Interpretation of visual analog scale ratings and change scores: a reanalysis of two clinical trials of postoperative pain

Efficacy of ultrasound therapy for the treatment of lateral elbow tendinopathy (the UCICLET Trial): study protocol for a three-arm, prospective, multicentre, randomised controlled trial

INTRODUCTION

Lateral elbow tendinopathy (LET) is a highly prevalent disease among the middle-aged population, with no consensus on optimal management. Non-operative treatment is generally accepted as the first-line intervention. Ultrasound (US) therapy has been reported to be beneficial for various orthopaedic diseases, including tendinopathy. The purpose of this study is to investigate the efficacy of US for LET treatment.

METHODS AND ANALYSIS

This protocol entails a three-arm, prospective, multicentre, randomised controlled trial. Seventy-two eligible participants with clinically confirmed LET will be assigned to either (1) US, (2) corticosteroid injections or (3) control group. All participants will receive exercise-based therapy as a fundamental intervention. The primary outcome is Patient-rated Tennis Elbow Evaluation. The secondary outcomes include Visual Analogue Scale for pain, shortened version of the Disabilities of the Arm, Shoulder and Hand for upper limb disability, pain free/maximum grip strength, Work Limitations Questionnaire-25 for functional limitations at work, EuroQol-5D for general health, Hospital Anxiety and Depression Scale for mental status, Global Rating of Change for treatment success and recurrence rate, and Mahomed Scale for the participant's satisfaction. Adverse events will be recorded. Intention-to-treat analyses will be used.

ETHICS AND DISSEMINATION

Ethics committees of all clinical centres have approved this study. The leading centre is Shanghai Sixth People's Hospital, whose approval number is 2021-153. New versions with appropriate amendments will be submitted to the committee for further approval. Final results will be published in peer-reviewed journals and presented at local, national and international conferences.

TRIAL REGISTRATION NUMBER

ChiCTR2100050547.

Comparative evaluation of low-level light therapy and ethinyl estradiol and desogestrel combined oral contraceptive for clinical efficacy and regulation of serum biochemical parameters in primary dysmenorrhoea: a prospective randomised multicentre trial

We aimed to compare low-level light therapy with oral contraceptive pills for pain relief and serum levels of nitric oxide and prostaglandin E₂ in patients with primary dysmenorrhoea. This was a randomised, active comparator-controlled, multicentre study. In total, 156 patients were randomised to receive either low-level light therapy with light-emitting diodes (LED) applying on two acupoints, namely, conception vessel 4 (CV4) and CV6 or conventional treatment with oral Marvelon, 30 µg of ethinyl estradiol and 150 µg of desogestrel (DSG/EE), for three consecutive menstrual cycles. The main outcome was the proportion of patients who achieved 33% or more decrease in pain scores measured using the visual analogue scale, which was deemed as efficient rate. Absolute changes in visual analogue scale scores, serum levels of nitric oxide (assessed by nitrites and nitrates reflecting nitric oxide metabolism) and prostaglandin E₂ (measured by enzyme-linked immunosorbent assay) were the secondary outcomes. A total of 135 patients completed the study (73 in the light therapy group and 62 in the DSG/EE group). The efficient rate at the end of treatment was comparable between the groups (73.6% vs. 85.7%, χ² = 2.994, p = 0.084). A more significant reduction in pain scores was observed in the DSG/EE group (39.25% vs. 59.52%, p < 0.001). Serum levels of prostaglandin E₂ significantly decreased from baseline but did not differ between groups (- 109.57 ± 3.99 pg/mL vs. - 118.11 ± 12.93 pg/mL, p = 0.51). Nitric oxide concentration remained stable in both groups. Low-level light therapy with LED-based device applied on acupuncture points CV4 and CV6 demonstrated a similar level of dysmenorrhoea pain reduction to DSG/EE combined contraceptive. Both treatment modalities achieved clinically meaningful levels of pain reduction. Registration on ClinicalTrials.gov: TRN: NCT03953716, Date: April 04, 2019.

The Mediating Effect of Perceived Injustice and Pain Catastrophizing in the Relationship of Pain on Fatigue and Sleep in Breast Cancer Survivors: A Cross-Sectional Study

OBJECTIVE

Multidimensional aspects of pain have raised awareness about cognitive appraisals, such as perceived injustice (PI) and pain catastrophizing (PC). It has been demonstrated that they play an important role in patients' pain experience. However, the mediating effect of these appraisals has not been investigated in breast cancer survivors (BCS), nor have they been related to fatigue and sleep.

METHODS

Cross-sectional data from 128 BCS were analysed by structural path analysis with the aim to examine the mediating effect of PI and PC in the relationship of pain on fatigue and sleep.

RESULTS

The indirect mediating effects of PI on fatigue (CSI*PI = 0.21; P < 0.01 and VAS*PI = 1.19; P < 0.01) and sleep (CSI*PI = 0.31; P < 0.01 and VAS*PI = 1.74; P < 0.01) were found significant for both pain measures (Central Sensitization Inventory (CSI) and Visual Analogue Scale (VAS)). PC, on the other hand, only mediated the relationship between pain measured by VAS and fatigue (VAS*PC = 0.80; P = 0.03). Positive associations were found, indicating that higher pain levels are positively correlated with PI and PC, which go hand in hand with higher levels of fatigue and sleep problems.

CONCLUSION

PI is an important mediator in the relationship of pain on fatigue and sleep, while PC is a mediator on fatigue after cancer treatment. These findings highlight that both appraisals are understudied and open new perspectives regarding treatment strategies in BCS.

Job requirements and physical demands (JRPD) questionnaire: cross-cultural adaptation and psychometric evaluation in Iranian Army personnel with chronic low back pain

BACKGROUND

Biomechanical risk factors have been identified as the main predisposing factor of chronic low back pain (CLBP), especially in Army personnel. The Job Requirements and Physical Demands (JRPD) questionnaire has been developed to assess the biomechanical exposures related to CLBP. Examining the biomechanical risk factors could prevent CLBP. This study aimed to translate and cross-culturally adapt the JRPD into Persian and assess its psychometric properties among Iranian male Army personnel with CLBP.

METHODS

In this cross-sectional study, the content validation of the JRPD was assessed after translating to Persian. The Persian JRPD was administered to 198 male Army personnel with CLBP, with an interval of 7 days, to assess test-retest reliability, including Cronbach's α, intraclass correlation coefficients (ICC), standard error of measurement (SEM), and minimal detectable change at 95% confidence interval (MDC_95%). Scores of the Persian JRPD were correlated with the scores of visual analog scale (VAS), Borg's category-ratio (CR10) scale, general health questionnaire-28 (GHQ-28), and physical functioning (PF₁ and PF₂) subscale of the 12-item short-form health survey (SF-12) to assess convergent validity using Spearman correlation for a priori hypotheses.

RESULTS

The Persian JRPD had good content validity evidenced by the higher content validity index (> 0.70). The questionnaire had a significant positive negligible to weak correlation with the VAS (rho = 0.27; p < 0.001), Borg's CR10 scale (rho = 0.19; p = 0.009), and the total score of GHQ-28 and its domains (rho ≤0.34; p < 0.05); and significant negative weak correlation with PF₂ (rho = - 0.27; p < 0.001) and significant negative moderate correlation with PF₁ (rho = - 0.35; p < 0.001), thus confirming the priori hypotheses (89%, 8/9). The internal consistency and ICC (α = 0.91; ICC = 0.80) were highly adequate, with SEM and MDC_95% of 7.91 and 21.3 respectively.

CONCLUSIONS

The JRPD was successfully adapted into Persian and had adequate psychometric properties in terms of content and convergent validity, internal consistency, and test-retest reliability. The questionnaire is found useable to assess the CLBP-related biomechanical exposures in Iranian male Army personnel.

Analgesic efficacy of corticosteroids and nonsteroidal anti-inflammatory drugs through oral route in the reduction of postendodontic pain: A systematic review

Analgesic medications in dentistry are indicated for the relief of acute pain, postoperative pain, chronic pain as well as controlling adjunctive intraoperative pain. The use of nonsteroidal anti-inflammatory drugs (NSAIDs) has shown an effective reduction of postendodontic pain by action on the cyclooxygenase pathway. Another medication which is used recently is corticosteroid which enables the reduction of pain. They are hormones secreted from the adrenal gland and have strong anti-inflammatory actions. This review aims to compare the analgesic efficacy of NSAIDs and corticosteroids when administered through oral route for reducing postendodontic pain. The secondary objective was to assess the anesthetic effect of the nerve block when an oral premedication of NSAIDs or corticosteroids was administered. The databases of PubMed, ScienceDirect, LILACS, and Cochrane were searched for related topics from 1983 to April 2020. Bibliographies of clinical studies were identified in the electronic search. Clinical studies with postendodontic pain reduction using NSAIDs and corticosteroids were selected. Clinical studies that met all inclusion criteria were reviewed. Data extraction was performed independently by two reviewers. All individuals who administered single dose analgesic (NSAID or corticosteroid) before initiating root canal treatment were taken into inclusion criteria. All the relevant data were extracted from the selected studies were reviewed by two independent reviewers using a standardized data collection form, and in case of disagreement, a third reviewer was enquired to achieve a consensus. Risk of bias of the selected studies was done using Cochrane Risk of Bias Tool (version 1). Mean pain score levels at various time intervals showed an increased analgesic success rate for corticosteroids ( 32-1) in comparison to NSAIDs ( 32-21.4). Anesthetic effect of the nerve block administered was seen to be better when an oral premedication of corticosteroids (38.2%–80.8%) was given in comparison to NSAID (25.5%–73.1%). From the present study, it can be concluded that oral administration of corticosteroids provides a better analgesic efficacy when compared to NSAIDs as an oral premedication for postoperative pain reduction. It can also be concluded that corticosteroids when used as an oral premedication provide a better anesthetic effect of the nerve block administered when compared to NSAIDs given as an oral premedication. These findings could help the clinician determine which pretreatment analgesic would have a better effect in reduction of pain posttreatment as well as increasing the anesthetic efficacy of administered block. Systematic Review Registration Number: CRD42021235394.

Validation of the European Quality of Life-5 Dimensions, 3-Level Version (EQ-5D-3L) in Patients With Osteoporotic Vertebral Fracture and Comparing Their Health-Related Quality of Life with That of the General Population in Korea

Objective

This study examined the validity of the European Quality of Life-5 dimensions, 3-Level version (EQ-5D-3L) in patients with osteoporotic vertebral compression fractures (OVCF) and compared the health-related quality of life (HRQOL) of these patients with that of the general population in Korea.

Methods

Study participants completed several questionnaires, such as the EQ-5D-3L, 12-item short-form health survey version 2.0 (SF-12v2), Roland-Morris disability questionnaire (RMQ), and Pain Numeric Rating Scale (Pain NRS). Spearman’s correlation analyses of the questionnaire results were conducted to examine the discriminant and convergent validity of the EQ-5D-3L. Finally, EQ-5D-3L results from study participants were compared with those from the comparison group of the general population that were match-sampled according to age and sex from the 2013 Korean National Health and Nutritional Examination Survey.

Results

Spearman’s correlation coefficients between EQ-5D-3L and pain NRS, SF-12v2, and RMQ were statistically significant. The coefficients between the relevant dimensions, such as mobility in the EQ-5D-3L and physical functioning in the SF-12v2, were higher than those between irrelevant ones. Problems reported by study participants in each dimension of EQ-5D-3L showed statistically significant lower scores in pain NRS, PCS, and MCS from the SF-12v2 and RMQ scores. In comparison with the general population, the problems reported in the patient group were statistically higher than those reported by the general population.

Conclusion

This study showed that EQ-5D-3L will be useful for patients with OVCF in Korea because it could be valid. The HRQOL of patients with OVCF was very low in all dimensions of the EQ-5D-3L.

Cross-Sectional Study of Headache in Flemish Children and Adolescents

Background: Although headache is common in pediatrics, data for the Flemish population are missing. We explored headache-prevalence, and its association with communication-technology (CT) and physical activity (PA) in Flemish children and adolescents. Methods: A cross-sectional exploratory school-based questionnaire study was designed. Flemish boys and girls (5–18 years) completed a symptom-questionnaire. Primary outcomes: sociodemographic background, headache-prevalence, headache-characteristics, CT-use and PA characteristics (self-report). Secondary outcomes: associations between headache-characteristics, age, gender, and CT-use and PA-characteristics. Results: Four hundred twenty-four questionnaires were analysed: 5–7-years: n = 58; 8–11-years: n = 84; 12–15-years: n = 137; 16–18-years: n = 145. Fifty-five percent suffered from headache. Prevalence increased with age. More 16–18-year girls versus boys had headache. CT-use was the main headache-provocateur. Headache prevalence was significantly higher in a frequently physical active population. Conclusion: Our results suggest presence of headache in Flemish children and adolescents. PA-level associates with headache prevalence. However, children and adolescents with headache did not report more CT-use compared to controls.

Clinical and objective gait outcomes remained stable seven years after total knee arthroplasty: A prospective longitudinal study of 28 patients

BACKGROUND

There is a paucity of data on mid to long-term gait outcomes after total knee arthroplasty. The aims of this longitudinal study were: to assess the evolution of both clinical and gait outcomes before and up to seven years after primary total knee arthroplasty (TKA) in a cohort of patients with knee osteoarthritis.

METHODS

This study included 28 patients evaluated before and up to seven years after primary TKA with both gait analysis and patient reported outcomes; of these, 20 patients were evaluated one year after surgery as well. Kinematic outcomes during gait (gait velocity, dimensionless gait veolicity, maximal knee flexion and knee range of motion), pain relief, Western Ontario and MacMaster Osteoarthritis Index (WOMAC), quality of life and patient satisfaction were assessed and compared at each visit with the paired Wilcoxon signed rank test (p < 0.05).

RESULTS

The significant improvement achieved at one year after TKA was stable up to seven years after surgery, with all clinical and kinematic outcomes unchanged, except for gait velocity, with a significant decrease over time (1.3 (1.1-1.4) m/s one year after TKA versus 1.0 (0.9-1.1) m/s, p < 0.05 up to seven years after).

CONCLUSION

Patients with knee osteoarthritis significantly improve their clinical and kinematic outcomes at one year postoperatively and maintain the gain up to seven years after primary TKA, except for gait velocity which decreases over time, most likely along with ageing.

Both younger and elderly patients in pain are willing to undergo knee replacement despite the COVID-19 pandemic: a study on surgical waiting lists

PURPOSE

To identify factors influencing patient's availability to re-schedule primary total knee replacement (TKR) or revision (RKR) surgery after the lockdown (March-May 2020) during the COVID-19 pandemic.

METHODS

A prospective cohort study through a telephone survey was performed in 156 patients (143 for primary and 13 for revision) included in the TKR and RKR surgical waiting list before March 2020. Contact of each patient with COVID-19, stress and anxiety, perceived pain, and function were obtained in the interviews, and also the preference of each patient to have re-scheduled surgery (early or late). Finally, we registered their response (acceptance or refusal) when surgery was effectively re-scheduled.

RESULTS

88 out of 156 patients waiting for knee replacement (76/143 of those waiting for TKR, 12/13 of those waiting for RKR) declared themselves ready for surgery in less than 1 month. When re-scheduled, 115 patients underwent surgery and 41 refused. Significantly different preferences were found for age (more prone to surgery if under 65), revision surgery (more readily available), pain (7.9 ± 1.7/10 in NRS in those undergoing surgery, 5.6 ± 2.3/10 in those refusing, p = 0.000), or COVID-19 diagnosis, but not other close contact with COVID-19, comorbidities, stress, or anxiety. A logistic regression model confirmed that revision surgery (OR 9.33), perceived severe pain (OR 5.21), and age under 65 years (OR 5.82) were significantly associated with patient preference. The probability of patients over 65 to prefer early surgery reached 60% only with pain at or above 9/10.

CONCLUSIONS

Surgical timing preferences for knee replacement vary between patients older than 65 years (immediate surgery only when pain is intense) and younger patients (immediate surgery no matter the amount of pain). Even if COVID-19 severely stroke our population, the need for knee replacement stood in the young population and even in the aged population at risk for COVID when pain was important.

Effect of early skin-to-skin contact after vaginal delivery on pain during perineal wound suturing: A randomized controlled trial

AIM

To evaluate whether early skin-to-skin contact at the end of the second stage of labor could relieve perineal wound suture pain.

METHODS

From March 2020 to November 2020, a total of 241 parturients with full-term single fetuses delivered through the vagina and who underwent episiotomy suture (n = 120) or perineal laceration repair (n = 121) in our hospital were included in the study. Parturients were categorized according to whether they received episiotomy suture or perineal laceration repair. They were randomized into an early skin contact group and a traditional neonatal care group. The primary outcome was pain, which was quantified by the Numerical Rating Scale, Visual Analog Scale, Verbal Rating Scale, Faces Pain Scale-Revised. The secondary outcomes were healing of the perineal wound, the maternal cooperation rate and operation time. The confounding factors of severe pain were analyzed.

RESULTS

Early skin-to-skin contact alleviated the pain of perineal laceration repair and episiotomy suture, shortened the operation time of episiotomy suture and improved the cooperation rate of parturients receiving suture. It had no effect on perineal wound healing, operation time, or the cooperation rate of perineal laceration repair. In addition to the operation and early skin contact, the occurrence of high-grade pain was also associated with prepregnancy body mass index, group B streptococcus (GBS) positive, and academic degree.

CONCLUSION

Early skin-to-skin contact at the end of the second stage of labor can alleviate pain and improve the delivery experience of vaginal delivery.

Effects of Prosthetic Rehabilitation on Temporomandibular Disorders: Protocol for a Randomized Controlled Trial

Background

Loss of teeth or occlusal imbalance is one of the proposed dental risk factors for temporomandibular disorders (TMDs). Losing some non–free-end teeth cause the original occluding tooth/teeth to supraerupt from the original upright position and causes neighboring tooth/teeth to shift in an angle, causing biomechanical imbalance on the mandible. Based on these sequelae, rehabilitation of missing teeth is the first step in managing TMD in edentulous patients. Even though the prevalence of TMD in association with edentulism and in rehabilitated patients has been increasing, proper guidelines for the management of such cases have not been established. This study describes the protocol to analyze the effect of prosthetic rehabilitation on patients with TMD.

Objective

This study aims to determine the effectiveness of prosthetic rehabilitation in the reduction of pain in edentulous patients with TMD and to determine the effect of the span of edentulism, the number of quadrants involved, pathological migration, the type of Kennedy classification, and the prosthetic status on temporomandibular joint dysfunction signs and symptoms.

Methods

In this randomized controlled trial, 300 patients diagnosed with TMD will be grouped into one of the three interventional groups based on the type of their edentulous state. The interventional groups are (1) partially edentulous arch: Kennedy Class I and II (prosthetic rehabilitation without splint); (2) partially edentulous arch: Kennedy Class III and IV (prosthetic rehabilitation with a splint); and (3) completely edentulous arches (prosthetic rehabilitation without splint). All three of the mentioned interventional groups have corresponding control groups that will receive symptomatic treatment and comprehensive counseling. The measured primary outcomes are pain and electromyogram, and the secondary outcomes include pain drawing, Graded Chronic Pain Scale, Jaw Functional Limitation Scale, Oral Behaviours Checklist, depression, physical symptoms, and anxiety. The outcome measurements will be recorded at baseline and at the end of 24 hours, 7 days, 28 days, and 3 months.

Results

Ethical approval was obtained from the Institutional Review Board of Amrita Institute of Medical Sciences, Kochi, India. Study participants’ recruitment began in May 2021 and is expected to conclude in March 2023. This clinical trial protocol was developed based on the SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) 2013 Statement.

Conclusions

The purpose of this study is to gather data on prosthetic rehabilitation as a treatment for TMD. Obtaining this goal will aid in the development of evidence-based therapy protocols for prosthetic rehabilitation in TMD management.

Trial Registration

Clinical Trials Registry - India CTRI/2020/06/026169; http://ctri.nic.in/Clinicaltrials/pdf_generate.php?trialid=42381

International Registered Report Identifier (IRRID)

DERR1-10.2196/33104

Wright's Technique with the Addition of Visualized Axial Cortical Windows in Odontoid Fractures

This study sought to investigate and evaluate a modified axial translaminar screw fixation for treating odontoid fractures. We performed a retrospective study at Wenzhou Medical University Affiliated Second Hospital between March 2016 and June 2018. We retrospectively collected and analyzed the medical records of 23 cases with odontoid fractures. All patients were identified as type II odontoid fractures without neurological deficiency and serious diseases following the classification of Anderson. The average age, gender ratio, and body mass index (BMI) were 54.3 ± 11.1 years, 12 men to 11 women, and 22.6 ± 2.4 kg/m² , respectively. Patients in this study accepted screw fixation using our modified axial translaminar screw fixation combined with atlas pedicle or lateral mass screw fixation. Within the technique, a small cortical "window" was dug in the middle of the axial contralateral lamina, such that the screws in the lamina were visualized to prevent incorrectly implanting the posterior spinal canal through the visualized "window." A total of 46 bone screws were accurately inserted into the axial lamina without using fluoroscopy. The length of all translaminar screws ranged between 26 and 30 mm, while the diameter was 3.5 mm. During the follow-up survey, the visual analog scale (VAS) and neck disability index (NDI) were measured. We provide a simple modification of Wright's elegant technique with the addition of "visualized windows" at the middle of the axial lamina. In all patients, screws were inserted accurately without bony breach and the screw angle was 56.1 ± 3.0°. Mean operative time was 102 ± 28 min with an average blood loss of 50 ± 25 mL. Postoperative hemoglobin and mean length of hospital stay were 12.0 ± 1.4 g/dL and 10.4 ± 3.4 days, respectively. The average follow-up time of all cases was 14.7 months and no internal fixation displacement, loosening, or breakage was found. All patients with odontoid fractures reported being satisfied with the treatment during the recheck period and good clinical outcomes were observed. At 1, 6, and 12 months, NDI and VAS showed that the symptoms of neck pain and limitations of functional disability improved significantly during follow-up. Our results suggest that the modified translaminar screw fixation technique can efficiently treat Anderson type II odontoid fracture, followed by the benefits of less soft tissue dissection, simple operation, no fluoroscopy, and accurate placement of screws.

Development, psychometric evaluation and cognitive debriefing of the rheumatoid arthritis symptom and impact questionnaire (RASIQ)

BACKGROUND

Rheumatoid arthritis (RA) is a chronic inflammatory disease often associated with persistent pain. There is a need for a patient-reported outcome measure (PROM) that is rooted in the patient experience and psychometrically validated. We describe the development of the Rheumatoid Arthritis Symptom and Impact Questionnaire (RASIQ), a novel PROM with potential to record key symptoms and impacts of RA with a 24-h recall period.

RESULTS

A literature review identified RA concepts that patients considered most important to their disease experience, including pain, fatigue, joint swelling and stiffness. From this, an initial item pool (33 items; 27 related to symptoms, 6 related to impacts) was developed with a recall period of 24 h. Two rheumatologists evaluated each item's relevance, and the second version of the RASIQ was refined (29 items; 21 related to symptoms, 8 related to impacts). Next, three rounds of cognitive debriefing interviews were conducted with patients with RA (n = 15 overall). The RASIQ was revised to remove items deemed irrelevant or redundant, leaving 16 items measuring symptoms (joint pain, energy/tiredness, joint stiffness) and impacts (rest, sleep). A parallel series of semi-structured concept elicitation interviews (n = 30) facilitated the design of a conceptual model of RA symptoms, impacts and treatment experiences. Post-hoc comparison of the model with RASIQ revealed that all items selected were among the most important and relevant symptoms and impacts for patients. A final round of cognitive debriefing interviews (n = 12) confirmed that the final 16-item RASIQ was relevant and easy to understand, with no further changes recommended. Psychometric evaluation using data from two Phase II RA clinical trials confirmed a 3-factor structure, as well as the reliability and validity of the scale scores, and the ability of RASIQ to detect changes in symptoms and impacts when administered at specific study timepoints, using a 24-h recall period.

CONCLUSIONS

RASIQ is a novel, 16-item PROM developed with substantial patient input. Results from concept elicitation, cognitive debriefing, and psychometric evaluation confirmed the validity of the instrument, which has the potential to measure symptoms and impacts through a 24-h recall period and complement existing disease activity instruments with longer recall periods.

Investigation of balance performance under different sensory and dual-task conditions in patients with chronic neck pain

BACKGROUND

Most studies suggest that people with chronic neck pain (CNP) have decreased balance abilities. However, balance performance during performing concurrent tasks is not clarified.

OBJECTIVES

To investigate balance performance under different sensory and dual-task conditions in people with and without CNP.

METHOD

Twenty-two women with CNP and twenty-two asymptomatic women were tested using the Biodex Stability System. Overall stability index (OSI), anterior/posterior stability index (APSI), medial/lateral stability index (MLSI) were obtained in two sessions: eyes-open and eyes-closed. Both sessions consisted of four conditions: quiet standing, rotating head, counting backward, standing on foam. Higher index scores mean poorer balance.

DESIGN

Case-Control study.

RESULTS

A mixed factorial ANOVA (2 × 8 design) showed that there was a main effect of CNP on OSI, APSI, and MLSI (p < 0.001), which indicates that CNP causes poor balance. Further, there was an interaction between CNP and test conditions for only OSI (p < 0.05). Simple effects tests showed that patients with CNP had higher OSI in all conditions except standing on foam with eyes-open, and quiet standing and counting backward with eyes-closed (p < 0.05). The largest effect size was obtained during rotating head with eyes-open (η²:0.301), followed by counting backward with eyes-open and quiet standing with eyes-open (η²:0.267 and 0.245). Performing a concurrent task, closing eyes, or standing on foam mostly increased OSI in both groups (p < 0.05).

CONCLUSIONS

Patients with CNP have poorer balance under different sensory and dual-task conditions. Addressing balance assessment while performing concurrent tasks, especially head rotations, may offer new insights into the management of CNP.

Application of high-intensity laser in pain treatment of patients with knee osteoarthritis

Osteoarthritis is a rheumatic disease characterized by degeneration and decay of cartilage in the joints. As the disease worsens, the joint space narrows causing numbness and pain, which often impairs movement. In addition to pharmacological therapy, low-intensity laser (LILT), high-intensity laser (HILT) and exercise are used to treat osteoarthritis (OA) of the knee. HILT is a new modality in our country and the experience from its application is small, especially in the treatment of OA of the knee. Aim of the paper was to compare the effect of HILT with LILT in the treatment of OA of the knee. Material and methods: This was a randomized comparative unilateral blind study involving 72 patients divided into two groups. The first group was treated with HILT, the second group treated with LILT. Outcome measure was the visual analogue scale (VAS) for pain, which was made on the first and tenth day of treatment. Statistical significance was defined as p <0.05. Results: We found a significant difference between the two groups in terms of VAS score after 10 therapies  in favor to a significantly lower score, that is, less pain in the HILT group (p = 0.0035). The comparison of the VAS score between the two times in the two groups separately showed that in both, the HILT and the LILT groups, the VAS score after 10 days of therapy was significantly lower compared to thatat 0 time, for consequently p = 0.00001vsp = 0.00001. Conclusion: Treatment with HILT and LILT significantly reduces pain and stiffness in patients with OA. Patients treated with HILT had better results, i.e., had a significant reduction in pain than patients treated with LILT. HILT was more effective than LILT.

Association between preoperative serum homocysteine and delayed neurocognitive recovery after non-cardiac surgery in elderly patients: a prospective observational study

BACKGROUND

Homocysteine, folate, and vitamin B₁₂ involved in 1-carbon metabolism are associated with cognitive disorders. We sought to investigate the relationships between these factors and delayed neurocognitive recovery (dNCR) after non-cardiac surgery.

METHODS

This was a prospective observational study of patients (n = 175) who were ≥ 60 years of age undergoing non-cardiac surgery. Patients were evaluated preoperatively and for 1 week postoperatively by using neuropsychological tests and were divided into dNCR or non-dNCR groups according to a Z-score ≤ - 1.96 on at least two of the tests. The relationship between the occurrence of dNCR and preoperative levels of homocysteine, folate, and vitamin B₁₂ was analyzed. Univariate and multivariable logistic regression analyses were conducted to identify factors associated with dNCR.

RESULTS

Delayed neurocognitive recovery was observed in 36 of 175 patients (20.6%; 95% confidence interval [CI], 14.5-26.6%) 1 week postoperatively. Patients who developed dNCR had significantly higher median [interquartile range (IQR)] homocysteine concentrations (12.8 [10.9,14.4] μmol/L vs 10.6 [8.6,14.7] μmol/L; P = 0.02) and lower folate concentrations (5.3 [4.2,7.3] ng/mL vs 6.9 [5.3,9.5] ng/mL; P = 0.01) than those without dNCR. Compared to the lowest tertile, the highest homocysteine tertile predicted dNCR onset (odds ratio [OR], 3.9; 95% CI, 1. 3 to 11.6; P = 0.02), even after adjusting for age, sex, education, and baseline Mini Mental State Examination.

CONCLUSIONS

Elderly patients with high homocysteine levels who underwent general anesthesia for non-cardiac surgery have an increased risk of dNCR. This knowledge could potentially assist in the development of preventative and/or therapeutic measures.

TRIAL REGISTRATION

NCT03084393 ( https://www.clinicaltrials.gov ).

Surgical versus Nonsurgical Multimodality Treatment in an Idiopathic Frozen Shoulder: A Retrospective Study of Clinical and Functional Outcomes

This retrospective study compared the clinical and functional outcomes of patients diagnosed with an idiopathic frozen shoulder with symptom onset of a maximum of six months, treated by arthroscopic capsular release followed by corticosteroid injection and physiotherapy to patients who received only corticosteroid injection followed by physiotherapy. The patients who underwent arthroscopic capsular release, intraoperative corticosteroid injection, and physiotherapy (Group I, n = 30) or received only corticosteroids injection and physiotherapy (Group II, n = 29) were examined in terms of shoulder range of motion (ROM), pain intensity, and function before a given treatment and three, six, and twelve months later. The groups were comparable pre-treatment in terms of ROM, pain, and functional outcome. Group I had statistically and clinically significantly better ROM and function at three and six months post-treatment than Group II. Despite being statistically significant, the between-group differences at twelve-month follow-up in ROM and function were too small to be considered clinically notable. The between-group comparison of pain revealed no significant differences at any post-treatment point of time. The early arthroscopic capsular release preceding corticosteroid injection and physiotherapy seemed more effective at three- and six-month follow-up; however, it brought a comparable result to corticosteroid injection and subsequent physiotherapy at twelve months follow-up.

Prognostic prediction models for chronic postsurgical pain in adults: a systematic review

ABSTRACT

Chronic postsurgical pain (CPSP) affects an estimated 10% to 50% of adults depending on the type of surgical procedure. Clinical prediction models can help clinicians target preventive strategies towards patients at high risk for CPSP. Therefore, the objective of this systematic review was to identify and describe existing prediction models for CPSP in adults. A systematic search was performed in MEDLINE, Embase, PsychINFO, and the Cochrane Database of Systematic Reviews in March 2020 for English peer-reviewed studies that used data collected between 2000 and 2020. Studies that developed, validated, or updated a prediction model in adult patients who underwent any surgical procedure were included. Two reviewers independently screened titles, abstracts, and full texts for eligibility; extracted data; and assessed risk of bias using the Prediction model Risk of Bias Assessment Tool. The search identified 2037 records; 28 articles were reviewed in full text. Fifteen studies reporting on 19 prediction models were included; all were at high risk of bias. Model discrimination, measured by the area under receiver operating curves or c-statistic, ranged from 0.690 to 0.816. The most common predictors identified in final prediction models included preoperative pain in the surgical area, preoperative pain in other areas, age, sex or gender, and acute postsurgical pain. Clinical prediction models may support prevention and management of CPSP, but existing models are at high risk of bias that affects their reliability to inform practice and generalizability to wider populations. Adherence to standardized guidelines for clinical prediction model development is necessary to derive a prediction model of value to clinicians.

The Use of Platelet-rich Plasma as a Novel Nonsurgical Treatment of the Female Stress Urinary Incontinence: A Prospective Pilot Study

OBJECTIVES

The aim of the study was to evaluate the efficacy and safety of platelet-rich plasma (PRP) for the treatment of stress urinary incontinence (SUI).

METHODS

This was a prospective observational pilot study conducted in a tertiary referral unit, enrolling women with SUI booked for SUI surgery. A total of 20 consecutive women met the inclusion criteria and attended all follow-ups. All participants underwent 2 PRP injections into the lower one third of the anterior vaginal wall at 4- to 6-week intervals. At baseline, they underwent urodynamic studies, a 1-hour pad test, and completed the International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms and King's Health Questionnaire. At follow-up visits (1, 3, and 6 months), patients underwent the 1-hour pad test and completed the King's Health Questionnaire, International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms, and Patient Global Impression Scale of Improvement. Primary outcome was to evaluate posttreatment SUI. Secondary outcomes included assessment of patient-reported questionnaires, assessment of urine loss (1-hour pad test), and the level of discomfort during injections (visual analog scale score). Statistical analysis was performed before PRP and 1, 3, and 6 months after the last treatment.

RESULTS

A significant improvement in SUI symptoms was observed 3 months after treatment with a further improvement at 6 months. A mean reduction of 50.2% in urine loss was observed in the 1-hour pad test. At the 6-month follow-up, 80.0% of women reported to be at least improved. No adverse effects were observed.

CONCLUSIONS

Platelet-rich plasma injections were both effective and safe at least in the short term and could be offered as an alternative outpatient procedure for the treatment of SUI. However, these encouraging findings warrant further investigation with randomized controlled trials.

The impact of shoulder pathology on individuals with distal radius fracture

BACKGROUND

Shoulder pathology can occur concurrently with a distal radius fracture (DRF) but few studies have examined this population.

PURPOSE

The purpose of this study was to expand the understanding of the impact of shoulder pathology on individuals with DRF.

STUDY DESIGN

Mixed Methods Design.

METHODS

A total of 45 participants with a DRF were categorized into a DRF only (n = 29) and shoulder pathology concurrent with DRF (SPCDRF) (n = 16) groups. Quantitative data gathered included demographics, Quick Disabilities of the Arm, Shoulder, and Hand, Tampa Scale of Kinesiophobia-11, Visual Analog Scale, and Compensatory Mechanism Checklist. Qualitative interviews were performed with 7 participants in the SPCDRF group. Within group correlations were analyzed via the Spearman Rank. The Mann Whitney U test was used to compare the two groups. Qualitative analysis was performed to describe the experience of participants in the SPCDRF group. A mixed methods analysis compared quantitative and qualitative data.

RESULTS

Sixteen participants (35.6%) in the sample presented with shoulder pathology; 6 participants (37.5%) presented at initial evaluation due to the fall; 10 participants (62.5%) developed shoulder pathology due to compensation or disuse. Average number of days to develop shoulder pathology after the DRF was 43 days. SPCDRF participants had significantly greater pain levels (p = .02) and more activity avoidance (p = .03) than the DRF only group. Four qualitative themes emerged: It's difficult to perform occupations and changes had to be made; There is fear and uncertainty; The impact of pain; Tried to be normal but could not Mixed methods analysis found that qualitative data further illuminated quantitative findings.

CONCLUSIONS

Individuals with shoulder pathology concurrent with a DRF may present with higher pain levels and avoid activity more. In addition, they may describe fearfulness in using their injured upper extremity especially if they have high levels of pain.

STUDY DESIGN

Mixed Methods Design.

Effectiveness of Custom-Made Foot Orthoses vs. Heel-Lifts in Children with Calcaneal Apophysitis (Sever’s Disease): A CONSORT-Compliant Randomized Trial

The aim of the present research was to determine the effectiveness of relieving calcaneal apophysitis pain using “off-the-shelf” heel-lifts and custom-made orthotics. Two intervention modalities were evaluated and compared in a 12-week follow-up trial. Inclusion criteria included 9- to 12-year-old children diagnosed with calcaneal apophysitis. Children were randomly stratified into treatment A (custom-made polypropylene foot orthoses) and treatment B (“off-the-shelf” heel-lifts) groups. Treatment effectiveness was measured by algometry and the visual analogical scale (VAS). A total of 208 patients were included. The treatment A group showed an increase in threshold algometry of 53.4% (95% CI 47.1% to 59.7%) and a decrease in VAS of −68.6% (95% CI −74.5% to −62.7%) compared with the treatment B group (p < 0.001). Calcaneal apophysitis pain perception was improved in both groups, but children who used custom-made foot orthoses showed a greater improvement.

Automatic Estimation of Self-Reported Pain by Interpretable Representations of Motion Dynamics

We propose an automatic method for pain intensity measurement from video. For each video, pain intensity was measured using the dynamics of facial movement using 66 facial points. Gram matrices formulation was used for facial points trajectory representations on the Riemannian manifold of symmetric positive semi-definite matrices of fixed rank. Curve fitting and temporal alignment were then used to smooth the extracted trajectories. A Support Vector Regression model was then trained to encode the extracted trajectories into ten pain intensity levels consistent with the Visual Analogue Scale for pain intensity measurement. The proposed approach was evaluated using the UNBC McMaster Shoulder Pain Archive and was compared to the state-of-the-art on the same data. Using both 5-fold cross-validation and leave-one-subject-out cross-validation, our results are competitive with respect to state-of-the-art methods.

Safety and efficacy of alpha-lipoic acid oral supplementation in the reduction of pain with unknown etiology: A monocentric, randomized, double-blind, placebo-controlled clinical trial

INTRODUCTION

Extensive evidence suggests that alpha-lipoic acid (ALA) is effective in diabetic neuropathy pain management. However, little is known on its safety and efficacy in reducing idiopathic pain in normoglycemic subjects. The aim of this study was to evaluate ALA food supplement safety and efficacy in the reduction of different forms of idiopathic pain.

METHODS

Two-hundred and ten normoglycemic adults suffering from idiopathic pain (i.e. 57 subjects with primitive neuropathic pain, 141 subjects with arthralgia with unknown etiology, and 12 subjects with idiopathic myalgia) were randomized to receive placebo, 400 mg/day, or 800 mg/day of ALA. Participants underwent two visits (at baseline = t0, and after 2 months = t1) in which two validated questionaries for pain (numerical rating scale [NRS] and visual analogue scale [VAS]) were collected; fasting blood glucose assessment, adverse effects, and renal and hepatic toxicity were also monitored.

RESULTS

At t1, none of subjects treated with ALA reported a decreased glycemia or adverse effects. The treated subjects showed a significant reduction in NRS (p < 0.001) while the placebo group did not show any NRS reduction (p = 0.86). Similar results were also obtained for VAS. Statistical analysis aimed at detecting possible differences in NRS and VAS scores among treatment groups based on the source of pain did not reveal any significant effect.

CONCLUSIONS

Since the management of idiopathic pain is challenging for physicians, the use of ALA food supplements could be a feasible option, based on its safety and efficacy compared to commonly-used analgesic drugs.

Do Patients of Chronic Low Back Pain have Psychological Comorbidities?

Background Individuals with chronic pain have been reported to have an increased incidence of psychological morbidities. We aimed to examine the prevalence of anxiety, depression, disability, alexithymia, insomnia, and sleep quality in patients having chronic low back pain (LBP) and study their association with the severity of pain and any disability arising from it. Methods This descriptive study was conducted in a tertiary care teaching hospital setting. Fifty adults with nonspecific LBP of > 6-week duration were included. Study instruments employed were patient health questionnaire-9 for depression, generalized anxiety disorder-7 for anxiety, visual analogue scale (VAS) score for pain, Oswestry disability index (ODI) to assess disability, Toronto alexithymia scale-20 for alexithymia, and insomnia severity index and Pittsburgh sleep quality index for insomnia. Descriptive results were expressed as numbers, means, and proportions. Association study between variables was performed using Fisher's exact test. Results Mean ODI score was 31.54% (95% CI, 26.09-36.99); mean VAS score was 6.08 (95% CI, 5.35-6.81). Insomnia of varying severity was found in 29 patients. Sleep quality was reported as good by 23 patients. One patient had alexithymia. There was significant association between the level of disability and depression, anxiety, insomnia, and sleep quality. The severity of pain had significant association with insomnia but the association with anxiety, depression, alexithymia, and sleep quality was not significant. Conclusions Patients with chronic LBP do have associated psychological comorbidities of varying extent. A "patient-centric" approach when treating patients with chronic LBP is necessary, so that appropriate evaluation of psychiatric and psychosocial comorbidities, sleep problems, and quality of life is done as part of their routine management to ensure the desired outcomes.

Quality of Life and Cost Considerations: Y-90 Radioembolization

Objective  Transarterial radioembolization (TARE) offers a minimally invasive and safe treatment option for primary and metastatic hepatic malignancies. The benefits of TARE are manifold including prolonged overall survival, low associated morbidities, and improved time to progression allowing prolonged treatment-free intervals. The rapid development of new systemic therapies including immunotherapy has radically changed the treatment landscape for primary and metastatic liver cancer. Given the current climate, it is critical for interventional oncologists to understand the benefits of TARE relative to these other therapies. Therefore, this report aims to review quality-of-life outcomes and the cost comparisons of TARE as compared with systemic therapies.

Breast Milk Production in Women Who Use Nipple Shields for Persistent Nipple Pain

OBJECTIVE

To examine relationships between nipple pain scores and 24-hour milk production volumes, breastfeeding and pumping frequencies, and breastfeeding duration in women using nipple shields for persistent nipple pain.

DESIGN

Secondary outcome analysis of a prospective cohort study.

SETTING

Research laboratory and participants' homes.

PARTICIPANTS

Twenty-five breastfeeding women (6 ± 4 weeks after birth) who used nipple shields for persistent nipple pain.

METHODS

We conducted a randomized trial to investigate the primary outcome of milk transfer with and without nipple shields among participants with and without nipple pain. Here, we report secondary outcomes of associations between 24-hour milk production, breastfeeding and pumping frequencies, breastfeeding durations, and intake in participants using a nipple shield for nipple pain. Participants completed demographic, health and breastfeeding questionnaires and, at two monitored breastfeeding sessions, completed a pain visual analogue scale and Brief Pain Inventory-Short Form (BPI-SF; total and subscale scores for pain interference with General Activity, Mood, Sleep, and Breastfeeding). Milk production (milliliters per 24 hours), feed volumes, and percentage of available milk removed were calculated from data and milk samples obtained by participants over one 24-hour period and at study visits. Participants logged 24-hour data on a customized research website. We used descriptive statistics as well as simple and multiple linear regression for analyses.

RESULTS

Milk production and feeding duration were not associated with nipple pain scores (visual analogue scale: p = .80, BPI-SF: p = .44). An increase in BPI-SF Breastfeeding subscale score of 1 unit, indicating pain interference with breastfeeding, was associated with a 0.28 decrease in breastfeeding frequency (p = .02) and an 18.8-ml decrease in 24-hour breastfeeding intake (p = .04).

CONCLUSION

Persistent nipple pain was associated with reduced breastfeeding frequency; therefore, continuing professional support is required to ensure adequate milk removal and pain management.

Predictors of persistent postoperative pain after surgery for idiopathic scoliosis

PURPOSE

To identify factors contributing to persistent postoperative pain in patients treated surgically for idiopathic scoliosis.

METHODS

In total, 280 patients aged ten through 25 years at surgery, were identified in the Swedish Spine registry; all having preoperative and postoperative visual analogue scale (VAS) for back pain scores. The patients were divided into a high and low postoperative pain group based on the reported postoperative VAS for back pain scores (by using 45 mm on the 0 mm to 100 mm VAS scale as a cut-off). The patient-reported questionnaire included VAS for back pain, the 3-level version of EuroQol 5-dimensional (EQ-5D-3L) instrument, the EuroQol VAS (EQ-VAS) and the Scoliosis Research Society 22r instrument (SRS-22r). Predictors of postoperative back pain were searched in the preoperative data.

RESULTS

The 67 (24%) patients that reported high postoperative VAS back pain (> 45 mm) also reported lower postoperative EQ-5D-3L, EQ-VAS and SRS-22r than patients with low postoperative VAS back pain (all p < 0.001). Two preoperative variables were independently associated with postoperative pain; each millimetre increase in preoperative VAS back pain (on the 0 mm to 100 mm scale) was associated with a higher risk of being in the high postoperative back pain group (odds ratio (OR) 1.03; 95% confidence interval (CI) 1.02 to 1.05) and each 1 point decrease on the preoperative SRS-22r mental health (scale from 1 to 5) was associated with a higher risk of being in the high postoperative back pain group (OR 1.68; 95% CI 1.03 to 2.73).

CONCLUSION

High preoperative back pain and low preoperative mental health are independent predictors of back pain after surgery for idiopathic scoliosis.

LEVEL OF EVIDENCE

III.

Cutoff criteria for the placebo response: a cluster and machine learning analysis of placebo analgesia

Computations of placebo effects are essential in randomized controlled trials (RCTs) for separating the specific effects of treatments from unspecific effects associated with the therapeutic intervention. Thus, the identification of placebo responders is important for testing the efficacy of treatments and drugs. The present study uses data from an experimental study on placebo analgesia to suggest a statistical procedure to separate placebo responders from nonresponders and suggests cutoff values for when responses to placebo treatment are large enough to be separated from reported symptom changes in a no-treatment condition. Unsupervised cluster analysis was used to classify responders and nonresponders, and logistic regression implemented in machine learning was used to obtain cutoff values for placebo analgesic responses. The results showed that placebo responders can be statistically separated from nonresponders by cluster analysis and machine learning classification, and this procedure is potentially useful in other fields for the identification of responders to a treatment.

Expert advice about therapeutic exercise in the management of sacroiliac dysfunction in pregnancy: Secondary analysis of a randomized trial

OBJECTIVE

To assess primiparous and multiparous women, and singleton and multiple pregnancies in a recently published randomized trial.

STUDY DESIGN

Secondary analysis of a randomized clinical trial was performed. In total, 500 women with sacroiliac dysfunction diagnosed in pregnancy were randomized into a study group (who received expert advice about therapeutic exercise) and a control group (who continued with their normal lifestyle habits). The outcome measures assessed were: pain intensity [visual analogue scale (VAS)] and degree of functional disability (Quebec scale) at enrolment and after 3 and 6 weeks. Primiparous and multiparous women, and singleton and multiple pregnancies in the study and control groups were analysed separately.

RESULTS

Sacroiliac dysfunction was more common in primiparous women compared with multiparous women (84.70% vs 77.16%), and in multiple pregnancies compared with singleton pregnancies (86.53% vs 80.07%). For all four subgroups analysed in this secondary analysis, the reduction in pain intensity (p = 0.001) and the degree of functional disability (p = 0.001) were better in the study group compared with the control group. Better results for the two outcome measures were found when comparing primiparous and multiparous women in the study group at follow-up, but the difference in functional disability disappeared 6 weeks after enrolment (p = 0.383). There was no difference in the two outcome measures between singleton and multiple pregnancies 3 and 6 weeks after enrolment (p = 0.061, p = 0.489 and p = 0.741, p = 0.353, respectively).

CONCLUSION

Expert advice about therapeutic exercise is effective for the reduction of symptoms of sacroiliac dysfunction in all four subgroups (primiparous and multiparous women, singleton and multiple pregnancies). Earlier reduction of pain intensity and degree of functional disability were obtained in primiparous women compared with multiparous women in the study group.

Late Post-Operative Occurrence of Dentin Hypersensitivity in Adult Patients Following Allogeneic Hematopoietic Stem Cell Transplantation-A Preliminary Report

Allogeneic hematopoietic stem cell transplantation (alloHSCT) is one of the most commonly performed transplantation procedures nowadays. Despite the significant progress made in the treatment, alloHSCT is still associated with numerous complications also affecting the oral cavity. One of them is dentin hypersensitivity (DH)-a sharp, short-term pain that occurs when stimuli act on exposed dentin. Various authors point out that DH may result in a significantly lower quality of life, among other things by impeding the consumption of food as well as causing difficulties in daily oral hygiene. The aim of the study was a preliminary analysis of the incidence rate and severity of DH pain in adult patients during late period after alloHSCT. The impact of chronic graft-versus-host disease (cGvHD) and time after alloHCT were also considered. A total of 80 patients were examined. cGvHD was identified in 52 participants. The incidence rate and severity of DH pain was assessed on the basis of a questionnaire and a clinical examination. DH pain appeared a serious problem in late period after alloHSCT regardless of post-transplant time. DH primarily affected cGvHD patients. The prevention-treatment protocol for DH should be developed for this group.

The Influence of Sex on Upper Extremity Joint Dynamics in Pediatric Manual Wheelchair Users With Spinal Cord Injury

INTRODUCTION

Manual wheelchair propulsion is a physically demanding task associated with upper extremity pain and pathology. Shoulder pain is reported in over 25% of pediatric manual wheelchairs users, and this number rises over the lifespan. Upper extremity biomechanics in adults has been associated with shoulder pain and pathology; however, few studies have investigated upper extremity joint dynamics in children. Furthermore, sex may be a critical factor that is currently unexplored with regard to pediatric wheelchair mobility.

OBJECTIVES

To investigate differences in upper extremity joint dynamics between pediatric male and female manual wheelchair users with spinal cord injury (SCI) during wheelchair propulsion.

METHODS

Novel instrumented wheelchair hand-rims synchronized with optical motion capture were used to acquire upper extremity joint dynamics of 20 pediatric manual wheelchair users with SCI (11 males, 9 females). Thorax, sternoclavicular, acromioclavicular, glenohumeral, elbow, and wrist joint kinematics and kinetics were calculated during wheelchair propulsion. Linear mixed models were used to assess differences between sexes.

RESULTS

Females exhibited significantly greater peak forearm pronation (p = .007), normalized wrist lateral force (p = .03), and normalized elbow posterior force (p = .04) than males. Males exhibited significantly greater peak sternoclavicular joint retraction (p < .001) than females. No significant differences between males and females were observed for the glenohumeral joint (p > .012).

CONCLUSION

This study found significant differences in upper extremity joint dynamics between sexes during manual wheelchair propulsion. Our results underscore the importance of considering sex when evaluating pediatric wheelchair mobility and developing comprehensive wheelchair training interventions for early detection and prevention of upper extremity pain and pathology.

Ganglion impar block in patients with chronic coccydynia

Introduction:

Coccydynia refers to pain in the terminal segment of the spinecaused by abnormal sitting and standing posture. Coccydynia is usually managed conservatively, however in nonresponsive patients, ganglion impar block is used as a good alternate modality for pain relief. This article studies the effect of ganglion impar block in coccydynia patients who were not relieved by conservative management.

Materials and Methods:

The study was carried out at the pain clinic in the departments of Physical Medicine and Rehabilitation and Radiology in a tertiary centre in India. It was a prospective hospital-based study, in which 35 patients with coccydynia were considered for fluoroscopy-guided trans-sacro-coccygeal ganglion impar block. The outcome assessment was done using Numerical Rating Scale (NRS) and Oswestry Disability Index (ODI) scores for a follow-up period of 6 months. Of the 35 patients, 4 were lost to follow-up. Analysis was done usingthe data from the remaining 31 patients.

Results:

The mean age of the patients suffering from chronic coccydynia was 42.9 ± 8.39 years, and patients' age range was 28–57 years. The mean score of NRS and ODI before the procedure was 7.90 ± 0.16 and 48.97 ± 1.05, respectively. The interquartile range (IQR) of NRS score remained almost unchanged during pre and postprocedure, however, IQR of ODI varied during the pre and post procedural events. The NRS and ODI scores immediately after the procedure decreased drastically showing significant pain relief in patients, and the difference of scores till the end of study was statistically significant.

Conclusion:

This study recommends the trans-sacro-coccygeal “needle inside needle” technique for local anesthetic block of the ganglion impar for pain relief in patients with coccydynia. This should be integrated with rehabilitative measures including ergonomical modification for prolonging pain free period.

Capitate shortening osteotomy with or without vascularized bone grafting for the treatment of early stages of Kienböck's disease

PURPOSE

The study evaluates the procedures of capitate shortening osteotomy with or without vascularized bone grafting (VBG) for the treatment of stage II or IIIA Kienböck's disease with neutral ulnar variance.

METHOD

Forty-five patients with stage II (n = 21) and IIIA (n = 24) Kienböck's disease were included in the study. Patients were classified into two groups; isolated capitate shortening (ICS) group included 21 patients (stage II [n = 10] and stage IIIA [n = 11]) treated by capitate shortening without VBG of the lunate. Combined capitate shortening (CCS) group includes 24 patients (stage II [n = 11] and stage IIIA [n = 13]) who treated by capitate shortening combined with VBG of the lunate from the dorsal distal radius based on the fourth + fifth extensor compartment artery. All patients were evaluated pre- and post-operative for pain as measured by visual analogue scale score (VAS), range of motion (ROM), grip strength, modified Mayo wrist score (MMWS), lunate height index (LHI) ratio, and carpal height index (CHI) ratio.

RESULTS

The mean operative time for CCS procedure was 85 min (76 to 120) and for ICS was 58 min (47 to 65). The mean follow-up period for all patients was 33 months (29 to 47). Patients with stage IIIA Kienböck's disease treated by CCS procedure had better post-operative VAS, ROM, grip strength, MMWS, LHI, and CHI ratio than patients treated by ICS procedure. ICS procedure reported 28% failure rate versus 8% for CCS. No differences were found between CCS and ICS procedures in patients with stage II Kienböck's disease in the term of clinical, radiographic outcomes, or failure rate.

CONCLUSION

Using CCS procedure for the treatment of stage IIIA Kienböck's disease (lunate height collapse) with neutral ulnar variance can restore height and dimensions of the collapsed lunate and subsequently improve the final outcomes with lower failure rate. However, in patients with stage II Kienböck's disease (maintained lunate height), no advantages were noticed for CCS over ICS procedure. Lunate height index might be considered a prognostic factor for the treatment outcomes of Kienböck's disease.

Achievement Goals, Fear of Failure and Self-Handicapping in Young Elite Athletes with and without Chronic Pain

Background: Pain is a common problem in elite athletes. This exploratory study compares goal orientations towards sport, fear of failure, self-handicapping and pain catastrophizing between active young elite athletes with and without chronic pain (CP) complaints (longer than three months). It examines the associations between chronic pain, fear of failure, goal orientations, self-handicapping and pain catastrophizing in young elite athletes. We explore how far goal orientation can be explained by these factors. Methods: Young elite athletes completed an online questionnaire. Data analysis: Independent samples t-test, correlational analyses and multivariate regression analyses. Results: Participants were 132 young elite athletes (mean 16 years); data for 126 were analyzed. A total of 47% reported current pain, of which 60% had CP. Adolescents with CP showed significantly more pain intensity, fear of failure, self-handicapping and mastery–avoidance goals than those without. Pain intensity was significantly related to fear of failure, self-handicapping, pain catastrophizing and mastery–avoidance. Self-handicapping and fear of failure contributed significantly to mastery–avoidance variance. Performance–avoidance and –approach goals were explained by fear of failure. Conclusion: CP was common, with sufferers showing more fear of failure and self-handicapping strategies, and being motivated to avoid performing worse (mastery–avoidance). Self-handicapping and fear of failure influenced mastery–avoidance orientation, and fear of failure explained part of performance–avoidance and –approach orientations. Longitudinal studies should explore the role of these factors in the trajectory of CP in these athletes.

Gait Analysis 1 Year after Primary TKA: No Difference between Gap Balancing and Measured Resection Technique

Mechanical alignment in total knee arthroplasty (TKA) can be achieved using dependent bone cuts. The hypothesis is that patients have a better balanced TKA, as a result. The aim of this study was to determine if this technique is superior to an independent bone cut technique in terms of gait parameters, patient-reported outcome measures (PROMs), and satisfaction assessed before surgery and at 1-year follow-up. A total of 58 patients were evaluated before and 1 year following TKA, using the Press Fit Condylar (PFC) Sigma posterior stabilizer (PS) design; 39 (70 ± 8 years; 27 women) with independent bone cuts and 19 (71 ± 7 years; 12 women) with dependent bone cuts using the Specialist TRAM. Gait was evaluated with a three-dimensional motion analysis system for spatiotemporal and kinematics parameters. Pain and functional levels were assessed using the Western Ontario and McMaster Universities arthritis index (WOMAC); general health was assessed by the short form (SF)-12. Global satisfaction, as well as patient satisfaction, related to pain and functional levels were assessed using a five-point Likert's scale. No significant difference was found between both groups in terms of age, body mass index, pain, and functional levels at baseline. At 1-year follow-up, despite an overall improvement in gait, WOMAC, SF-12 physical score and pain, none of the patients showed gait parameters comparable to a healthy control group. No surgical technique effect was observed on gait, clinical outcomes, and satisfaction level. While observing an overall improvement at 1-year follow-up, we did not find any significant difference between the two surgical techniques in terms of gait parameters, patients' outcomes, and satisfaction.

Effects of Proprioceptive and Craniocervical Flexor Training on Static Balance in University Student Smartphone Users with Balance Impairment: A Randomized Controlled Trial

Purpose

University student smartphone users adopt flexed neck postures during smartphone use, creating an increased compressive load on their neck structures. This study was conducted to compare the effects of proprioceptive and craniocervical flexor training with a control group on static balance in a group of university student smartphone users with balance impairment.

Methods

A double-blinded, randomized controlled trial was conducted involving 42 university students (19.67±1.68 years old) with balance impairment. Participants were randomized into a proprioceptive training (ProT) group (n=14), a craniocervical flexor training (CCFT) group (n=14), and a control group (CG; n=14) for a 6-week intervention. The balance error scoring system (BESS), cervical joint position sense (CJPS), craniocervical flexion (CCF) test, and visual analog scale (VAS) for neck pain were evaluated using univariate analysis of covariance (ANCOVA).

Results

After 6 weeks of intervention, the ProT group showed significantly greater improvement of CJPS than the CG (p=0.000) and the CCFT group significantly improved of CCF test than CG (p=0.002). Findings, at 4 weeks after intervention, were (i) the ProT group had significantly more improvement in BESS than the CCFT group (p=0.014) and CG (p=0.003), (ii) the ProT group had significantly more improvement of CJPS than the CG (right and left rotate) (p=0.001, p=0.016, respectively) and CCFT group (right rotate) (p=0.004), (iii) the CCFT group had significantly more improvement of craniocervical flexor strength than CG (p=0.004), and (iv) the ProT group and CCFT group had significantly more decreased pain than CG (p=0.015, p=0.033, respectively). No adverse effects occurred during or after training in any group.

Conclusion

ProT is important for regaining static balance and CJPS, while CCFT improved craniocervical flexor strength. Moreover, both ProT and CCFT can reduce neck pain. We recommend performing ProT to improve static balance, CJPS and to reduce neck pain in smartphone users with static balance impairment.

Clinical Trail Registration Number

TCTR20190909003.

Rest-activity daily rhythm and physical activity levels after hip and knee joint replacement: the role of actigraphy in orthopedic clinical practice

Elective hip and knee joint replacement for osteoarthritis are cost-effective surgical procedures requiring specific rehabilitation programs. Actigraphy is widely used in both research and clinical practice to study activity patterns with great accuracy and validity but it has never been utilized in orthopedic patients. Therefore, the aim of this study was to objectively assess, through actigraphy, physical activity (PA) levels and rest-activity daily rhythm (RAR) in patients undergoing hip or knee joint replacement and hospitalized for ten days after surgery. Twenty subjects (11 males and 9 females; age: 62.68 ± 10.39 years old; BMI: 29.03 ± 3.92 kg/m²) wore the Actiwatch 2 actigraph (Philips Respironics, Portland, OR) to record both PA levels and RAR for 11 consecutive days and data on subjective scores of pain, by a visual analog scale (VAS), and functional and clinical scores were collected. The following time-points were considered for the statistical analysis: pre-surgery (PRE), the first (POST1), the fourth (POST4) and the tenth (POST10) day after surgery. RAR were processed with the population mean cosinor to describe the rhythm's characteristics (acrophase, amplitude and MESOR) while data on actigraphy-based PA, VAS, and functional clinical scores were compared among PRE, POST1, POST4 and POST 10 with the RM-ANOVA or the non-parametric Friedman test. The day after surgery the subjects had a flattened RAR compared to the other conditions: lower values were detected in POST1 compared to both PRE, POST4 and POST10 for MESOR (p < .0001; η²_p = .71, large) and amplitude (p < .0001; η²_p = .63, large) while RAR's acrophase (p < .0001; η²_p = .61, large) was delayed in PRE (16:45) compared to POST1 (12:42), POST4 (14:38), and POST10 (14:38). PA levels were significantly lower at POST 1 (76.7 ± 33.4) compared to PRE (192.3 ± 91.5; p < .0001 and ES: 1.68, large), POST4 (137.9 ± 45.9; p < .0001 and ES: 1.54, large), and POST10 (131.2 ± 54.3; p < .0001 and ES: 1.21, large) whereas VAS and functional clinical values significantly improved at POST10. Hip and knee joint replacement negatively influenced RAR and PA the first day after surgery but a progressive improvement in the circadian pattern of rest-activity cycle, PA levels, VAS and functional ability was recorded from POST4 to POST10. Actigraphy has the ability to collect real-life data without interfering with clinical practice and give clinicians a new measure of performance that is currently not available. This tool could allow to identify patients with disrupted circadian rhythm and reduced PA in the peri-operative period in orthopedic surgery, and timely intervene on these subjects with personalized rehabilitative intervention.

Erbium, Chromium:Yttrium-Scandium-Gallium-Garnet Laser for Root Conditioning and Reduction of Postoperative Morbidity in the Treatment of Gingival Recession Defects: A Randomized Controlled Clinical Trial

Objective: This clinical trial evaluates the effect of erbium, chromium:yttrium-scandium-gallium-garnet (Er,Cr:YSGG) root surface biomodification and laser harvesting of de-epithelialized gingival graft (DGG) on root coverage clinical outcomes and postoperative morbidity, and compares this to the conventional blade-harvested DGG method without Er,Cr:YSGG root surface biomodification in treatment of Miller's class I, II gingival recessions (GR). Background: The application of laser technology to enhance tooth root coverage clinical outcomes as well as the impact of laser on postoperative morbidity after harvesting autogenous soft tissue grafts requires further research. Methods: This study is a randomized, single-blinded controlled trial, including 24 volunteers with isolated GR defects. They were allocated into three treatment groups to receive one of the following three interventions: blade-harvested DGG (control group: B-DGG); Er,Cr:YSGG-harvested DGG and root surface biomodified [test 1 group: L-laser-harvested DGG (L-DGG)/laser root biomodification (LRB)]; and B-DGG and Er,Cr:YSGG root surface biomodification (test 2 group: B-DGG/LRB). Clinical and radiographic parameters were recorded at baseline (1 week before surgery) and 3, 6, and 9 months postoperatively. Results: Root coverage did not show a statistically significant difference between control and test groups. Statistically significant differences were found for Visual Analog Scale on the day of surgery and day 3 and 4 postoperatively, as well as pain medication on the day of surgery favoring the L-DGG group. Conclusions: The use of Er,Cr:YSGG laser in root surface biomodification improved root coverage outcomes at 9 months. Even these changes were not statistically significant from the control group; the L-DGG technique was associated with decreased postoperative morbidity in the palatal donor site.

Sense of effort is distorted in people with chronic low back pain

BACKGROUND

Proprioceptive deficits in people with low back pain (LBP) have traditionally been attributed to altered paraspinal muscle spindle afference and its central processing. Studies conducted in the upper limb demonstrated that sense of effort is also an important source of kinaesthetic information.

OBJECTIVES

To better understand proprioceptive deficits in people with chronic LBP (cLBP), this study aimed to test whether sense of effort is affected in people with cLBP.

DESIGN

Cross-sectional study.

METHOD

Fourteen participants with cLBP and fourteen healthy participants performed a 120 s force matching task with their trunk extensor muscles at a low intensity.

RESULTS

When visual feedback of the generated force was provided, both groups performed the task accurately. Removal of visual feedback resulted in an increase in error for both groups (p < 0.0001), but the increase in error was significantly larger for the cLBP group (p = 0.023). This larger error could be attributed to undershooting of the target force (p = 0.020). The control group did not consistently undershoot or overshoot the target force (p = 0.93). Furthermore, the amount of undershooting for the cLBP group increased as the task progressed (p = 0.016), which was not observed for the control group (p = 0.80).

CONCLUSIONS

The results of this study revealed that sense of effort is affected in cLBP. People with cLBP overestimated the trunk extension force they generated, and the error increased as the trial progressed. With visual feedback however, people with cLBP were able to compensate and perform the task as accurately as people without cLBP.

Efficacy of Vitamin D Supplementation in Addition to Aerobic Exercise Training in Obese Women with Perceived Myalgia: A Single-Blinded Randomized Controlled Clinical Trial

Obese women were more susceptible to myalgia because of their significantly lower vitamin D concentrations; the present study investigated the efficacy of vitamin D in addition to an aerobic interval training in the management of obese women with myalgia. Forty-five obese women with vitamin D deficiency and myalgia (30 to 40 years old) were assigned randomly into three equal groups. Group A received an aerobic interval training with vitamin D supplementation, Group B received vitamin D supplementation only, and Group C received aerobic interval training only; participants in all groups were on calorie deficient diets. The study outcomes were the Visual Analog Scale (VAS) for Pain Evaluation, serum vitamin D level, and Cooper 12-Minute Walk Test for Functional Capacity Evaluation, while the Short-Form Health Survey (SF) was used for assessment of quality of life. We detected a significant improvement in pain intensity level, serum vitamin D level, and quality of life in all groups with significant difference between Group A and groups B and C. We also detected a significant improvement in functional capacity in groups A and C, with no significant change in Group B. Aerobic interval training with vitamin D supplementation was more effective for the management of obese women with perceived myalgia.

Ultrasound-Guided Percutaneous Peripheral Nerve Stimulation: A Pragmatic Effectiveness Trial of a Nonpharmacologic Alternative for the Treatment of Postoperative Pain

BACKGROUND

Percutaneous peripheral nerve stimulation (PNS) is an analgesic modality involving the insertion of a lead through an introducer needle followed by the delivery of electric current after needle withdrawal. This modality has been used extensively to treat chronic pain, but only small series have been published involving postoperative pain. The ultimate objective of this study is to determine the postoperative effects of percutaneous PNS following moderately to severely painful ambulatory surgery within a real-world clinical practice setting. The primary hypothesis is that surgical pain and opioid consumption during the initial 7 days after surgery will be reduced by percutaneous PNS compared with usual and customary analgesia (dual primary outcome measures).

DESIGN

A multicenter pragmatic effectiveness trial. We are randomizing participants having painful orthopedic surgical procedures of the upper and lower extremity to receive 14 days of either 1) electrical stimulation or 2) sham in a double-masked fashion. End points are being assessed at various time points over 12 postoperative months.

SUMMARY

The postoperative experience will be much improved if percutaneous PNS provides potent analgesia while concurrently decreasing opioid requirements following painful surgery. Because this modality can be administered for up to 60 days at home, it may provide postoperative analgesia that outlasts surgical pain yet has relatively few risks and, unlike opioids, has no systemic side effects or potential for abuse, addiction, and overdose. Percutaneous PNS has the potential to revolutionize postoperative analgesia as it has been practiced for the past century. This study will inform key stakeholders regarding an evidence-based nonpharmacologic approach to the management of postoperative pain.

Efficiency and safety of pharmacotherapy for postoperative pain in cardiac surgery

Intraoperative injury with the formation of a sternotomy wound is inevitably accompanied by postoperative pain, which has a negative effect on the postoperative period and prognosis of patients. Today, moderate and severe pain affects at least half of patients in the early postoperative period after cardiac surgery. Inadequate pain relief in the early postoperative period can lead to chronic pain, which significantly reduces the quality of life of patients. The concept of multimodal analgesia with different painkillers is a priority, effective and safe technique both after cardiac surgery and in other areas of surgery. The current review article is devoted to the analysis of efficacy and safety of various drug groups for postoperative pain relief in cardiac surgery.

Effect of Elastic Abdominal Binder on Pain and Functional Recovery Following Gynecologic Cancer Surgery: A Randomized Controlled Trial

Background and Objectives: Clinicians have been using elastic abdominal binder for stabilizing incision site after major abdominal surgery. However, the benefits of that practice have never been formally assessed. The aim of this study was to examine the effects of the use of elastic abdominal binder on postoperative pain and recovery of gynecologic cancer patients. Materials and Methods: One-hundred and nine women diagnosed with cervical, endometrial, or ovarian cancer, who underwent open abdominal surgery were assigned randomly into two groups: intervention (56 patients) and control (53 patients). The women in the intervention group applied abdominal binder from postoperative day 1. For the control group, the women did not wear the binder or similar devices. The primary outcomes were pain and functional recovery. Subgroup analysis on participants age ≥ 50 was also performed. Results: For the entire study cohort, the baseline, postoperative day 1, and postoperative day 2 pain scores in the intervention group were significantly lower than the control group. However, there was no significant difference between the groups for postoperative day 3 pain score and for the change in pain scores from the baseline value. Of note, the age ≥ 50 subgroup represented a more balanced cohort with comparable baseline pain scores between the study groups. For this population, the pain scores for postoperative day 1–3 were significantly lower in the intervention group. The intervention group had a longer six-minute walking distance on postoperative day 3 with a trend toward a smaller difference in the day 3 distance from the baseline. Conclusions: The potential benefits of abdominal binder use in reducing postoperative pain and improving functional recovery after open gynecologic cancer surgery could be demonstrated only in those age ≥ 50.

Increased disease activity in early arthritis patients with anti-carbamylated protein antibodies

The initial management of rheumatoid arthritis (RA) has a high impact on disease prognosis. Therefore, we need to select the most appropriate treatment as soon as possible. This goal requires biomarkers of disease severity and prognosis. One such biomarker may be the presence of anti-carbamylated protein antibodies (ACarPA) because it is associated with adverse long term outcomes as radiographic damage and mortality. Here, we have assessed the ACarPA as short-term prognostic biomarkers. The study was conducted in 978 prospective early arthritis (EA) patients that were followed for two years. Our results show the association of ACarPA with increased levels of all the disease activity measures in the first visit after arthritis onset. However, the associations were more significant with the high levels in local measures of inflammation and physician assessment than with the increases in systemic inflammation and patient-reported outcomes. More notably, disease activity was persistently increased in the ACarPA positive patients during the two years of follow-up. These differences were significant even after accounting for the presence of other RA autoantibodies. Therefore, the ACarPA could be considered short-term prognostic biomarkers of increased disease activity in the EA patients.

Pain evaluation after day-surgery using a mobile phone application

INTRODUCTION

Few studies assess postoperative outcomes after discharge in the ambulatory setting. The aim of this study was to investigate postoperative pain and adverse effects at 24 h and at 7 days after day surgery using an e-health follow-up smartphone-based application named SATELIA®.

MATERIALS AND METHODS

This retrospective, observational and monocentric cohort study was conducted at the University Hospital of Bordeaux. All eligible patients for SATELIA® follow-up between May 2018 and June 2019 were screened for the analysis. Data were extracted from two databases. Those with a missing primary outcome were excluded from the analysis. The main outcome was the worst pain score on POD 1, self-reported via SATELIA®. The secondary outcomes were the incidence of adverse effects on POD1, as well as the worst pain score and adverse effects on POD7. Quantitative data were reported by the median (IQR) and categorical data were presented as absolute numbers (%).

RESULTS

A total of 2283 patients were screened for analysis, from which 592 were excluded due to missing data for the main outcome; 1691 patients were thus finally included. The median worst pain score at POD 1 was 3.0 (1.0-5.0); 35.5% (n = 601/1691) and 29.1% (n = 492/1691) of the patients reported moderate-to-severe pain at POD1 and POD7, respectively.

CONCLUSION

This retrospective study shows that 35.5% of patients experience moderate-to-severe pain after day surgery. Even if SATELIA® should be further developed and evaluated, it also demonstrates the interest of using phone based software to follow patients after discharge and ensure a better personalised management.

Oral Health in Rheumatoid Arthritis: Listening to Patients

INTRODUCTION

Rates of periodontal disease and tooth loss are increased in individuals with rheumatoid arthritis (RA). Understanding factors that contribute to the increased burden of periodontal disease in RA is critical to improving oral health and arthritis outcomes.

OBJECTIVES

To determine the perceptions held by people with RA relating to their oral health, to identify patient-centered priorities for oral health research, and to inform optimal strategies for delivering oral health knowledge.

METHODS

Semistructured interviews were conducted with patients with RA. Recorded interview transcripts were iteratively reviewed to reveal surface and latent meaning and to code for themes. Constructs were considered saturated when no new themes were identified in subsequent interviews. We report themes with representative quotes.

RESULTS

Interviews were conducted with 11 individuals with RA (10 women [91%]; mean age, 68 y), all of whom were taking RA medication. Interviews averaged 19 min (range, 8 to 31 min) and were mostly conducted face-to-face. Three overall themes were identified: 1) knowledge about arthritis and oral health links; 2) oral health care in RA is complicated, both in personal hygiene practices and in professional oral care; and 3) poor oral health is a source of shame. Participants preferred to receive oral health education from their rheumatologists or dentists.

CONCLUSIONS

People with RA have unique oral health perceptions and experience significant challenges with oral health care due to their arthritis. Adapting oral hygiene recommendations and professional oral care delivery to the needs of those with arthritis are patient priorities and are required to improve satisfaction regarding their oral health.

KNOWLEDGE TRANSLATION STATEMENT

Patients living with long-standing rheumatoid arthritis described poor oral health-related quality of life and multiple challenges with maintaining optimal oral health. Study findings indicate a need for educational materials addressing oral health maintenance for patients with rheumatic diseases and their providers.

Intradermal mesotherapy versus intravenous dexketoprofen for the treatment of migraine headache without aura: a randomized controlled trial

BACKGROUND

Migraine is a prevalent disabling primary headache disorder that is classified into two major types: migraine without aura and migraine with aura. New therapeutic methods to reduce migraine headaches in the emergency department (ED) include intradermal mesotherapy.

OBJECTIVE

Compare the efficacy of intradermal mesotherapy versus a systemic therapy in pain control in patients with headache related to migraine without aura.

DESIGN

Prospective parallel-group randomized controlled trial.

SETTING

University hospital in Turkey.

PATIENTS AND METHODS

Patients 18 years of age and older who were admitted to the ED over a 15-month period with headache related to migraine without aura were eligible for inclusion if they had a VAS score of 4 or above. Patients were randomly allocated to one session of mesotherapy or intravenous dexketoprofen. Changes in pain intensity were measured by the score on a visual analog scale (VAS) at 30, 60, and 120 minutes and 24 hours after treatment. Efficacy was also assessed by the need for use of an analgesic drug within 24 hours, by readmission with the same complaint to the ED within 72 hours, and by adverse effect rates.

MAIN OUTCOME MEASURE

Pain intensity on the VAS scale.

SAMPLE SIZE

148 patients (154 enrolled and treated; 1 patient in the mesotherapy and 5 patients in the systemic therapy group lost to follow up).

RESULTS

Pain intensity on the VAS scale decreased from a median score of 8 to 4 in the mesotherapy group and from 8 to 5 in the systemic therapy group. These differences were statistically significant from baseline for all time intervals (P=.001 to 30 minutes, P=.004 to 60 minutes, P=.005 to 120 minutes, and P=.002 to 24 hours). The need to use analgesics and the rate of readmission to the ED were higher in the systemic therapy group (P=.013 and P=.030, respectively). Adverse effect rates were minimal and similar in the study groups during the one-week follow-up period.

CONCLUSIONS

Mesotherapy is more efficacious than intravenous dexketoprofen in the management of acute attack of migraine without aura in the ED.

LIMITATIONS

Unblinded. Valid for assessing short-term pain relief, but not sufficient to predict long-term efficacy. Not generalizable because single center and small sample size.

CONFLICT OF INTEREST

None.

REGISTRATION

ClinicalTrials.gov (NCT04519346).