Chronic musculoskeletal pain (CMP) is one of the most common symptoms of musculoskeletal disorders. Carpal tunnel syndrome (CTS) and subacromial syndrome (SAS) are the most prevalent musculoskeletal disorders of the upper limbs. By collecting the opinions of patients with CTS and SAS, we aim to identify variables that could be introduced in the follow-up of CMP, and to detect barriers and facilitators of its treatments to improve their acceptance. This qualitative study is being conducted in Lleida, Spain, and explores the experiences and feelings of patients, and their acceptance of the standard of care. It follows the consolidated criteria for reporting qualitative research (COREQ) through focus groups, addressing issues with rigor and representativeness. By collecting patients’ opinions, we expect to obtain valuable information to complement the set of variables previously used by health professionals in the follow-up of CMP, and to understand treatment barriers and facilitators. In 1979, the International Association for the Study of Pain (IASP) defined pain as “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”  and descAccording to a systematic review, approximately 1710 million people in the world experience musculoskeletal disorders, with chronic musculoskeletal pain (CMP) being one of the most common symptoms . In 2005The majority of studies on CMP favor a conservative treatment, which, in addition to having fewer complications than surgery, has shown a functional long-lasting improvement . The firHowever, pain treatments could be differently seen by each professional involved in therapy, and by each patient. As shown by Kohrt et al., incorporating patients’ experiences, social determinants, and comorbidities into healthcare models would help professionals to provide personalized care . The latIn this context, our objective is to identify which variables could be introduced in the follow-up of CMP, and to detect the barriers and facilitators of treatments, in order to improve their acceptance. We will achieve that by collecting the opinions of patients with CTS and SAS. Our research is being conducted in the context of a regular care practice for people with CTS or SAS treated in PC Health Centers, within the framework of a study with mixed methodology , and following the recommendations of the Medical Research Council. Our multidisciplinary approach with the collaboration of patients could better address society’s needs and guide public health policies towards more experiential population health ,18, withThis is a qualitative study with a phenomenological perspective that began in Lleida, Spain, in February 2022, and is expected to end in December 2023. It follows the consolidated criteria for reporting qualitative research (COREQ)  and addrWe are collecting information on individual experiences of pain from upper limb disorders (CTS and SAS) among focus groups of patients. This way, we will gain insight into patients’ opinions on follow-up methods and current treatments. We will mean to obtain information about three thematic blocks, and dimensions of interest, structures according to the researching multidisciplinary team opinion. The approach allows holistic configuration study, subject to a flexible and dynamic structure that let to address deeply the livelihoods, opinions and experiences of the participants.The sample is intentional , and parPatients are accessed through medical professionals from different Lleida PC Health Centers and pre-selected according to the CTS or SAS clinical records, obtained from the electronic medical records stored in the centralized ECAP database. Professionals are in charge of making the first approach, asking patients if they are interested in participating, giving them the informed consent and the study information sheet, and collecting their contact details. Then, patients are given time to consider the request before the research team calls them to confirm the profile, request their informed consent, and finally arrange their participation in a focus group. Groups are defined according to profiles and adapted to the patients’ availability and preferences.Six focus groups of 8–10 people will be formed with a semi-structured script . These gThis project has been evaluated and accepted by the Research Ethics Committee of the Primary Care Research Institute IDIAPJ Gol with the code 4R22/067. The study is being carried out following the recommendations of the Declaration of Helsinki and Tokyo. The records of the discussion groups, the data, and the variables collected will be treated anonymously, guaranteeing confidentiality. The evaluation will be done in compliance with Regulation 2016/679 of the European Parliament and of the Council, which took place on 27 April 2016, regarding the protection of natural persons, the processing of personal data, and the free circulation of these data. The evaluation will also comply with the Organic Law 3/2018, which took place on 5 December, on the Protection of Personal Data, and the Guarantee of Digital Rights. The participant lists and the group recordings will be kept electronically and protected by utilizing identification codes with dissociation of the data. The files will be located in a corporate environment with restricted access, remain in the research team’s possession, and will be treated confidentially. The data will undergo an anonymization process prior to their use. Anonymized database will be accessible and only used by the research and collaborating teams working on this study. Data will be stored until the results are disseminated. If patients give consent for transfer and portability for other scientific research purposes, their wishes will be respected. Data will be preserved for 10 years at least. Data linked to a publication or verification of the investigation will be preserved in the long term. The data will be stored in an ICS institutional repository. Personal data collected for this research will not be shared with other databases.An inductive thematic content analysis will identify the core meanings within a wide and varied content and thus obtain a unique and original analysis of the previously defined thematic blocks.  Table 1Table 1.Specifically, we will perform verbatim transcripts of the recorded sessions, properly anonymized. Such transcripts will be then entered into the Atlas-Ti software and examined, coded and categorized by thematic units/dimensions. The outcome will be analyzed by the research team. To give more rigor to the project and validity to the study, and to ensure the quality of the interpretation, the data will be triangulated between researchers. Afterwards, a thematic analysis of the literal transcription of the interviews will be carried out manually and separately by several research team members. Finally, a joint effort will unify the results by reconciling the differences, and a summary will be generated. An analysis of the discourse will be carried out following the model proposed by Braun and Clarke . If neceWith this study, we expect to obtain information about patients’ experiences and opinions on the follow-up and treatments of CMP in CTS or SAS. This way, we would identify new variables to be introduced in the follow-up of CMP, e.g., articular functionality, pain range, participation in the treatment process, complementary tests, use of concurrent treatments, complications of the standard of care, specific complications of the puncture treatments (I and UI), and patient satisfaction. Additionally, we will obtain information on treatment  barriers and facilitators that patients may encounter, and determine treatment acceptance.Being able to work with the most accepted follow-up model represents a solid basis to establish the therapeutic alliance between health professionals and patients, and to address psychosocial influences on pain. According to Cuyul et al., interventions on the biological dimension should be congruent with interventions on psychosocial factors . In linePossibly our results will be in line with findings from other publications: injected treatments are considered less favorably than oral medications ; patientThis research may open new possibilities through a better investigative approach, involving common people as active participants and improving patient empowerment . CitizenThese contributions will be integrated as new approaches in clinical practice and will be evaluated in a randomized clinical trial setting that will be done in a later phase. The objective of the trial will be to evaluate the functional outcomes of I, UI, and PT treatments, cost-effectiveness and cost-utility, and overall patient satisfaction. The study is registered on ClinicalTrials.gov under code 4R22/067.Pain is a subjective sensation that is experienced by individuals throughout their life, affecting their well-being ,29. It iSometimes individual sensations of patients experiencing pain are unknown to the professionals taking care of them that, therefore, do not offer the best pain management. Indeed, healthcare providers may equip patients with guidelines for self-management and lifestyle, but patients’ actions are influenced by multiple factors, including job requirements, beliefs, and environment . Thus, tThe management of patients with pain can be complex and may require a multidisciplinary approach considering all the factors described above to provide safe and quality care . MoreoveIn the present study, we propose to integrate the information provided by patients with CMP caused by CTS and SAS in their follow-up . KnowingOur study design has some limitations. First, incorporating the focal group technique within investigation could make the participants feel uncomfortable because of the group presence or the dominance of one member. However, this could be solved through the correct leadership of the focal group conductor, either by means of his experience or his skillfulness may imply its success. Besides, the aim of the investigation, the sensitivity of the treated subject, and any other logistical aspects could also solve this issue. Another limitation is represented by the data analysis and transference, which can be quite difficult when dealing with a subjective matter such as pain. A good design of the study with the right adaptability and the flexibility to investigate new aspects will be needed.We expect to understand for the first time the experience of patients, and so to incorporate it in the follow-up strategies and acceptance of the treatments, acknowledging the difficulties and facilitations they may find.


Myofascial pain syndrome (MPS) is thought to stem from masticatory muscle hypersensitivity. Masticatory myofascial pain syndrome (MMPS) is characterized by multiple trigger points (MTrPs), also known as hyperirritable points, in taut bands of affected muscles, regional muscle pain, or referred pain to nearby maxillofacial areas like teeth, masticatory muscles or the temporomandibular joint (TMJ). Muscle stiffness, reduced range of motion, muscle weakening without atrophy, and autonomic symptoms may accompany regional discomfort. Multiple treatments have been utilized to reduce trigger points and mandibular function restrictions. As a result of these incapacitating symptoms, MMPS can significantly impair many elements of quality of life. The application of Kinesio tape (KT) is a non-invasive method of treating dormant myofascial trigger points. Utilizing the body’s innate capacity for self-repair, this technique entails taping specific regions of the skin. KT alleviates discomfort, decreases swelling and inflammation, enhances or suppresses motor function in the muscles, stimulates proprioception, promotes lymphatic drainage, stimulates blood flow, and expedites tissue recovery. However, studies conducted to assess its effects have frequently yielded contradictory results. To the best of our knowledge, just a few research has looked into the therapeutic effects of KT on MMPS. The purpose of this review is to determine the efficacy of KT as a therapeutic tool for regular treatment or as an adjunct to existing therapy for MMPS based on the evidence presented in this review. To establish KT as a reliable independent treatment option, additional research is necessary to confirm the efficacy of KT techniques and applications, specifically randomized clinical trials. Myofascial pain syndrome is a multifactorial musculoskeletal disorder with a wide range of possible regionalized manifestations in terms of symptoms and severity. Masticatory myofascial pain syndrome (MMPS) is characterized by multiple trigger points (MTrPs), also known as hyperirritable points, in taut bands of affected muscles, regional muscle pain, or referred pain to nearby maxillofacial areas like teeth, masticatory muscles or the temporomandibular joint (TMJ). MMPS is frequently diagnosed in clinical practice, with a prevalence as high as 30% and a ratio of up to 85% . DespiteA physical examination can quickly identify myofascial trigger points (MTrPs) inside a tight band of the afflicted muscle, probing which may elicit referral pain and a local twitch reaction. Muscle stiffness, reduced range of motion, muscle weakening without atrophy, and autonomic symptoms may accompany regional discomfort ,7,8. As The Kinesio Taping is a therapeutic tool that is used by rehabilitation specialists in all programs, including pediatric, geriatric, orthopedic, neurological, oncology, and others, as well as levels of acute care, inpatient rehabilitation, outpatient rehabilitation, home care, and Day Rehab ,19,20. AThe relevant literature was comprehensively searched through PubMed, Saudi Digital Library, Science direct, and Medline from start until April 2022 using the following terms “Kinesio taping”, “Kinesiology”, “kinesiology tape”, “Ktape”, “Taping” in conjunction with “Myofascial Pain Syndrome” or “MPS” or “MPDS” or “Musculoskeletal pain” or “Musculoskeletal disorder” to construct this review. A manual search of bibliographic references in major papers and reviews, as well as Google Scholar, yielded additional studies. Abstracts and papers written in languages other than English were excluded. Additional articles were uncovered by checking the reference lists of the articles that were already examined. The specific question addressed was, “What are the possible applications of KT for masticatory myofascial pain dysfunction?”.Dr. Kenzo Kase, a Japanese chiropractor and acupuncturist, created Kinesio taping (KT) in 1973 to support the musculoskeletal system without excessive immobilization ,41. InitKinesio is woven cotton and elastic tape used to manage movement and accomplish functional goals. Kinesio Tape’s elastic fibers might be cotton or polyester. Tape is applied to the paper backing using an acrylic adhesive and 10–15% stretching ,45. In KFor humans, there are four Kinesio Tape varieties and two for animals. Clinicians pick tape based on the patient’s purpose and skin condition. Classic or Performance+ Tape is suggested for beginners. KT varies in size and form ,23,42.Types of KT and its features and tape selection based on types of applications are mentioned in The skin is the body’s largest sensory organ and a key conduit for eliciting the appropriate motor responses. The required therapeutic motor impact can be achieved by applying the KT to certain skin sensory receptors ,30. So, Pain and abnormal sensations are minimized, muscles are supported, subcutaneous lymphatic fluid and blood are emptied, and joint derangement is repaired. This product lifts skin, improves space between muscles and skin, and reduces pressure. Reduced pressure diminishes subcutaneous pain receptor activation, allowing pain-free movement ,46. PrevTaping may affect proprioception, placebo effect, and biomechanics. Patients with patellofemoral pain syndrome may benefit from further KT . Gate cop-value = 0.013. The conclusions of the research were, however, restricted due to the low number of studies and the inherent biases in those investigations [KT, when used in conjunction with other therapy modalities, may provide additional advantages such as enhanced proprioceptive feedback and enhanced joint stabilization. To be able to recommend KT to a patient, a practitioner has to be aware of the patient’s previous medical history, the nature of the patient’s occupation or activity, as well as the biomechanics of the injury, and the duration of the damage. A complete physical examination will include inspection, palpation, and active and passive ranges of motion (ROM), as well as the identification of the MTrPs. There have been a number of investigations on the effectiveness of KT for the management of myofascial pain syndrome in TMJ patients. According to a systematic review and meta-analysis, the kinesiology tape had a significant effect on the masseter muscles, with tremendous pain relief assessed with VAS after using the tape for one week in comparison to other interventions occlusal splint, compressions to deactivate MTrPs, and counseling are some of the treatment options in people who suffered from temporomandibular disorders (TMDs). The inverse variance approach was used throughout the process of doing the meta-analysis. The mean value that was displayed on the visual analog scale was regarded to be the intervention effect measure. measure. The experimental group had 1.4 points of pain intensity decrease in VAS, with a igations .p = 0.001), sadness (p = 0.006), and disability ratings (p = 0.01), but not the control group. To sum it up, when it comes to TMDs, KT is more beneficial than counseling and exercise by itself (or even in combination) [The efficacy of KT for treating temporomandibular joint (TMJ) problems were studied in a single-blind, randomized, controlled experiment undertaken by Coskun Benlidayi and colleagues . Patientination) .p < 0.01 and p < 0.05, respectively) decreased. The TMJ’s ROM has significantly increased (p < 0.05). These findings showed that Kinesio taping reduced pain in latent MTrPs that was brought on by overexerting the SCM muscle, and that the ROM of the TMJ also changed as overexerting the SCM muscle decreased. The control group, on the other hand, exhibited no change between the times of the taping and before. Significant differences in VAS and PPT scores as well as TMJ ROM were found when comparing the groups (p < 0.05). Hence it was concluded KT could be used to treat latent MTrPs [Patients with latent MTrPs in the sternocleidomastoid muscle (SCM) were taped using Kinesio taping to see how that affected their myofascial discomfort and temporomandibular joint range of motion. A total of 42 individuals between the ages of 20 and 30 took part in the study . One group received KT, and the other received a placebo. The SCM was Kinesio-taped three times a week for two weeks. The amount of discomfort felt while pressing on a tight band or nodule was recorded and analyzed. VAS and pressure pain threshold (PPT) was used to assess the degree of discomfort. The temporomandibular joint’s range of motion was assessed. Each participant’s temporomandibular joint range of motion, VAS, and degree of discomfort were evaluated pre- and post-treatment. It was discovered that pain in the SCM muscle was relieved after Kinesio taping was applied to subjects with latent MTrps and restriction of the ROM of the TMJ. This was demonstrated by the fact that the VAS score and PPT significantly . Physiotherapy was performed on Group MTrP, which included the ischemic compression approach for the release of trigger points. There was a total of 16 females and 14 males in this group. The results show that MTrP inactivation and the KT technique had significant therapeutic analgesic effects throughout pain-related functional abnormalities of the muscles involved in mastication. After utilizing the KT strategy, which increased the analgesic effect in patients with dysfunction, the researchers noticed that the treatment positively impacted the patients. There was no discernible effect of either the patient’s gender or age on the therapy outcomes. In addition, they concluded that there is a need for the development of algorithms for diagnosing and treating oral facial pain, as well as how dentists and physiotherapists contribute to the process .p = 0.035, p = 0.035, p = 0.029, and p = 0.035, respectively [Previous studies prospectively compared the early results of Kinesio tape (KT) to those of corticosteroid injection (CSI) and the rest-and-medication group (RMG) for the treatment of lateral epicondylitis. Nirschl scores were used to categorize patients, and the VAS, QDASH, and the Turkish adaptation of the Patient-Related Elbow Evaluation were used for further evaluation (PREE-T). All groups showed statistically significant gains by the end of the second week. The functional scores for those in the RMG and CSI groups decreased slightly from week to week, and only KT remained effective throughout the entire study. At week four, the average QDASH score for the KT group was 18.1 (4.5–35), the VAS score was 2 (1–3), the VAS score for resisted wrist extension was 4 (2–4), and the Nirschl score was 2 (1–3). It was found that the KT group performed better than the RMG in all four of these measures, ectively .p < 0.05). Treatment with TPI and KT on the trapezius muscle for MPS has shown promise in halting the chronic process, preventing recurrence, and breaking the pain cycle. Due to its limited role in the long-term management of MPS, MTrP injection runs the risk of creating dependence in patients when used as the primary therapy. The combined therapy appears to generate a more influential outcome in the long run, than monotherapy, in alleviating pain and reforming functional amelioration in the management of MPS [The effectiveness of trapezius-muscle kinesio taping (KT) in addition to TPI  for the treatment of MPS was investigated in a separate study. Fifty patients diagnosed with MPS were divided into two groups of 25 individuals using a random number generator. Group 1 TPI plus KT; TPI plus sham KT in Group 2. At pretreatment, one, and three months posttreatment, patients filled out a VAS and a Neck Disability Index (NDI). VAS and NDI scores at 3 months were significantly lower in Group 1 versus Group 2 . Supplementing an exercise regimen with DN or KT applications improved outcomes for patients with MPS. Comparative effectiveness between DN and KT was not observed [The results of KT and dry needling (DN) for the treatment of trapezius muscle myofascial pain syndrome were compared in another recent study. A blinded evaluator took readings on a Visual Analog Scale (VAS), Pressure Pain Threshold (PPT), Neck Disability Index (NDI), and Global Perceived Effect Scale (GPES) at the beginning and end of the second week. The pain, disability, and global effects of MPS treatment are significantly better for those who undergo KT and DN as opposed to those who do not . The Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS), comprising Torticollis severity, Disability, and Pain scales, was used to quantify the severity of CD. The Craniocervical Dystonia Questionnaire was used to assess the quality of life (CDQ4) [Among adult patients with cervical dystonia (CD), the application of KT after botulinum toxin (BoNT) injection did not affect the severity of dystonia but did improve quality of life (e (CDQ4) . HoweverDespite extensive research, KT has only recently been used in the maxillofacial region. Additionally, little is known about the potential impact on MMPS. KT has not been proven to be an effective stand-alone treatment for MMPS, but the studies we’ve highlighted in this review suggest it may be useful as an adjunct to conventional care. To be accepted as a viable independent treatment option, KT must be thoroughly explored in future studies, especially randomized clinical trials.KT has only recently been used in the maxillofacial region, and there haven’t been many studies published on this topic; it is still relatively new in the field of dentistry. Furthermore, not much is known about how KT can affect the TMJ and masticatory muscles. In addition, the current research has numerous flaws because, despite the fact that the sample size was sufficient for a statistical analysis that successfully identified significance in comparisons, it’s more reasonable to back the findings of this research with trials with a larger sample size. Some researchers did not include a placebo group. The usefulness of KT, if any, should be clarified via placebo-controlled research with more significant sample numbers independent of the placebo effect. So, more studies are required in this field that should strive to use KT over other methods of intervention in the maxillofacial region. In addition, there is a specific limitation in using KT under the circumstances like open wounds, deep vein thrombosis, allergy, fragile skin, and active malignant sites. Self-application of tape, however, can be challenging due to a lack of familiarity with the taping procedure, the need to use both hands, the placement of the MTrP, and a lack of knowledge of anatomy or biomechanics. As a result, the vast majority of people can’t tape independently.Treatment of MMPS may be challenging due to its complex pathology and underlying peripheral and central neural mechanisms, particularly during the chronic phase. The inability to recognize trigger points, a lack of experience with the taping technique, and a lack of knowledge of anatomy or biomechanics are some other obstacles to self-taping. From a variety of treatment options , the choice of kinesiology taping remains up to the individual practitioner and clinic policy. Healthcare professionals may, however, continue to view kinesiology taping as a practical therapeutic non-pharmacological approach for MMPS management in light of the current evidence. It allows for a significant reduction in edema and discomfort without endangering the patient’s metabolism or digestive system, is simple to perform, affordable, and less traumatic. Finally, studies included in this review demonstrated that, despite its limitations, KT can be considered an adjunctive therapeutic tool to standard therapy for the treatment of MMPS and has not been shown to be a valid independent treatment option. It’s still unclear whether Kinesio taping is more effective in the long run than other treatments. Future studies are necessary to confirm the effectiveness of KT techniques and applications, particularly randomized clinical trials, to establish KT as a reliable independent treatment option.


Qigong includes training for body and mind, one method is Zhineng Qigong. Scientific literature on qigong for chronic low back pain (LBP) is sparse. This study aimed to investigate feasibility including evaluation of a Zhineng Qigong intervention for pain and other lumbar spine-related symptoms, disability, and health-related quality of life in patients with chronic LBP and/or leg pain.Prospective interventional feasibility study without control group. Fifty-two chronic pain patients (18–75 years) with LBP and/or leg pain  were recruited from orthopaedic clinics  and primary healthcare (chronic LBP). Patients from orthopaedic clinics were 1–6 years postoperative after lumbar spine surgery or on lumbar surgery waiting list. Patients received a 12-week training intervention with European Zhineng Qigong. The intervention consisted of face-to-face group activities in non-healthcare setting (4 weekends and 2 evenings per week), and individual Zhineng Qigong training. Main health outcomes were self-reported in a 14-day pain diary, Oswestry Disability Index (ODI), Short Form 36 version 2 (SF-36v2), and EuroQol 5 Dimensions 5 Levels (EQ-5D-5L), once directly before and once directly after the intervention.Recruitment rate was 11% and retention rate was 58%. Dropouts did not report higher pain (baseline), only 3 dropped out because of lumbar spine-related pain. Adherence was median 78 h group attendance (maximum 94 h) and 14 min daily individual training. Ability to collect outcomes was 100%. Thirty patients completed (mean 15 years symptom duration). Twenty-five had degenerative lumbar disorder, and 17 history of lumbar surgery. Results showed statistically significant (within-group) improvements in pain, ODI, all SF-36v2 scales, and EQ-5D-5L.Despite low recruitment rate, recruitment was sufficient. A multicentre randomized controlled trial is proposed, with efforts to increase recruitment and retention rate. After this Zhineng Qigong intervention patients with chronic LBP and/or leg pain, also patients with considerable remaining LBP/sciatica after lumbar surgery, had significantly improved in pain and function. Results support involvement of postoperative patients in a future study. The results are promising, and this intervention needs to be further evaluated to provide the most reliable evidence.NCT04520334. Retrospectively registered 20/08/2020.The online version contains supplementary material available at 10.1186/s12891-023-06581-w. Low back pain (LBP) for ≥ 3 months is defined as chronic  and is aNumerous studies have evaluated non-surgical interventions for the patient population with chronic LBP and/or leg pain. Several non-pharmacologic therapies, including different types of exercise , have shIn more severe cases or if non-surgical treatments are unsuccessful, lumbar spine surgery relieves suffering for many patients with degenerative disorders . HoweverTo improve pain and function, there is a need to identify effective non-pharmacologic treatments for radicular LBP  and non-A literature review on qigong research for chronic musculoskeletal pain concluded that qigong may help relieve pain and that more research is needed, as the English language literature is promising but inconclusive . It was It is important that effect studies are well planned and tested and that possible threats are identified and prevented . TherefoThe study design was a quasi-experimental interventional feasibility study without a control group, with one measurement directly before and one directly after the intervention. The Transparent Reporting of Evaluations with Nonrandomized Designs (TREND) statement  was usedthe best description of pain for the past 2 weeks, in accordance with the Swedish spine surgery register (SweSpine) [SweSpine, patients 1–6 years postoperative (PO) with residual symptoms after lumbar spine surgery .Primary healthcare (PHC) (eight PHC centres).The waiting list for lumbar spine surgery (WLS) .A screening tool was developed for the study for eligibility assessment of patients Table . Only a weSpine) . During The intervention was conducted for 12 weeks with the European Zhineng Qigong school, with which all patients were unfamiliar. Both group activities and individual Zhineng Qigong training were part of the intervention. The group activities  were held during 4 weekends (12 h each) and 2 evenings per week (2 h each). All group activities were performed face-to-face with the whole group and included lectures, demonstrations and training. An obligatory introductory lecture (2 h) on Zhineng Qigong was given the evening before the first weekend. The training was intensified step-by-step, in accordance with the qigong teacher’s experience. Daily individual training was recommended and was supported by an instructional compact disc . Each patient received this CD.The training in the intervention consisted of dynamic Zhineng Qigong exercises, with soft patterns of movement which were never forcefully done. The exercises were performed standing up or sitting in a chair if needed. The training included physical movements with concentration and relaxation, with no breath control. The exercises aim to improve homeostasis, thereby achieving a healthier state. During the group activities the patients received detailed instructions about how to perform the exercises and the patients were carefully supervised, with their body postures and movements being corrected if needed. The patients also received instructions not to extend the movements beyond their individual physical ability. One teacher planned and led the intervention and was assisted by 3 additional teachers. All 4 teachers had several years of experience in both training and teaching Zhineng Qigong, having been educated and authorized by the main teacher of the qigong school, a qigong master.The group activities were performed in a non-healthcare setting in the city of Lund in Skåne, Sweden. The first author (GP) was present to passively observe the progress and reactions of the patients but did not contribute to the intervention.Identified and interested patients received brief written information about the study. PO patients received it after a phone call by staff or first author (GP), PHC patients from their physician or physiotherapist, and WLS patients after a phone call by staff. Some background data in the screening tool, including lumbar spine diagnoses, was pre-filled and originated from SweSpine or medical records  and a general questionnaire (GQ), both developed for this study; the Oswestry Disability Index (ODI) version 2.1a; the Short Form 36 version 2 (SF-36v2); and the EuroQol 5 Dimensions, 5 Levels (EQ-5D-5L). The pain diary and questionnaires were completed once directly before and once directly after the intervention, with no further follow-up.The patients’ attendance at group activities was registered. Additionally, the patients filled in a training diary with their individual Zhineng Qigong training time each day during the intervention and 2 weeks afterwards (group activities not included).The recruitment rate  was defiThe retention rate  was defiAdherence to the intervention was evaluated in terms of hours of attendance (at the group activities) and mean daily individual Zhineng Qigong training time in minutes (from the training diary).The ability to collect outcome measures was defined as the percentage of completed health outcomes at baseline and after the intervention.most usual pain intensity for LBP and/or leg pain  once daily for 14 days directly before and directly after the intervention. The primary health outcome was the mean pain intensity of each 14-day pain diary. To facilitate the filling in of the pain diary, pain intensity was labelled in the diary completion instructions as none (0), mild (1–3), moderate (4–6) and severe (7–10) [The pain diary measured the e (7–10) . NRS wase (7–10) . Furthere (7–10) .n = 0–4): ‘LBP’, ‘tendency for lumbago’, ‘pain into buttocks/hip/leg/foot’, and ‘pain in both legs’ : ‘low back weakness/fatigue’, ‘low back sense of instability’, ‘urgency of micturition’, ‘difficulty controlling urine/faeces’, ‘numbness and/or reduced sensory function into buttocks/hip/leg/foot’, ‘weakness/fatigue/reduced function in one leg’, and ‘weakness/fatigue/reduced function in both legs’  [The ODI measured spine-related disability elling’) . The indelling’) , being velling’) .4-week recall), with 36 generic questions [The SF-36v2 measured HRQoL , each with 5 severity levels [The EQ-5D-5L measured generic HRQoL y levels , 29. They levels . The EQ-y levels . For paty levels .the past week : ‘concentration’, ‘stressed out’, ‘sleep’, ‘energy level’, ‘sad or depressed’, ‘irritable’, and ‘tense or anxious’ .In the between-group analyses of ordinal or continuous data, the Mann–Whitney U test was used, and for nominal data, Fisher’s exact test was used.p values were exact, two-tailed, with < 0.05 regarded as statistically significant.Analyses were performed using IBM SPSS Statistics version 22. All As enrolment initially progressed slowly, the study also enrolled patients for a 3 weeks shorter intervention. A separate introductory lecture and starting weekend was arranged for the 9-week group, after which these patients joined those who had already started the original 12-week intervention. Thirty-seven patients were enrolled for 12 weeks and 15 for 9 weeks  or was self-reported in the screening tool, resulting in enrolment of 4 patients and 1 patient, respectively.In total, 52 of the 171 patients who submitted the screening tool were enrolled .The retention rate was 58%, with the reasons for dropout shown in Fig. For the whole study group, the median group activity attendance was 78 h (IQR 54–80). For the patients who could attend 94 h (12 weeks), the median was 76 h (IQR 54–84), while for those who could attend 82 h (9 weeks), the median was 79 h (IQR 50–80).The training diaries showed a median of 14 min (IQR 10–18) of daily individual qigong training for the whole study group. The patients who could attend 94 h, had median 14 min (IQR 11–18), while those who could attend 82 h, had median 11 min (IQR 3–20).n = 52). After the intervention, 100% of health outcomes were collected (n = 30). This resulted in an overall ability to collect outcome measures of 99.7%.At baseline, 99.6% of health outcomes were collected  (n = 30), having a mean age of 57 (SD 11), is shown in Table The background data of the study group .The number of ‘non-pain symptoms’ decreased  having a mean age of 63 (SD 8), 12 had spinal stenosis and 4 had spondylolysis-olisthesis. At study inclusion the patients with spinal stenosis were distinguished by severe leg pain intensity, mean VAS score 64 (SD 25).Among the PO patients (p < 0.001. Fourteen (88%) had decreased pain intensity, whereof 7 (44%) had decreased pain intensity of ≥ 30%. At baseline, 14 patients (88%) reported being almost never ‘free from pain’, and 12 (75%) reported being almost never ‘free from non-pain symptoms’; both decreased to 7 (44%) after the intervention. All statistically significant improvements for the study group were also significant for the PO patients , except for time ‘free from non-pain symptoms’ (p = 0.055), ‘urgency of micturition’ (p = 0.250), and ‘role emotional’ (p = 0.145). Furthermore, the PO patients had made improvements in ‘concentration’ (p = 0.037) and ‘irritable’ (p = 0.045).For the PO patients, the mean change in pain intensity with 95% confidence interval was -1.88 (-2.78 to -0.98), p ≤ 0.031). In this subgroup (n = 28), ‘concentration’ also improved (p = 0.047).Two of the 5 patients with VAS scores of 25–30 completed the study. At baseline, they had pain intensity scores of 5.7 (PO patient) and 3.4 (PHC patient). All statistically significant improvements for the study group were also significant if these 2 completers were excluded  to 1 and the SD to 2, resulting in 64 patients per group.For postoperative patients, we approximated the mean difference in pain intensity to 1.5 and the SD to 1.8, resulting in 24 patients per group.In the second scenario, we assumed that the pain intensity in a waiting list control group would decrease by 13%, as was observed in a somewhat similar study . Based oFor postoperative patients, we estimated the mean difference in pain intensity to 1.13 and the SD to 1.8, resulting in 41 patients per group.In the power calculations for a future RCT, we assumed that the patients would have similar baseline levels and SDs for pain intensity  as in the present study. Furthermore, we assumed that the control group would also improve. Two different scenarios were used for the power calculations, with a statistical power of 0.80 and alpha of 0.05:There will still be dropouts in an RCT, and given the same dropout frequency as in the present study Fig. , additioThe present study was conducted to study a Zhineng Qigong intervention in terms of feasibility and subjective health outcomes in patients with chronic LBP and/or leg pain from lumbar disorder. Patients were recruited from orthopaedic clinics and primary healthcare, where postoperative patients were found to be the most feasible for involvement in a future RCT. Qigong is still rather unknown and there is limited evidence of its effects on pain, which might explain the difficulties recruiting and a retention rate lower than expected. Interestingly, all validated health outcomes were significantly improved (within-group) after this intervention.Three RCTs for chronic LBP were included in the literature review on qigong for chronic musculoskeletal pain , for aduThe retention rate was higher in the RCTs which were performed in Germany and Thailand. Compared to this study, some spine-related and additional medical conditions were to varying degrees excluded and there were restrictions in analgesic intake. This may indicate a more severe pain situation for the enrolled patients in the present study who also had leg pain, which probably contributed to difficulties participating. Furthermore, qigong may be more familiar to people in these countries , 36 compA clinical reasoning mentioned in the literature review, is that qigong through its postures and gentle movements performed with concentration and relaxation may reduce both physical and psychological symptoms, that may relieve pain and increase wellbeing . SeveralIn qigong interventions for chronic musculoskeletal pain several factors may possibly influence the results, including pain history, medical conditions, and qigong teacher characteristics and expertise . More reThe recruitment rate was lower than expected, highlighting both the need to increase the quantity of ‘possibly eligible’ patients and to increase interest during recruitment in a future RCT. During the provision of the verbal information to eligible patients, several were interested but found the intervention too time consuming. Probably, the recruitment rate would increase with fewer scheduled hours.n = 49), as chronic LBP is a common condition and 8 PHC centres were involved during 4 months. One reason for the low submission may be that healthcare professionals may not have found the time to engage in the study or did not recommend the intervention because of a lack of evidence for qigong.Concerning the recruitment of PHC patients, we believe that the number of patients who submitted the screening tool was low , it was also filled in for days with group activities and thus did not reflect the total daily training time.The arrangement with regular weekly group activities, together with the instructional CD, made it easier to perform the individual training. The training diary was also a reminder to practise and it was probably motivating.The collection of outcome measures showed a high level of data completion. Several questionnaires, as well as the pain diary, were collected to cover the preliminary hypotheses. While giving the verbal information before enrolment, patients were informed about the importance of completing all the forms.The result showed statistically significantly reduced chronic LBP and/or leg pain (within-group) after this intervention. For pain intensity, which was the primary health outcome, 43% of patients achieved the minimal clinically important change as suggested to be 30% improvement .almost never had time ‘free from pain’, which significantly improved after the intervention, as well as ODI and most HRQoL outcomes. The finding that all SF-36v2 scales were significantly improved, supports [Patients reported experiencing symptoms for 15 years in mean, and most (83%) were diagnosed with a degenerative lumbar spine disorder. At baseline, 80% reported that they supports  that Zhisupports , 41. PaiSeveral patients probably had symptoms caused by disruption in neural structures, as 73% had a structural diagnosis  and 57% previously underwent lumbar surgery. One such symptom is ‘urgency of micturition’, which was significantly reduced in number. Also the PO patient subgroup reported significant improvements in pain intensity, time ‘free from pain’, and the number of ‘non-pain symptoms’. These improvements are interesting, as the degenerative process normally continues even if surgery relieved mechanical obstruction . HoweverSample size calculations based on results from feasibility studies are uncertain and should be used cautiously because of limited sample sizes . Since oIn addition to recruiting PHC patients, it was decided to target PO and WLS patients with spinal stenosis, spondylolisthesis, or segmental pain. These diagnoses were chosen as they are associated with somewhat lower surgery satisfaction rates. One year postoperatively, unchanged or increased pain has been reported in 15–24% (back) and 13–23% (leg) . It is aThe present study was initiated in response to feedback from persons with neuropathic pain and chronic diseases who experienced symptomatic improvements and restoration of functions when training with the qigong school engaged in this study. Qigong’s potential effectiveness for structural diagnoses is still a rather new concept, with sparse evidence in the scientific literature. The results of the present study were in line with the preliminary hypotheses, with all validated outcome measures significantly improved in this rather small sample, strengthening the rationale for a future RCT.The study limitations are lack of control group and long-term follow-up, and relatively small sample size. The study did not control for unspecific effects such as Hawthorne, placebo, and regression towards the mean. Also, sample heterogeneity is a limitation. However, our largest recruitment subgroup (PO patients) is generally expected to have more difficulty improving through training, but showed similar improvements to the whole study group. Additionally, as the GQ was developed for this study and is not validated, we suggest that its findings be interpreted with caution as well as the power calculations.Despite a somewhat low recruitment rate, the expected number of patients was enrolled during the short recruitment period, making recruitment sufficient. A multicentre RCT with a longer recruitment time and possibly somewhat shorter intervention than in this feasibility study are proposed, with efforts to increase the recruitment and retention rate. After this Zhineng Qigong intervention patients with chronic LBP and/or leg pain, also patients with considerable remaining LBP/sciatica after lumbar spine surgery, had significantly improved in self-reported pain, function, and HRQoL. The health results for the PO patients support involvement of postoperative patients in a future study. The results are promising, and this intervention needs to be further evaluated to provide the most reliable evidence through larger sample size, control group, adequate blinding, and long-term follow-up.Additional file 1. Questions in the general questionnaire for lumbar spine‑related symptoms and HRQoL.


Background and aimGenerally, asymptomatic hyperuricemia is considered a benign metabolic abnormality with little clinical significance in the absence of gout or renal calculus. However, its clinical association with plantar fasciitis is still not known and is a subject of interest. The study aims to investigate the association between asymptomatic hyperuricemia and plantar fasciitis in otherwise healthy patients.Materials and methodsA cross-sectional study was performed, which included 284 patients aged 21-65 years with plantar fasciitis and without any comorbidities between February 2020 and November 2022. One hundred and fifty patients with hyperuricemia who attended the endocrinology and medicine outpatient department without heel pain were included as a control group. Serum uric acid levels were assessed in all cases. Student’s t-test, correlation tests, and multiple linear regression were used to ascertain the association between uric acid levels and plantar fasciitis. Statistical analyses were conducted using IBM SPSS Statistics for Windows, Version 19.0 .ResultsAmong the 284 patients, 189 were female (66.5%) and 95 were male (33.4%). Their mean age was 43 ± 9 years (range: 21-65 years). The p-values of the duration of symptoms, visual analog scale for pain (VAS), and foot function index (FFI) total score were p = 0.061, p = 0.068, and p < 0.001, respectively. The mean uric acid levels were 7.6 ± 1.5 mg/dL in males and 7.3 ± 1.3 mg/dL in females in the sample group, and 8.3 ± 1.8 mg/dL in males and 8.1 ± 1.5 mg/dL in females in the control group. According to a Pearson correlation analysis, there was no correlation between serum uric acid level and BMI, VAS, duration of symptoms, FFI pain, disability sub-scores, or FFI total score.ConclusionAlthough asymptomatic hyperuricemia is a common metabolic abnormality, the present study did not find any significant association between it and plantar fasciitis. Therefore, we can conclude that routine screening for asymptomatic hyperuricemia is not recommended in plantar fasciitis. Evidence level: II Plantar fasciitis affects millions of individuals globally. It is estimated that 7% of people over 65 years of age are diagnosed and treated for heel pain, which accounts for over one million physician consultations every year in the United States ,2. HowevPlantar fasciitis pain is usually at the anteromedial aspect of the heel. The intensity of the pain increases through dorsiflexion of the toes. On presentation, the patient may have had pain symptoms for weeks or months, which are often worse in the morning when trying to stand up from bed or walk. As soon as the patient starts walking, the intensity of pain generally reduces, but it can persist throughout the day and is often exacerbated by walking or exercise, especially on hard surfaces . Many riHyperuricemia is generally defined as a serum urate level above 7.0 mg/dL in men and above 6.0 mg/dL in women . AsymptoTherefore, the present study aimed to investigate whether plantar fasciitis is associated with AH in otherwise healthy, young individuals.A cross-sectional study was performed, which included 284 patients aged 21-65 years with plantar fasciitis and without any comorbidities between February 2020 and November 2022. During the study period, 150 patients with other medical conditions like diabetes and hypertension who attended endocrinology and medicine OPD at Military Hospital, Ambala, Haryana, India, and were detected to have raised serum uric acid during the routine investigation but without any symptoms of plantar fasciitis were included as a control group.Inclusion criteria were age between 21 and 65 years, no medical comorbidities, and not taking any medication that raises serum uric acid levels. The duration of the symptoms should be more than two weeks. All study-group patients were evaluated through rheumatological workup to rule out any existing inflammatory joint disease or autoimmune arthritis such as systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), ankylosing spondylosis, psoriasis, and inflammatory bowel disease, which could cause plantar fasciitis or heel pain. The patients were also evaluated for calcaneal spurs by taking a lateral-view heel X-ray. BMI, job profile, and physical activity level were also recorded. The visual analog scale (VAS) was used to evaluate pain intensity, and the patients were asked to plot their scores. Informed written consent was obtained from all study participants. Approval from the Institutional Ethical Committee of Military Hospital, Ambala, India, was obtained , and the study was conducted in accordance with the Helsinki Declaration.Statistical analysisWe used IBM SPSS Statistics for Windows, Version 19.0  and Microsoft Excel  for data analysis. We performed a power analysis to determine the appropriate sample size. A value of 0.05 was set for type I error (α), and the power of the test was set at 0.90 while maintaining a confidence level of 75.Standard descriptive statistics were used to summarize the characteristics of the patients, including means and standard deviations (SDs) of all continuous variables and numbers, and percentages for categorical variables. We used Pearson’s correlation coefficient (r) to compare serum uric acid level against age, sex, BMI, symptom duration, morning stiffness, heel tenderness test positivity, foot function index (FFI) pain score, VAS, FFI disability score, FFI activity limitation score, and FFI total score. The statistical significance level was set at p<0.05.A total of 295 patients with a main complaint of plantar heel pain were initially enrolled in our study. However, 284 patients were ultimately included in the study, as seven patients, upon clinical examination, were found to have radicular pain and lumbar spondylosis and were excluded. In addition, two patients were found to have ankylosing spondylitis, and two others had large calcaneal spurs as the cause of heel pain, and all four were also excluded.In the study group of 284 participants, 189 were female (66.5%) and 95 male (33.4%). The mean age was 43 ± 9 years (range: 21-65 years). Right-side plantar fasciitis was noted in 78 patients (27.4%), left-side plantar fasciitis in 91 patients (32%), and bilateral plantar fasciitis in 115 patients (40.4%) (Table The mean duration of symptoms was 8 ± 32 weeks (range: 4-112 weeks), and the mean VAS was 6 ± 1 (range: 3-10). Two hundred and forty-four patients (85.5%) had morning stiffness. The heel compression test was positive in 201 patients (70.7%), with plantar fascia tenderness present in all cases  curve, an area under the ROC curve (AUC) of 0.2986  was observed between asymptomatic hyperuricemia and plantar fasciitis, indicating no association between them  crystal deposition ,19. The Dalbeth et al. noted in their study of 92 gout patients that the Achilles tendon was affected in 39.1% of cases and peroneal tendons in 18.1% of cases, whereas other tendons were less or rarely involved . The autComberg and Schach found that uric acid is associated with musculoskeletal joint pain . Their rGout can lead to significant morbidity by causing severe pain and limitation of activity through the deposition of urate crystals in the joints. In the present literature, it is well established that hyperuricemia plays an important role in the manifestation of gout, but whether it can also cause plantar fasciitis has not been studied thus far, nor whether AH alone is an indication to start anti-gout treatment. It is equally well established that the degree of hyperuricemia is a strong predictor in developing gout -28, but Limitations of the studyThe study has a few limitations. First, the patient-reported pain of plantar fasciitis is subjective and may lead to overdiagnosis. Second, the study was carried out in our hospital; therefore, hospital bias cannot be ruled out. Third, ultrasonographic imaging of the plantar fascia was not performed.Plantar fasciitis has many causes such as calcaneal spur, autoimmune disease, rheumatologic disorders, and ankylosing spondylosis. As isolated plantar fasciitis may not be associated with hyperuricemia, based on the present study, we do not recommend routine screening of patients with plantar fasciitis for AH, as both are not at all or poorly associated. However, the early detection of hyperuricemia in asymptomatic patients can give physicians the opportunity to modify or correct the underlying cause.


Regarding the impact of BoNTA on patients’ health-related quality of life, there were significant improvements in both the physical and mental health domains (p < 0.05) of SF-36 tool. BoNTA may be a safe and effective treatment option for patients with refractory TGN when added on to carbamazepine or oxcarbazepine. The use of a single BoNTA session for TGN treatment may be an alternative to surgical interventions and as add-on treatment to oral medications, providing patients with a minimally invasive, effective, safe and well-tolerated option. We sought to assess the efficacy of combining onabotulinumtoxinA (BoNTA) as add-on therapy to carbamazepine or oxcarbazepine in treatment-refractory patients with trigeminal neuralgia (TGN) who failed to respond (less than 30% response rate) to adequate monotherapy. We conducted a retrospective study on 15 patients with a definite diagnosis of TGN, according to the established criteria, and underwent BoNTA as part of their treatment plan. A single BoNTA session was administered subcutaneously, according to patients’ perceived zone of pain, at different dosages ranging from 30 to 200 units (mean ± standard deviation: 87.3 ± 39.2). All patients  reported large reductions in the severity of their TGN-related neuropathic pain. The mean pain score on the VAS scale significantly decreased from 9.3 ± 1.1 to 3.7 ± 1.2 at 2 weeks after injecting BoNTA ( Neuropathic pain is defined as a pain of nervous origin which is initiated or caused by a primary lesion or dysfunction of the peripheral or central nervous system . The thrBased on the etiology, TGN is classified into idiopathic, classic, and secondary TGN. The first is characterized by unknown causes and usually remains without a definite etiologic diagnosis. Classic TGN is associated with neurovascular compression (NVC) most frequently by the superior cerebellar artery of the trigeminal nerve roots into the pons. This compression usually results in the demyelination of nerve fibers, which then start firing ectopically. Secondary TGN may be caused by an underlying disease such as tumors or artery malformations and has also been associated with multiple sclerosis ,7,8. GenCarbamazepine (CBZ) or oxcarbazepine (OXC) are the medications (both are potent VGSC blockers) of choice for providing long-term effective relief but often are not efficacious or poorly tolerated. Lamotrigine, gabapentin, BoNTA, pregabalin, baclofen, and phenytoin can be used alone or in combination with other medications. It is suggested that surgery may be offered if the pain is not adequately controlled with pharmacological options or if these medications are not tolerated well. In individuals with classic TN, microvascular decompression is indicated as first-line surgery . If no NIn terms of OnabotulinumtoxinA (BoNTA), its licensed use was only granted as a preventative treatment for chronic migraine in adults, based on the favourable safety/efficacy outcomes of the pooled analysis of PREEMPT trials . NonetheThe purpose of this research was to report on the treatment’s clinical outcomes, such as improvements in pain scores, medication use, and quality of life, in a case series of patients with refractory TGN who had BoNTA injections as part of their treatment strategy. More specifically, we present here some additional data from a retrospective study that sought to assess the efficacy of combining pharmacological therapy with BoNTA add-on to CBZ or OXC in treatment-refractory patients with TN who failed to respond (less than 30% response rate) to adequate monotherapy.We reviewed the medical files of 15 treatment-refractory patients with TGN who attained combined treatment with a single BoNTA course add-on to CBZ or OXC. The follow-up period for each patient was 6 months. CBZ or OXC was delivered at median doses of 1200 mg (range: 800–1600) and 1800 mg (range: 1200–2400), respectively, at the time of evaluation for further treatment with BoNTA. The study sample consisted of 5 males (33.3%) and 10 females (66.7%) with a mean age of 58.5 ± 12.5 (range: 27–88) years. The distribution of TGN was as follows: five patients had V2 involvement in the maxillary division of the trigeminal nerve, three had V3 involvement, four had both V2 and V3, one had V1 involvement, and two had V1, V2, and V3 involvement. The mean duration of TGN was 25.9 ± 19.6 months (range 6–60). Eight patients had involvement of right side and seven of left side. The frequency of attacks was more than 5/day for all patients (range 5–>40 per day). All patients had failed to respond to at least two types of conventional treatments. Approximately all patients have tried paracetamol, NSAIDS, and tramadol when needed. Six of them have been on duloxetine as well, and fourteen have tried pregabalin in the past. Lidocaine patch has been tried by five patients. The patients underwent magnetic resonance imaging, which did not detect any structural pathology or suggest the need for surgical procedures. p < 0.001); it decreased even more at 4 weeks after treatment, 0.6 ± 0.8; and it remained at significantly reduced levels 6 months after treatment, 2.9 ± 1.1 (p < 0.001). The mean duration of pain relief was 22.5 weeks (range 8–24). There was no significant difference in pain reduction between patients with maxillary versus mandibular involvement, while the same applied in patients with primary TGN at 2 weeks after injecting BoNTA, compared to those with secondary TGN. Likewise, the duration of clinical benefit was comparable in each TGN subgroup (primary vs. secondary). The overall clinical effect of BoNTA against TGN-related neuropathic pain is summarized in All patients  reported a significant reduction in the severity of their neuropathic pain, which was related to their TGN, after the application of a single BoNTA session. The mean pain score on the VAS scale significantly decreased from 9.3 ± 1.1 to 3.7 ± 1.2 at 2 weeks after injecting BoNTA (p < 0.05) of SF-36 to further document the merits of treating pharmaco-refractory TGN patients with BoNTA.Regarding the impact of BoNTA therapy on patients’ health-related quality of life (HRQOL), the mean sum score on the Short Form 36 (SF-36) questionnaire improved from 36.5 at baseline to 58.2 at 3 months after treatment. There were significant improvements in both the physical and mental health domains  2 weeks after treatment. Specifically, one patient scored 5, five patients scored 6, and nine patients scored 7 on PGIC. Notably, 10 patients (67%) reported that they would choose BoNTA injections as their first-line treatment option if they were to experience a TGN recurrence. The overall PGIC for every visit post-treatment is summarized in No major adverse events were observed in any of our enrolled patients. Mild and transient tenderness and/or erythema or wheals in the injection sites was reported by five patients, which resolved within 48 h. There was no evidence of facial asymmetry, masticatory abnormalities or other commonly reported significant complaints after BoNTA treatment for TGN. None of the patients required additional medications or procedures for pain relief during the study period. A total of 53% of patients stopped taking CBZ or OXC during the observational period without any relapses in their TGN-related pain. The objective of our current research was to test the efficacy of BoNTA add-on to CBZ or OXC in treatment-refractory patients with TGN so as to add to the expanding body of literature on the topic and to provide physicians with useful insights into the possible role of this medication to interfere with the pathogenesis of TGN, in order to eventually achieve successful management of this quite difficult paradigm of neuropathic pain.There is evidence to suggest that both peripheral and central sensitization and the involvement of the trigemino-vascular system form the major components of TGN pathogenesis . PeripheNatural or manufactured BoNTA is one of the most potent neurotoxins. It inhibits the presynaptic release of axonal acetylcholine (Ach) to limit neuromuscular transmission and to eventually cause muscle relaxation. In 2002, Micheli et al. were the first to identify BoNTA as a potential pharmacological option for providing clinically meaningful analgesia in TGN . FurtherThe actual mechanism of BoNTA action in providing pain reduction appears to be multifactorial and not yet fully elucidated. When BoNTA is injected directly into contracting muscles, it attaches to presynaptic nerve terminals and becomes internalized, preventing the neurotransmitter Ach from being exocytosed at neuromuscular junctions. BoNTA may also induce peripheral neurovascular activity by blocking neurotransmitter release, including substance P, neurokinin A, CGRP, noradrenaline, dopamine, enkephalin, and enteral polypeptide. These transmitters operate on blood vessels and glutamate, decreasing afferent nerve impulses and suppressing neurogenic inflammation in order to eventually inhibit peripheral sensitization by diminishing the number of pain signals that reach the brain and, indirectly, preventing central sensitization ,20,21. CFour double-blind randomized controlled trials found that BoNTA injections were beneficial for patients with TGN, with considerable clinical benefits ,25,26,27Furthermore, several case reports were published describing the effect of BoNTA administered directly to trigeminal ganglion or intradermally and/or submucosally in refractory TGN. New techniques in several cases have also been described, such as injecting BoNTA intraorally into the mental foramen, which resulted in pain relief as well ,30. FinaThe results we herein report further provide evidence to suggest that a single BoNTA course may be an effective treatment for treatment-refractory TGN patients, with 60.2% and 93.5% reduction in mean pain VAS scores at 2 weeks (9.3 to 3.7) and 4 weeks (9.3 to 0.6) after injecting BoNTA, respectively. The reduction of 60.2% in pain VAS at 2 weeks post-treatment in our study is similar to that previously systematically reviewed and reported (68% reduction in mean pain VAS from 7.5 before treatment to 2.4 post-treatment) . NonetheGenerally, our findings are consistent with previous studies that have also demonstrated the efficacy of BoNTA in reducing pain associated with various chronic neuropathic pain conditions, including migraine headaches and chronic low back pain . TellingNonetheless, our study has some limitations that should be considered. Firstly, this was a retrospective, single-arm, uncontrolled case series. These limitations prevent us from making robust causal inferences about the effect of BoNTA on TGN. Secondly, the duration of the effect of BoNTA on TN is unclear, and further long-term research is needed to determine the optimal dosing and timing of injections. In addition, our sample size was relatively small, and a larger sample size is needed to confirm these findings. The national reimbursement policy that is currently applied expensive therapies, including BoNTA, restricted us from having a larger sample size, as BoNTA can only be approved to be fully reimbursed by the Greek National Health System as an off-label treatment option in TGN patients who are failing to respond to or have been unable to tolerate at least three previous first-line oral preventatives. As such, only a few applications pass through the Electronic Prior Authorization System (ePAS) to receive approval for commencement in patients in the context of full reimbursement. In conclusion, BoNTA injections may be a safe and effective treatment option for patients with refractory TGN when added-on to CBZ or OXC. The beneficial effect may last for 6 months after commencing a single BoNTA course; however, we should note that the persistence of the clinical benefit with BoNTA use at the follow-up of 24 weeks post-treatment might not be completely true, as TGN often has a remission period lasting from weeks to years where patients are pain-free [After obtaining written, informed consent from each patient and approval from the institutional review board and ethics committee of the University Hospital of Larissa, Greece, in line with the principles of the Helsinki Declaration, we retrospectively reviewed the medical files of adult (>18 years) patients with a definite diagnosis of TGN, according to the criteria of the International Classification of Headaches Disorders-III . Enrolle® 100UI/fl; Allergan-Abbvie, Greece) was reconstituted with isotonic sodium chloride solution to reach a concentration of 5 or 2.5 units/0.1 mL. Administration was guided by each patient’s perceived pain and trigger zones, delivering BoNTA via a syringe of 1 mL. As such, subcutaneous injections of 5 units were administered at 1 cm intervals to the skin area where the patient described the pain, starting from the area where the pain was most intense. Subcutaneous BoNTA injections of 2.5 units/0.1 mL were selectively applied in areas with less intense pain. In this way, BoNTA was applied to the entire painful area as depicted in BoNTA  or numerical rating scale from 0–10, with higher score to indicate worse severity) and duration of TGN remission. We generally considered patients with an at least a 50% reduction in VAS score and/or pain frequency at 2 weeks post-BoNTA, compared to pre-treatment, as responders. Furthermore, we also assessed for every patient the consistency (duration) of BoNTA clinical effect with the use of a VAS score at 4 weeks and 24 weeks post-treatment. Notably, the 24-week results were obtained after delivering just a single course of BoNTA, as previously described, and not after a second repeated BoNTA session at 12 weeks.Secondary outcomes included the changes in HRQOL, as measured by a validated questionnaire such as the SF-36, which is also available and validated in Greek language ,35. BrieThe satisfaction of patients to BoNTA was also recorded with a short self-report 7-point PRO questionnaire “Patient Global Impression of Change” (PGIC) (1 stands for “no change” and 7 for “considerable improvement”). Patients with PGIC 5 had “clinically significant benefit”, whereas patients with PGIC 4 had “no benefit .t-tests. The same approach was followed to assess all secondary outcomes. Unless otherwise stated, all tests were two-sided, and significance was set at p < 0.05. The SPSS for Windows  performed the statistics. Descriptive statistics were computed depending on the nature of the analyzed variable, including means, standard deviations, and percentages. The changes in subsequent pain scores and overall clinical efficacy scores from baseline vs. post-BoNTA were assessed using paired samples


Periarticular infiltration (PI) is a common procedure during total knee arthroplasty (TKA) for postoperative pain management. This retrospective, case-matched study aimed to evaluate the effectiveness of PI with dexamethasone and bupivacaine in combination with an adductor canal block (ACB) and compare it with that of ACB alone in reducing postoperative pain in patients with TKA.  Data were collected from 66 patients who underwent TKA performed by a single surgeon. Thirty-three of them received ACB + PI, and 33 received ACB alone. However, both groups underwent identical surgical techniques and postoperative care protocols. The pain scores and fentanyl consumption of the two groups were compared. p=0.033, 0.004, 0.038, and 0.049, respectively). The percentage of patients requiring fentanyl as a rescue medication was significantly higher for the ACB alone group (90.9%) than for the ACB + PI group . The total fentanyl consumption was also lower for the ACB + PI group (p < 0.001).  The ACB + PI group had significantly lower pain scores than the ACB alone group at 8, 16, 24, and 48 hours postoperatively ( The periarticular injection of the combination of dexamethasone and bupivacaine plus ACB was more effective than ACB alone in reducing postoperative pain and fentanyl consumption in patients undergoing TKA. Further studies comparing different doses of dexamethasone or other cocktail regimens may provide additional insights into this approach. After undergoing total knee arthroplasty (TKA), managing pain effectively is crucial as it can markedly influence patient recovery and function . InadequThe peripheral nerve block is effective in reducing pain after TKA. There are several types of peripheral nerve blocks, such as the femoral nerve block , sciaticPeriarticular infiltration (PI) is widely performed during TKA. It involves the intraoperative injection of a local anesthetic combined with other medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs) or steroids, into the soft tissue around the knee joint , 13. A pSeveral studies have compared the efficacies of PI combined with ACB and ACB alone for pain management following TKA, but the results are inconclusive , 16. WhiHowever, there has been limited research on the effects of PI with dexamethasone and bupivacaine in patients who have undergone TKA and have already received ACB. Thus, the purpose of this study was to evaluate the effect of PI with dexamethasone and bupivacaine in combination with ACB on postoperative pain in patients who underwent TKA and compare it with that of ACB alone.This was a retrospective, case-matched study that utilized data extracted from the electronic hospital database of patients who underwent primary TKA between July 2020 and June 2022. The local ethics committee and the Institutional Review Board approved this study, and the requirement for patient consent was waived.The inclusion criteria were patients who underwent TKA for primary osteoarthritis and received a combination of spinal anesthesia and ACB. Patients with incomplete data, previous knee surgery, or pain medication protocols that did not match the study protocol were excluded. Patients who underwent TKA between July 2020 and December 2020 were categorized into the control group . In contrast, patients who underwent TKA between January 2021 and June 2022 and received a combination of PI and ACB were included in the experimental group.All surgeries were performed by a single surgeon using a uniform technique . A cemented posteriorly stabilized knee prosthesis was used. The tourniquet was inflated throughout the surgery. All patients received spinal anesthesia and ultrasound-guided ACB. However, patients in the experimental group received PI with a mixed solution of 0.5% bupivacaine 20 mL, dexamethasone 8 mg, and adrenaline 0.3 mg in saline solution in a total volume of 100 mL. Approximately 30 ml of the mixed solution was injected into the deep tissues around the medial and lateral collateral ligaments before implant insertion. After the cement was set, 40 ml of the mixture was injected into the joint capsule and muscle, 10 ml of the mixture was injected into the synovial tissue at the suprapatellar area, and 20 ml was injected at the subcutaneous and skin areas.The same postoperative care and rehabilitation protocols were applied to all the patients. The patients received a standardized postoperative analgesic regimen consisting of oral paracetamol 500 mg every 8 hours and oral pregabalin 50 mg once daily before bedtime. Parecoxib (40 mg) was administered intravenously every 12 hours in three doses. For patients older than 65 years and those with body weights less than 55 kg, the dose was decreased to 20 mg. This was followed by a switch to oral celecoxib (400 mg) once daily. In the case of breakthrough pain, intravenous fentanyl was administered as rescue analgesia.Following surgery, the patients were instructed to perform ankle pumping and quadriceps isometric exercises. They were provided with a supportive device to assist in walking, and range of motion exercises were introduced on the first day after the procedure. The severity of pain was assessed using a verbal numerical scale score ranging from 0 to 10, with 0 indicating no pain and 10 indicating the worst imaginable pain. A nurse evaluated the severity of pain at 4-hour intervals after surgery until the patient was discharged from the hospital.t-test was used to compare the patient's demographic data, including age, weight, height, body mass index (BMI), preoperative hemoglobin level, platelet count, and durations of surgery and hospital stay. The effects of sex, side of surgery, and American Society of Anesthesiologists (ASA) classification were assessed using the chi-squared test, while the pain score and fentanyl consumption were evaluated using the Wilcoxon rank-sum test. All statistical analyses were conducted using R, version 3.1.0 . Statistical significance was defined as p ≤ 0.05.An independent We analyzed 66 patients who met the eligibility criteria. The control group included 33 patients who only received ACB, whereas the experimental group included 33 patients who received PI and ACB. The postoperative pain score was significantly lower in the PI group at 8, 16, 24, and 48 hours. However, there was no difference between the pain scores at 36 and 72 hours. The pain scores are presented in p=0.03). The fentanyl consumption was lower for the patients who had ACB + PI in all timeframes . However, the duration of hospital stay (from the day of surgery until discharge) was significantly lower for the ACB + PI group . None of the patients in either group developed a deep infection or thromboembolism or required reoperation.The duration of surgery was slightly higher for the ACB + PI group, but this was not statistically significant (84.30 ± 26.66 minutes for the ACB alone group and 91.82 ± 20.15 minutes for the ACB + PI group, The combination of ACB and periarticular injection is widely used for pain management following TKA, and several studies have explored its effectiveness. However, research investigating the potential benefits of adding periarticular injections of dexamethasone and bupivacaine to patients who have already undergone ACB during TKA remained inconclusive –20. In oIn this study, patients who received PI had lower pain scores than those in the control group. These results are consistent with those of other studies, such as that conducted by Sawhney et al., who compared the effects of periarticular injection in patients who had received ACB with a normal saline solution containing ropivacaine, morphine, ketorolac, and normal saline alone . SawhneyOur results demonstrated that patients in the periarticular injection group had lower fentanyl consumption for up to 72 hours postoperatively. Similar to a previous study that used an injection cocktail containing ropivacaine, morphine, and ketorolac, it was found that patients in the periarticular injection group used less hydromorphone on postoperative days 0 and 1 . A smallThe length of hospital stay is an important outcome measure in patients undergoing TKA. Our study found that patients who received periarticular injections had shorter hospital stays than those in the control group. This contradicted the reports of previous studies, including that conducted by Kampitak et al.  and a stThis study has several limitations that should be acknowledged. First, this was a retrospective study; therefore, the surgeon and the evaluator were not blinded. However, all surgeries were performed by a single surgeon using an identical protocol, and the protocol for the patients was also identical, except for the addition of periarticular injection in one group. Second, we were only able to analyze pain scores at rest and were unable to assess pain during motion and range of motion because of the limited data available in our electronic database. Future prospective studies should incorporate these in their protocols. Finally, our periarticular injection cocktail contained two active substances: bupivacaine and dexamethasone. Therefore, it is difficult to determine the one with the greatest pain reduction effect after TKA. However, we hypothesized that both substances had synergistic effects on pain control.Our study suggests that periarticular injections of a combination of dexamethasone and bupivacaine, in addition to ACB, are more effective than ACB alone in reducing pain and fentanyl consumption following TKA. These findings highlight the potential benefits of periarticular injections during TKA. However, further studies are needed to investigate the optimal doses of dexamethasone and bupivacaine and compare the efficacies of different cocktail regimens. Overall, our study contributes to the growing body of evidence regarding the use of periarticular injections for pain management after TKA.