Effects of N-acetylcysteine on the expressions of UCP1 and factors related to thyroid function in visceral adipose tissue of obese adults: a randomized, double-blind clinical trial.

BACKGROUND: Evidences have shown that obesity is influenced by various factors, including various hormones such as thyroid hormones and the body's metabolism rate. It seems that practical solutions such as weight loss diets and common drugs can affect these potential disorders. In this study, we investigate one of these common drugs, N-Acetylcysteine (NAC), on expressions of UCP1 and factors related to thyroid function in adults with obesity. METHODS AND ANALYSIS: The current investigation was carried out as a randomized clinical trial (RCT) including 43 adults with obesity who were potential candidates for bariatric surgery. These individuals were randomly divided into two groups: 600 mg of NAC (n = 22) or placebo (n = 21) for a duration of 8 weeks. Visceral adipose tissue was utilized in the context of bariatric surgery to investigate the gene expression of UCP1 and thyroid function. Polymerase chain reaction (PCR) was performed in duplicate for UCP1, DIO2, DIO3, THRα and ß, and 18s RNA (as an internal control) using the provided instructions to investigate the expression of the respective genes. RESULTS: Our findings revealed that after 8 weeks compared to placebo, NAC caused a significant decrease in the expression of the DIO3 gene as one of the genes related to thyroid function and metabolism. However, regarding other related genes, no statistically significant was found (despite the increase in UCP1, DIO2, and THRα expression and decrease in THRß expression). In addition, after adjustment of possible confounders, no significant effect was observed on anthropometric factors and serum levels of thyroid hormones. CONCLUSION: The results of this study indicate that, following an 8-week period, NAC effectively decreases the expression of the DIO3 gene in the visceral fat tissue, in comparison to the placebo.

Comparison of the Effect of Intracarpal Injection of Ketorolac With Triamcinolone in Carpal Tunnel Syndrome: A Randomized Controlled Trial.

BACKGROUND: The most prevalent entrapment neuropathy is carpal tunnel syndrome (CTS). Although nonsteroidal antiinflammatory drugs (NSAIDs) are frequently prescribed for musculoskeletal disorders, oral NSAIDs do not provide any additional benefits for CTS. Nevertheless, the use of NSAID phonophoresis has shown significant improvement, possibly due to increased concentration in the target tissue. The effects of intracarpal injection of NSAIDs on CTS have not been studied. OBJECTIVE: We conducted a controlled trial to compare the efficacy of ketorolac and triamcinolone in treating CTS. METHODS: Mild to moderate CTS patients were randomly assigned to receive either a local injection of 30 mg ketorolac or 40 mg triamcinolone. Patients were evaluated using visual analog scale (VAS) for pain, severity, function, electrodiagnostic findings, patient satisfaction, and any complications at the injection site, at baseline and 12 weeks after the procedures. RESULTS: Fifty patients participated, and 43 completed the study. Both groups showed significant improvement in the VAS, severity, function, and electrodiagnostic scores at 3 months compared with the baseline. A comparison of the groups showed significant differences in VAS, severity, and function, with the improvement being significantly higher in the triamcinolone group. CONCLUSION AND RELEVANCE: The present study showed that injection of triamcinolone or ketorolac into the carpal tunnel relieved pain, increased function, and improved electrodiagnostic findings in patients with mild to moderate CTS. It also showed that triamcinolone was superior to ketorolac in terms of analgesic effect and resulted in greater improvement in symptom severity and function.

Efficacy of ultrasound guided caudal epidural steroid injection with or without ozone in patients with lumbosacral canal stenosis; a randomized clinical controlled trial.

BACKGROUND: Lumbosacral canal stenosis is known as the most common cause of back surgery with several complications. Selecting a minimally invasive treatment with high efficacy in such patients is necessary. This study was designed to evaluate the effectiveness of ozone therapy in combination with caudal epidural steroid in patients with lumbar spinal stenosis. METHODS: A double-blind randomized clinical trial was conducted on 50 patients with lumbar spinal stenosis allocated into two study groups. Under ultrasound guidance, the first group received 80 mg of triamcinolone hexavalent with 4 mL of Marcaine 0.5% and 6 mL of distilled water to the caudal epidural space. The second group received an injection similar to the first group, combined with 10 mL of ozone (O2-O3) gas at a concentration of 10 µg/cc. The patients were followed at baseline, one, and six months after injection with clinical outcomes measures using Visual Analog Scale (VAS), Walking Distance (WD) and Oswestry Disability Index (ODI). RESULTS: The mean age of subjects, 30 males (60%) and 20 females (40%), was reported as 64.51 ± 7.19 years old. Reduction of pain intensity based on VAS score was statistically significant in both groups at follow-up periods (P < 0.001). The VAS changes in the first month and sixth months showed no significant difference between the two groups (P = 0.28 and P = 0.33, respectively). The improvement in disability index (ODI) in both types of treatment during follow-up was significant (P < 0.0001), and there was no difference between the two treatment groups in one month and six months (P = 0.48 and P = 0.88, respectively). As for walking distance, the improvement process with both types of treatment during follow-up periods was significant (P < 0.001). However, after one and six months of treatment, the rate of improvement in patients' walking distance in the caudal epidural steroid injection plus ozone group was significantly higher than in the epidural steroid group (p = 0.026 and p = 0.017, respectively). CONCLUSIONS: In this study, the results of VAS and ODI outcomes showed that caudal epidural steroid injection combined with ozone has no advantage over caudal epidural steroid injection alone. Interestingly, our results demonstrated that the group receiving caudal epidural steroid injection plus ozone scored significantly higher on the walking distance index than the group receiving caudal epidural steroid alone. TRIAL REGISTRATION: IRCT IRCT20090704002117N2 (registration date: 07/08/2019).

Cost-utility analysis and net monetary benefit of Platelet Rich Plasma (PRP), intra-articular injections in compared to Plasma Rich in Growth Factors (PRGF), Hyaluronic Acid (HA) and ozone in knee osteoarthritis in Iran.

PURPOSE: To evaluate the cost-effectiveness of Platelet Rich Plasma (PRP), Plasma Rich in Growth Factors (PRGF), Hyaluronic Acid (HA) and ozone as effective treatment approaches in knee osteoarthritis management from Iran Health care perspective. METHODS: A decision tree model was conducted to assess the cost-effectiveness of four common intra-articular treatment approaches in patients with mild and moderate knee osteoarthritis. The data on clinical effectiveness was obtained from a randomized controlled trial (RCT) conducted in Iran and used to estimate utility values. The direct medical costs were estimated according to tariffs for public medical centers and hospitals, approved by the Iran Ministry of Health and Medical Education in 2021. The incremental cost-effectiveness ratio (ICER) and the net monetary benefit (NMB) were used to evaluate the cost-utility analysis. Deterministic and probabilistic sensitivity analyses are performed to investigate the robustness of the results and account for the different sources of uncertainty. RESULTS: In this study, HA intra-articular injection-related costs ($581.67/patient) were defined as the highest cost, followed by PRGF ($328.10/patient), PRP (318.58/patient), and Ozone (103.20/patient). According to the utility value, PRP and PRGF (0.68) have the same and the most utility among Intra-articular injections in knee osteoarthritis management. However, the PRP injection method was identified as the most cost-effective intervention due to its high NMB and ICER estimates. Based on the Monte Carlo Simulation, PR intervention, compared to other ones, was introduced as the dominant strategy regarding knee OA management, with a WTP of $10,000 for 100% of cases. CONCLUSION: The study result demonstrated that intra-articular injection of PRP, compare to other injections, is a cost-effective treatment option for patients with mild and moderate knee osteoarthritis. In addition, intra-articular injection of PRP was identified as the best injection, with the highest level of net monetary benefit, for knee OA management.

The Efficacy of Intradermal Injection of Botulinum Toxin Type-A on Painful Diabetic Neuropathy: A Systematic Review.

Context: Diabetes is one of the most common causes of neuropathy. Morbidity and mortality increase in patients suffering from diabetic polyneuropathy and are experienced by approximately 10 to 54% of diabetic patients. Severe pain, loss of sensation, increased risk of ulceration, and even amputation are the complications of diabetic neuropathy. Intradermal injection of botulinum toxin type-A (BTX-A) is a relatively novel method for the treatment of painful diabetic neuropathy. This method is becoming popular considering its acceptable and long-lasting pain control and minimal systemic side effects. Methods: This narrative systematic review aimed to evaluate the effectiveness of intradermal BTX-A injection on painful diabetic neuropathy. The queried databases included PubMed, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov, Web of Science, Scopus, and Google Scholar. The final search was performed in February 2022, and no time limits were set for the search. All the relevant clinical trials were included. The inclusion criteria and search strategy were set as follows: Type of study: Randomized clinical trial (RCT) or other types of interventional studies; publication date: All published studies until February 22, 2022; sample size: No restrictions; outcomes: Effect on diabetic neuropathy pain; quality: Earning a minimum acceptable score based on critical appraisal; and language: English. The searches and article screening were performed by two independent reviewers to minimize the possibility of bias. In case of disagreement about a study, the comments of an expert (as a third person) were used to resolve the ambiguity. Results: In a review of 4 RCTs and 1 case-control study on the effectiveness of BTX-A in reducing the pain of diabetic neuropathy, 273 patients were evaluated in total. The lowest and highest number of subjects was 18 and 141. The sex distribution included 43.22% men and 56.77% women, all of whom were 47.8 to 74.8 years old. Three studies were conducted in Iran, Taiwan, and Egypt. The results of this review showed significant improvement in pain reduction, e.g., based on the Visual Analog Scale (VAS) and Neuropathic Pain Scale (NPS). A few studies evaluated sleep and psychosocial complications, and their results indicated a statistically significant improvement in the Pittsburgh sleep quality index (PSQI) and the physical subscale of the 36-Item Short Form Survey (SF-36). Conclusions: The results of this systematic review demonstrated that intradermal injection of BTX-A causes significant and long-term (up to 12 weeks) improvement in diabetic neuropathy pain. The improvement in sleep and mental or physical functions was not consistent, and no conclusive result could be reached.

Comparison between the effects of ultrasound guided intra-articular injections of platelet-rich plasma (PRP), high molecular weight hyaluronic acid, and their combination in hip osteoarthritis: a randomized clinical trial.

BACKGROUND: Intra articular (IA) injection of platelet-rich plasma (PRP) and hyaluronic acid (HA) are of the new methods in the management of hip osteoarthritis (OA). The aim of this study was to compare the effectiveness of IA injections of PRP, HA and their combination in patients with hip OA. HA and PRP are two IA interventions that can be used in OA in the preoperative stages. Due to the different mechanisms of action, these two are proposed to have a synergistic effect by combining. METHODS: This is a randomized clinical trial with three parallel groups. In this study, patients with grade 2 and 3 hip OA were included, and were randomly divided into three injection groups: PRP, HA and PRP + HA. In either group, two injections with 2 weeks' interval were performed into the hip joint under ultrasound guidance. Patients were assessed before the intervention, 2 months and 6 months after the second injection, using the visual analog scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Lequesne questionnaires. RESULTS: One hundred five patients were enrolled randomly in HA, PRP and PRP + HA groups. All three groups showed significant improvement in WOMAC, VAS, and Lequesne at 2 months and 6 months compared with baseline. Comparison of the 3 groups demonstrated significant differences regarding WOMAC and Lequesne total scores and the activities of daily living (ADL) subscale of Lequesne (P = 0.041, 0.001 and 0.002, respectively), in which the observed improvement at 6th month was significantly higher in the PRP + HA and PRP groups compared to the HA group. CONCLUSION: Although all 3 interventions were associated with improvement of pain and function in patients with hip OA, the therapeutic effects of PRP and PRP + HA injections lasted longer (6 months), and the effects of these two interventions on patients' performance, disability, and ADL were superior to HA in the long run. Moreover, the addition of HA to PRP was not associated with a significant increase in the therapeutic results. TRIAL REGISTRATION: The study was registered at Iranian Registry of Clinical Trials (IRCT) website http://www.irct.ir/ , a WHO Primary Register setup, with the registration number of IRCT20130523013442N30 on 29/11/2019.

Post-COVID-19 functional limitations in hospitalized patients and associated risk factors: A 3-month follow-up study.

BACKGROUND AND PURPOSE: Many patients experience post-COVID-19 functional limitations. This study aimed to monitor the functional improvement of patients over 3 months of follow-up and determine the risk factors. METHODS: This prospective cohort study evaluated 100 hospitalized patients who recovered from COVID-19 infection. The mean age was 53.2 ± 13.1 years. Fifty-nine had at least one comorbid condition. The mean lengths of the hospital and ICU stays were 7.8 ± 3.3 and 5.3 ± 2.5 days, respectively. The functional status of the patients was evaluated using functional independence measure (FIM) and post-COVID-19 functional status (PCFS) questionnaires at four time-points of discharge, 1 week, 1 month, and 3 months after discharge. RESULTS: Mean FIM score was 107.2 ± 17.4 at the time of discharge, 113.3 ± 14.9 at 1 week, 120.3 ± 10.2 at 1 month, and 124.3 ± 6.4 at 3 months after discharge (p < 0.001). The PCFS score was 2.71 ± 1.25 at discharge, 2.09 ± 1.3 at 1 week, 1.14 ± 1.1 at 1 month, and 0.64 ± 0.59 at 3 months after discharge (p < 0.001). Female sex, older age, and the lengths of hospital and ICU stays were negatively correlated with the functional status score. DISCUSSION: Post-COVID-19 functional limitations are observed in hospitalized patients and improve over 3 months after discharge. Female sex, older age, longer hospital, and ICU stays are risk factors that negatively impact functional status.

Autologous conditioned serum applications in the treatment of musculoskeletal diseases: a narrative review.

AIM: Autologous conditioned serum has been studied as a treatment option in musculoskeletal disorders and resulted in varying outcomes. This study aims to pool the current data on this matter. MATERIALS & METHODS: Major databases were searched for the topics, and after screening the results, the final 21 papers (level of evidence I or II) were included. RESULTS & CONCLUSION: This study showed a major focus of the literature on the effectiveness of autologous conditioned serum in osteoarthritis, in which there is much high-quality evidence suggesting its safety and efficacy. Also, some of the available experiments are assessing its application in tendinopathies and radiculopathies which, despite positive results, recommend further evaluations on this topic.

The comparison effects of intra-articular injection of Platelet Rich Plasma (PRP), Plasma Rich in Growth Factor (PRGF), Hyaluronic Acid (HA), and ozone in knee osteoarthritis; a one year randomized clinical trial.

BACKGROUND: Our study compare the short and long-term efficacy of the intra articular injections (IAIs) of hyaluronic acid (HA), platelet-rich plasma (PRP), plasma rich in growth factors (PRGF), and ozone in patients with knee osteoarthritis (OA). METHODS: In this randomized clinical trial, 238 patients with mild to moderate knee OA were randomized into 4 groups of IAIs: HA (3 doses weekly), PRP (2 doses with 3 weeks interval), PRGF (2 doses with 3 weeks interval), and Ozone (3 doses weekly). Our outcome measures were the mean changes from baseline (immediately from the first injections) until 2,6, and 12 months post intervention in scores of visual analog scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Lequesne index. RESULTS: A total of 200 patients enrolled in the final analysis. The mean age of patients was 56.9 ± 6.3 years, and 69.5% were women. In 2 months follow up, significant improvement of pain, stiffness, and function were seen in all groups compared to the baseline, but the ozone group had the best results (P < 0.05). In 6 month follow up HA, PRP, and PRGF groups demonstrated better therapeutic effects in all scores in comparison with ozone (P < 0.05). At the end of the 12th month, only PRGF and PRP groups had better results versus HA and ozone groups in all scores (P < 0.05). Despite the fact that ozone showed better early results, its effects begin to wear off earlier than other products and ultimately disappear in 12 months. CONCLUSIONS: Ozone injection had rapid effects and better short-term results after 2 months, but its therapeutic effects did not persist after 6 months and at the 6-month follow up, PRP,PRGF and HA were superior to ozone. Only patients in PRP and PRGF groups improved symptoms persisted for 12 months. Therefore, these products could be the preferable choices for long-term management. TRIAL REGISTRATION: Registered in the Iranian Center of Clinical Trials ( www.irct.ir ) in 11/11/2017 with the following code: IRCT2017082013442N17.

Beliefs, attitude, and knowledge of the Iranian physiatrists towards neuromusculoskeletal ultrasound and common barriers in its application.

BACKGROUND: Regarding the increasing application of neuromusculoskeletal sonography among medical specialties, specifically physiatrists, this study aims to assess the knowledge and skill level of these specialists in neuromusculoskeletal sonography in Iran. METHODS: This descriptive, cross-sectional study was performed in 2018. The utilized questionnaire developed based on previous studies in collaboration with 6 university lecturers of Shaheed Beheshti, Iran, and Tabriz medical universities and a physiatrist from Hacettepe University (Turkey); it included questions entailing demographic data, knowledge, and performance levels. Its validity and reliability were evaluated through face validation, pilot study, and the Cronbach α calculated via SPSS. Data extraction and analysis were also performed by SPSS-25. RESULTS: Of 364 questionnaires distributed, 300 were properly filled and entered into the study, of which, 38% were filled by clinical residents, 10% university lecturers, and 52% other categories (e.g. private sector). The average number of musculoskeletal patient visits was 140.6 ± 119 and the mean number of musculoskeletal sonographies requested was 8.2 ± 5.2 per month (the three most common indications reported as the shoulder, carpal tunnel syndrome, and tendon injuries). 95% of the participants considered the importance of sonography for physiatrists to be "very high" or "high"; with the most valuable applications "as a guide for procedures (90%), its diagnostic utility (68%), and follow up/evaluating the response to treatment (45%). 86% of physiatrists reported they had participated in musculoskeletal sonography courses, 60% during residency, and the rest through workshops. Also, the participants mentioned safety (83%), the possibility of performing simultaneous diagnosis and intervention procedures (70%), repeatability (58%), and dynamic imagery (52%) as the major advantages of musculoskeletal ultrasound. CONCLUSION: a large number of doctors consider musculoskeletal sonography to be essential for physiatrists, though insufficient education on the subject and the low number of ultrasound devices are some of the obstacles in enhancing the use of this technology in PM&R setting. Presenting certified specific training courses during residency, provision of necessary rotations, using the capacities of the PM&R scientific committee, and the private sector for running workshops and professional training courses are suggested for enhancing the knowledge and skills of neuromusculoskeletal sonography.

Efficacy of single high-molecular-weight versus triple low-molecular-weight hyaluronic acid intra-articular injection among knee osteoarthritis patients.

BACKGROUND: To compare intra-articular (IA) knee injections of a cross-linked high-molecular-weight hyaluronic acid (HMW-HA) with a linear low-molecular weight HA (LMW-HA) in terms of pain and functional improvement among knee osteoarthritis (OA) patients. METHODS: In this single-blinded RCT, the patients were randomly divided into two groups for HA injections. The first group received an HMW-HA (Arthromac) injection, while the other received three weekly LMW-HA (Hyalgan) injections. Pain and function were assessed using the outcome measures including WOMAC, Lequesne and VAS indices, once prior to injection, as well as 2 and 6 months after injections. RESULTS: A total of 90 patients were included. There was no significant difference in baseline characteristics including age and sex between the two groups. Our analysis showed that total WOMAC, Lequesne and VAS mean scores remarkably improved at both follow-up time-points compared to the baseline measurements (p < 0.001). There was no significant superiority between the two therapeutic protocols according to our outcome measures at any time-point of follow-up. The only except was about the improvement in WOMAC stiffness subscale that was significantly higher in LMW-HA group compared to HMW-HA (p = 0.021). Moreover, no significant difference was observed in minor complications and injection-induced pain scores between the two groups. CONCLUSION: This study proved that a single HMW-HA injection is as effective as multiple injections of LMW-HA counterparts in periods of 2 and 6 months follow-up. This study protocol was registered in Iranian database of RCTs (IRCT; www.irct.ir ) with the trial registration number IRCT20130523013442N24 and registration date 2018-07-13.

Platelet-Rich Plasma-Derived Growth Factor vs Hyaluronic Acid Injection in the Individuals with Knee Osteoarthritis: A One Year Randomized Clinical Trial.

OBJECTIVE: In this study, we aimed at performing a comparison between intra-articular injections of PRP-derived growth factor (PGRF) and hyaluronic acid regarding their effect on pain and patient's function in knee osteoarthritis, as well as their safety profiles. METHODS: During our single-masked randomized clinical trial, the candidates with symptomatic knee osteoarthritis received two intra-articular injections of PRGF with 3 weeks apart or received three weekly injections of HA. The mean improvements from before treatment until the second, sixth, and twelfth months post-intervention in scores obtained by visual analog scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Lequesne index were our primary outcomes. RESULTS: A total of 102 candidates were finally included in the study. Patients' mean age was 57.08±7.3 years old in the PRGF group compared to the mean age of 58.63±7.09 years old in HA patients. In the PRGF group, total WOMAC index decreased from 41.96±11.71 to 27.10±12.3 (P = 0.02), and from 39.71±10.4 to 32.41±11.8 in the HA group after 12 months (P > 0.05). Regarding the Lequesne index, pain, ADL, and global scores significantly decreased after 12 months in the PRGF group compared to the HA group (P<0.001). There was also a meaningful higher rate of satisfaction in the PRGF group compared to the HA group after 12 months of treatment (P<0.001). CONCLUSION: Besides significantly higher satisfaction belonging to the PRGF group, there was a statistically significant improvement in VAS score and global, pain, and ADL score of Lequesne by passing 12 months from injection in PRGF compared to HA.

Using the Systems Biology Approach and Molecular Method to Investigate the Role of the Dopaminergic Pathway in Osteoarthritis: A Case Control Study.

OBJECTIVE: Osteoarthritis is the most common type of arthritis and one of the leading causes of job loss and motor disabilities. Recently, the involvement of dopaminergic pathways and dopamine receptor genes has been considered in this disease. Therefore, studying and comparing the expression pattern of these receptor genes can lead to a greater understanding of the pathogenesis of this disease. METHODS: In this research, we used the systems biology approach to investigate the role of the dopaminergic pathway in osteoarthritis. Then the gene expression pattern of dopamine receptor genes was examined in an osteoarthritis patientgroup in comparison with healthy individuals by Real-time PCR method. RESULTS: The analysis of the transcriptome dataset of osteoarthritis identified some genes in the dopaminergic pathway and the six most important genes in this disease are in the network with a significant relationship to dopamine receptors which differentially expressed compared to health groups. Statistical analysis of the case control study showed a significant difference (P-value<0.05) in DRD1 and DRD2 family in the patients in comparison to healthy individuals. DISCUSSION: We attained the significant expression pattern of dopamine receptors in the blood of osteoarthritis patients which could be useful to identify new strategies for the diagnosis, management, or treatment of this disease.

MRI Changes After Platelet Rich Plasma Injection in Knee Osteoarthritis (Randomized Clinical Trial).

PURPOSE: Few papers have studied the objective effects of PRP on cartilage. In this study, we investigated the effect of PRP on cartilage characteristics by special MRI sequencing in knee osteoarthritis (IRCT registration number: 2014020413442N6). PATIENTS AND METHODS: In this double blind randomized clinical trial, patients with bilateral knees osteoarthritis-grade 1, 2, and 3 were included in the study. Each patient's knees were randomly allocated to either control or treatment groups. PRP was injected in two sessions with 4 week intervals in PRP group. The VAS (visual analog scale) and WOMAC (Western Ontario and McMaster Universities Arthritis Index) were utilized and MRI was performed for all patients, before, and 8 months after treatment. The MRI sequences taken were transverse 3D TRUFISP and coronal and sagittal fat saturated proton-density. Imaging was scored according to four cartilage characteristics. RESULTS: 46 knees (from 23 patients) were included in this study. 23 knees in the case group and 23 knees in control group were studied. All patients were female with mean age of 57.57±5.9 years. Mean total WOMAC and VAS changes before and after treatment in control group were 11.61±8.5 and 1.3±1.1 respectively. In PRP group, mean total WOMAC and VAS changes showed better improvement with 20±12.3 and 3.2±1.6 respectively (P-value <0.05). In PRP group, all of the radiologic variables (patellofemoral cartilage volume, synovitis and medial and lateral meniscal disintegrity), with the exception of subarticular bone marrow abnormality, had significant improvement (P-value <0.05). In a comparison between the two groups, patellofemoral cartilage volume and synovitis had significantly changed in the PRP group (P-value <0.05). CONCLUSION: In this study, in addition to the effect of PRP on VAS and WOMAC, there was a significant effect on radiologic characteristics (patellofemoral cartilage volume and synovitis). For further evaluation, a longer study with a larger sample size is recommended.

Ultrasound-Guided Injection of High Molecular Weight Hyaluronic Acid versus Corticosteroid in Management of Plantar Fasciitis: A 24-Week Randomized Clinical Trial.

BACKGROUND AND AIMS: Plantar fasciitis (PF) is the leading cause of heel pain in adults. This study was designed to evaluate the effect of hyaluronic acid (HA) injection in reducing the symptoms of PF, compared with corticosteroid (CS) injection as a conventional treatment. METHODS: In this triple-blind, randomized, clinical trial, 75 patients who had the symptoms of PF for at least 3 months were randomly divided into two groups of 38 and 37 individuals. Then, each patient received either a single injection of high molecular weight (>2000 kDa) HA (1 mL HA 20 mg + 1 mL lidocaine 2%) or CS (1 mL methylprednisolone 40 mg + 1 mL lidocaine 2%) under the ultrasonography (US) guidance. Visual analog scale (VAS), foot ankle ability index (FAAI), pressure pain threshold (PPT), functional foot index (FFI), and plantar fascia thickness (PFT) were measured using US at baseline, 6 weeks and 24 weeks after the injection. Eventually, at the end of the treatment period, the patients' satisfaction was measured. Intention to treat analysis was used to assess the results. RESULTS: After 24 weeks of follow-up, results from 60 subjects were fully obtained; however, results of 73 patients included into intention to treat analysis in the sixth-week follow-up. In both groups, VAS, PFT and FFI decreased, while FAAI and PPT increased significantly (P <0.001). At the baseline and at the 24th-week, no significant difference between the two groups was observed in any of the variables. However, a comparison between the baseline and the sixth-week results shows a prominent decrease in PPT and PFT in the CS group compared to the HA group (P = 0.004 and P = 0.011). Finally, there were no statistical differences between the two groups in treatment satisfaction (P = 0.618). CONCLUSION: Both CS and HA were effective modalities for PF and can improve pain and function with no superiority in 24th-week follow-ups, although CS seems to have a faster trend of improvement in the short term.

Randomized controlled trial of aquatic exercise for treatment of knee osteoarthritis in elderly people.

Aim: The aim of this study is to assess the efficacy of aquatic exercise on pain, gait, and balance among elderly patients with knee osteoarthritis. Methods: We performed a randomized controlled trial at a university hospital. Overall, 32 men with knee osteoarthritis, aged ≥ 60 years, were included. Pain, balance, and gait were evaluated before and 2 months after interventions. The group control used acetaminophen and followed lifestyle recommendations. The intervention group performed the aquatic exercise three sessions per week for 8 weeks. Results: At the end of the study, mean pain scores were significantly different between the groups (p = 0.010). Within-group analyses showed that group intervention experienced significant pain relief (p = 0.019), whereas group control did not show the significant change (p = 0.493). There was significant improvement in favor of aquatic exercise with regard to static (p = 0.001) and dynamic (p = 0.001) balance, step length (p = 0.038), stride length (p < 0.001), and cadence (p < 0.001). However, we did not find a significant difference in step time and width between the two groups. Conclusions: Aquatic exercise would be beneficial in decreasing subjective pain of osteoarthritis. There are some recognizable improvements in patients' gait and balance as well.

The Effect of High-Power and Low-Power Lasers on Symptoms and the Nerve Conduction Study in Patients With Carpal Tunnel Syndrome. A Prospective Randomized Single-Blind Clinical Trial.

Introduction: Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment. Various treatments have been suggested for CTS and there is no consensus on their superiority and the order of their use. Laser therapy is a non-invasive treatment method for many musculoskeletal diseases, including CTS. This study aimed to determine and compare the effect of high-power lasers (HPLs) and low-power lasers (LPLs) on pain severity, function, pinch strength, and nerve conduction study findings in patients aged 30-50 years with mild or moderate CTS. Methods: This is a prospective, randomized, single-blind clinical trial. The study population included 45 patients aged 30-50 years who came to the physical medicine and rehabilitation clinic of Shohada-e-Tajrish hospital and mild or moderate CTS was confirmed for them. Patients were randomly assigned to control, LPL therapy, and HPL therapy groups. Pain, function, pinch strength, and nerve conduction study findings were recorded in all groups before, immediately and 12 weeks after the treatment. All data were compared using SPSS version 21. Results: All groups showed improvement regarding pain, function, and pinch strength. Laser therapy showed significantly better results compared to a wrist splint, but no significant difference was seen between high-power and LPL therapy groups. Nerve conduction evaluation findings did not reveal any significant difference. Conclusion: Both the wrist splint and laser therapy can improve the symptoms of carpal tunnel syndrome. HPL therapy showed better results, although not significantly different from LPL therapy.

Rumination-Focused Cognitive-Behavioral Therapy for Chronic Low Back Pain: A Randomized Controlled Trial.

BACKGROUND: Chronic pain remains or reappears for more than 3 to 6 months, and it is influencing 20% of the global population. The pain catastrophizing affects pain intensity and psychological conditions of patients with chronic pain. Rumination-focused cognitive-behavioral therapy (RFCBT) targets rumination as the key component of pain catastrophizing. The aim of this study was to determine the effectiveness of RFCBT on depression, anxiety, and pain severity of individuals with chronic low back pain (LBP). MATERIALS AND METHODS: In a randomized controlled trial, 30 patients aged between 20-55 years with diagnosed chronic LBP were chosen by convenience sampling and randomly allocated into intervention and control groups. All patients used their prescribed medications for pain management, but the intervention group received 12 weekly sessions of RFCBT, which was manualized psychotherapy to change unconstructive rumination to constructive rumination. Depression Anxiety and Stress scale-21 and chronic pain grade questionnaire were administered as pre-tests and re-administered after 3 and 6 months as post-test and follow-up assessments, respectively. RESULTS: RFCBT significantly reduced depression (F1=23.01, P=0.001), anxiety (F1=25.7, P=0.001) and pain severity (F1=7.17, P=0.012) in patients with chronic LBP. CONCLUSION: RFCBT may offer benefits for treating patients with chronic low back pain when added to their usual pharmacological treatment. This benefit may be the result of targeting rumination as the key element of pain catastrophizing.

The Effects of Knee Orthosis with Two Degrees of Freedom Joint Design on Gait and Sit-to-Stand Task in Patients with Medial Knee Osteoarthritis.

OBJECTIVES: Knee bracing as a conservative treatment option for patients with medial knee osteoarthritis (KOA) is of great interest to health practitioners and patients alike. Optimal orthotic knee joint structure is essential to achieve biomechanical and clinical effectiveness. Therefore, this study aimed to identify the effects of a knee orthosis with a new two-degrees-of-freedom (DOF) joint design on selected gait parameters and in a sit-to-stand task in patients with mild-to-moderate medial KOA. METHODS: This study was conducted both at the Physical Medicine and Rehabilitation Clinic in Shahid Modarres Academic Hospital and the Biomechanical Laboratory of Rehabilitation Faculty of Iran University of medical Sciences in Tehran, Iran from September 2015 to October 2017. The gait performance of 16 patients was assessed without an orthosis, using a common one-DOF (DOF) knee orthosis and using the same knee orthosis with a two-DOF orthotic joint design. The interactive shearing force between limb and brace in the shell area during a sit-to-stand test was also identified. Repeated measures analysis of variance was used to analyse the data. RESULTS: Compared with walking with no orthosis, both orthosis conditions reduced the external knee adduction moment significantly (P ≤0.05). A significant increase between the one-DOF and two-DOF conditions in terms of walking speed (P = 0.041 and P = 0.009, respectively) and stride length (P = 0.028 and P = 0.038, respectively) was observed. In a sit-to-stand test, wearing the orthosis significantly decreased knee transverse plane range of motion (P ≤0.05). There was a 41.31 ± 8.34 Newtons reduction in knee flexion constraint force. CONCLUSION: The two-DOF knee orthosis was more comfortable compared to the one-DOF knee orthosis during deep knee flexion. Otherwise, the one-DOF- and two-DOF-braces performed similarly.

Extracorporeal Shockwave Therapy Combined with Drug Therapy in Chronic Pelvic Pain Syndrome : A Randomized Clinical Trial.

PURPOSE: Chronic prostatitis/ chronic pelvic pain syndrome (CP/CPPS) is a nonspecific pelvic pain in the absence of signs of infection or other obvious local pathology for at least three of the last 6 months. Evidence for treatment approach is limited. So the aim of this study is to investigate the effect of extracorporeal shock wave therapy (ESWT) combined with pharmacotherapy in the treatment of CP/CPPS. MATERIALS AND METHODS: In this randomized clinical  trial, 31 patients with CP/CPPS were investigated in two groups: the intervention group (n=16) was treated with a combination of an alpha-blocker, an anti-inflammatory agent, a muscle relaxant and a short course of antibiotic in combination with 4 sessions of focused ESWT (a protocol of 3000 impulses, 0.25 mJ/mm2  and 3 Hz of frequency). The control group (n=15) received the aforementioned pharmacotherapy with 4 sessions of sham-ESWT . Follow-up was performed 4 and 12 weeks following ESWT by using the Visual Analogue Scale (VAS), International index of Erectile function (IIEF) 5, National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI) and International Prostate Symptom Score (IPSS) questionnaires. Post void residual (PVR) urine and maximum flow rate (Qmax) were also assessed in both groups. RESULTS: The patients mean age was 43.7 ±12.6 years. In both groups, the mean scores of NIH-CPSI (total and sub-domains) and VAS showed statistically significant improvements after 4 and 12 weeks compared to the baseline (P < .001). In the intervention group, IPSS (mean difference: 4.25) and Qmax (mean difference: 2.22) were also significantly improved (P < .001).  There was a significant improvement in NIH-CPSI (mean difference: 1.1) and VAS scores (mean difference: 1.1) in the intervention group as compared to the control group (P < .01). Qmax, PVR and IIEF score were not statistically different in the two groups. CONCLUSION: ESWT in combination with pharmacotherapy could improve the treatment outcome in patients with CP/CPPS.