Facet joint is a potential structure to be the source of chronic low back pain (LBP) affecting lumbar motion, pain, and disability. Other than the recommended treatment of lumbar stabilization exercise (LSE), several manual procedures including muscle energy technique (MET) are commonly used in physical therapy clinic. However, little evidences of the effects of MET have been reported.This study aimed to compare the immediate effects of MET and LSE in patients with chronic LBP with suspected facet joint origin.Twenty-one patients with low back pain were recruited and randomly assigned to receive treatment either MET or LSE. The outcomes were kinematic changes, pain intensity, and disability level. Lumbar active range of motion (ROM) of flexion, extension, left and right lateral flexion, and left and right rotation were evaluated using the three-dimension motion analysis system at baseline and immediately after treatment. Pain intensity was evaluated using visual analogue scale (VAS) at baseline, immediately after, and two days after treatment. Thai version of the modified Oswestry disability questionnaire (ODQ) was utilized at baseline and two days after treatment. The mixed model analysis of variance was used to analyze all outcomes.The results showed that all outcomes were not different between groups after treatments. Although there were statistically significant improvements after the treatments when collapsing the groups, the minimal clinically important change was found only for pain but not for lumbar movements and disabilities scores.The effect of MET and LSE alone in single session might not be intensive enough to improve movements and decrease disability in patients with chronic LBP with suspected facet joint origin. A study was conducted previously to test the effect on the kinematic of osteopathic manipulative treatment combined with specific exercise in patients with chronic LBP.8 However, the study only measured the forward flexion in sagittal plane.Decreased lumbar motions, as well as an increased pain and disability are the main impairments in patients with chronic LBP including ones with facet joint origin. The possible mechanism is the forces on articular facets which could stretch the joint capsules and the sinu-vertebral capsular nerve might be irritated and provoking muscular guarding.9 However, the reports of the MET effectiveness were mostly based on asymptomatic subjects11 or cases with heterogeneous clinical pictures.12 Studies using MET showed its effectiveness to improve disability and functional level in patients with acute LBP13 and a short-term positive effect in patients with lumbopelvic pain.14 For chronic cases, the evidences of MET effectiveness are still very limited. A study of MET compared with Maitland’s mobilization presented moderately better outcomes of function and range of motion (ROM) in the subjects with chronic LBP due to sacroiliac joint dysfunction.15 The six-day intervention of MET compared with conventional physical therapy also showed that the MET could restore functional leg length difference to nearly normal. However, both groups presented similar results for pain and disability.16The Muscle Energy Technique (MET) has been suggested for treating patients with LBP especially ones with facet joint dysfunction.6 MET procedures focus on identifying the restriction and mobilizing joints and tissues through the local muscle effort.17 The proposed treatment mechanisms involve the neurological and biomechanical responses, including hypoalgesia, proprioception, motor control, and changes of tissue fluid.20 The pain alleviated mechanisms involve central and peripheral modulations such as activation of muscle and joint mechanoreceptors and centrally neural mediated pathways.21 Localized mobilization using MET might also inhibit the motor neuron activity which effectively relaxes the motion segment as well as normalizes the proprioceptive and motor coordination of the involved region.23From a physiological perspective, MET serves the treatment goals of patients with chronic LBP with facet joint origin in restoring motion and eliminating muscle spasm.24 A systematic review supported the evidence that lumbar stabilization exercise (LSE) could reduce pain and disability level in patients with chronic LBP.25 The main focus of this treatment is also to improve the neuromuscular control of lumbar spine by the trunk muscles,25 therefore it was chosen to be the control intervention in this study.The lumbar spinal stabilization exercise is a common intervention used in physical therapy clinic for treating LBP patients.The evidence to support the results of MET for symptomatic subjects was limited. Therefore, this study aimed to compare the immediate effects of MET and LSE for patients with chronic LBP with clinical symptoms of suspected facet joint origin on active ROM, pain intensity and disability level.This pilot study was compared between two groups of LBP patients who were treated with two different treatments i.e., the MET and the LSE. Randomized group allocation and blinded assessor procedure were applied. The outcomes were the kinematic changes, pain intensity, and disability level. This study was conducted after the protocol was approved by the Ethics Committee Mahidol University Institutional Review Board . This study was registered with the ISRCTN, trial registration code ISRCTN 18528219.et al. were used since they were applicable and routinely used in physical therapy clinic.5 The criteria consisted of (1) localized unilateral back pain, (2) referred pain not exceeding the knee level, (3) no sign of a nerve root irritation  and nerve root compression , (4) pain aggravated by pressure over lumbar facet joint, (5) pain aggravated in extension, (6) pain aggravated in three plane movements  to the ipsilateral side, (7) pain eased in flexion, (8) increased stiffness of the facet joint during passive accessory movement, and (9) unilateral muscle spasm over the affected lumbar facet joint. The interrater reliability of this examination scheme in patients with LBP was reported to be acceptable (86.7%), with percent agreements for items ranging from 73.3% to 91.1%, and overall Kappa coefficient of 0.492 ). Nine out of 11 diagnostic criteria of facet joint pain origin according to Wilde 27 To prevent random errors from raw data that might contain additive noises from many sources during data collection, harmonic or frequency analysis was conducted. Residual analysis to choose cut-off frequency and filter technique with Butterworth was used. The cut-off frequency in this study was 5 hertz. The movements measured included flexion, extension, right and left lateral flexion and rotation. All movements were repeated three times, and the average value was used in the analyses. The measurement errors of this system were 7.3928The three dimension motion analysis system  was used to assess the lumbar ROM. The reflective markers were attached on the 12th thoracic segment, the left and right anterior superior iliac spines, and the midpoint between the left and right posterior superior iliac spines.29 The subjects were asked to put a mark on the line to represent their level of pain intensity. The Thai version of modified Oswestry Disability Questionnaire (ODQ) was applied to assess the level of disability related to LBP. The test–retest reliability of this questionnaire was reportedly excellent  dysfunction was posited. If one transverse process was more prominent in the extended position and symmetric in the fully flexed position, the restriction with flexion, rotation, and side bend (FRS) was posited. A neutral dysfunction was suspected if three or more transverse processes were prominent in all positions. The direction for treatment was the same with movement barrier and opposite with positional diagnosis. Prior to the treatment, the therapist arranged the appropriate position and assessed the pain or resistance barrier of the subject. The physical therapist used palpation to monitor the dysfunction segment and muscle contraction at that specific level during treatment.31 Since the pain was chronic, a light to moderate active contraction force was applied. After the contraction effort, the subject was instructed to completely relax the back, and the therapist reengaged movement limitation. Before repositioning to a new barrier resistance, the subject was relaxed and his/her muscles could be stretched to a new resting length. These procedures were repeated for about three to five times.9For the MET group, the selection of technique was based on the symptoms and diagnosis of the direction of the dysfunction according to the textbook “Greenman’s principles of manual medicine”.32 Before the exercise, the abdominal breathing and abdominal hollowing were practiced as training. The exercises were performed in supine position including abdominal hollowing, unilateral knee abduction, extension and knee raise, and bilateral knee raise. The levels of exercise and progressions were customized for each subject, depending on the ability to learn to perform the co-contracting of the lumbar stabilizers. Approximately, 25 min was taken to complete the session for both MET and LSE treatments.For the LSE group, the procedure of exercise to relearn a precise co-contraction pattern of the deep trunk muscles including the transversus abdominis and lumbar multifidus muscles was conducted.8 The authors compared the kinematic data, pain, and disability from two groups of treatments: the group which was treated with specific exercises (SE) plus OMT, and the other group with the SE alone. The calculation with criteria of 80% power and 8Since there was no previous study on the immediate effect of MET on the kinematic data, the sample size calculation was based on the most resembling of specific exercise and osteopathic manipulative therapy (OMT).To analyze the data, all results gained in this study were computed with the IBM SPSS Statistics for Windows, Version 19.0 . Besides, the mixed model analysis of variance was applied for the analysis of all outcomes. Also, the independent sample As shown in Fig. Table There were no significant differences of all kinematic variables , VAS, and ODQ scores for both MET and LSE groups at the baseline. No significant interaction effects of all kinematic variables, pain intensity, and disability level were found. The main effect analysis showed significant differences between times for right lateral flexion, VAS, and ODQ scores (33 These results might be influenced by the reflexive relaxation on spasm muscle, as most of the subjects had pain on left, especially the MET group. However, the change was not clinically meaningful according to a previous study.30 This finding was similar to a previous report which studied the MET effects on lumbar movements in which significant increases (5–10.534 However, there were no significant differences of movements gained between two groups who were treated with the MET and myofascial release techniques.34This study was the first one to compare the immediate effects of the MET and the LSE in patients with chronic LBP with suspected facet joint origin. There was a trend of an increased active ROM for all directions after treatments in both groups except the extension in LSE group. No significant differences between groups were presented and the effect sizes of all movements were minimal, except for the right lateral flexion which had a medium effect size.35 However, those results should be implemented with care because they also applied the combination of treatments including moist heat, transcranial electrical nerve stimulation, and conventional exercises in both groups. These might result in the cumulative effects of several interventions.The results of treatment on pain were not different between two groups, and the effect size was also minimal. However, there was a significant main effect of time. The decrease in pain at immediate and two days after treatments was found when the data of both groups were combined. This implied that active exercise treatments either MET or LSE had an effect on pain in patients with chronic LBP. This result was in accordance with a previous study in which similar effects comparing MET with ultrasound were observed.36 The mean changes of the VAS score for both groups in this study were 19.24 points at immediately after treatments, and 24.34 points at 2-day follow-up. The decreased pain levels reflected the effectiveness of both treatments in participants with moderate pain level.In addition, the altered pain intensity in this study was considerably an actual change, when considering the reported minimal important change of more than 15 points or 30% improvements from the baseline interventions.37 The rhythmic muscle contractions and stimulation of joint mechanoreceptors could affect the central mediated pathways through the stimulation of low-threshold mechanoreceptors. This would excite the neurons in the dorsal horn resulting in gating effects i.e., modulating the pain.18 The descending inhibition from the higher centers of central nervous system is also hypothesized.18 For peripheral mechanism, the light muscle contraction might stimulate fluid flow rates including blood and lymph, as well as stretch the connective tissues. The reduced pain might be associated with the change in stretch tolerance with decreasing of the muscle spindles sensitivity, and ultimately reduce pain sensitivity of both the efferent and afferent nerves.22 MET was proposed to not only break the pain or spasm cycle by inhibiting alpha motor neuron activity via a stretch reflex, but also to inhibit Ia afferent nerves via post-activation depression.22The possible explanation is the light contraction forces of both techniques which could enhance hypoalgesia in chronic pain condition both central and peripheral mechanisms.38 so a single session of both MET and LSE could not improve ODQ in patients with chronic LBP. A previous study suggested that the MET when combined with other treatments might be more effective on disability after multiple treatment sessions.14 Moreover, a systematic review which included 12 trials showed a low quality of evidence of the MET as the addition or comparison to other treatments on pain and disability.39 These findings of pain and disability levels are needed to be clarified in further studies by examining the effects of long-term and repeated MET and LSE treatment programs.For disability, while considering the main effect of time, there were statistically different disability scores between times. However, from pre-treatment to 2-day follow-up, the mean change scores were 6.0 and 8.8 for the MET group and LSE group, respectively. These scores did not meet the clinically important change of 15 points in ODI score,5 Out of the 12 criteria listed, two important indicators of “positive response to intra-articular facet joint injection” and “pain relieved by fluoroscopically guided double-anesthetic blocks of the medial branch of the dorsal ramus supplying the lumbar facet joint” were also omitted due to the nature of physical examination in physical therapy practice. Therefore, the validity of facet joint diagnosis was not confirmed.Another concern of this study is about the diagnostic tests to identify the patients with suspected pain from facet joint origin. Clinicians should be noted that the clinical criteria used in this study were based on the results of a Delphi study to gather the consensus of expert opinions.In conclusion, the different effects between MET and LSE were not found in this pilot study though attempting to include only patients with suspected pain of facet joint origin. Although this study showed statistically a significant increase of the active side-bending ROM to the painful side, as well as the decreases of the pain and disability levels, the results should be interpreted with care. The major limitation of considerably small sample size might lead to the insignificant different results. The study also monitored only immediate effect which does not reflect the usual treatment program. Further studies should be focused on long-term treatments and the evaluation with a larger sample size.The authors declare that they have no competing interests.No funding was received.WW designed the study, evaluated the patients, analyze data and wrote the paper. MV proved the study design, treated the patients and edited the paper. SB, KM and RA proved the study design, assisted the patient recruitment, data collection, read and approved the paper.


Prolonged air leak (PAL) after pulmonary resection is one if the most common complications in thoracic surgery. The dataset was obtained from a prospective randomized study investigating autologous blood patch pleurodesis in PAL. Patients were randomized to either receiving 100 ml autologous blood injected at postoperative days five and six (group A) or to watchful waiting (group B). The primary and secondary endpoints focused on differences in the duration of PAL in each group and possible complications. The results were reported in The Journal of Surgical Research. In this Data in Brief article, we provide additional data concerning pain medication and pain score during the first ten postoperative days. This should provide additional insights into the trial. Specifications table•Our prospectively collected data may be useful for clinicians and researchers working in the fields of thoracic surgery or pneumology. The data may also be useful for pain research.•The data provide an insight in details of pain medication after lung surgery.•The dataset provides a valuable starting point for further prospective studies in the field of thoracic surgery.This dataset contains rare data of a surgical cohort with PAL treated with autologous blood patch pleurodesis or watch and wait. We evaluated postoperative patient data on a daily basis, starting with the first postoperative day and up to 10 days postoperatively. This corresponds to day 5 after randomization. The dataset includes baseline data like gender, age, pain medication on discharge and pre-existing pain medication as well .Tab. 1PaAt the first day after operation median pain score in resting position was 1 (range 0 to 4) in the watch and wait arm. On same day median pain score was 0 (range 0 to 3) if patients received autologous blood pleurodesis. From day two until the 10th day after the operation the median pain score was between 4 (range 0 to 10) and 3 (range 0 to 10) in both arms. Table 2.TMedian pain score on first day after the operation when moving was 5 (range 0 to 10) in the watch and wait group and 4 (range from 0 to 8) in the blood pleurodesis group. Between the second and the 10th day after operation median pain score when moving was between 0 (range 0 to 5) and 2 (range 0 to 10). Study design: Investigator initiated prospective randomized single-center study. Due to the type of intervention blinding was not performed. All patients who demonstrated a persistent air leakage at postoperative day 5 after pulmonary resection were screened for eligibility and asked for consent. Patients were then either randomized to receiving 100 ml autologous blood injected at postoperative days five and six (group A) or to watchful waiting (group B). In case of an expanded lung routinely no suction was applied, however the decision to apply suction in case of insufficient lung expansion was left to the decision of the consultant in charge. The drains were removed as soon as no air leakage was determined for 24 h and fluid production was < 350 ml/24 h.Routine management: At the end of surgery water seal test was performed to exclude air leakage. In case of observed air leakage all necessary measures were taken to close the fistula. Routinely Ch24 chest tubes were placed. The decision to place one or two chest tubes was depending on the intraoperative situation and the degree of adhesions as well as bleeding tendency. In standard anatomical lung resections usually one posteroapical drainage was used. Digital and conventional chest drainages were used depending on availability and surgeon preference. In standard lung resections – 20 cm H2O suction was applied. In patients with severely emphysematous lungs and after lung volume reduction surgery no suction was used. The decision for drainage removal was based on absence of air leakage for 24 h and fluid production <350 ml/24 h.Blood patch pleurodesis: Blood patch with autologous blood was performed on ward in aseptic conditions and without any additional analgesia. A quantity of 100 ml blood was taken from a peripheral vein of the upper extremity in sterile conditions and injected immediately in the apical chest tube. No Heparin was added. If possible the chest tube was clamped for a period of 20 min otherwise the chest drain was elevated above the level of the patient´s chest, in order to keep the injected blood within the chest but allow air drainage.The indication for surgical revision given if a collapsed lung in the chest X-ray despite suction combined with persistent air leakage was observed.Pain assessment was conducted every day via visual analog scale. We assessed status of pain from the first postoperative day until the tenth day after operation.Statistical analysis was conducted by using MedCalc software Version 11.6.1.0 . Pain score (VAS) was analysed by multivariat analysis (ANOVA). A Bonferroni corrected p value <0.05 was considered as significant.(1) All third-party financial support for the work this article:We report no third-party finical support of any author for this work.(2) All financial relationships with any entity that could be viewed as relevant to data described in this manuscript;We report no finical relationship for any author.(3) All sources of revenue with relevance to this work where payments have been made to authors, or their institutions on their behalf, within the 36 months prior to submission;We declare no payment for any author.(4) Any other interactions with the sponsors, outside of the submitted work;We declare no other interaction with the sponsor.(5) Any relevant patents or copyrights ;There is no patent or copyright related to this work.(6) Any other relationships or affiliations that may be perceived by readers to have influenced, or give the appearance of potentially influencing, what has been written in this article.The authors declare that they have no known competing financial interests or personal relationships which have, or could be perceived to have, influenced the work reported in this article.We declare also no competing interest.


To investigate the functional connectivity (FC) in nonacute sciatica and the neuronal correlation of acupuncture analgesia.A prospective study employing resting‐state functional magnetic resonance imaging was conducted. Twelve sciatica patients were enrolled to receive six or 18 acupoints of acupuncture treatment twice a week for 4 weeks. Regional homogeneity (ReHo) and seed‐based FC were performed.Regional homogeneity analysis demonstrated a greater alteration in the right posterior cingulate cortex (PCC) during the pre‐acupuncture phase than during the postacupuncture phase. Compared to that of healthy controls, the PCC‐seeded FC  of sciatica patients exhibited hyperconnectivity of PCC‐FC with the PCC‐bilateral insula, cerebellum, inferior parietal lobule, right medial prefrontal cortex, and dorsal anterior cingulate cortex during the pre‐acupuncture phase as well as hypoconnectivity of PCC‐FC with the right cerebellum, left precuneus, and left dorsal medial prefrontal cortex during the postacupuncture phase. Correlation analysis between PCC‐seeded FC and behavior measurements revealed a positive association with the duration of sciatica in the right inferior parietal lobule prior to acupuncture treatment.Acupuncture in chronic sciatica patients is associated with normalized DMN activity and modulation of descending pain processing. The changes in the subclinical endophenotype of brain FC after acupuncture treatment may provide clues for understanding the mechanism of acupuncture‐mediated analgesia in chronic pain. Acupuncture modulation elicited a bidirectionally regulated effect on default mode network (DMN) in chronic sciatica patients. The changes in subclinical endophenotype of brain FC after acupuncture treatment may provide clues for understanding the mechanism of acupuncture‐mediated analgesia in chronic pain. Exclusion criteria were (a) known or suspected serious spinal pathology , (b) pregnant or breast‐feeding women, (c) scheduled or being considered for spinal surgery or interventional procedures for sciatica during the 8‐week treatment period, (d) administration of sedative or analgesic drugs within 24 hr before the fMRI scan, (e) comorbidities of systemic malignancy, bleeding tendency, rheumatic arthritis, and other known autoimmune diseases, (f) focal neurological deficits with progressive or disabling symptoms, (g) history of receiving acupuncture treatment in the past 1 month, (h) contraindications for acupuncture or MRI, (i) visual analog scale <3, and (j) low back pain without sciatica.In addition to inclusion and exclusion criteria, the patient's diagnosed sciatica met at least two of the following items: (a) radicular pain in the L4, L5, or S1 dermatome; (b) physical examination consistent with radicular pain, motor or sensory neurological findings, or decreased reflex in the L4, L5, or S1 nerve root distribution; (c) positive straight‐leg‐raising test; (d) increased leg pain on coughing, sneezing, or straining; and (e) MRI demonstrating a unilateral disk herniation impinging on the L4, L5, or S1 nerve root  and after 4 weeks of treatment (eight sessions), rsfMRI scans were obtained. The total observation period in this study was 4 weeks for each patient. All patients received brain fMRI and behavioral scales twice (at baseline and 4 weeks after acupuncture treatment). The healthy individuals received one fMRI and behavior scale only, without any intervention.qi, based on the theory of Traditional Chinese Medicine  since 1970 and selected acupoints that were effective for treatment  stainless steel needles  were used. Needles were only used once and were generally inserted to a depth of 5–30 mm, depending on the acupuncture point. Insertion was followed by manual stimulation to elicit the “de qi” sensation. Needles were retained in position for 20 min of acupuncture treatment. The acupuncture treatment was provided twice weekly for 4 weeks in both groups .2.4The primary outcome was the 100‐mm visual analog scale (VAS) for sciatica, measured at baseline and week 4. The pain scores ranged from 0 to 10; higher values represented worse outcomes. The patients were asked to rate their average leg pain over the last 24 hr with 0 representing “no leg pain” and 10 representing the “worst pain imaginable” . With eye fixation after correction of visual acuity, the baseline study of resting brain was obtained with (a) 5‐min sensory deprivation after explaining the resting condition to subjects and (b) subject's response at the end of the scan, verifying their state of consciousness. An online real‐time analysis of head motion, using the methods modified from Analysis of Functional Neuroimaging (NIMH), ensured the quality of fMRI images with head translation <1 mm and head rotation <0.5° within each session. Studies of head motion exceeding the motion criteria were repeated or rejected from data analysis. Structural MRI studies included (1) 3D magnetization‐preparation T1‐weighted structural image . The total scan time of the rsfMRI was approximately 13 min. Head cushions and earplugs were provided to reduce head motion and noise. During the fMRI examination, the patient's vital signs such as heart rate, O2 saturation, and respiratory rate were monitored and recorded.Resting‐state fMRI scans were obtained from each group at baseline and after 4 weeks of treatment to detect the regional features of spontaneous brain activity. Resting‐state fMRI was performed with a 3.0‐Tesla scanner  and 12‐channel head coil. Echo‐planar imaging was used for the rsfMRI scans  between the seeds and the related brain regions. After calculating the correlation between the reference time course and the time course of each voxel in the brain, r‐values were converted into z‐values using Fisher's r‐to‐z transformation to normalize the distribution. The FC was considered significant if the family‐wise error level was p < .05 at the voxel level.The preprocessing of the FC analysis protocol was the same as that of the ReHo analysis, except that the images were (a) coregistered to individuals' anatomical image and then normalized to the standard T1 MNI template; (b) spatially smoothed using a 3D Gaussian kernel of 8 mm full‐width at half‐maximum; and (c) treated with the global mean signal for additional nuisance variables. Because the global signal regression may cause a negative shift in the distribution of correlations . Treatment effects such as 100 mm VAS, SBI, RDQS, and WHOQOL‐BREF, measured at baseline and week 4, were evaluated using a paired t test for within‐group analysis.SPSS statistical package program  was used. The significance level used for the statistical analysis with two‐tailed testing was 5%. Continuous variables were presented as means ± standard deviation with 95% confidence intervals (CI). Categorical variables were described as 2.7.2t tests were performed to derive group maps of FC (ReHo‐seeded FC), paired t tests were performed to compare the changes in FC before and after acupuncture in patients with sciatica, and independent‐sample t tests were performed to compare changes in FC in the patients with sciatica and healthy controls. A cluster‐corrected p < .05 (family‐wise error correction) level was used as the threshold for statistical significance.One‐sample 2.7.3t test to examine the correlation between behavior inventories  and baseline in patients with sciatica. Two‐sample t tests were conducted to determine the correlation between behavior inventories and ReHo‐seeded FC in the acupuncture group for the condition of before and after treatment, respectively. Significance was set at the uncorrected voxel level p < .005, followed by the family‐wise error‐corrected cluster level p < .05.Between ReHo‐seeded FC and behavior, data were analyzed using a one‐sample 33.1Twelve patients  completed the study. Each patient received two fMRI scans (one at baseline and one after eight sessions of acupuncture at 4 weeks). The average ages of patients were 61.42 ± 14.84 years. The mean disease duration was 20.75 ± 16.44 months. Six patients had right sciatica, and six patients had left sciatica. The mean VAS, SBI, RDQS, and total WHOQOL‐BREF at baseline were 5.42 ± 1.83, 11.83 ± 5.37, 10.75 ± 4.85, and 53.19 ± 9.48, respectively . However, there were nonsignificant changes observed in SBI and WHOQOL‐BREF after acupuncture treatment (Table There were significant differences between before and after acupuncture treatment with regard to VAS and RDQS (nt Table .3.3pretreatment − Sciaticapost‐treatment) in the coordinate , which is in the region of the PCC/PCu, according to the MNI template. Compared with healthy controls, patients after acupuncture treatment had increased ReHo alternation in the right precentral gyri , there was a greater ReHo alteration  as a region of interest (ROI) to examine changes in PCC‐seeded interregional FC. The PCC‐seeded FC exhibited a characteristic DMN pattern of FC in the sciatica and healthy groups   at baseline (Figure 4This preliminary study assessed the clinical effect of acupuncture in treating sciatica and proposed whether acupuncture targeted certain regions of the brain in nonacute/chronic sciatica patients. Through our study, acupuncture may achieve pain relief and resolve disability in patients with sciatica. Seed‐based FC derived from ReHo‐contrast analysis may provide a clue for understanding the central mechanism of acupuncture modulation. We demonstrated that PCC/PCu was a pivotal hub in sciatica treatment with acupuncture. Furthermore, using PCC as an ROI for seed‐based FC whole‐brain analysis, we observed that DMN may play a crucial role in the central analgesic effect of acupuncture. The changes of PCC‐seeded DMN through acupuncture modulation were mainly located in pain‐processing regions such as the bilateral insula, cerebellum, IPL, right mPFC, and dACC. In ReHo, whole‐brain analysis revealed that the precentral gyrus was related to acupuncture modulation. Finally, correlation analysis between PCC‐seeded FC and behavior measurements revealed a positive association with the duration of sciatica in the right IPL prior to acupuncture treatment.The present findings demonstrate that the nonacute/chronic sciatica group had greater PCC ReHo values than did the healthy control and postacupuncture groups. Higher ReHo values have been reported in several areas of the pain‐related brain network (Shi et al., Furthermore, we selected PCC based on the contrast of the ReHo map as a ROI to examine the effect of acupuncture analgesia on the DMN. The PCC/PCu plays a crucial role in the DMN (Fransson & Marrelec, The DMN may be reorganized by chronic pain and exhibits maladaptive connectivity in different types of chronic pain (Baliki et al., There are several limitations to the current study. First, the number of subjects recruited was relatively small, and there was nonsignificant improvement in the quality of life. However, despite the small number of the patients, those treated with acupuncture obtained significantly improved pain relief and decreased disability due to sciatica. Second, we cannot exclude the possibility of a natural course of the disease of the patients. Nevertheless, all twelve patients have received contemporary Western medicine but did not attain a satisfactory therapeutic effect. Furthermore, even sham needles have a placebo effect (Lund, Naslund, Naslund, & Lundeberg, 5In summary, the present study suggests that acupuncture treatment may relieve pain in sciatica patients and normalize its modulation in the relevant brain areas, especially the DMN and DPMS. The endophenotypic changes in brain FC based on acupuncture modulation may provide clues to understand the mechanisms underlying the analgesic effects of acupuncture on chronic pain. Acupuncture may promote robustness in the system (Xu et al., The authors declare that they have no conflict of interest.


Adolescent idiopathic scoliosis (AIS) has been associated with diminished postural stability and a greater prevalence of back pain. Currently, the literature is lacking information on the effect of spinal fusion on both postural stability and its association with back pain. Our objectives were to evaluate the postsurgical effect of spinal morphological changes on static standing balance and assess the influence of these alterations on reported pain throughout the perioperative period.Twenty consecutive AIS patients schedule to undergo spinal fusion surgery were recruited and followed prospectively at the Shriners Hospitals for Children-Canada. Data was collected at the preoperative, 6 weeks and 6 months postoperative visits. Spinal morphology data was collected through 3D reconstructed simultaneous standing biplanar radiographs using the SterEOS software. Postural balance was assessed through Moticon© sensor insoles and analyzed through their software. The data was simultaneously collected as part of the Global Biomechanical and morphological Assessment. Pain was evaluated through self-reported questionnaires.P = 0.017) at 6 weeks. Of note, preoperative balance parameters were associated with the degree of right thoracic Cobb angles (P = 0.029 R = 0.528). Pain scores significantly improved 6 weeks and 6 months after the surgery. Pain intensity diminished in the thoracic and lumbar spine but worsen in the neck region at the 6 weeks and 6 months postoperative time points (P = 0.044). Greater residual Cobb angle difference between Mid thoracic and Thoracolumbar/Lumbar curves was associated with greater pain severity at 6 weeks postop (P < 0.005). In addition, greater residual thoracic deformity was associated with significant pain severity 6 months after surgery (P < 0.05).Morphological curve parameters were significantly reduced after surgery. Balance parameters did not change significantly throughout the perioperative period with the exception of the Center of Pressure of the left foot medial/lateral transient shift (Improved spinal morphology of postsurgical AIS patients has no significant impact on their static standing balance. Suggesting that other factors apart from the spinal morphology may contribute to AIS patients’ balance during stance. Although balance did not influence pain severity, spinal morphology and its correction appear to have influenced the intensity and location of back pain. The latest literature seems to agree that adolescents with idiopathic scoliosis have poorer balance control compared to adolescents without scoliosis –6. WhethCorroborative evidence of this assumption has been previously reported. Valles et al. have shown significant improvement in objective parameters of postural control during quiet standing with both eyes opened and closed up to 1-year postoperatively in AIS patients . HoweverIt is also important to consider the consequences, such as back pain, of AIS caused spinal morphology and postural balance. In fact, back pain prevalence is higher in AIS patients compared to adolescents without scoliosis –20. DespIn order to evaluate the influence of morphology and postural balance on back pain, we designed a longitudinal study with AIS patients undergoing surgical treatment. Our objectives were to investigate the association between spinal deformity correction and postural balance changes and to evaluate its impact on postoperative back pain.Twenty (20) consecutive patients  between the ages of 10 and 18 diagnosed with AIS and scheduled for a spinal fusion surgery were recruited at the Shriners Hospitals for Children - Canada. The mean age of the cohort was 14.9 ± 1.68 years, the average body mass index (BMI) was 20.66 ± 3.25 and the mean exposure time was 20.62 ± 2.93 s at the preoperative time point. Regarding to the curve type, there were (8) patients with Lenke 1, (5) Lenke 2, (2) Lenke 3, (1) Lenke 4, (2) Lenke 5, and (2) Lenke 6. Preoperative morphological results can be seen in Table Due to the lack of literature on simultaneous assessments of balance and spinal morphology an evaluation bias between the two can be observed. Thus, we created the Global Biomechanical and Morphological Assessment (GBMA). This simultaneous evaluation is comprised of a three-dimensional (3D) modelling assessment of the scoliotic spine and a balance assessment using wireless sensor insoles. These sensor insoles captured live data of the patient’s balance during their standing biplanar radiographs. A Cartesian plane was placed on the floor of the radiographic cabin as to associate the location and orientation of the feet to the spinal morphology. After the acquisition, the spinal morphology was reconstructed in 3D for better evaluation. The morphological data was then analyzed in parallel with the postural balance data to find associations. Since all variables are captured at the same time in the same position, this technique eliminates the bias of two separate evaluations of the balance and the spinal morphology while also providing a visual representation of their associations . The GBMA was used at every time point during this study.Patients underwent simultaneous two-dimensional head-to-toe posterior-anterior  and lateral  radiographs using the EOS-Imaging system  as part of the standard of care. This was done at every time point: preoperatively, 6 weeks and 6 months postsurgical. Patients were asked to place their hands on the wall in front of them to expose the spine without the obstruction of the humerus in the sagittal plane. This position also reduced the potential of a second exposure. Patients were asked to keep their eyes open and keep a normal breathing cycle not to disturb the image. Once the acquisition complete, all 60 spinal radiographs were reconstructed in three-dimension (3D) through the SterEOS software version 1.6.4.7977  by trained professionals.Scientific Reports.Radiological parameters extracted from the SterEOS software were: Cobb angles from the Proximal Thoracic (PT), Mid Thoracic (MT) and Thoracolumbar/Lumbar (TL/L) curves; the rotation in all three planes of these curves apical vertebrae (AVR); the intervertebral rotation in all planes of every vertebrae; the T1-T12 kyphosis; the L1-S1 lordosis; the pelvic incidence, axial rotation and tilt in the lateral and frontal planes; and the sacral slope. All of these variables were taken in the patient’s reference plane for time point comparison. The patient reference plane is a reconstruction based on all three-dimensional planes. It bases itself on the location of the acetabula inside the cabin to reconstruct the spine instead of the position of the patient, which changes from visit to visit . This alThe static standing balance assessment was conducted with Moticon© OpenGo sensor insoles  during the radiological capture. They were activated and then slipped under the patient’s feet in the cabin just prior to the radiographic exposure. The plantar recording was time matched with the radiograph acquisition to have a simultaneous picture of the effect of the abnormal spine on the biomechanics of the feet.Every patient was sized for a pair of insoles. The patients were asked to stand comfortably with their feet pointing forward in the centre of the cabin. Once the patient entered the cabin and the insoles were slipped under their feet, their feet were marked upon the Cartesian plane. The patient’s feet were not moved nor reoriented to evaluate, as much as possible, their normal stance.The insoles measured nine different balance parameters through 13 sensors in each insole. All parameters were based on the percentage of pressure or the centre of pressure (CoP) of each individual foot. These variables are as follows: the mean and standard deviation of the anteroposterior and mediolateral CoP location (CoP AP and CoP ML respectively), where a positive result is seen in the anterior and medial plane based on the zero located approximately at the metatarsal-phalangeal joints and in the midline of the foot; the CoP velocity, measured in mm/s; the CoP trace length, measured in meters; the CoP anteroposterior and mediolateral bounding box, where the greater the measurement the greater the CoP distance travelled in said plane; The CoP sway area, which is the product of both planes bounding box measurements; the mean foot pressure; and the pressure distribution in the front, mid and back of the foot. Moticon© OpenGo software version 01.11.00_11072-929d380 was used to analyze the balance variables at every time point. .Self- reported questionnaires were given to the patient after their morphological and biomechanical assessment at each time point. The questionnaires given to the patients were: the Scoliosis Research Society Questionnaire-30 (SRS-30), and a modified version of the Adolescent Pediatric Pain Tool (APPT) containing a back diagram for pain location and intensity. The latter was evaluated with a 0–10 numeric rating scale where 0 is no pain and 10 is the worst pain imaginable. Pain severity groups were then created: mild (0–3), moderate (4–6) and severe (7–10). The questionnaires were asked to be done without the help of their parents to avoid bias. If for any reason the patient would have questions, the research assistant was at their disposal to answer them. All questionnaires were reviewed after completion and entered into a database.P < 0.005.All statistical analyses were conducted using the software SPSS version 25 . Descriptive and inferential statistics (mean and standard deviations) were used to display the patients’ demographic, morphological, balance and pain data. Paired student t-Tests were used to evaluate the differences between the preoperative and the postoperative time points for demographics, morphology, balance, and pain. Pearson correlations were done to estimate the association between 3D spinal structure and balance variables, and to assess the relationship between the morphological and pain-related parameters. A one-way ANOVA with Bonferroni Post-Hoc test was used to assess the significance between different pain severity groups. A Chi-square test was used to analyze the proportions of patients with pain throughout the perioperative period per painful back location. Significance for all evaluation was set at P < 0.001). The MT apical vertebra translation (P < 0.001), the TL/L apical vertebral rotation , MT’s absolute torsion  and the sacral slope  also followed suit in their significant reduction at 6 weeks and 6 months postoperative. Others, MT apical vertebra rotation and L1-S1 lordosis were significantly reduced at 6 weeks but were no longer at 6 months postoperative. The T1-T12 kyphosis oppositely was significantly increased at 6 months but not at 6 weeks postoperative.As seen in Table P = 0.017). Although when compared to the 6 months postoperative time point, no difference was observed with the preoperative results. Therefore, since no significant difference in postural balance was observed between the preoperative and the 6 months postoperative time points, no significant associations could be made with the changes in spinal morphology.All but one mean balance parameter did not differ significantly throughout the perioperative period Table . The lefP = 0.265), and the number of painful regions (P = 0.625) were not significantly different. All APPT worst pain, thoracic and lumbar pain severity, and painful regions were reduced significantly after 6 months. These finding were also corroborated with the results of the SRS-30 Pain score as they improved significantly (p = 0.004) at 6 months posterior spinal fusion (PSF). In contrast, pain in the neck area was significantly worse (P = 0.044). Self-reported pain was significantly reduced in the lumbar and pelvic region (P = 0.002 and P = 0.041 respectively) after surgery  and the severity of the right thoracic translation . A strong correlation  was seen between the severity of the proximal thoracic Cobb angle and the severity of the pain .Six weeks after the surgical intervention, the difference between the lumbar and thoracic residual Cobb angles was associated with the pain severity reported Fig. . It suggP = 0.032 and P = 0.041 respectively). Another significant association emerged when looking at the reported severity of the pain and lumbar translation: the apical translation of the lumbar spine was also associated with a greater pain severity (P = 0.023).At 6 months post PSF, an association between the residual thoracic area deformity and the pain severity reported was identified Fig. . It showP = 0.009; R = 0.569) was observed at 6 months. Also, while comparing patients that reported no/mild and moderate pain, patients that fell in the latter applied more pressure on the back of their feet (P = 0.050). Balance parameters were also associated with the degree of right thoracic Cobb angles at the preoperative time point (P = 0.029 R = 0.528) (Fig. Regarding postural balance and pain, an association between the trace length of the CoP of the right foot and the SRS-30 pain score (This study presents a novel comprehensive evaluation, the GBMA, simultaneously assessing the spinal morphology and postural balance of AIS patients. It uses state-of-the-art 3D reconstruction of biplanar radiographs to examine the spinal morphology variables in all three planes while also using the wireless capacity of sensor insoles to concurrently evaluate postural balance. The results presented in this study concerning our first research question indicate that objective balance parameters have not changed post-operatively despite the realignment of the spine. Thus, suggesting no association between the change in morphology and the postural balance. These results, contradict our hypothesis but are supported by some of the literature on the subject –14, 28. Our study reports no significant difference in balance in the perioperative period in patients with AIS. This would suggest that the change of the spinal morphology would not affect the balance in this short postoperative period of time. This might be due to the lack of time for the body to fully adapt to the new posture. Patients were used to the way they stood before surgery and it possibly takes a longer period to adapt its balance to the new spinal morphology. Schimmel et al. , de AbreThese reported results, for the exception of an association between the severity of the pain and pressure in the back of the feet at 6 months post-surgery, also suggest that since the mean postural balance does not change throughout the perioperative period it has little effect on the pain felt by the patient. de Abreu et al.  evaluateIn accordance with previous literature, our results highlight a decrease in pain severity after PSF and they also identify spinal morphological variables associated with the pain felt throughout the perioperative period. This, in part, confirms our second hypothesis, for which the morphology does impact the pain felt. The decrease in the severity of pain compliments the works of authors such as Sieberg et al. , Merola Interestingly, we identified that self-reported pain prevalence Table  and painWhen considering our independent time point results, they indicate moderate to strong correlations between the thoracic deformity and the pain felt in the thoracic area before surgery. Recent literature , 33, fouAt 6 weeks and 6 months post PSF, our results show an association between the residual curves of the spine and the pain felt. To our knowledge, this is the first time this has been reported. Although the fusion of the lumbar vertebrae is usually avoided unless necessary to permit the flexibility of the spine, results presented in this study suggest that not ensuring stability in the lumbar region by diminishing the lumbar translation and reducing the lumbar AVR, creating a greater difference between the severity of the residual lumbar and thoracic curves, could be detrimental to the pain felt in the early postsurgical period. This association is not observed at 6 months, thus suggesting that it might only be a result of acute postsurgical pain. This might explain why authors such as Mimura et al. have not observed these effects later on in the postoperative period. We hypothesize that this might be due to the sudden uneven adaptation of muscle activation in the lower back for support creating a strenuous pain. Future research should explore the difference in the early postsurgical report of pain and last vertebrae fused. The 6 months postoperative association indicates a relationship between residual thoracic deformity and pain severity. Suggesting, that if the initial deformity is not corrected properly, it could result in greater severity of pain and possibly in its chronicity. Future studies should validate these results with greater sized cohorts. Although, pain is multifactorial  and biomSpine from St-Georges et al. 2020, they do lack specificity in CoP displacement in static standing evaluation [This study has limitations that should be taken in consideration. The small sample size restricts the power of the analysis and diminishes the possibility of subgrouping by type of curves. Therefore, the evaluation of the effect of different curvatures on spinal balance was restrained. Evaluating patients with a right thoracic curve and patients with both right thoracic and left lumbar curves as part of the same cohort with possibly different balance , could haluation –39. TherTo our knowledge, this was the first study of its kind to evaluate simultaneous 3D standing biplanar radiographs at the same time as postural balance to understand pain. This methodological strength permits the assessment of the effect of the 3D morphology of the spine on balance without reducing the direct correspondence that comes with different evaluations. Which also present a stronger morphological and biomechanical profile to associate to the perioperative pain report of the patient.Spinal morphology in AIS influences pressure distribution across patients’ feet preoperatively. However, balance parameters do not change throughout the perioperative period, suggesting that other factors beyond the spinal morphology could contribute to AIS patients’ balance during stance. Although balance shows no association to pain, spinal morphology and its correction appears to influence the severity and location of back pain.