes do grupo SP do que nos do ST desde opós-operatório imediato, e essa diferença foi estatisticamente significante até o 7ºDPO , foram calculadas e comparadas asmédias dos números dos descritores escolhidos e as médias da somatória dos índicesdesses descritores para cada dia de avaliação. Essa avaliação foi realizada do 1º ao10º DPO e repetida no 21º DPO e no 60º DPO. Quando comparou-se o número total dedescritores escolhidos pelos pacientes nas quatro categorias avaliadas, foi observadoum número maior de descritores no grupo SP em relação ao número total no ST. Aintensidade de dor pós-operatória avaliada por essa escala demonstrou que a dor foimaior nos pacientes do grupo SP. Essa diferença foi estatisticamente significanteentre os dois grupos até o 10º DPO . A  Os autores daquela revisão, utilizando a base de dados da BibliotecaCochrane Plus através das palavras-chaves "dor", "toracotomia" e "sutura", levantaram174 publicações que vinculavam a técnica cirúrgica empregada à dor pós-operatória.Desse total, 11 publicações preencheram os critérios de seleção estabelecidos e,desses, 6 comparavam a técnica de fechamento do espaço intercostal com a dorpós-toracotomia, sendo apenas 4 estudos aleatorizados. Concluíram os revisores queseria necessário maior evidência científica sobre determinados aspectos técnicos dasutura dos espaços intercostais e a dor pós-toracotomia. Assinalaram ainda que só sepoderia estabelecer recomendações a esse respeito com o desenvolvimento de estudosprospectivos aleatorizados que permitissem comparar especificamente as distintasvariantes das técnicas de fechamento de toracotomias descritas na literatura e suarelação com a dor pós-toracotomia. Entretanto, um aspecto que a revisão deixou claropara a redução da dor pós-toracotomia, e que deve ser comum a todas as técnicas defechamento, é o enfoque na preservação dos nervos intercostais.Corroborando o nosso interesse pelo tema, no decorrer do presente estudo foipublicada uma revisão sistemática sobre as técnicas de sutura do espaço intercostalem toracotomias e suas relações com a dor pós-toracotomia. Os autoEntre as variáveis selecionadas no presente estudo a dor foi a que apresentou maiordificuldade do ponto de vista avaliativo, pois trata-se de uma variável contínua edifícil de ser quantificada. Além de ser um sintoma, é uma experiência subjetiva eacaba sofrendo a influência de diversos fatores, tais como fatores ambientais,emocionais, comportamentais e sociais. Por esse motivo, utilizaram-se duasferramentas padronizadas (EVA e questionário de dor McGill). A variável dor foi avaliada através de uma escala numérica de dor equestionário de dor McGill. Esses instrumentos foram aplicados na segunda semanapós-operatória, assim como no primeiro, segundo e terceiro mês pós-operatório. Osautores concluíram que, nos pacientes tratados com ST, a intensidade de dor foi menordo que nos pacientes submetidos à técnica de fechamento pericostal. Apesar de aqueleestudo não ser aleatorizado, ele apresentou um nível de evidência consistente pararecomendar o uso da ST no fechamento de toracotomias.O estudo prospectivo de maior casuística pertinente a esse assunto incluiu 280pacientes submetidos a toracotomias posterolaterais, distribuídos em dois grupos:suturas transcostais foram realizadas em 140 pacientes, e suturas pericostais foramrealizadas em 140. A variáotomias. Sete animais tiveram o fechamento realizado por SP rente à bordainferior da costela inferior, comprimindo o feixe neurovascular , e 6 cãesforam submetidos a fechamento por ST. A dor foi avaliada através daescores de limiar da dor, baseados em parâmetros como FC e FR, por um período de 24h. O estudo demonstrou que a dor foi significativamente inferior no grupo tratado comST. Embora tal estudo experimental adotara uma metodologia semelhante emrelação à técnica cirúrgica empregada, mostrando-se de muito valor para evitar acompressão e a lesão do nervo intercostal, teve como limitação a avaliação da dorapenas no pós-operatório imediato.Em um estudo experimental em cães, avaliou-se a dor no pós-operatório imediato após atoracotomia em 13 animais. Sete an comST. Embora mediato.No presente estudo, foi possível verificar através da EVA e do questionário de dorMcGill que os pacientes do grupo ST apresentavam menor intensidade de dor em relaçãoaos pacientes do grupo SP; esses resultados são semelhantes aos resultadosapresentados em estudos anteriores.,17 também utilizaram a ST no fechamento de toracotomias; porém, houvevariações na técnica de abertura do espaço intercostal durante a abordagem dacavidade pleural, de modo que seus resultados não são comparáveis aos resultados dopresente estudo e aos de um outro estudo, no qual foram utilizadas variações técnicas na execução da toracotomiaatravés da liberação de retalhos musculares intercostais para a proteção do feixeneurovascular do afastador torácico. Desse modo, a avaliação do limiar da dor nopós-operatório ficou prejudicada na comparação dos grupos de fechamento transcostal epericostal porque houve intervenções diferentes.Estudos anteriores,,19 ta estudo, no qualSabe-se que a utilização de afastadores de Finochietto durante a abertura torácica éresponsável por grande parte da dor após o procedimento cirúrgico. Em nosso estudo,levamos esse fato em consideração, motivo pelo qual foi utilizada a mesma metodologiade abertura em ambos os grupos, ou seja, sem variações na técnica da abertura, comosugerida anteriormente por outros autores.,16(6) que comparou a dor,através do questionário de dor McGill, de 40 pacientes submetidos a toracotomiaposterolateral e a esternotomia. O número médio de descritores apresentados nospacientes do grupo que realizou toracotomia posterolateral foi de 16, com escoremédio de 30, valores esses muito próximos aos encontrados no presente estudo.Ainda com relação à dor, foi observado no presente estudo que os pacientes do grupoSP utilizaram um elevado número de descritores para caracterizar sua dor no períodopós-operatório - em média 11 descritores no 1º DPO, com um escore médio de 26. Essefato também foi observado em um estudo prospectivo1 e PFEsignificantemente menores no 21º DPO quando comparados com seus resultados nopré-operatório. Esses resultados são historicamente esperados no pós-operatório detoracotomias e foram semelhantes aos relatados em estudos anteriores.Com relação à função pulmonar, observou-se que os pacientes submetidos ao fechamentotorácico convencional (grupo SP) apresentavam valores de CVF, VEFeriores.,21 foi investigada a função pulmonar em 16 pacientes após a realização detoracotomias amplas. As espirometrias foram realizadas no 14º DPO. Os autoresobservaram que CVF, VEF1 e PFE eram significativamente menores em relaçãoaos valores pré-operatórios.  A recuperação dos pacientes em relação a essas variáveis se deu pelamelhora na capacidade ventilatória, pela redução da lesão cirúrgica da paredetorácica e pelo alívio da dor.Em um estudo anterior, foi invtórios.  A recup As espirometrias foram realizadas no pré-operatório e no 6º mêspós-operatório. Foram verificadas reduções estatisticamente significantes nos valoresde VEF1, PFE e CVF quando comparados com os valores no pré-operatório.Tais resultados eram esperados e estão relacionados ao impacto direto da ressecçãocirúrgica e à dor no período pós-operatório.Em um estudo prospectivo com 33 pacientes submetidos à cirurgia torácica, foiavaliada a repercussão da ressecção pulmonar sobre a função pulmonar de pacientes comcâncer de pulmão submetidos a toracotomias. As espiratório.1 e PFE. No grupo SP, cujo registrode dor foi mais intenso, as reduções dos valores espirométricos foram maiores.No presente estudo, por se tratar de procedimentos cirúrgicos que implicam emressecção de parênquima pulmonar, espera-se uma redução nas variáveis espirométricas;no entanto, os procedimentos executados em ambos os grupos foram bastante similares ehouve concordância entre uma menor intensidade de dor pós-operatória no grupo ST comuma menor queda nos valores da CVF, VEFEm conclusão, os pacientes submetidos ao fechamento de toracotomias posterolaterais eanterolaterais por ST apresentaram significante redução da intensidade de dorpós-operatória, tanto imediata como tardia, quando comparados aos pacientessubmetidos à técnica pericostal. Além disso, os pacientes do grupo ST apresentarammenores reduções nos parâmetros espirométricos. Dessa forma, a técnica de fechamentodo espaço intercostal por ST é recomendada por apresentar vantagens sobre a técnicapericostal.


Multimorbidity is a highly prevalent health problem, which may reduce adherence, produce conflicts in treatment, and is not yet supported by evidence-based clinical recommendations. Many older people suffer from more than one chronic disease as well as from chronic pain. There is some evidence that disease management can become more complex if multimorbid patients suffer from chronic pain. In order to better consider the patients’ comorbidity spectrum in clinical pain treatment recommendations, evidence is needed regarding which disease combinations are frequently related with the presence of chronic pain. Therefore, our aim is to identify diseases and disease combinations in a multimorbid population, which are associated with the patient-reported presence of chronic pain.Analyses are based on cross-sectional data of the MultiCare Cohort Study, an observational cohort study based on interviews with 3189 multimorbid patients aged 65+, randomly selected from 158 practices, and their GPs. The response rate was 46.2 %. Data were collected in GP interviews and comprehensive patient interviews. Diseases and disease combinations associated with chronic pain were identified by CART (classification and regression tree) analyses performed separately for both genders. 46 chronic conditions were used as predictor variables and a dichotomized score from the Graded Chronic Pain Scale was used as outcome variable.About 60 % of the study participants were female. Women more often reported chronic pain than men. The most important predictor of a higher pain level in the female population was chronic low back problems, especially if combined with chronic gastritis, hyperuricemia/gout, cardiac insufficiency, neuropathies or depression. Regarding the pain level the male population was also divided best by chronic low back problems, especially if combined with intestinal diverticulosis, neuropathies or chronic ischemic heart disease.Our analyses are a first step in identifying diseases and disease combinations that are related to chronic pain. The most important condition seems to be low back problems. Back pain and pain in other body regions seems to be interrelated with cardiometabolic conditions. In women, psychosocial issues like depression also seem to be relevant.ISRCTN89818205. Multimorbidity is a highly prevalent health problem. Depending on definition and operationalization studies show prevalence rates in the elderly ranging from 55 to 98 % . For theMultimorbidity is associated with many adverse patient-related health outcomes like decline of functional status, lower quality of life, higher mortality, increased health care utilization and therefore rising costs of care , 8. A laCare for patients with multimorbidity is a challenging task for the GP because of three reasons: Firstly, multimorbidity may produce conflicts in treatment decisions, because indications and contra-indications for a specific treatment are often found in the same person. Secondly, multimorbidity is not yet supported by evidence-based clinical recommendations. Thirdly, due to its complexity, multimorbidity may reduce patients’ adherence to treatment plans . The infThe analyses are based on baseline data from the MultiCare Cohort Study . The methods of this study have been described in detail in the published study protocol . In shorPatients were excluded from the study if they were no regular patients of the participating practice , if they were unable to participate in interviews  or if they were not able to speak and read German. Further exclusion criteria were residence in a nursing home, severe illness probably lethal within three months according to the GP, insufficient ability to consent  and participation in other studies at the present time.We randomly selected 24,862 patients from the study practices and checked them for multimorbidity and exclusion criteria. 13,935 of these patients were not multimorbid according to our definition or suffered from dementia. 3755 patients were excluded because of the other exclusion criteria described above. The remaining 7172 patients were eligible for study participation and contacted for informed consent to participation in our study. 3317 patients agreed to participate which corresponds to a total response rate of 46.2 %. Retrospectively we had to exclude 128 patients, because they died before the baseline interview or we found out in contact with the patients that they complied with the exclusion criteria without the GP’s knowledge. After all, 3189 patients could be included in the study . RecruitWe used the patients’ morbidity data from standardized GP interviews at baseline based on a list of 46 groups of chronic conditions. This list was designed to cover the most prevalent chronic conditions from both primary care and ambulatory insurance claims data. The methods for compiling the list of 46 diagnosis groups have been described elsewhere in detail . In shorWe also included the patients’ age and gender from GP charts. Chronic pain was operationalized as self-reported pain intensity  and pain-related disability  persisting over the last six months and assessed in comprehensive patient interviews using the Graded Chronic Pain Scale (GCPS) . For theMissing values in the dataset arising from item non-response have been imputed by Hot Deck Imputation in order to avoid bias generated by listwise deletion of subjects with missing values from statistical analyses . RelatedX2-tests.Descriptive data were presented separately for both genders as means and standard deviations in case of continuous variables and as percentages in case of categorical variables. We excluded missing values from our descriptive analyses and reported the number of available data sets. Statistical significance of differences between genders was assessed by t-tests and X2-tests. Bonferoni-adjustment for multiple testing was applied. A minimum sample size of 100 cases was defined for father branches and 50 cases for child branches. Stability of the branches was assured by 10-fold cross-validation. We performed our CART analyses for both genders separately, because there are big differences between males and females in the prevalence rates of pain symptoms and chronic conditions and we, therefore, wanted to allow for a possibly different association structure.We used CART (classification and regression tree) analyses to identify diseases and diseases combinations bearing a higher proportion of patients with chronic pain than in the total study population. This method splits the data set recursively into two subsets based on the predictor variable (here: the chronic disease) which has the largest effect on the outcome variable (here: the proportion of patients with chronic pain). This process is repeated for each subset as long as the criteria for splitting are true. The 46 chronic conditions from our list were used as predictor variables and the dichotomized GCPS score was used as outcome variable. Splitting eligibility of predictor variables were determined by X2-tests were conducted using Stata 12.1. CART analyses were performed using SPSS 20.0.0.For all analyses an alpha-level of 5 %  was defined as statistically significant. Descriptive statistics, t-tests and About 60 % of the 3189 multimorbid study participants were female , especially if combined with intestinal diverticulosis (48.8 %), neuropathies (46.4 %) or chronic ischemic heart disease (38.4 %). Among male patients without chronic low back problems, the proportion of individuals with pain was lower (22.5 %), especially if they also did not suffer from joint arthrosis (19.3 %) and neuropathies (17.3 %). Compared to the general (multimorbid) male population men without back problems, but with joint arthrosis also had an increased probability of pain (31.1 %), especially if they had the additional diagnosis of chronic ischemic heart disease (40.2 %). The proportion of cases incorrectly classified in men was 28.7 %.In this cross sectional analysis of the MultiCare Cohort Study chronic low back problems emerged as the most important chronic condition dividing our population of multimorbid primary care patients in chronic pain sufferers and non-chronic pain sufferers. In our data set 79 % of back problem diagnoses in females and 83 % in males were spondylosis, intervertebral disc disorders, spinal osteochondrosis or other degenerative back problems. Although back problems seem to be the condition with the strongest association with chronic pain, more than 50 % of women and more than 60 % of men with the diagnosis of chronic low back problems do not report chronic pain symptoms. For these reasons the diagnosis group “chronic low back problems” seems to incorporate mostly organic complaints which are or are not related to chronic pain.In both, women and men, chronic low back problems are located in the top of a CART-tree of comorbid disease clusters and both trees include neuropathies and intestinal diverticulosis, however, the other elements of these clusters differ between genders. While the role of depression, cardiac insufficiency, hyperuricemia/gout and chronic gastritis/GERD  is stressed in the female population, chronic pain in the male population more depended on chronic ischemic heart disease and joint arthrosis. Except for depression, which seems to be a larger problem in females than in males , there aWith regard to the pain clusters identified in both genders there is little agreement with our earlier analyses of disease-based multimorbidity clusters, which divided the disease spectrum in multimorbid patients into cardiovascular/metabolic, psychiatric/pain-related and neuropsychiatric disorders . ChronicOn the one hand, the misclassification rate was comparably high, especially in women. The reason for this finding is that our diseases have a low specificity in predicting chronic pain as chronic pain can have a huge variety of reasons and only the most prevalent are covered in our analyses. On the other hand there is a large spread between the disease combinations with the highest and the lowest proportion of chronic pain, which is 33.7 to 62.8 % in females and 17.3 to 48.8 % in males. Our CART trees therefore are not suitable for predicting chronic pain, but they are a first step in identifying disease combinations that are related to chronic pain for a high proportion of patients.In terms of generalizability of the results, it should be considered that the MultiCare Cohort Study only includes elderly multimorbid patients from general practice. However, this group comprises 44 % of the patients in this age group . We wereThe generalizability of the MultiCare Cohort Study could also be affected by our criteria for exclusion at baseline. We excluded patients with dementia because of their inability to consent as well as patients residing in a nursing home. Our recruitment only took place in larger German cities, so that rural areas were not included in our study. Nevertheless, our study is representative of an older, urban, multimorbid cohort in primary care . Like otA strength of our study relates to a high data quality that results from the fact that interviewers were regularly trained and monitored and a multitude of procedures for prevention of insufficient data quality, detection of inaccurate or incomplete data and actions to improve data quality were performed, e.g., user reliability trainings, automatic plausibility and integrity checks and data error reports to the collaborating centres.There are also some limitations that result from the CART method. Although we conducted separate analyses for both genders, we could not adjust for other possibly confounding factors. For this reason our results might be confounded by variables like age or socio-economic status if they are associated with the prevalence of specific chronic conditions and also have an influence on the prevalence of chronic pain. Furthermore CART-analyses divide the data set by the best separating variables until the subsets are too small to continue . As the sample size rapidly decreases with each split we might have missed some diseases or disease combinations associated with a higher prevalence of chronic pain.As reported in the literature, chronification of low back pain is associated with decreased subjective general health, decreased socioeconomic status, stress and psychosocial co-symptoms as indicated below . In a prAs suggested above, low back problems have an important role in patients with multimorbidity. Low back pain is one of the most frequent consultation reasons in primary care , 26. BotAlso, in chronification of pain derived from other body regions psychosocial factors are suggested to have a higher impact than biomedical  issues. Therefore, anxiety and depression as well as somatoform disorders and dysfunctional coping strategies have previously been described as the main drivers of pain chronification . In lineOur explorative analyses are a first step in identifying diseases and disease combinations that are related to chronic pain for a high proportion of patients. The most important condition in multimorbid primary care patients suffering from chronic pain seems to be chronic low back problems. In both genders, chronic low back pain as well as chronic pain in other body regions seem to be strongly interrelated with cardiometabolic conditions. In women, psychosocial issues like depression also seem to be relevant. However, more research is needed to better understand the patient perspective regarding pain symptoms associated with multiple chronic conditions.Our results have a number of implications. In medical education, information about the relationship between chronic pain problems and comorbidity should be given. And in health care for patients with multimorbidity, possible pain symptoms resulting from chronic low back problems should be discussed when prioritizing diseases. Furthermore, interactions of back pain with cardiometabolic and psychiatric disorders should be assessed in order to prevent chronification of pain, if possible.CART, classification and regression tree; GCPS, Graded Chronic Pain Scale; GERD, gastroesophageal reflux disease; GP, general practitioner.


The effect of low intensity laser radiation in the treatment of acute and chronic pain is now established in many studies. Tri-geminal neuralgia is a pain passes through nerve's branches and its trigger is located in skin or mucosa that could lead to pain with a trigger stimulus. The pain involved branches of trigeminal nerve that sometimes has patients to seek the treatment for several years. Nowadays different treatments are used for relief of pain that most of them cause tolerance and various side effects. This paper reviews and summarizes scientific papers available in English literature publishedin PubMed, Scopus, Science Direct, Inter science, and Iran Medex from 1986 until July 2011 about the effect of these types of lasers on trigeminal neuralgia which is one of the most painful afflictions known. In different studies, the effect of laser therapy has been compared with placebo irradiation or medicinal and surgical treatment modalities. Low-level laser therapy (LLLT) is a treatment strategy which uses a single wavelength light source. Laser radiation and monochromatic light may alter cell and tissue function. However, in most studies laser therapy was associated with significant reduction in the intensity and frequency of pain compared with other treatment strategies, a few studies revealed that between laser and placebo group there was not any significant difference according to the analgesic effect. Low-level laser therapy could be considered in treatment of trigeminal neuralgia without any side effects. It is estimated that 1 in 15,000 people suffers from trigeminal neuralgia; however, numbers may be significantly higher due to frequent misdiagnosis.1Although trigeminal neuralgia 1Trigeminal neuralgia (TN) is mainly a periodic, unilateral, sharp, and electric shock-like pain which passes through trigeminal nerve branches and feels in the eyes, lips, nose, scalp, forehead, and jaw and is limited to one side of the face in majority of cases (95%).1The episodes of pain last up to two minutes and between two episodes the patient is painless. It may occur spontaneously or be triggered by daily activities, such as washing, shaving, talking, brushing teeth, eating and drinking. This pain usually takes only a few seconds. Its frequency varies from a single attack during the day to more than one attack per minute that affects the individual’s quality of life.2 Pain usually starts after stimulation of trigger points. Some normal activities such as chewing and speaking are common triggers for beginning of the pain.2The most commonly involved branches are maxillary or mandibular division and the least frequently involved is ophthalmic branch.Different methods have been used for relief of the pain, and the aim of this study was to review studies on the use of laser therapy for trigeminal neuralgia as a new strategy with few side effects. Etiology and pathogenesis as well as management of trigeminal neuralgia are also described.3The exact etiology and pathogenesis of TN is not clearly understood. However, theories of the TN pathogenicity are divided to peripheral and central. Peripheral theories are based on peripheral axon and myelin changes which lead to chemical and physical stimuli threshold changes. Central pathogenecity theories are based on similarity between TN and focal epilepsy due to pressure on nerve branches or ganglia.1Some researchers believe both central and peripheral mechanisms are present. For example, pressure on entering branches of brain stem may lead to myelin injury, nerve demylination, abnormal depolarization, ectopic pulses, and pain.1 Traumatic accidents, dental treatment, and various infections could cause trigeminal nerve injury. Some studies revealed that an important reason for primary onset is artery pressure on the nerve, as superior cerebellar artery may irritate the trigeminal nerve.4There are certain factors that can trigger the onset of TN such as compression of the nerve , demyelinating conditions (such as multiple sclerosis—MS), infectious agents (human herpes simplex virus), and nerve trauma.5When the cause of the TN is identifiable, treatment involves elimination of the cause. In idiopathic cases, however, a variety of medicinal and surgical treatment modalities should be considered. Medicinal management includes carbamazepine, phenytoin, baclofen, gabapentin, oxcarbazepine, lamotrigine, pimozide, and tizanidine hydrochloride.6Although medication is the first line of treatment, tolerance may develop as the treatment period and the need for extra dosage increase, which leads to more side effects. Nearly 50% of TN sufferers are not satisfied with medical therapy, because of incomplete control of pain or drug-related side effects. Drowsiness, fatigue, dizziness, nausea, nystagmus, memory loss, and a sense of exhaustion are common side effects of carbamazepine which necessitates finding alternative treatment.6Other management which is indicated when medication is not useful include peripheral nerve branch procedures , percutaneous procedures, percutaneous radiofrequency thermocoagulation (coagulation), glycerol injections, and balloon compression.6 Newly proposed treatment methods include microneurovascular decompression, radiofrequency coagulation, gamma knife stereotactic radiosurgery, cryosurgery, and laser therapy.16Open surgical procedures include trigeminal root section, sectioning of the trigeminal tract in the lower medulla, and microvascular decompression surgery.Surgical treatments are considered when drug therapy fails in controlling of TN pain. The results depend on the experience, expertise, and correct selection of technique of neurosurgery team.18 Many authors have reported significant pain reduction in a number of conditions such as rheumatoid arthritis, fibromyalgia, post-operative pain, headache, nervous system diseases, myofascial pain syndrome, chronic neck pain, and low back pain as a result of laser application.23Low-level laser therapy (LLLT) is a treatment strategy which uses a single wavelength light source. Laser radiation and monochromatic light may alter cell and tissue function.24Clinical studies of the effects of LLLT on injured nerves have revealed an increase in nerve function and improved capacity for myelin production. LLLT has also been shown to be effective for promoting axonal growth in injured nerves in animal models.Here we review papers available about the effect of low-level lasers on trigeminal neuralgia. An online search of PubMed, Scopus, Science Direct, Inter science, and Iran Medex using key words “trigeminal neuralgia” and “low-level laser” from 1986 until July 2011 was performed. Studies with methods not including the exact details of laser therapy were excluded from the review.25 The investigators used four-grade estimation, visual analog scale (VAS), and modified McGill pain questionnaire (m-MPQ) after every 10 of 50 irradiations to determine efficacy of treatment. Results showed that repeated irradiation with low-power He-Ne laser is an effective and safe therapy for post-herpetic neuralgia (PHN).25In one study, 18 outpatients suffering severe post-herpetic neuralgia (PHN) were exposed to low-power helium–neon (He-Ne) laser.23 36 patients suffering from PHN were exposed to low-power He-Ne laser 2 or 3 times a week. The results showed that the efficacy of the laser at the end of 20 trials was 88.9%, and the degree of pain relief was 55.3%.In another study by Iijima et al,26 used low power He-Ne laser  in patients with chronic pain. He treated 26 patients with trigeminal neuralgia, post-herpetic neuralgia, sciatica, and osteoarthritis. He irradiated the affected sites 30 to 90 seconds three days per week for 10 consecutive weeks. Nineteen patients revealed significant reduction in frequency and also intensity of their pain after the treatment duration.26Walker24In another study, Walker et al. exposed the patients with the history of TN with He-Ne laser  in a double blind study. Duration of exposure for each site was 20 seconds for skin overlying peripheral nerves and painful facial areas. The control group received no irradiation with a laser apparatus identical to the laser group. Both groups received irradiation three times a week for ten weeks. Laser therapy was associated with significant reduction in the intensity and frequency of pain.27Eckedral designed a double-blind, placebo controlled study to investigate effectiveness of low-level laser therapy (LLLT) on TN in Denmark. Sixteen patients suffering from TN were radiated with laser for 5 weeks  and compared with 14 patients as control group. After one year follow-up they got to the point that LLLT is an effective method and an excellent supplement to conventional methods for TN therapy.28 performed a double-blind cross-over trial of low-level laser therapy (LLLT) in treatment of established PHN of at least 6 months duration with no response to conventional methods of treatment. Patients were treated with a gallium aluminium arsenide (GaAlAs) diode-laser (830 nm: 60mW). Results demonstrated a significant reduction in the intensity and distribution of pain (74% of patients) due to a course of LLLT (4 consecutive laser treatments).Moore et al.29 divided 137 patients with typical TN in 4 groups. Thirty patients (G1) received EHF therapy (extremely high frequency puncture), 30 patients exposed to laser (G2), 67 patients treated with combination of laser and EHF-puncture (G3), 10 patients were in control group received physiotherapy. All patients were given carbamazepine. Best results were given from G3 which 31% of cases could stop carbamazepine and the rest of them could reduce its dose by 50-70%.Samosiuk et al.th session. 30Vernon and Hasbun reported a 61-year-old female with TN. They treated her with GaAlAs diode-laser  with protocol of every day irradiation with two days interval after each five day. Total of 20 sessions of exposure performed. The patient reported no pain at the 1231 evaluated the efficacy of low -level laser in 63 patients with PHN. They used GaAlAs laser  as LLLT system. The immediate effect after the initial LLLT was very good and good in 26 and 30 patients, respectively. The long term effect after completion of exposure period resulted in no pain in 12 cases and slight pain in 46 patients. In this study, no complications and side effects was reported.Kemmotsu et al32 used He-Ne, GaAlAs and CO2 laser in patients suffering from trigeminal neuralgia. Twenty five patients divided in two groups: one group treated with low-level laser therapy and another group treated with laser and medication. Visual analogue scale showed that compared with the combined therapy, the laser therapy alone cause more pain relief.Kim et al3333 investigated the efficacy of combi-laser in 50 patients with PHN. In each patient the laser therapy was given for 15 days with the period of 5 minutes and 6 seconds exposure for each appointment. The therapeutic effect of the laser was evaluated after 5th and 10th and 15th day with visual analogue scale (VAS). Patients started responding after third day and after completion of therapy, 43 out of 50 showed great relief (76-100%), four cases showed good relief (51-75%), two cases with fair relief (26-50%) and one case with poor relief (1-25%).33Mann et al.34 reported that because of high density of receptors in the facial skin and short distances of conductions in comparison with limb extremities, laser evoked potential (LEP) recordings after trigeminal stimulation are easier and quicker. They represented that oral mucosa, upper lip, skin of supra-orbital region, chin and temples are sensitive areas to laser irradiation.Romaniello et al.35In contrast to most studies, another study revealed that between laser and placebo irradiation groups there was not any statistically significant difference according to the analgesic effect.However few studies have been performed on effect of low -level laser therapy on trigeminal neuralgia, regarding the results of the most studies and the pain relief effect of laser on chronic pains, it seems that laser therapy could be an appropriate substitute for current treatments in which side effects are really annoying for the patient.25 used He-Ne laser which resulted in favorable reduction in PHN after both 20 and 50 sessions. Walker found that He-Ne laser was effective in patients with trigeminal neuralgia, post-herpetic neuralgia, sciatica, and osteoarthritis after 30 sessions of irradiation.26 In addition, in another study He-Ne laser was used in treatment of TN with wavelength of 632.5 nm and power of 1 mW for 30 sessions and found it useful after one-year follow up.24Among Studies, two studies by Ijima et al36In the mentioned studies, each point had received 6 to 10 J in chronic forms and 3 to 6 J in acute ones. Laser had been radiated in various points: trigger points, nerve pass out of bone, and also acupuncture points. No study has been performed to compare different points of radiation. Simunovic believes that He-Ne laser is the most proper laser for TN and radiation in trigger points is more effective than any other points.28 Kemmotsu et al31 also used GaAlAs and irradiated laser for 36 sessions on average and demonstrated good long-term results in resistant PHN cases. Vernon and Hasbun30 used GaAlAs laser to treat a patient with TN. They found LLLT very effective in pain relief after 12 sessions. However, they completed 20 sessions of irradiation. Mann et al33 also reported great pain relief after 15 radiation sessions with combi-laser (1000Hz and 12x70 watts). In addition, Mittal et al37 used combi-laser (5000 Hz and 8 J/cm2) for16 sessions and demonstrated the same results.Effectiveness of LLLT in resistant PHN was also found. In that study, they used GaAlAs with wavelength of 830 nm and power of 60mW. They reached favorable results after 4 sessions which is less than treatment with He-Ne laser.2 into PG type I2, increase in beta-endorphins level in CSF, increase in glucocorticoids urinary secretion (glucocorticoids are beta-endorphin synthesis inhibitor), increase in pain threshold in nerve fibers, increase in serotonin urinary secretion, decrease in histamine and serotonin secretion, decrease in bradykinin synthesis (pain inducer substance), change in norepinephrine and epinephrine activity, increase in ATP production, increase in local microcirculation, lymph node circulation enhancement and edema decline.40Different mechanisms have been considered for the pain attenuation of the low-level lasers include effect on prostaglandin (PG) synthesis, increase in the change of PG type G and PG type H41Also, LLLT can modulate inflammatory pain by reducing levels of biochemical markers , neutrophil cell influx, oxidative stress, and formation of edema and hemorrhage in a dose-dependent manner.It should be mentioned that distinguishing neuralgia from other chronic pains such as atypical facial pain plays an important role in effectiveness of treatment.Briefly, however, studies about low-level laser therapy on trigeminal neuralgia are various according to numbers of sessions and wavelengths and duration of irradiations, most of them demonstrated effectiveness of laser therapy in pain relief. A study is recommended for comparison of different methods for finding the most effective properties of laser therapy on trigeminal neuralgia.The studies revealed that low-level laser therapy could be considered in treatment of trigeminal neuralgia. Laser causes pain relief without any side effects. It could be helpful especially in patients suffering from neuralgia tolerated to drug therapy. It should be mentioned that distinguishing neuralgia from other chronic pain such as atypical facial pains is important in effectiveness of treatment.


Chronic neck pain is a highly prevalent condition, and is often treated with non-steroidal anti-inflammatory drugs. Limited clinical studies with short-term follow-up have shown promising efficacy of acupuncture as well as miniscalpel-needle (MSN) release. In this retrospective study, we examined whether MSN release could produce long-lasting relief in patients with chronic neck pain.We retrieved the medical records of all patients receiving weekly MSN release treatment for chronic neck pain at this institution during a period from May 2012 to December 2013. Only cases with the following information at prior to, and 1, 6, and 12 months after the treatment, were included in the analysis: neck disability index (NDI), numerical pain rating scale (NPRS), and active cervical range of motion (CROM). The primary analysis of interest is comparison of the 12-month measures with the baseline. Patients who took analgesic drugs or massage within 2 weeks prior to assessment were excluded from the analysis. For MSN release, tender points were identified manually by an experienced physician, and did not necessarily follow the traditional acupuncture system. MSN was inserted vertically  until breaking through resistance and patient reporting of distention, soreness or heaviness. The depth of the needling ranged from 10 to 50 mm. The release was carried out by moving the MSN up and down 3–5 times without rotation.A total of 559 cases (patients receiving weekly MSN release treatment for chronic neck pain) were screened. The number of cases with complete information  was 180. After excluding the cases with analgesic treatment or massage within 2 weeks of assessment (n = 53), a total of 127 cases were included in data analysis. The number of MSN release session was 7 (range: 4–11). At 12 months after the treatment, both NPRS and NDI were significantly lower . All 6 measures of CROM were significantly higher at 12 months vs. the baseline. No severe complications (such as nerve damage and hematoma) were noted.MSN release is effective, even 12 months after the treatment, in patients with chronic neck pain. Caution must be exercised in data interpretation due to the respective nature of the study and lack of a comparator group. Chronic neck pain affects most adults at some point during their lifetime –3. AnnuaTreatment for chronic neck pain includes exercise, massage, spinal manipulation, cervical traction, acupuncture, and the use of non-steroidal anti-inflammatory agents. Massage increases the compliance of soft tissue by mobilizing and elongating the connective tissue and shortening soft tissue –8. A sysAcupuncture has been shown to provide short-term benefits in patients with chronic neck pain –17. MiniPrevious studies have reported superior efficacy of MSN release in patients with cervical myofascial pain syndrome over trigger point injection and acupuncture , 20, 23.This retrospective observational study was approved by the Ethics Committee of the First Affiliated Hospital of Guangzhou Medical University (Permit No 2015–15). Verbal informed consent for the MSN treatment was on medical records in all included cases. All patients signed informed consent to publish this material.All cases with non-specific chronic neck pain on electronic records in the Department of Rehabilitation Medicine of the First Affiliated Hospital of Guangzhou Medical University, during a period from May 2012 and December 2013 were reviewed. The diagnosis of non-specific chronic neck pain was established by attending physicians, and defined as pain of mechanical origin located in the neck, with or without radiation to the head, trunk or limbs . All patThe protocol for the MSN release treatment is based on previous clinical reports , and wasAfter the last session of the MSN treatment, patients received educational material containing: the use of hot packs, stretching of the upper trapezius muscle and levator scapulae muscle, and postural correction exercises. Patients were asked to return at 1, 6, 12 months for a follow-up examination.The subjective outcome measures included pain intensity, as measured using a 10-point numerical pain rating scale (NPRS)  and neckObjective outcome measures were obtained using active cervical range of motion (CROM) . The CROVariables are reported as the mean ± standard deviation upon normal distribution, and as the median (range) otherwise. Data  after the MSN release were compared to the baseline using the Wilcoxon matched-pairs signed rank test with SPSS Statistics 19 software . Statistical significance was assumed if p < 0.05.A total of 559 were identified in the screening. The number of cases with complete information  was 180. After excluding the cases with analgesic treatment or massage within 2 weeks of assessment (n = 53), a total of 127 patients with chronic neck pain were included in data analysis  experienced subcutaneous bleeding and transient distending pain; the symptoms/signs dissipated with management. No severe adverse complications  were reported.Previous studies have reported that MSN treatment produces greater short-term pain relief in patients with cervical myofascial pain syndrome than trigger point injection and acupuncture , 20, 23.In this study, we used both subjective (NPRS and NDI) and objective (CROM) outcome measurements to investigate the long-term effects of MSN treatment in patients with chronic neck pain. To minimize the impact of confounding factors, cases with the use of “pain-killers” or massage within 2 weeks prior to assessment were not included in the analysis. Such a design excluded majority of the cases. However, the results in the remaining cases (n = 127) were sufficient to show significant improvement at 12 months after the cessation of MSN release treatment in all 3 measures .MSN treatment was developed in China in the 1980s, and is structurally based on traditional acupuncture needles . We beliMSN treatment retains the benefits of traditional acupuncture needling. Numerous studies have shown that acupuncture could alter the metabolism of substrates involved in both the ascending facilitory pathway  and the descending inhibitory pain pathways  –36. For Myofascial pain syndrome is one of the most frequent causes of chronic musculoskeletal pain , 40. HowPotential adverse experiences of MSN release are typically minor, and include subcutaneous bleeding, coldness, burning sensation, and muscle pain . In the The current study is retrospective by design. A randomized controlled trial with a comparator arm would have been more convincing, but practically difficult. The fact that majority of the initially screened subjects were not included in data analysis in the current study (a retrospective study) highlights the technical difficulty. Regardless, we attempted to minimize potentially important confounding factors. Specifically, patients who took analgesic agents or massage within 2 weeks of assessment were not included in data analysis.MSN release could provide long-lasting benefits in patients with chronic neck pain. The safety profile is acceptable.S1 Table(XLS)Click here for additional data file.


Recurrent chest pain is common in patients with and without coronary artery disease. The prevalence and burden of these symptoms on healthcare is unknown.To compare chest pain return visits (recidivism) in patients with unexplained chest pain (UCP) against reference group of patients with coronary artery disease (CAD) and estimate the annual cost of recurrent chest pain.In a retrospective cohort study, a Veteran Affairs (VA) administrative and clinical database of Veterans who were deployed to or served in support of the wars in Iraq or Afghanistan was queried for first disease specific ICD-9 code to form two cohorts (UCP or CAD). Patients were followed between 09/2001-09/2010 for the first and cumulative return visits for UCP or cardiac pain (ACS or angina) to clinic, emergency department or admission; or for all-cause death. Time to return was analyzed using Cox regression and negative binomial models and adjusted for age, gender, race, marital status, and risk factors . Direct total costs included inpatient, outpatient and fee basis (non-VA) costs.earlier with any chest pain ; or unexplained chest pain than CAD patients . UCP patients were also likely to return more frequently for any chest pain  or UCP than CAD patients . Per 100 patients, the 1-year cumulative returns were 37 visits for reference group and 45 visits for UCP cohort. The annual costs for chest pain averaged $69,009 for CAD and $57,336 for UCP patients .Of 749,036 patients, 20,521 had UCP and 5303 had CAD. UCP patients were young and had a lower burden of risk factors than CAD cohort (p < .01). Yet, these patients were likely to return Chest pain recidivism is common and costly even in patients without known CAD. We need evidence-based guidelines for these patients to minimize returns.The online version of this article (doi:10.1186/s12875-015-0287-9) contains supplementary material, which is available to authorized users. Chest pain is one of the most common conditions seen in the primary care setting. In fact, 20-40 % of the population experiences some chest pain over their lifetime. In the United States, over eight million patients with chest pain are evaluated in the outpatient setting each year, posing a significant health burden . PrimaryWe evaluated these questions in the Veteran Affairs (VA) health care system using the Women Veteran Cohort Study (WVCS), with its detailed electronic health records providing longitudinal data of service utilization and costs of Veterans of Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF) and Operation New Dawn (OND) . Prior rThe Defense Manpower Data Center provided the VA OEF/OIF/OND roster for personnel discharged from the US military from 09/12/2001 to 09/30/2010 and enrolled for VA care. Data on their services and costs were linked to the VA administrative and clinical encounters to the VA National Patient Care Database, Decision Support Systems (DSS), National Data extracts and the VA Corporate Data Warehouse. Detailed information on services paid for by VA but provided by non-VA facilities or contract providers, including inpatient, outpatient and pharmacy care was obtained from the DSS Fee Basis files. The Human Investigation Committees at West Haven VA Medical Center and Yale University School of Medicine approved this study.th Revision (ICD-9) was used and medical conditions were included if the specific code was noted at least once for an inpatient stay, observation or ED stay or at least twice for an outpatient visit. This methodology for the use of ICD-9 codes in VA database has been validated elsewhere [For diagnostic data, the International Classification of Disease, 9lsewhere .For co-morbidities, we used previously validated diagnostic algorithms for diabetes, hypertension, dyslipidemia, obesity, and CAD . We defifirst diagnosis after entry into the VA system (end of last deployment). Those with an encounter listed as ICD-9 code ‘786.50’ entered the unexplained chest pain cohort and those with CAD codes  for either unexplained chest pain or cardiac chest pain , or death. Patients were followed until study outcome or exit from the cohort during a ten-year study period. ICD-9 codes included were chest pain (786.50), CAD (414.x and 429.x), acute myocardial infarction (410.x), unstable angina (411.x) or angina (413.x) as primary or secondary diagnosis. Time to return visit as well as the cumulative number of chest pain visits were recorded.Total health care costs were computed by summing all costs across inpatient, outpatient and pharmacy services after identification of cohort. Costs included both costs of services delivered in VA facilities as well as costs of services delivered by non-VA care(fee-basis) providers. Finally each of these measures were linked to the cardiac ICD-9 codes outlined above to determine the cost of care for both groups of patients.t test. Nominal or dichotomous variables were expressed as proportions and compared by chi-square test. Kaplan Meier curves were estimated to show those without a return visit by cohort and gender for (a) any chest pain  and b) unexplained chest pain only. Time to return visit and incident rate for death was compared using Cox regression with adjustment for age, gender, race, marital status, education, hypertension, dyslipidemia, smoking, diabetes, obesity (defined as BMI ≥30), cohort and interaction terms with gender.Continuous variables were expressed as mean +/− standard deviation and compared by unpaired Student’s Cumulative incident return rates were calculated per patient from the point of entry to last follow up. Crude incident rates were calculated by dividing the total number of return visits for chest pain by the total number of patients in each cohort for the duration of observation for each patient. All eligible index visits for chest pain were used as the unit of analysis. This way we captured multiple visits for the same patients. All rates were expressed as the total per 10000 visits. Rate ratios and confidence level for all rates were calculated using a generalized linear model with a negative binomial distribution and an offset of the log years of follow-up given the variable observation period for each patient. Separate adjusted models were constructed using the socio-demographic and cardiac risk factors listed above. The mean number of return visits per subject was calculated using a nonparametric estimator .Total costs were compared across the two cohorts using geometric means and Mann-U-Whitney tests because of extreme right skewness. A generalized linear model with a log link function was developed to identify and adjust for differences in demographic, cardiac risk factors and year of entry (to account for inflation). Because pharmacy costs are not coded by diagnosis, all prescription use was compared for the two cohorts.All analysis was performed using SAS v.9.0. P-values of <0.05 were considered statistically significant.The study cohort followed 749,036 patients prospectively over ten years of which 2592 (2.9 %) females and 18,010 (2.7 %) males reported chest pain. After entering the VA system, 20,521 patients entered the unexplained chest pain (UCP) cohort and 5303 patients constituted the CAD (reference) cohort based on the first diagnosis and were analyzed. As expected, our cohort was young with median age 34 years ,11 % female and 66 % white. Overall cardiac risk factor profile was as follows: 39 % had hypertension, 12 % were diabetic, 45 % had dyslipidemia, 38 % smoked and 31 % were obese. Known CAD patients were more likely to be older, male, white, married and had a higher rate of co-morbidities   Fig. . Adjusteunexplained chest pain alone was higher (13.4 % and 25.3 %) in the UCP cohort than the reference group (4 % and 10.8 %)   Fig. . After aNegative binomial regression comparing cumulative return visits for chest pain for the duration of follow up revealed that patients with UCP were 58 % more likely to return for any chest pain  and 2.6 times more likely to return with unexplained chest pain than the reference group  . Costs were heavily skewed, as the median costs as well as distribution of costs were similar between both groups  and unlikely to have alternate insurance such as Medicare. Our results may then actually underestimate the rates of return visits. Third, it is possible that some patients were redeployed during the follow up period, however symptomatic patients with chest pain are unlikely to be deployed. Fourth, it is possible that coding errors occurred. However our findings from previous studies show good reliability . Fourth,Unexplained chest pain is common and a frequent cause of recidivism in young Veterans without known CAD. With a projected annual cost of over $300 billion, unexplained chest pain represents an unidentified source of major cost to the health system and warrants further investigation.Abstract from this study has been accepted for presentation at the American Heart Association Scientific Session 2013 to be held in Dallas, TX.Additional file 1:ICD-9 Codes for CAD.


Back pain is a major health issue in Western countries and 60%–80% of adults are likely to experience low back pain. This paper explores the impact of back pain on society and the role of physical activity for treatment of non-specific low back pain. A review of the literature was carried out using the databases SPORTDiscuss, Medline and Google Scholar. A general exercise programme that combines muscular strength, flexibility and aerobic fitness is beneficial for rehabilitation of non-specific chronic low back pain. Increasing core muscular strength can assist in supporting the lumbar spine. Improving the flexibility of the muscle-tendons and ligaments in the back increases the range of motion and assists with the patient’s functional movement. Aerobic exercise increases the blood flow and nutrients to the soft tissues in the back, improving the healing process and reducing stiffness that can result in back pain. Back pain is a major health issue in Western countries and is associated with increasing medical expenditure, work absence ,2 and isIt is recommended for patients with NSCLBP to remain physically active, as long periods of inactivity will adversely affect recovery ,14. A vaPhysical activity (PA) to increase aerobic capacity and muscular strength, especially of the lumbar extensor muscles, is important for patients with CLBP in assisting them to complete activities of daily living . HoweverEight-five percent of back pain cases have an unknown cause , normallA systematic review was carried out between 2014 and 2015 using the databases SPORTDiscuss, Medline and Google Scholar. The first author selected intervention programmes published between 2005 and 2015 which investigated the effect of PA or exercise interventions for NSCLBP patients involving aerobic exercise, muscular strength and stabilisation exercises and/or flexibility training on NSCLBP. The first author read and reviewed the articles. Chronic pain was defined as pain remaining for longer than three months and further inclusion criteria was that the participants involved in the studies should be ≥18 years old. The intervention programmes were identified using the search terms “non-specific chronic low back pain and exercise” which returned 141 results. Other search terms included “chronic low back pain and aerobic exercise” (187 results), “chronic low back pain and muscular strength” (120 results) and “non-specific chronic low back pain” (173 results). A total of 14 studies were included within the final review. The review summarised the effect on NSCLBP within the included intervention programmes.Studies were included within the final review based on the following: population, intervention and the outcome.Population: NSCLBP patients aged 18 years or older.Intervention: Aerobic exercise, muscular strength or stabilisation exercises and/or flexibility training intervention programmes. There was no restriction on the inclusion of a follow up in the included studies.Outcome: Investigate effect of the intervention on NSCLBP which was not limited to one specific measure for pain.Literature reviews and any article which did not involve a delivery of an intervention programme to NSCLBP patients.Back pain is defined as chronic when the pain remains for longer than three months . CLBP caBack pain is then further categorised into specific or non-specific back pain. Non-specific back pain is diagnosed when the cause of the back pain is unknown ,43, and PA increases the blood flow to the back which is important for the healing process of the soft tissues in the back . Being pThe difference between PA and exercise is that exercise is planned and structured which involves disrupting homeostasis by concentric, eccentric and isometric muscular activity and involves repetitive movements . PA is nMost people with non-specific acute low back pain recover in 4–6 weeks with or without a treatment . TherefoFurthermore, a review of six randomised controlled trials researched the effect of exercise programmes on patients with non-specific sub-acute low back pain . The revAerobic exercise can benefit CLBP as it increases the blood flow and nutrients to the soft tissues in the back, improving the healing process and reducing stiffness that results in back pain . In addi2max) was significantly lower by 10 mL/kg in men with CLBP compared to men without [2max was also significantly lower by 5.6 mL/kg in women with CLBP compared to healthy counterparts.A low aerobic fitness level is associated with CLBP ,61, and  without . VO2max Aerobic exercise for 20 min on a cycle ergometer at 70% peak oxygen uptake reduced the pain perception for more than 30 min for patients with CLBP . AerobicA 6-week moderate intensity aerobic exercise programme  for 52 sedentary NSCLBP patients was compared to a 6-week programme involving specific strengthening exercises for the trunk and upper and lower limbs . CLBP siAn 8-week moderate intensity aerobic exercise intervention at 40%–60% of heart rate reserve combined with conventional physiotherapy, significantly reduced NSCLBP by 47% . This wa2max. This increase was not significant, and also suggests that additional factors excluding aerobic fitness levels must have had an influence on reducing CLBP. This was in contrast to previous research which suggested aerobic fitness levels to be associated with CLBP [The 8-week intervention programme was also found to increase aerobic fitness by 3.3% as measured by VOith CLBP ,61. The A 12-week high intensity aerobic exercise programme involving running on a treadmill at 85% of heart rate reserve and was compared to passive treatment (ultrasound and did not include any form of PA) . The 12-The effect of high intensity aerobic exercise on CLBP was further supported by a 12-week high intensity aerobic exercise programme (running on a treadmill at 85% heart rate reserve) which significantly reduced NSCLBP by 30% . This stHowever the study  excluded2max does not significantly increase cortisol levels [Walking is known to be a safe form of exercise for CLBP patients as it is associated with a low injury rate  and doesl levels , and lowl levels .These studies indicate that although similar outcomes can be achieved despite differences in aerobic exercise intensity. Thus moderate exercise should be promoted over high or low intensity programmes given the reduced risks, enhanced compliance, optimal benefits and reduced impact .Exercising at a comfortable intensity for the patient is important in reducing fear avoidance , which iModerate intensity aerobic exercise (40%–60% heart rate reserve) should be promoted for NSCLBP rehabilitation. Aerobic fitness, behavioural treatment and multi-disciplinary treatment programmes are important for reducing CLBP and improving disability .A reduction in core strength can lead to lumbar instability , and lumA high volume of stress placed on the vertebral column muscles can lead to back pain , and pooStabilisation exercises have been shown to be effective in reducing NSCLBP ,21,24, bStrengthening exercises are considered the most effective treatment for functional gain including walking speed . This isCore stabilisation programmes ,21,23,24A 3-month intervention involving 30 NSCLBP patients compared core stabilisation exercises including slow curl ups, bird dog, the plank and sit ups (raising the head and shoulders off the ground with the hands under the head) to conventional spine exercises . The conCore stabilisation exercises significantly reduced NSCLBP by 76.8% compared to a 62.8% significant reduction following the conventional exercises. These findings suggested both core stabilisation and conventional exercises to be significantly beneficial in reducing CLBP. However the core stabilisation group reported a significantly greater improvement compared to conventional exercises, highlighting the importance of core stability for CLBP patients.An 8-week core stability intervention programme for 10 NSCLBP patients involved activating core stability responses using unstable standing surfaces and unexpected movements of the upper limbs . CLBP siAnother study involved an 8-week stabilisation programme  involvinAnkle dorsiflexion exercises were included in the exercise programme because the proprioceptive neuromuscular facilitation irradiation technique, increases core muscular strength by stimulating stronger muscles from the lower body , which pThe study reported that the experimental group significantly reduced NSCLBP by 32.5% (according to the VAS), 23.2% (Pain Disability Index) and 21.5% . The control group significantly reduced CLBP by 16.8% (VAS), 12.4% (Pain Disability Index) and 8% .This study  also incCore stability measured by the active straight leg raise was also shown to improve by 56.1% in the experimental group, and 27.4% in the control group after 8 weeks. The results highlighted the importance of core stability in reducing CLBP, especially as core stability had improved by an additional 33.8% at the two month follow up compared to the 8-week measurement in the experimental group, and consequently CLBP had been shown to reduce further. Therefore the results suggested that the addition of ankle dorsiflexion exercises when combined with drawing in the abdominal wall to be an effective exercise in reducing CLBP.The addition of ankle dorsiflexion exercises to drawing in the abdominal wall is a unique technique for improving core stability for NSCLBP patients, as this technique has only been previously researched in 40 healthy participants . This stThe importance of core stability and muscular strength was emphasised by research which had reported that a slumped sitting posture involving lumbar flexion, resulted in a lower activation of the core muscles such as the lumbar multifidus, iliocostalis lumborum pars thoracis and the transverse fibers of internal oblique . ConsequPatients with low back pain adopt a sitting posture with significantly more lumbar flexion than those without low back pain ,109. TheA 12-month exercise programme focused on increasing control of the lumbar neutral zone  and invoA muscular strength 8-week intervention programme involving 47 women with NSCLBP  investigTrunk extension flexibility was also shown to improve in all three groups. However the biggest increase of 22% was reported in the inversion −60° group compared to an increase of 13.3% in the inversion −30° group, and 4.8% in the supine group. This suggested that a range of factors are responsible for the decrease in NSCLBP, and indicates that a general intervention programme focusing on a range of different areas of fitness is important for NSCLBP rehabilitation.A 4-week core muscular strength programme (control group) was compared to a core stability programme in addition to core muscular strength exercises , in 160 patients with NSCLBP . NSCLBP Four variables exist which may determine the success of a stabilisation exercise programme for CLBP . The fouFinally, a 15-item questionnaire on clinical instability has been identified , which rIncreasing the strength of deep abdominal muscles and improving the stabilisation of the spine is effective at reducing NSCLBP. A core stabilisation programme combined with muscular strength should be considered for NSCLBP patients, as this was shown to be more effective than core muscular strength exercises alone . This suStretching the soft tissues in the back, legs and buttock such as the hamstrings, erector muscles of the spine and hip flexor muscles, ligaments and tendons can help to mobilise the spine, and an increase in the range of motion of the spine can assist back pain . This isAccording to the pelvic cross syndrome theory, muscle abnormalities in the postural muscles such as a decreased flexibility and shortening of the hip flexor and back extensor muscles, can result in additional mechanical stress to the joints and soft tissue of the lumbar spine, and can cause lumbar lordosis . Lumbar Flexibility exercises are often used in exercise rehabilitation programmes as they have been shown to be effective at reducing the pain associated with CLBP ,27. HoweA 4-week intervention programme involving 40 female NSCLBP patients between 45 and 65 years  includedr = −0.581). However these results cannot be generalised to men.The study reported a 54% significant increase for lumbar flexion and 98% for lumbar extension. Back pain also significantly improved by 58%. The results suggested that completing exercises to improve lumbar flexion and extension is important in reducing NSCLBP in women. This is because during the baseline measurements lumbar flexion was found to be correlated with back pain  had a significantly reduced lumbar flexion compared to the participants without current low back pain (15 participants). However no significant difference was identified in hamstring flexibility between the two groups. In addition no significant difference was identified in lumbar flexion or hamstring flexibility between the participants who had experienced low back pain at some point in their lives (21 participants), or had not experienced low back pain (5 participants).The results suggested that hamstring flexibility was not associated with low back pain occurrence, and therefore improving hamstring flexibility is not important for preventing low back pain or for an intervention programme for a patient with low back pain. Although, the results did highlight the importance of improving lumbar flexion for patients with current low back pain, and also suggested that a reduced lumbar flexion is an important factor for an occurrence of low back pain.However the study  did not A 3-month intervention programme for 86 NSCLBP patients  investigBack pain significantly decreased post intervention by 44% in the intensive training group, 32% in the home exercise group and 39% in the control group. The 6-month follow up identified that back pain had decreased further in the home exercise group to a 47% reduction which was significantly different to baseline. The intensive training group which increased compared to post intervention to a 32% reduction compared to baseline, although this was still significantly different. The control group also increased compared to post intervention to 28% and was not significantly different to baseline.The flexibility of the hamstrings significantly increased at post intervention from 87°–90° in the intensive training group and 83°–87° in the home exercise group. However at the 12-month follow up hamstring flexibility had reduced to 83° in the intensive training group and 82° in the home exercise group. This suggests the importance of maintaining exercise which is aimed at improving flexibility, as both exercise groups lost the improved degree of hamstring flexibility. Although there was no correlation between back pain and flexibility which suggested the importance of other factors on back pain, such as an increase in core strength and aerobic fitness ,19,23. HImproving the flexibility of the lumbar spine and hamstrings can significantly reduce CLBP by 18.5%–58% ,27. ThisAn improvement in lumbar flexibility can increase the range of motion of the spine, which can help to reduce back pain and assist with movement . HamstriExercise intervention programmes involving either muscular strength, flexibility or aerobic fitness is beneficial for NSCLBP but not acute low back pain. Non-specific acute low back pain patients recover in 4–6 weeks with or without a treatment , and exeNSCLBP is multi factorial in nature ,120, and