Evaluation of musculoskeletal adverse effects in patients on systemic isotretinoin treatment: A cross-sectional study

Objectives: This study aims to investigate the frequency of musculoskeletal adverse effects in acne vulgaris patients receiving systemic isotretinoin treatment. Patients and methods: Between January 2016 and December 2017, a total of 200 severe acne patients (22 males, 178 females; mean age: 21.8±0.4 years; range, 15 to 53 years) who were on isotretinoin treatment were retrospectively analyzed. Data including age, sex, body mass index (BMI), duration of disease, diagnosis, and comorbidities were recorded. Back pain severity was evaluated with the Visual Analog Scale (VAS). Results: The treatment period was mean 8.5±0.1 (range, 6 to 12) months. The dose of isotretinoin was mean 0.6±0.1 (range, 0.5 and 1) mg/kg. Musculoskeletal side effects were seen in 99 (49.5%) patients. Back pain was reported during the treatment period in 78 (78.7%) patients. The diagnosis was mechanical back pain in 31 (39.7%) and inflammatory back pain in 47 (60.3%) patients. The moderate-severe back pain group received higher cumulative isotretinoin doses than the mild back pain group (p=0.003). The BMI values did not show a significant difference between the patients with and without back pain (p=0.55). There was no significant correlation between the BMI and VAS scores (p=0.06). The VAS scores were found to be correlated with age (p=0.04). Sacroiliitis was diagnosed in four (4%) patients. One (1%) patient was diagnosed with enthesitis. Creatine kinase elevation was reported in 18 (18.1%) patients, while three (3%) patients described myalgia of mild severity. Conclusion: Low back pain is one of the most common musculoskeletal side effects of isotretinoin treatment that usually resolves with dose reduction. The cumulative dose of isotretinoin does not seem to play a role in the development of back pain, but can determine pain severity. Pain severity is directly correlated with the increasing age. Evaluation of the patients for musculoskeletal side effects during isotretinoin use is important in clinical practice, as it is a common occurrence.

Evaluation of hematological parameters related to systemic inflammation in acute and subacute/chronic low back pain

Aim: To compare the hematological parameters associated with systemic inflammation between acute and subacute/chronic nonspecific low back pain and to evaluate their diagnostic roles in relation to chronicity in low back pain. Materials & methods: This retrospective case–control study included 150 participants aged 18–65 years with acute nonspecific low back pain, 150 with subacute/chronic nonspecific low back pain, 150 as the control group. Results: Red cell distribution width was significantly higher in the subacute/chronic pain group compared with the acute pain group (p = 0.003), and had a poor diagnostic value for chronicity (Cutoff: 11.95, p = 0.003). There were no significant differences in terms of other parameters (p > 0.05). Conclusion: Red cell distribution width has a poor diagnostic value for chronicity in nonspecific low back pain.

Risk factors for shoulder pain after stroke: A clinical study

Objectives: To investigate the risk factors for shoulder pain after stroke, and prevent its occurrence effectively. Methods: The patients with stroke treated in our hospital between September 2016 and October 2020 were reviewed retrospectively. The medical records of the included patients including age, gender, lesion side, stroke duration, hospital stay, diabetes, hypertension, heart disease, limitation of shoulder joint activity, alcohol abuse, smoking, type of stroke, Ashworth scale, Brunnstrom stage, sensory disorders, and motor arm score of National Institutes of Health Stroke Scale (NIHSS) were collected and analyzed to determine the risk factors for shoulder pain after stroke. Results: A total of 1390 patients were included based on the inclusion and exclusion criteria, consisting of 162 patients with shoulder pain after stroke and the prevalence was 11.6%. The included patients were divided into shoulder pain group and non-shoulder pain group. There were significant differences in age, stroke duration, hospital stay, diabetes, limitation of shoulder joint activity, Ashworth scale, Brunnstrom stage, sensory disorders, and motor arm score of NIHSS between the two groups (P < 0.05). Based on the multivariate regression analysis, the independent risk factors for shoulder pain after stroke included diabetes, limited shoulder joint activity, Brunnstrom grade I-III period, Ashworth 3-4 grade, motor arm score of NIHSS 3-4 points, and sensory disturbance. Conclusion: Great emphasis should be placed on the stroke patients with diabetes, limited shoulder joint activity, Brunnstrom grade I-III period, Ashworth 3-4 grade, motor arm score of NIHSS 3-4 points, or sensory disturbance, as these patients have higher risks for shoulder pain after stroke. doi: https://doi.org/10.12669/pjms.38.1.4594 How to cite this:Hao N, Zhang M, Li Y, Guo Y. Risk factors for shoulder pain after stroke: A clinical study. Pak J Med Sci. 2022;38(1):---------. doi: https://doi.org/10.12669/pjms.38.1.4594 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Brain Networks With Modified Connectivity in Patients With Neuropathic Pain and Spinal Cord Injury

Background. Neuropathic pain (NP) following spinal cord injury (SCI) affects the quality of life of almost 40% of the injured population. The modified brain connectivity was reported under different NP conditions. Therefore, brain connectivity was studied in the SCI population with and without NP with the aim to identify networks that are altered due to injury, pain, or both. Methods. The study cohort is classified into 3 groups, SCI patients with NP, SCI patients without NP, and able-bodied. EEG of each participant was recorded during motor imagery (MI) of paralyzed and painful, and nonparalyzed and nonpainful limbs. Phased locked value was calculated using Hilbert transform to study altered functional connectivity between different regions. Results. The posterior region connectivity with frontal, fronto-central, and temporal regions is strongly decreased mainly during MI of dominant upper limb (nonparalyzed and nonpainful limbs) in SCI no pain group. This modified connectivity is prominent in the alpha and high-frequency bands (beta and gamma). Moreover, oscillatory modified global connectivity is observed in the pain group during MI of painful and paralyzed limb which is more evident between fronto-posterior, frontocentral-posterior, and within posterior and within frontal regions in the theta and SMR frequency bands. Cluster coefficient and local efficiency values are reduced in patients with no reported pain group while increased in the PWP group. Conclusion. The altered theta band connectivity found in the fronto-parietal network along with a global increase in local efficiency is a consequence of pain only, while altered connectivity in the beta and gamma bands along with a decrease in cluster coefficient values observed in the sensory-motor network is dominantly a consequence of injury only. The outcomes of this study may be used as a potential diagnostic biomarker for the NP. Further, the expected insight holds great clinical relevance in the design of neurofeedback-based neurorehabilitation and connectivity-based brain–computer interfaces for SCI patients.

Prevalence and Role of Psychiatric Conditions in Patients Diagnosed with Anterior Knee Pain (192)

Objectives: Anterior knee pain is a common musculoskeletal complaint with a multifactorial etiology. Psychiatric conditions may play a significant role in both the evolution of anterior knee pain and recovery from it. This retrospective, matched case-control study evaluates the prevalence of psychologic conditions in patients with anterior knee pain to assess their role as a potential contributor. Methods: 126 patients with anterior knee pain were retrospectively identified using ICD-10 codes and were individually matched to controls based on gender, age, and BMI. Patient demographics, surgical history, medications, and prior or current diagnoses related to musculoskeletal or psychiatric health were recorded. Demographic data between the anterior knee pain group and controls were evaluated using independent t-tests. Differences between the matched pairs related to psychiatric conditions and medication usage were evaluated using a McNemar Test. A subgroup analysis was also performed and defined by gender, age greater than or less than 35, and BMI greater than or less than 25. Results: Evaluation of demographic data between the anterior knee pain group and controls showed no difference with regards to age, gender, and BMI (p>0.05). Analysis of the 126 matched pairs demonstrated similar rates of psychiatric conditions and medication usage between the anterior knee pain group (23 patients, 18.3%) and the control group (18 patients, 14.3%). Statistically, there was no difference between the two groups (p = 0.472). A subgroup analysis also demonstrated no difference between the anterior knee pain group and controls when stratified by gender (Male [p = 0.80]; Female [p = 0.12]), age (< 35 [p = 1.00]; > 35 [p = 0.50]), and BMI (< 25 [p = 0.10]; > 25 [p = 0.82]). Conclusions: There was no difference in the prevalence of psychiatric conditions between patients with anterior knee pain and their controls. This suggests a low likelihood that the psychologic condition of patients with anterior knee pain differ from that of the general population and implies that psychologic conditions alone are unlikely to play an isolated role in the etiology of anterior knee pain.

Psychometric Evaluation of the Taiwanese Version of the Western Ontario Rotator Cuff Index

Background: The Western Ontario Rotator Cuff (WORC) index is a self-report questionnaire that measures the disease-specific quality of life in patients with rotator cuff injuries. The aim of this study was to evaluate the psychometric properties of the Taiwanese version of WORC (T-WORC) in patients with rotator cuff tear (RCT) before surgery. Methods: A cross-sectional study design was used. The study was composed of two phases: translation of the WORC into Taiwanese version of WORC, and 210 patients with rotator cuff tear before surgery completed the questionnaire twice within 2 weeks. The main outcome measures included reliability and validity. Reliability was assessed with internal consistency and test-retest. Internal consistency was assessed using the Cronbach’s alpha and test-retest reliability was assessed using the intraclass correlation coefficient (ICC). Construct validity was evaluated by examining convergent, divergent, known-group validity, and exploratory factor analysis (EFA). Results: The T-WORC demonstrated satisfactory reliability with the Cronbach's alpha of .94, and ICC (2 week-interval) of .79. The convergent validity showed that the T-WORC was significantly positively correlated with the disability of the arm, shoulder, and hand and numerical rating scales of pain, but negatively correlated with the Short Form-12. The divergent validity was shown by the low correlation between T-WORC and state anger scale. The known-group validity showed a significant difference between the high pain group and the low pain group. The EFA revealed 4 factors, daily activities and function, physical symptoms, emotion, and shoulder clicking and recreation, which explained 66.13 % of the variance. Conclusions: The findings of this study did not support the 5-domain structure proposed by the original version. Nevertheless, the T-WORC still demonstrated adequate psychometric properties and could be a useful instrument for assessing the RCT patients' quality of life before surgery.

Plasma inflammatory cytokines and treatment-resistant depression with comorbid pain: improvement by ketamine

Background Treatment-resistant depression (TRD) and pain frequently coexist clinically. Ketamine has analgesic and antidepressant effects, but few studies have evaluated individual differences in antidepressant outcomes to repeated ketamine in TRD patients with comorbid pain. Our aims were to determine the difference in ketamine’s antidepressant effects in TRD patients with or without pain and then to examine whether inflammatory cytokines might contribute to ketamine’s effect. Methods Sixty-six patients with TRD received six infusions of ketamine. Plasma levels of 19 inflammatory cytokines were assessed at baseline and post-infusion (day 13 and day 26) using the Luminex assay. Plasma inflammatory cytokines of sixty healthy controls (HCs) were also examined. Results TRD patients with pain had a higher antidepressant response rate (χ2 = 4.062, P = 0.044) and remission rate (χ2 = 4.062, P = 0.044) than patients without pain. Before ketamine treatment, GM-CSF and IL-6 levels were higher in the pain group than in the non-pain and HC groups. In the pain group, levels of TNF-α and IL-6 at day 13 and GM-CSF, fractalkine, IFN-γ, IL-10, MIP-3α, IL-12P70, IL-17α, IL-1β, IL-2, IL-4, IL-23, IL-5, IL-6, IL-7, MIP-1β, and TNF-α at day 26 were lower than those at baseline; in the non-pain group, TNF-α levels at day 13 and day 26 were lower than those at baseline. In the pain group, the changes of IL-6 were associated with improvement in pain intensity (β = 0.333, P = 0.001) and depressive symptoms (β = 0.478, P = 0.005) at day 13. Path analysis showed the direct (β = 2.995, P = 0.028) and indirect (β = 0.867, P = 0.042) effects of changes of IL-6 on improvement in depressive symptoms both were statistically significant. Conclusion This study suggested that an elevated inflammatory response plays a critical role in individual differences in TRD patients with or without pain. Ketamine showed great antidepressant and analgesic effects in TRD patients with pain, which may be related to its effects on modulating inflammation. Trial registration ChiCTR, ChiCTR-OOC-17012239. Registered on 26 May 2017

Comparison of Sleep Quality Deterioration by Subgroup of Painful Temporomandibular Disorder Based on Diagnostic Criteria for Temporomandibular Disorders

This study investigated whether sleep deterioration in patients with painful temporomandibular disorder depends on the origin of pain, and also analyzed which clinical disease characteristics and whether psychological distress affected sleep quality. A total of 337 consecutive patients (215 women; mean age, 33.01 ± 13.01 years) with painful temporomandibular disorder (myalgia [n = 120], temporomandibular joint arthralgia [n = 62], mixed joint–muscle temporomandibular disorder pain [n = 155]) based on the diagnostic criteria for temporomandibular disorder were enrolled. They completed a battery of standardized reports on clinical sign and symptoms, and answered questions on sleep quality, excessive daytime sleepiness, and patients’ psychological status. The mean global Pittsburgh Sleep Quality Index scores were significantly higher in the mixed temporomandibular disorder pain group (6.97 ± 3.38) and myalgia group (6.40 ± 3.22) than in the arthralgia group (5.16 ± 2.94) (p = 0.001). Poor sleepers were significantly more prevalent in the mixed temporomandibular disorder pain group (76.8%) and myalgia group (71.7%) than in the arthralgia group (54.8%) (p = 0.006). The presence of psychological distress in the myalgia group (β = 1.236, p = 0.022), global severity index of the Symptom Checklist-90-Revised in the arthralgia group (β = 1.668, p = 0.008), and presence of headache (β = 1.631, p = 0.002) and self-reported sleep problems (β = 2.849, p < 0.001) in the mixed temporomandibular disorder pain group were associated with an increase in the Pittsburgh Sleep Quality Index score. Because there is a difference in sleep quality and influencing factors according to the pain source of painful temporomandibular disorder, and the complex interplay between sleep and pain can vary, sophisticated treatment is required for patients.

Shoulder Range of Motion Deficits in Youth Throwers Presenting With Elbow Pain

Background: Glenohumeral internal rotation deficit (GIRD) and total arc of motion difference (TAMD) have been associated with elbow injuries in throwing athletes. Hypothesis: Youth pitchers with elbow pain will have greater GIRD and TAMD compared with youth pitchers without elbow pain. Study Design: Cross-sectional study. Level of Evidence: Level 3. Methods: Glenohumeral range of motion of 25 consecutive throwing athletes presenting with elbow pain and that of a matched control group of 18 asymptomatic throwing athletes were compared. Bilateral glenohumeral internal rotation, external rotation, and horizontal adduction at 90° were measured and GIRD and TAMD were then calculated. An analysis of variance was performed to compare range of motion between throwers with and without elbow pain. Results: The average GIRD of the elbow pain group was 32.7° compared with 14.5° in the control group ( P < 0.05). The average TAMD in the elbow pain group was 28.3° compared with 6.7° in the control group ( P < 0.05). GIRD and TAMD were present in 88% (22 of 25) and 96% (24 of 25) of the elbow pain group versus 33.3% (6 of 18) and 55.6% (10 of 18) of the control group, respectively. Conclusion: Compared with asymptomatic youth pitchers, those presenting with elbow pain have a statistically significant GIRD and TAMD. Clinical Relevance: This study suggests that a GIRD and TAMD may predispose youth pitchers to present with symptomatic elbow pain.