Assessment of muscle strength in chronic low back pain patients: Comparison between isocinetic rehabilitation and conventional rehabilitation.

INTRODUCTION: Chronic low back pain is a public health problem in view of its functional repercussions and the functional rehabilitation is an integral part of its management. AIM: To compare the evolution of muscle strentgh of spinal extensors and flexors in chronic low back pain patients after an isokinetic rehabilitation protocol and a conventional rehabilitation one. METHOD: This was a prospective and comparative study carried out in the Physical Medicine Department of the Tunis Military Hospital over a period of 7 months. Fifty patients were included, randomly divided into two groups of 25. The first group (G1) benefited from an isokinetic rehabilitation protocol and the second one (G2) from a classic active physiotherapy. We performed a clinical (Sorensen test and Shirado test) and isokinetic evaluation of the trunk muscles before and after rehabilitation. RESULTS: The mean age of the general population was 42±8.6 years old. Clinical evaluation showed a deficit in the extensor and flexor muscles of the spine, more important in the extensors in both groups. After rehabilitation, there was a significant improvement in clinical tests of muscular endurance in G1 and G2. Isokinetic assessment showed a greater muscle deficit in the extensors in both groups. After isokinetic rehabilitation, peak torque for flexors and extensors increased by 21% and 23% respectively, power was 34% and 37% higher, and total work increased by 26% and 47%. On the other hand, the (F/E) ratios were unchanged for all three speeds. In Group 2, peak torque values for flexors and extensors increased by 22 and 15% respectively, power was higher by 31 and 23% and total work was also up by 29 and 17%, while F/E ratios were also unchanged. Group 1 showed the greatest improvement in extensor strength at 60°/s, and in power at 90°/s for the various muscles. CONCLUSION: In our study, we concluded that endurance and muscular strength improved the most after isokinetic rehabilitation.

Assessment of somatosensory profiles by quantitative sensory testing in children and adolescents with and without cerebral palsy and chronic pain.

OBJECTIVE: We investigated differences in somatosensory profiles (SSPs) assessed by quantitative sensory testing in children and adolescents with cerebral palsy (CCP) with and without chronic pain and compared these differences to those in a group of typically developed children and adolescents (TDC) with and without chronic pain. METHOD: All included subjects were consecutively recruited from and tested at the same outpatient orthopedic clinic by the same investigator. The subjects had their reaction times tested. The SSP consisted of the following tests: warmth (WDT), cool (CDT), mechanical (MDT), and vibration (VDT) detection thresholds; heat (HPT), pressure (PPT), and mechanical (MPT) pain thresholds; wind-up ratio (WUR); dynamic mechanical allodynia (DMA) and cold pressor test (CPT) using a conditioned pain modulation (CPM) paradigm. RESULTS: We included 25 CCP and 26 TDC. TDC without chronic pain served as controls. In TDC with chronic pain, WDT, HPT, HPT intensity, and PPT were higher than in controls. No differences in SSPs between CCP with and without chronic pain were observed. In CCP, the MDT, WDT, CDT, and HPT intensity were higher than in controls. CCP had longer reaction times than TDC. There were no differences regarding the remaining variables. DISCUSSION: In CCP, the SSPs were independent of pain status and findings on MR images. In all CCP the SSPs resembled TDC with chronic pain, compared to TDC without chronic pain. This suggests that CCP do not have the normal neuroplastic adaptive processes that activate and elicit functional changes in the central and peripheral nervous systems.

Chronic pain in pediatric patients: epidemiology, pathophysiology, and mitigation strategies.

PURPOSE OF REVIEW: To provide an updated summary on the epidemiology, pathophysiology, and treatment strategies of chronic pain in pediatric patients and its differences with chronic pain in adults. RECENT FINDINGS: Chronic pain in children is common, can be debilitating and can progress into adulthood, thus it requires an interdisciplinary evaluation and management. Targeting interdisciplinary care, including psychology, physical, and/or occupational therapy, has been shown to improve pain and function. Recent decline in mental health post pandemic has correlated with increase in pediatric chronic pain thus the need to identify patients at risk and offer early interdisciplinary treatment. SUMMARY: Chronic pediatric pain should be addressed under the biopsychosocial model, where the biological, psychological, and social factors are evaluated on how they influence the pain perception, pain experience, functional ability, and treatment focus. Pain education to patients and their families is the crucial initial step towards a functional rehabilitation of pain.

Examining the Role of Structural and Functional Social Network Characteristics in the Context of Chronic Pain: An Ego-centered Network Design.

The well-being and functioning of individuals with chronic pain (CP) vary significantly. Social factors, such as social integration, may help explain this differential impact. Specifically, structural (network size, density) as well as functional (perceived social support, conflict) social network characteristics may play a role. However, it is not yet clear whether and how these variables are associated with each other. Objectives were to examine 1) both social network characteristics in individuals with primary and secondary CP, 2) the association between structural network characteristics and mental distress and functioning/participation in daily life, and 3) whether the network's functionality mediated the association between structural network characteristics and mental distress, respectively, functioning/participation in daily life. Using an online ego-centered social network tool, cross-sectional data were collected from 303 individuals with CP (81.85% women). No significant differences between individuals with fibromyalgia versus secondary CP were found regarding network size and density. In contrast, ANCOVA models showed lower levels of perceived social support and higher levels of conflict in primary (vs secondary) CP. Structural equation models showed that 1) larger network size indirectly predicted lower mental distress via lower levels of conflict; 2) higher network density increased mental distress via the increase of conflict levels. Network size or density did not (in)directly predict functioning/participation in daily life. The findings highlight that the role of conflict, in addition to support, should not be underestimated as a mediator for mental well-being. Research on explanatory mechanisms for associations between the network's structure, functionality, and well-being is warranted. PERSPECTIVE: This paper presents results on associations between structural (network size, density) and functional (social support, conflict) social network characteristics and well-being in the context of CP by making use of an ego-centered network design. Results suggest an indirect association between structural network characteristics and individuals with CP their mental well-being.

How do the mindfulness and sensory-behavioural-emotional aspects influence the painful experience related to temporomandibular disorder?

BACKGROUND: Chronic pain is persistent or recurrent pain lasting longer than 3 months. The experience of temporomandibular disorder (TMD)-related pain is modulated by emotional and social factors, with mindfulness encapsulating these aspects. OBJECTIVE: To investigate the association between cognitive-behavioural-emotional characteristics, mindfulness and the painful experience in women with chronic pain-related TMD. METHODS: A cross-sectional study was conducted, including 90 women aged between 18 and 61 years old, diagnosed with chronic pain-related TMD according to the Diagnostic Criteria for Temporomandibular Disorder, considering both temporomandibular joint and muscle pain. Specific instruments were employed to assess cognitive-behavioural-emotional aspects. The Mindful Attention Awareness Scale and the Five Facets of Mindfulness Questionnaire scales evaluated the level and construct of mindfulness. The relationship between variables was analysed using bivariate association tests (.05 > p < .20), followed by multiple regression tests (p < .05). RESULTS: The heightened experience of pain correlated with increasing age, a low level of education, the attribution of the locus of control by chance, and lower levels of mindfulness (p < .05). The heightened experience of pain was negatively influenced by mindfulness levels (p < .05). On the other hand, the painful experience was mainly influenced by facets describing negative formulation, distraction, non-reactivity and non-judgement (p < .05). CONCLUSION: Demographic, cognitive-behavioural-emotional data and levels of mindfulness and its facets presented different influence weights on the painful experience. These findings provide support for future studies focusing on mindfulness strategies, education and pain management in women with chronic pain-related TMD.

A randomized controlled trial investigating the impact of a single flash cupping session on patients with chronic lower back pain using multichannel surface electromyographic assessment.

BACKGROUND: Chronic lower back pain (CLBP) is one of the most common disorders worldwide. Flash cupping has the ability to relieve CLBP; nevertheless, its impact on CLBP and the likely mechanism of action have not been studied. OBJECTIVE: The goal of this study was to assess the impact of a single, brief cupping session on CLBP and low back muscle activity using multichannel surface electromyography (sEMG). METHODS: In this randomized controlled trial, 24 patients with CLBP were enrolled and randomly assigned to the control group (treated by acupuncture) and cupping group (treated by acupuncture and flash cupping). Acupuncture was applied on the shen shu (BL23), dachang shu (BL25), and wei zhong (BL40) acupoints in both the groups. A brief cupping treatment was applied to the shen shu (BL23), qihai shu (BL24), dachang shu (BL25), guanyuan shu (BL26), and xiaochang shu (BL27) acupoints on both sides of the lower back in the cupping group. The numeric rating scale (NRS) was used to assess therapy efficacy for lower back pain (LBP) before and after treatment. Surface EMG data collected during symmetrical trunk flexion-extension movements were utilized to measure lower back muscle activity and the effectiveness of LBP therapy. RESULTS: There was no statistically significant difference (P= 0.63) in pain intensity between the two groups before and after treatment. There was a statistically significant difference (P= 0.04) between the control group and the cupping group in the sEMG topographic map parameter CoGx-To-Midline. CONCLUSION: This study established a connection between the action mechanism of flash cupping and enhanced horizontal synchronization of lower back muscular activity.

Temporomandibular disorders cases with high-impact pain are more likely to experience short-term pain fluctuations.

Temporomandibular disorders (TMD) patients can present clinically significant jaw pain fluctuations which can be debilitating and lead to poor global health. The Graded Chronic Pain Scale evaluates pain-related disability and its dichotomous grading (high/low impact pain) can determine patient care pathways and in general high-impact pain patients have worse treatment outcomes. Individuals with low-impact TMD pain are thought to have better psychosocial functioning, more favorable disease course, and better ability to control pain, while individuals with high-impact pain can present with higher levels of physical and psychological symptoms. Thereby, there is reason to believe that individuals with low- and high-impact TMD pain could experience different pain trajectories over time. Our primary objective was to determine if short-term jaw pain fluctuations serve as a clinical marker for the impact status of TMD pain. To this end, we estimated the association between high/low impact pain status and jaw pain fluctuations over three visits (≤ 21-day-period) in 30 TMD cases. Secondarily, we measured the association between jaw pain intensity and pressure pain thresholds (PPT) over the face and hand, the latter measurements compared to matched pain-free controls (n = 17). Jaw pain fluctuations were more frequent among high-impact pain cases (n = 15) than low-impact pain cases (n = 15) (OR 5.5; 95% CI 1.2, 26.4; p value = 0.033). Jaw pain ratings were not associated with PPT ratings (p value > 0.220), suggesting different mechanisms for clinical versus experimental pain. Results from this proof-of-concept study suggest that targeted treatments to reduce short-term pain fluctuations in high-impact TMD pain is a potential strategy to achieve improved patient perception of clinical pain management outcomes.

Complexity Assessment of Chronic Pain in Elderly Knee Osteoarthritis Based on Neuroimaging Recognition Techniques.

The chronic pain of knee osteoarthritis in the elderly is investigated in detail in this paper, as well as the complexity of chronic pain utilising neuroimaging recognition techniques. Chronic pain in knee osteoarthritis (KOA) has a major effect on patients' quality of life and functional activities; therefore, understanding the causes of KOA pain and the analgesic advantages of different therapies is important. In recent years, neuroimaging techniques have become increasingly important in basic and clinical pain research. Thanks to the application and development of neuroimaging techniques in the study of chronic pain in KOA, researchers have found that chronic pain in KOA contains both injury-receptive and neuropathic pain components. The neuropathic pain mechanism that causes KOA pain is complicated, and it may be produced by peripheral or central sensitization, but it has not gotten enough attention in clinical practice, and there is no agreement on how to treat combination neuropathic pain KOA. As a result, using neuroimaging techniques such as magnetic resonance imaging (MRI), electroencephalography (EEG), magnetoencephalography (MEG), and near-infrared spectroscopy (NIRS), this review examines the changes in brain pathophysiology-related regions caused by KOA pain, compares the latest results in pain assessment and prediction, and clarifies the central brain analgesic mechanistic. The capsule network model is introduced in this paper from the perspective of deep learning network structure to construct an information-complete and reversible image low-level feature bridge using isotropic representation, predict the corresponding capsule features from MRI voxel responses, and then, complete the accurate reconstruction of simple images using inverse transformation. The proposed model improves the structural similarity index by about 10%, improves the reconstruction performance of low-level feature content in simple images by about 10%, and achieves feature interpretation and analysis of low-level visual cortical fMRI voxels by visualising capsule features, according to the experimental results.

Low Back Pain Assessment Based on Alpha Oscillation Changes in Spontaneous Electroencephalogram (EEG).

Objectively and accurately assessing pain in clinical settings is challenging. Previous studies showed that alpha oscillations of electroencephalogram data are correlated with subjective perceived pain. Based on this finding, this study is aimed at assessing chronic low back pain based on alpha oscillations. Multichannel electroencephalogram data were recorded from 27 subjects with chronic low back pain under the simple conditions of closing eyes or opening eyes. Spectral analyses were conducted to extract the alpha band responses, and the alpha powers were calculated for the two conditions, respectively. Normalized alpha power was calculated by subtracting the alpha power in the eyes-open condition from that in the eyes-closed condition. The correlation between the alpha power and the subjective pain intensity was evaluated in frontal, central, and posterior regions. The normalized alpha power in the central region was negatively correlated with the subjective pain intensity (R = -0.50, P = 0.01), with the strongest correlation occurring at the Cz electrode (R = -0.59, P = 0.04). The correlation analysis results demonstrated the possibility of using the differences of alpha spectral power between eyes-closed and eyes-open conditions as a measure for assessing chronic low back pain. The findings suggest that the normalized alpha power in the central region may be used as a measurable and quantitative indicator of chronic pain for clinical applications.

Assessment of the responsiveness of four scales in geriatric patients with chronic neck pain.

The purpose of this study was to evaluate the responsiveness of Copenhagen Neck Functional Disability Scale (CNFDS), Neck Disability Index (NDI), Neck Bournemouth Questionnaire (NBQ), Neck Pain and Disability Scale (NPDS) in geriatric patients with non-specific chronic neck pain. A total of 52 geriatric patients with non-specific chronic neck pain were included in the present study. All participants were included in a physical therapy and rehabilitation program for five sessions per week that lasted 3 weeks. All participants were evaluated before and after the treatment. Pain and disability were assessed with the Visual Analog Scale-pain (VAS-pain), VAS-disability, muscle spasm, CNFDS, NDI, NBQ, NPDS scales. Additionally, patient satisfaction scores were questioned both before and after the treatment. Following the 3-week physical therapy and rehabilitation program, significant improvements were detected in the VAS-pain, VAS-disability, muscle spasm, CNFDS, NDI, NBQ, and NPDS scores (p < 0.05). Responsiveness values were found to be as follows: CNFDS [effect size (ES) = 0.78; standardized response mean (SRM) = 0.90], NDI (ES = 0.66; SRM = 1.18), NBQ (ES = 0.82; SRM = 0.97) and NPDS (ES = 0.87; SRM = 0.98). Our study demonstrated that CNFDS, NDI, NBQ, and NPDS are responsive scales in determining treatment-related changes in geriatric patients with non-specific neck pain. These results also suggest that all of these four scales can be used in the assessment of treatment induced changes in geriatric patients with chronic neck pain.

Comparative safety review of current treatment options for chronic low back pain and unmet needs: a narrative review.

Introduction: The healthcare expenditures in the United States are substantial for the management of refractory, chronic low back pain (CLBP). The objective of this review is to summarize and evaluate the safety profiles of different pharmacological treatment options used in the management of CLBP.Areas covered: The authors conducted a search of randomized controlled trials (RCTs) assessing the safety profiles of different pharmacological agents used in the management of CLBP. This narrative review covered corticosteroids, opioids, antidepressants, gabapentinoids, nonsteroidal anti-inflammatory drugs, muscle relaxants, anti-nerve growth factor antibodies and topical agents, as monotherapy or in combination.Expert opinion: The risk-benefit ratio of a particular treatment is a subject driving the ongoing development of pharmaceuticals. The most commonly reported AEs across all drug classes are of gastrointestinal nature, followed by neurological and skin-related. These AEs include nausea, dizziness, constipation, arthralgia, headache, dry mouth, pruritus, etc. The majority of the AEs reported are not life-threatening, although they may lower patients' quality of life, thus, affecting their compliance. One of the biggest limitations of our review stems from the paucity of safety assessments in published RCTs. Advances in our understanding of the neurobiology of pain will promote development of new therapeutic strategies.

Physiotherapeutic assessment and management of chronic pelvic pain syndrome: A case report.

INTRODUCTION: Chronic pelvic pain syndrome is difficult for the diagnosis and therapy and that means the patient attending the physician or physiotherapist may present various symptoms. There are no guidelines concern physiotherapy diagnosis and treatment of chronic pelvic pain syndrome. This study presents the physiotherapeutic assessment and management in men with pelvic pain symptoms. PATIENT CONCERNS: Forty-six-year-old man attended the physiotherapy consulting room due to symptoms of pain in the perineum, lower abdomen, urethra, and scrotum for a year. Earlier, the patient had consulted a urologist who made a diagnosis of cystitis and prescribed medications that did not get results. DIAGNOSIS: Ultrasound imaging and manual inspection (per rectum) of the pelvic floor was conducted by physiotherapist. Also, the abdominal and lower extremities muscles were assessed. Patient reported pain symptoms during examination of the musculus ischiocavernosus, puboanalis, pubococcygeus, iliococcygeus, coccygeus, and canalis pudentalis seu Alcocki. INTERVENTIONS: The patient was given physiotherapeutic interventions consisting in the manual therapy of the lumbopelvic hip complex and the manual therapy per rectum. OUTCOMES: During 10th session of the physiotherapeutic treatment, patient reported improvement in pain symptoms. A month later, patient reported total alleviation of the pain symptoms during control visit. CONCLUSION: Therapy of chronic pelvic pain syndrome is a process that involves application of different therapies and different approaches. Functional and structural assessment and also therapy conducted by physiotherapist is becoming an integral part of urology and represents 1 possible conservative treatment form.

When Do We Not Face Our Fears? Investigating the Boundary Conditions of Costly Pain-Related Avoidance Generalization.

Excessive generalization of fear and avoidance are hallmark symptoms of chronic pain disability, yet research focusing on the mechanisms underlying generalization of avoidance specifically, is scarce. Two experiments investigated the boundary conditions of costly pain-related avoidance generalization in healthy participants who learned to avoid pain by performing increasingly effortful (in terms of deviation and force) arm-movements using a robot-arm (acquisition). During generalization, novel, but similar arm-movements, without pain, were tested. Experiment 1 (N = 64) aimed to facilitate generalization to these movements by reducing visual contextual changes between acquisition and generalization, whereas Experiment 2 (N = 70) aimed to prevent extinction by increasing pain uncertainty. Both experiments showed generalization of pain-expectancies and pain-related fear. However, Experiment 2 was the first and only to also demonstrate generalization of avoidance, ie, choosing the novel effortful arm-movements in the absence of pain. These results suggest that uncertainty about the occurrence of pain may delay recovery, due to reduced disconfirmation of threat beliefs when exploring, resulting in persistent avoidance. PERSPECTIVE: This article demonstrates generalization of instrumentally acquired costly pain-related avoidance in healthy people under conditions of uncertainty. The results suggest that targeting pain-related uncertainty may be a useful tool for clinicians adopting a psychological approach to treating excessive pain-related avoidance in chronic pain.

Risk Factors Associated With Transition From Acute to Chronic Low Back Pain in US Patients Seeking Primary Care.

Importance: Acute low back pain (LBP) is highly prevalent, with a presumed favorable prognosis; however, once chronic, LBP becomes a disabling and expensive condition. Acute to chronic LBP transition rates vary widely owing to absence of standardized operational definitions, and it is unknown whether a standardized prognostic tool (ie, Subgroups for Targeted Treatment Back tool [SBT]) can estimate this transition or whether early non-guideline concordant treatment is associated with the transition to chronic LBP. Objective: To assess the associations between the transition from acute to chronic LBP with SBT risk strata; demographic, clinical, and practice characteristics; and guideline nonconcordant processes of care. Design, Setting, and Participants: This inception cohort study was conducted alongside a multisite, pragmatic cluster randomized trial. Adult patients with acute LBP stratified by SBT risk were enrolled in 77 primary care practices in 4 regions across the United States between May 2016 and June 2018 and followed up for 6 months, with final follow-up completed by March 2019. Data analysis was conducted from January to March 2020. Exposures: SBT risk strata and early LBP guideline nonconcordant processes of care (eg, receipt of opioids, imaging, and subspecialty referral). Main Outcomes and Measures: Transition from acute to chronic LBP at 6 months using the National Institutes of Health Task Force on Research Standards consensus definition of chronic LBP. Patient demographic characteristics, clinical factors, and LBP process of care were obtained via electronic medical records. Results: Overall, 5233 patients with acute LBP (3029 [58%] women; 4353 [83%] White individuals; mean [SD] age 50.6 [16.9] years; 1788 [34%] low risk; 2152 [41%] medium risk; and 1293 [25%] high risk) were included. Overall transition rate to chronic LBP at six months was 32% (1666 patients). In a multivariable model, SBT risk stratum was positively associated with transition to chronic LBP (eg, high-risk vs low-risk groups: adjusted odds ratio [aOR], 2.45; 95% CI, 2.00-2.98; P < .001). Patient and clinical characteristics associated with transition to chronic LBP included obesity (aOR, 1.52; 95% CI, 1.28-1.80; P < .001); smoking (aOR, 1.56; 95% CI, 1.29-1.89; P < .001); severe and very severe baseline disability (aOR, 1.82; 95% CI, 1.48-2.24; P < .001 and aOR, 2.08; 95% CI, 1.60-2.68; P < .001, respectively) and diagnosed depression/anxiety (aOR, 1.66; 95% CI, 1.28-2.15; P < .001). After controlling for all other variables, patients exposed to 1, 2, or 3 nonconcordant processes of care within the first 21 days were 1.39 (95% CI, 1.21-2.32), 1.88 (95% CI, 1.53-2.32), and 2.16 (95% CI, 1.10-4.25) times more likely to develop chronic LBP compared with those with no exposure (P < .001). Conclusions and Relevance: In this cohort study, the transition rate to chronic LBP was substantial and increased correspondingly with SBT stratum and early exposure to guideline nonconcordant care.

The Early Impact of COVID-19 on Chronic Pain: A Cross-Sectional Investigation of a Large Online Sample of Individuals with Chronic Pain in the United States, April to May, 2020.

OBJECTIVE: Individuals with chronic pain are uniquely challenged by the COVID-19 pandemic, as increased stress may exacerbate chronic pain, and there are new barriers to receiving chronic pain treatment. In light of this, using a large online sample in the United States, we examined 1) the early impact of COVID-19 on pain severity, pain interference, and chronic pain management; and 2) variables associated with perceived changes in pain severity and pain interference. DESIGN: A cross-sectional study. METHODS: Online survey data for 1,453 adults with chronic pain were collected via Amazon's Mechanical Turk platform. RESULTS: Although a large proportion of participants reported no perceived changes in their pain severity and pain interference since the outbreak, approximately 25-30% of individuals reported exacerbation in these domains. Individuals identifying as Black and of non-Hispanic origin, who experienced greater disruptions in their mood and sleep quality, were more likely to report worsened pain interference. The majority of participants reported engaging in self-management strategies as usual. However, most appointments for chronic pain treatment were either postponed or canceled, with no future session scheduled. Furthermore, a notable proportion of participants had concerns about or difficulty accessing prescription opioids due to COVID-19. CONCLUSIONS: We may expect to see a long-term exacerbation of chronic pain and related interference in functioning and chronic pain management among individuals most impacted by the pandemic. These individuals may benefit from remotely delivered intervention to effectively mitigate COVID-19-related exacerbations in chronic pain and interruptions in face-to-face treatment.

Objective assessment of chronic pain in donkeys using the donkey chronic pain scale (DCPS): A scale-construction study.

Assessment of chronic pain is very important for monitoring and improving welfare and quality of life in donkeys. Freedom from disease and pain is one of the 'five freedoms' underlying animal welfare. The aim of the current study was to develop a pain scale for assessment of chronic pain in donkeys (Donkey Chronic Pain Scale; DCPS), including behavioural and facial expression-related parameters. The scale was applied to 77 donkeys (38 donkeys diagnosed with chronic health problems by means of clinical examination and additional diagnostic procedures and 39 healthy control animals). Animals were assessed twice daily for three consecutive days by two observers that were not masked to the condition of the animals but were unaware of the analgesic treatment regimens. Both composite, facial expression-based and combined DCPS pain scales showed excellent inter-observer reliability (Cronbach's alpha = 0.98, 0.96 and 0.98 respectively; P < 0.001). Individual composite and facial expression-based pain scores and the resulting combined DCPS showed significant differences between donkeys with chronic conditions and control donkeys at all time points (P < 0.001). A DCPS cut-off of 6 showed good sensitivity and specificity (92% and 82.5% respectively) for presence of a chronic painful condition. Facial expression-related parameters separately showed low sensitivity. In conclusion, it is possible to use a composite pain scale for assessment of chronic pain in donkeys, based on behavioural and facial expression-based parameters. Further studies are needed to validate this pain scale before it can be used in veterinary practice.

Assessment of aerobic fitness in individuals with and without nonspecific chronic low back pain: a pilot study.

Aerobic fitness assessment in patients with low back pain (LBP) may help clinicians to plan how to progress the aerobic training. This was a pilot study designed to evaluate the performance of people with LBP on two different aerobic fitness tests performed on a treadmill and to compare the measure of aerobic fitness between people with LBP and healthy individuals. Ten people with LBP and 10 healthy individuals underwent two aerobic fitness protocols, the modified Bruce and maximum incremental test protocols, performed on a treadmill. Data collected during the protocols were: oxygen consumption, heart rate (HR), blood lactate concentration, respiratory quotient, rating of perceived exertion response, and pain intensity. Independent t-test and two-way analysis of variance were used respectively to assess difference between groups characteristics and physiological responses to the protocols. Our results showed that both groups were similar with regards to age (P = 0.839) or HRrest (P = 0.730) but the LBP group showed higher BMI compared to the healthy group (P = 0.031). Regarding the performance of both groups on the aerobic fitness tests, the only significant difference was reported for respiratory quotient which showed a main effect of test (P = 0.015) with higher values favoring the modified Bruce over the incremental test. Our study showed that most people with LBP are able to perform and tolerate both aerobic fitness tests but no significant differences between people with LBP and healthy individuals on both protocols were reported.

Efficacy of pregabalin as a monotherapy versus combined pregabalin and milnacipran in the management of fibromyalgia.

AIM: To compare the efficacy and tolerability of combined pregabalin (PGB) and milnacipran (MLN) in female patients with fibromyalgia (FM) versus PGB as a monotherapy. METHODS: The present randomized open study included 58 female patients diagnosed with FM (registered on 4/2/19: NCT03905486). Patients were randomly divided into 2 groups (2:2); group 1 included 29 patients who received PGB monotherapy (150 mg twice daily) and group 2 included 29 patients who received combined PGB (150 mg twice daily) and MLN (50 mg twice daily) for 3 months. At the initial visit, patients were subjected to demographic data collection and assessed by the visual analog scale (VAS) for pain and the FM impact questionnaire (FIQ). Outcome measures after 3 months: FIQ, VAS and Leeds Sleep Evaluation Questionnaire. RESULTS: The median disease duration was 2 years in group 1 (6 months to 5 years) and 2 years in group 2 (6 months to 12 years). The dropout rate was 20.7% in group 1 (n = 6) and 10.3% in group 2 (n = 3). At the follow-up evaluation, a statistically significant improvement was observed in VAS and FIQ scores in both groups (P < 0.001). Although the percentage of patients demonstrating significant improvement in pain, disease impact and sleep pattern were higher in group 2, this did not reach statistical significance. CONCLUSION: Although PGB as a monotherapy and in combination with MLN have both shown adequate efficacy in the treatment of patients with FM, the combined therapy did not demonstrate superiority over the monotherapy.

The effect of endometriosis on sexual function as assessed with the Female Sexual Function Index: systematic review and meta-analysis.

AIM: To systematically compare sexual function between non-treated women with and without endometriosis. METHODS: A systematic review was performed on PubMed/Medline, Scopus, EMBASE, Web of Science and Cochrane Library databases searching studies that analyzed sexual function (assessed with the 19-item Female Sexual Function Index [FSFI]), and dyspareunia, chronic pelvic pain and dysmenorrhea (assessed with a visual analogue scale [VAS]) in women with and with endometriosis. RESULTS: In 4 studies, non-treated women with endometriosis presented a higher risk of female sexual dysfunction (mean total FSFI score ≤ 26.55; OR = 2.38; 95% confidence interval [CI] = 1.12, 5.04). Although mean total FSFI scores were not significantly different between women with and without endometriosis (mean difference [MD] = -2.15; 95% CI -4.96, 0.67); all FSFI domain scores were significantly lower in women with endometriosis (n = 4 studies): desire (MD = -0.43; 95% CI -0.57, -0.19); arousal (MD = -0.66; 95% CI -1.15, -0.17); lubrication (MD = -0.41; 95% CI -0.79, -0.02); orgasm (MD = -0.40; 95% CI -0.73, -0.06); satisfaction (MD = -0.45; 95% CI -0.72, -0.18); and pain (MD = -1.03; 95% CI -1.34, -0.72). Women with endometriosis displayed differences (more severity) in terms of VAS scores (2 studies) for dyspareunia (MD = 1.88; 95% CI 0.38, 3.37) and chronic pelvic pain (MD = 2.92; 95% CI 1.26, 4.58); but not for dysmenorrhea. CONCLUSION: Non-treated women with endometriosis displayed altered sexual function as evidenced by lower scores in all FSFI domains, and severity of dyspareunia and chronic pelvic pain.