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Li X, Zhai G, Zhang H, Li X, Wu M, Zhang S, Cui J, Tang Z, Hu Z. Clinical efficacy of acupuncture therapy combined with core muscle exercises in treating patients with chronic nonspecific low back pain: a systematic review and meta-analysis of randomized controlled trials. Front Med (Lausanne) 2024; 11:1372748. [PMID: 38638928 PMCID: PMC11024316 DOI: 10.3389/fmed.2024.1372748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 03/18/2024] [Indexed: 04/20/2024] Open
Abstract
Introduction This meta-analysis aimed to determine the clinical efficacy of acupuncture combined with core muscle exercises on pain and functional status in patients with chronic nonspecific low back pain. Methods This study followed the Preferred Reporting Items for Systematic Reviews and meta-analysis criteria for systematic reviews and meta-analyses. Randomized controlled trials published till November 2023 were searched in PubMed, Web of Science, Cochrane, Embase, China National Knowledge Infrastructure, Chinese Biomedical Literature, and Wanfang databases. The search strategy was related to disease type, intervention, and control measures and was structured around the search terms "low back pain," "acupuncture therapy," and "exercise." Two reviewers applied inclusion and exclusion criteria. Sensitivity and fixed effects analyses were performed to determine the primary outcomes. Results We included 11 randomized controlled trials (n = 727) on acupuncture combined with core muscle exercises in patients with chronic nonspecific low back pain. Compared with controls, clinical efficacy was significant, with improvements in pain scores (visual analog pain scale and numerical rating scale) and Oswestry Disability Index in the intervention group. Discussion Acupuncture therapy combined with core muscle exercises improved pain and functional status in patients with chronic nonspecific low back pain, with favorable clinical outcomes compared with single-core muscle training. Multicenter large-sample trials are required to obtain more reliable conclusions.
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Affiliation(s)
- Xia Li
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Guohua Zhai
- Fenglin Community Health Service Centre, Shanghai, China
| | - Hongkai Zhang
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Xuefei Li
- Longhua Clinical Medical College of Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Mingqi Wu
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Sidi Zhang
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jiawen Cui
- School of Rehabilitation Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Zhanying Tang
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Jinshan District Hospital of Integrated Chinese and Western Medicine, Shanghai, China
| | - Zhijun Hu
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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Farrokhi S, Bechard L, Gorczynski S, Patterson C, Kakyomya J, Hendershot BD, Condon R, Perkins LTCM, Rhon DI, Delitto A, Schneider M, Dearth CL. The Influence of Active, Passive, and Manual Therapy Interventions for Low Back Pain on Opioid Prescription and Health Care Utilization. Phys Ther 2024; 104:pzad173. [PMID: 38112119 DOI: 10.1093/ptj/pzad173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 08/10/2023] [Accepted: 10/19/2023] [Indexed: 12/20/2023]
Abstract
OBJECTIVE The aim of this study was to explore associations between the utilization of active, passive, and manual therapy interventions for low back pain (LBP) with 1-year escalation-of-care events, including opioid prescriptions, spinal injections, specialty care visits, and hospitalizations. METHODS This was a retrospective cohort study of 4827 patients identified via the Military Health System Data Repository who received physical therapist care for LBP in 4 outpatient clinics between January 1, 2015 and January 1, 2018. One-year escalation-of-care events were evaluated based on type of physical therapist interventions (ie, active, passive, or manual therapy) received using adjusted odds ratios. RESULTS Most patients (89.9%) received active interventions. Patients with 10% higher proportion of visits that included at least 1 passive intervention had a 3% to 6% higher likelihood of 1-year escalation-of-care events. Similarly, with 10% higher proportion of passive to active interventions used during the course of care, there was a 5% to 11% higher likelihood of 1-year escalation-of-care events. When compared to patients who received active interventions only, the likelihood of incurring 1-year escalation-of-care events was 50% to 220% higher for those who received mechanical traction and 2 or more different passive interventions, but lower by 50% for patients who received manual therapy. CONCLUSION Greater use of passive interventions for LBP was associated with elevated odds of 1-year escalation-of-care events. In addition, the use of specific passive interventions such as mechanical traction in conjunction with active interventions resulted in suboptimal escalation-of-care events, while the use of manual therapy was associated with more favorable downstream health care outcomes. IMPACT Physical therapists should be judicious in the use of passive interventions for the management of LBP as they are associated with greater likelihood of receiving opioid prescriptions, spinal injections, and specialty care visits.
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Affiliation(s)
- Shawn Farrokhi
- Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, Virginia, USA
- Department of Physical and Occupational Therapy, Naval Medical Center San Diego, San Diego, California, USA
- Department of Rehabilitation Medicine, Uniformed Services University of Health Sciences, Bethesda, Maryland, USA
| | - Laura Bechard
- Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, Virginia, USA
- Department of Physical and Occupational Therapy, Naval Medical Center San Diego, San Diego, California, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine Inc, Bethesda, Maryland, USA
| | - Sara Gorczynski
- Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, Virginia, USA
- Department of Physical and Occupational Therapy, Naval Medical Center San Diego, San Diego, California, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine Inc, Bethesda, Maryland, USA
| | - Charity Patterson
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Joseph Kakyomya
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Brad D Hendershot
- Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, Virginia, USA
- Department of Rehabilitation Medicine, Uniformed Services University of Health Sciences, Bethesda, Maryland, USA
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Rachel Condon
- Army-Baylor Doctoral Program in Physical Therapy, Fort Sam Houston, Texas, USA
| | - L T C Matthew Perkins
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Daniel I Rhon
- Department of Rehabilitation Medicine, Uniformed Services University of Health Sciences, Bethesda, Maryland, USA
| | - Anthony Delitto
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michael Schneider
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Christopher L Dearth
- Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, Virginia, USA
- Department of Rehabilitation Medicine, Uniformed Services University of Health Sciences, Bethesda, Maryland, USA
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
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Yu H, Wang D, Verville L, Southerst D, Bussières A, Gross DP, Pereira P, Mior S, Tricco AC, Cedraschi C, Brunton G, Nordin M, Shearer HM, Wong JJ, Connell G, Myrtos D, da Silva-Oolup S, Young JJ, Funabashi M, Romanelli A, Lee JGB, Stuber K, Guist B, Muñoz Laguna J, Hofstetter L, Murnaghan K, Hincapié CA, Cancelliere C. Systematic Review to Inform a World Health Organization (WHO) Clinical Practice Guideline: Benefits and Harms of Needling Therapies for Chronic Primary Low Back Pain in Adults. JOURNAL OF OCCUPATIONAL REHABILITATION 2023; 33:661-672. [PMID: 37991648 PMCID: PMC10684627 DOI: 10.1007/s10926-023-10125-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/15/2023] [Indexed: 11/23/2023]
Abstract
PURPOSE Evaluate benefits and harms of needling therapies (NT) for chronic primary low back pain (CPLBP) in adults to inform a World Health Organization (WHO) standard clinical guideline. METHODS Electronic databases were searched for randomized controlled trials (RCTs) assessing NT compared with placebo/sham, usual care, or no intervention (comparing interventions where the attributable effect could be isolated). We conducted meta-analyses where indicated and graded the certainty of evidence. RESULTS We screened 1831 citations and 109 full text RCTs, yeilding 37 RCTs. The certainty of evidence was low or very low across all included outcomes. There was little or no difference between NT and comparisons across most outcomes; there may be some benefits for certain outcomes. Compared with sham, NT improved health-related quality of life (HRQoL) (physical) (2 RCTs; SMD = 0.20, 95%CI 0.07; 0.32) at 6 months. Compared with no intervention, NT reduced pain at 2 weeks (21 RCTs; MD = - 1.21, 95%CI - 1.50; - 0.92) and 3 months (9 RCTs; MD = - 1.56, 95%CI - 2.80; - 0.95); and reduced functional limitations at 2 weeks (19 RCTs; SMD = - 1.39, 95%CI - 2.00; - 0.77) and 3 months (8 RCTs; SMD = - 0.57, 95%CI - 0.92; - 0.22). In older adults, NT reduced functional limitations at 2 weeks (SMD = - 1.10, 95%CI - 1.71; - 0.48) and 3 months (SMD = - 1.04, 95%CI - 1.66; - 0.43). Compared with usual care, NT reduced pain (MD = - 1.35, 95%CI - 1.86; - 0.84) and functional limitations (MD = - 2.55, 95%CI - 3.70; - 1.40) at 3 months. CONCLUSION Based on low to very low certainty evidence, adults with CPLBP experienced some benefits in pain, functioning, or HRQoL with NT; however, evidence showed little to no differences for other outcomes.
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Affiliation(s)
- Hainan Yu
- Institute for Disability and Rehabilitation Research and Faculty of Health Sciences, Ontario Tech University, Oshawa, Canada
| | - Dan Wang
- Institute for Disability and Rehabilitation Research and Faculty of Health Sciences, Ontario Tech University, Oshawa, Canada
| | - Leslie Verville
- Institute for Disability and Rehabilitation Research and Faculty of Health Sciences, Ontario Tech University, Oshawa, Canada
| | - Danielle Southerst
- Institute for Disability and Rehabilitation Research and Faculty of Health Sciences, Ontario Tech University, Oshawa, Canada
| | - André Bussières
- Département Chiropratique, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada
- School of Physical and Occupational Therapy, Faculty of Medicine and Health Sciences, McGill University, Montreal, Canada
| | - Douglas P Gross
- Department of Physical Therapy, University of Alberta, Edmonton, Canada
| | - Paulo Pereira
- Department of Neurosurgery, Centro Hospitalar Universitário São João, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Silvano Mior
- Institute for Disability and Rehabilitation Research and Faculty of Health Sciences, Ontario Tech University, Oshawa, Canada
- Department of Research and Innovation, Canadian Memorial Chiropractic College, Toronto, Canada
| | - Andrea C Tricco
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Canada
- Epidemiology Division and Institute for Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Queen's Collaboration for Health Care Quality Joanna Briggs Institute Centre of Excellence, Queen's University, Kingston, Canada
| | - Christine Cedraschi
- Division of General Medical Rehabilitation, Geneva University and University Hospitals, Geneva, Switzerland
- Division of Clinical Pharmacology and Toxicology, Multidisciplinary Pain Centre, Geneva University Hospitals, Geneva, Switzerland
| | - Ginny Brunton
- Institute for Disability and Rehabilitation Research and Faculty of Health Sciences, Ontario Tech University, Oshawa, Canada
- EPPI-Centre, UCL Institute of Education, University College London, London, England, UK
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Margareta Nordin
- Departments of Orthopedic Surgery and Environmental Medicine, NYU Grossman School of Medicine, New York University, New York, USA
| | - Heather M Shearer
- Institute for Disability and Rehabilitation Research and Faculty of Health Sciences, Ontario Tech University, Oshawa, Canada
- Department of Research and Innovation, Canadian Memorial Chiropractic College, Toronto, Canada
- Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Canada
| | - Jessica J Wong
- Institute for Disability and Rehabilitation Research and Faculty of Health Sciences, Ontario Tech University, Oshawa, Canada
| | - Gaelan Connell
- Institute for Disability and Rehabilitation Research and Faculty of Health Sciences, Ontario Tech University, Oshawa, Canada
| | - Danny Myrtos
- Department of Clinical Education, Canadian Memorial Chiropractic College, Toronto, Canada
| | - Sophia da Silva-Oolup
- Department of Undergraduate Education, Canadian Memorial Chiropractic College, Toronto, Canada
- Department of Graduate Education, Canadian Memorial Chiropractic College, Toronto, Canada
| | - James J Young
- Department of Research and Innovation, Canadian Memorial Chiropractic College, Toronto, Canada
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, Canada
- Center for Muscle and Joint Health, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Martha Funabashi
- Département Chiropratique, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada
- Department of Research and Innovation, Canadian Memorial Chiropractic College, Toronto, Canada
| | - Andrew Romanelli
- Department of Clinical Education, Canadian Memorial Chiropractic College, Toronto, Canada
| | - Joyce G B Lee
- Department of Research and Innovation, Canadian Memorial Chiropractic College, Toronto, Canada
| | - Kent Stuber
- Department of Research and Innovation, Canadian Memorial Chiropractic College, Toronto, Canada
- Parker University Research Center, Dallas, USA
| | - Brett Guist
- Department of Graduate Education, Canadian Memorial Chiropractic College, Toronto, Canada
| | - Javier Muñoz Laguna
- EBPI-UWZH Musculoskeletal Epidemiology Research Group, University of Zurich and Balgrist University Hospital, Zurich, Switzerland
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zurich, Switzerland
- University Spine Centre Zurich (UWZH), Balgrist University Hospital and University of Zurich, Zurich, Switzerland
| | - Léonie Hofstetter
- EBPI-UWZH Musculoskeletal Epidemiology Research Group, University of Zurich and Balgrist University Hospital, Zurich, Switzerland
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zurich, Switzerland
- University Spine Centre Zurich (UWZH), Balgrist University Hospital and University of Zurich, Zurich, Switzerland
| | - Kent Murnaghan
- Library and Information Services, Canadian Memorial Chiropractic College, Toronto, Canada
| | - Cesar A Hincapié
- EBPI-UWZH Musculoskeletal Epidemiology Research Group, University of Zurich and Balgrist University Hospital, Zurich, Switzerland.
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zurich, Switzerland.
- University Spine Centre Zurich (UWZH), Balgrist University Hospital and University of Zurich, Zurich, Switzerland.
| | - Carol Cancelliere
- Institute for Disability and Rehabilitation Research and Faculty of Health Sciences, Ontario Tech University, Oshawa, Canada.
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Jordon M, Grubb M, Tudini F. Duration of Electro-Dry Needling Does Not Change the Pain Response After Repeated Nociceptive Thermal Stimuli in Asymptomatic Individuals: A Randomized Intervention Study. Arch Rehabil Res Clin Transl 2023; 5:100267. [PMID: 37312978 PMCID: PMC10258375 DOI: 10.1016/j.arrct.2023.100267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023] Open
Abstract
Objective To assess the effects of 5 different durations of electro-dry needling (EDN) on asymptomatic individuals' pain response after repeated noxious thermal stimuli. Design Randomized, non-controlled intervention trial. Setting University laboratory. Participants Asymptomatic participants (N=50) were recruited for the study and randomized into 5 groups. There were 33 women with an average age of 26.8 (±4.8) years. To participate in the study, individuals had to be between the ages of 18 and 40, free of any musculoskeletal injury which prevented participation of daily activities, and not pregnant or trying to become pregnant. Interventions Participants were randomly assigned to receive 5 different durations of EDN: 10, 15, 20, 25, and 30 minutes. To perform the EDN, 2 monofilament needles were inserted lateral to the lumbar spinous processes of L3 and L5 on the right. Needles were left in situ with electrical stimulation at a frequency of 2 Hz and an amplitude which resulted in a 3 to 6 out of 10 intensity pain rating by the participant. Main Outcome Measures The change in the magnitude of pain in response to repetitive heat-pulses before and after the EDN procedure. Results There was a significant reduction in the magnitude of pain in response across the groups after EDN (F(1,42)=94.12, P<.001, ƞp2=.691). However, the interaction between time and group was not significant (F(4,42)=1.019, P=.409, ƞp2=.088), indicating that no duration of EDN was superior to another in reducing temporal summation. Conclusions This study suggests that in asymptomatic individuals, performing EDN beyond 10 minutes does not provide any additional benefits in the reduction of the magnitude of pain in response to thermal nociceptive stimuli. Additional study in symptomatic populations is required for generalizability in clinical settings.
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Affiliation(s)
- Max Jordon
- Department of Physical Therapy, University of Tennessee at Chattanooga, Chattanooga, TN
| | - Matthew Grubb
- Department of Physical Therapy, University of Tennessee at Chattanooga, Chattanooga, TN
| | - Frank Tudini
- Department of Physical Therapy, University of Tennessee at Chattanooga, Chattanooga, TN
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The effectiveness of dry needling in patients with chronic low back pain: a prospective, randomized, single-blinded study. Sci Rep 2022; 12:15803. [PMID: 36138055 PMCID: PMC9500077 DOI: 10.1038/s41598-022-19980-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 09/07/2022] [Indexed: 11/16/2022] Open
Abstract
Dry needling (DN) is a standard procedure for treating musculoskeletal disorders. However, there are no clear recommendations for using DN in low back pain (LBP). Therefore, this study aimed to assess the effectiveness of the novel DN program for reducing pain intensity and improving functional efficiency in patients with chronic LBP. A group of 40 patients with chronic LBP due to the L5-S1 discopathy were eligible and randomized into experimental (n = 20) and control (n = 20) groups. The DN program was performed for the experimental group according to the Five Regulatory Systems (FRS) concept. The control group received sham therapy using placebo needles. DN sessions were performed twice a week for 4 weeks. A single needling application lasted 60 min. Both groups received standard treatment and physical exercise of LBP for 1 month. Subjective pain was measured by a visual analog scale (VAS), functional efficiency was assessed with the Oswestry Disability Index (ODI), and the lower spine range of motion was measured with the Schober test. There were significant differences in pain reduction (VAS) in both groups (p < 0.001). The strongest analgesic effect in the DN group yielded 6.45 points immediately after the therapy, 6.2 points after 1 month, and 6 points after 3 months. The DN group scored higher VAS reduction than the control group (p < 0.001). There were significant differences in the functional state (ODI) in the experimental group (p < 0.001). There was a significant ODI decrease by 18.1 points, after 1 month by 18.9 points, and after 3 months by 17.6 points. No significant differences were found in the control group (p > 0.05). Intergroup differences were observed in the functional efficiency in ODI in all measurement time-points (p < 0.001). There were significant differences in the range of motion (Schober test) in the DN group (main effect: p < 0.001). For all measurements, differences (p < 0.001) were observed in favor of DN compared to the control. In conclusion, DN program according to the FRS concept stands for the novel treatment method supplemented by an exercise program, effectively reducing pain and improving functional efficiency in LBP patients.
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Xu D, Ma X, Sun C, Han J, Zhou C, Wong SH, Chan MTV, Wu WKK. Circular RNAs in Intervertebral Disc Degeneration: An Updated Review. Front Mol Biosci 2022; 8:781424. [PMID: 35071323 PMCID: PMC8770867 DOI: 10.3389/fmolb.2021.781424] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 12/13/2021] [Indexed: 01/26/2023] Open
Abstract
Low back pain, a common medical condition, could result in severe disability and inflict huge economical and public health burden. Its pathogenesis is attributed to multiple etiological factors, including intervertebral disc degeneration (IDD). Emerging evidence suggests that circular RNAs (circRNAs), a major type of regulatory non-coding RNA, play critical roles in cellular processes that are pertinent to IDD development, including nucleus pulposus cell proliferation and apoptosis as well as extracellular matrix deposition. Increasing number of translational studies also indicated that circRNAs could serve as novel biomarkers for the diagnosis of IDD and/or predicting its clinical outcomes. Our review aims to discuss the recent progress in the functions and mechanisms of newly discovered IDD-related circRNAs.
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Affiliation(s)
- Derong Xu
- Department of Spine Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xuexiao Ma
- Department of Spine Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Chong Sun
- Department of Spine Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Jialuo Han
- Department of Spine Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Chuanli Zhou
- Department of Spine Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Sunny Hei Wong
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Matthew T V Chan
- Department of Anaesthesia and Intensive Care and Peter Hung Pain Research Institute, The Chinese University of Hong Kong, Hong Kong, China
| | - William K K Wu
- Department of Anaesthesia and Intensive Care and Peter Hung Pain Research Institute, The Chinese University of Hong Kong, Hong Kong, China.,State Key Laboratory of Digestive Diseases, LKS Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, China
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