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    "고립된 반복적 국소 등 열감이 위험신호, 비의뢰 특징, 양성 또는 진단이라는 주장.",
    "완전하거나 서열화한 감별진단 또는 경쟁 안전 갈래의 완전한 대표성.",
    "목표 표현형의 진단정확도, 유병률, 예후, 인과기전, 치료효과 또는 비교 안전성.",
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    "보편적 의뢰 규칙, 한국 시행 경로, 응급 연락, 서비스 구성, 영상 적응증 또는 개인별 의학 조언.",
    "자발 감각, 유발검사, 객관적 온도, 한국어 표현, 영어 표현과 역사 용어 사이의 동등성.",
    "확보하지 못한 전문 또는 보충자료의 세부나 보고된 분모 충돌의 해결.",
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    "shared-cluster bilingual exit reconciliation 또는 bilingual-package 단계 완료."
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          "analyticParaphrase": "The guideline also names constrained non-referral or reassurance contexts: recurrent numbness or tingling in an adult already diagnosed with functional neurological disorder by a specialist when there are no new neurological signs; outer-thigh symptoms in the lateral cutaneous nerve distribution, with pain referral considered only if severe; and limb tingling or sensory disturbance on waking that lasts under 10 minutes, attributed in the rationale to sleeping-posture compression.",
          "allowableUse": "Demonstrate that a known diagnosis, absence of new signs, precise distribution, trigger, duration, and severity can support non-referral decisions.",
          "notSupported": "General reassurance for undiagnosed back burning or transfer of these narrowly specified contexts to other anatomy or timing."
        },
        {
          "passageId": "PV-NG127-URGENCY-DEFINITIONS",
          "locator": {
            "pdfPage": 49,
            "section": "Terms used in this guideline"
          },
          "evidenceLayer": "guideline-definition",
          "analyticParaphrase": "Within NG127, immediate referral means specialist assessment within hours or faster if needed; urgent referral means within two weeks; unqualified referral and consideration of referral denote routine referral.",
          "allowableUse": "Interpret NG127's urgency verbs according to its own definitions.",
          "notSupported": "Assuming the same time definitions govern other jurisdictions or unrelated guidelines."
        },
        {
          "passageId": "PV-NG127-EVIDENCE-BASIS",
          "locator": {
            "adultPdfPages": [
              60,
              61
            ],
            "childPdfPages": [
              77,
              78
            ],
            "sections": [
              "Rationale — Sensory symptoms including tingling or numbness in adults",
              "Rationale — Sensory symptoms such as tingling or numbness in children"
            ]
          },
          "evidenceLayer": "guideline-rationale-and-evidence-limit",
          "analyticParaphrase": "For both adult and child sensory-symptom sections, NICE states that the committee developed recommendations from its knowledge and experience and that reviewed evidence yielded nothing able to support recommendations. The rationales then explain the clinical reasoning behind specific patterns; these are consensus safety boundaries, not estimates from a directly supportive evidence base.",
          "allowableUse": "Qualify the authority and evidentiary basis of the sensory redirection rules.",
          "notSupported": "Diagnostic-accuracy estimates, prevalence, causal inference, or a claim that trials or comparative studies validated these sensory patterns."
        },
        {
          "passageId": "PV-NG127-CHILD-POPULATION-DISTINCTION",
          "locator": {
            "recommendations": [
              "1.27.1",
              "1.27.2",
              "1.27.3",
              "1.27.4",
              "1.27.5"
            ],
            "pdfPage": 42,
            "rationalePdfPages": [
              77,
              78
            ],
            "section": "Sensory symptoms such as tingling or numbness in children"
          },
          "evidenceLayer": "guideline-recommendation-and-rationale",
          "analyticParaphrase": "For children, tingling with weakness or bladder or bowel dysfunction, or with motor-impairment features suggesting acute polyneuropathy, prompts urgent assessment. Episodic isolated tingling, altered sensation, or paraesthesia is referred when it is not linked to nerve compression. Temporary symptoms clearly triggered by compression activities are not routinely referred, and transient limb tingling may also follow hyperventilation.",
          "allowableUse": "Keep paediatric thresholds separate and show how associated findings and a clear provocation alter disposition.",
          "notSupported": "Transferring paediatric episodic-sensation recommendations to adults or treating a child's isolated recurrent back-heat descriptor as equivalent to tingling or paraesthesia."
        },
        {
          "passageId": "PV-NG127-THERMAL-NONFINDING",
          "locator": {
            "scope": "Entire 86-page PDF",
            "searchTerms": [
              "back heat",
              "localized heat",
              "localized warmth",
              "warmth",
              "burning",
              "skin temperature",
              "temperature"
            ]
          },
          "evidenceLayer": "structured-negative-finding",
          "analyticParaphrase": "Targeted full-document searches found no passage naming back heat, localized heat or warmth, burning, skin temperature, or temperature as a recognition or referral criterion. Relevant recommendations instead use numbness, tingling, altered sensation, pain, anatomical distribution, tempo, triggers, reflexes, weakness, imbalance, function, and bladder, bowel, sexual, or perineal findings.",
          "allowableUse": "Record that this guideline does not establish isolated recurrent localized back heat as a neurological redirect and identify the dimensions it actually uses.",
          "notSupported": "Proof that isolated back heat is benign, proof that no neurological condition can present with heat or burning, or a claim about all guidelines or evidence."
        }
      ],
      "interpretation": {
        "evidenceRole": "Authoritative but indirect safety-boundary source.",
        "clusterUse": "NG127 can support a discriminating safety framework based on exact population, onset and progression, distribution, provocation, neurological examination, associated functions, severity, and disability. It cannot turn the focal thermal complaint itself into a red flag.",
        "safetyBoundary": "Any later redirect language must reproduce the relevant constellation and urgency faithfully. The absence of a thermal criterion is a source-specific non-finding, not reassurance or exclusion of disease."
      },
      "claimsNotEstablished": [
        "Isolated recurrent heat or burning confined to the back is an urgent or routine neurological referral criterion.",
        "Back heat is equivalent to numbness, tingling, paraesthesia, radiculopathy, neuropathy, myelopathy, epilepsy, or cauda equina syndrome.",
        "Any named sensory pattern has established diagnostic accuracy, prevalence, causal meaning, or predictive value.",
        "Absence of NG127 thermal wording establishes benignity or rules out neurological disease.",
        "Adult and child thresholds are interchangeable.",
        "The guideline evaluates objective skin temperature, deep temperature, spontaneous warmth, burning quality, or subjective-objective thermal discordance."
      ],
      "unresolvedBlockers": [
        "T1-SAFETY-NG234 remains passage-unverified, so the safety-redirect gate cannot yet close.",
        "The companion NG127 full evidence document was not part of this frozen Tier 1 acquisition. The current guideline's own rationale explicitly records no evidence capable of supporting the adult or child sensory recommendations; this unit does not independently reconstruct every evidence review question.",
        "NG127 is UK guidance and does not by itself establish Korean care pathways, service availability, or jurisdiction-specific urgency implementation."
      ],
      "verificationDecision": "verified-for-qualified-pattern-specific-safety-boundaries-and-source-specific-negative-finding",
      "nextWorkUnit": "Verify T1-SAFETY-NG234 as one bounded passage-verification unit from the frozen official guideline PDF, focusing on exact cancer-population qualifiers, spinal pain patterns, neurological signs, urgency, exceptions, evidence basis, and transfer limits to isolated recurrent back heat."
    },
    {
      "artifact": "passage-verification-t1-safety-ng234.json",
      "schemaVersion": 1,
      "clusterId": "BRC-CL-2026-001",
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        "kind": "shared-cluster"
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      "candidate": {
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        "familyId": "NICE-NG234",
        "reference": "NG234",
        "title": "Spinal metastases and metastatic spinal cord compression",
        "eligibilityDecision": "include-as-authoritative-indirect-safety-and-redirection-boundary",
        "eligibilityReason": "The current official guideline gives cancer-context, pain-pattern, neurological-sign, urgency, imaging, and negative-screening boundaries for spinal metastases and metastatic spinal cord compression. It does not address recurrent heat or burning confined to the back, and heat quality alone is not a listed recognition factor."
      },
      "sourceVerification": {
        "guideline": {
          "locator": "https://www.nice.org.uk/guidance/ng234/resources/spinal-metastases-and-metastatic-spinal-cord-compression-pdf-66143896133317",
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          "verifiedAt": "2026-08-14T01:35:30Z",
          "versionState": "The frozen official NG234 page records publication on 2023-09-06 and review on 2026-03-19, and states that NG234 updates and replaces CG75. The PDF title, subject, keyword, author, and reference identify NG234; the rendered footer is © NICE 2026.",
          "identityCheck": "PDF title, subject, keyword, author, reference, page count, byte count, and SHA-256 match the frozen acquisition record."
        },
        "targetedRead": {
          "searchType": "Targeted within-PDF passage verification of the already acquired official guideline; no new bibliographic retrieval, inventory rebuild, or broad pagination.",
          "queryDate": "2026-08-14",
          "queryTermsWithinFullText": [
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            "pain characteristics suggesting spinal metastases",
            "symptoms and signs suggesting cord compression",
            "past or current diagnosis of cancer",
            "suspected diagnosis of cancer",
            "severe unremitting back pain",
            "progressive back pain",
            "mechanical pain",
            "night-time back pain",
            "localised tenderness",
            "radicular pain",
            "numbness",
            "paraesthesia",
            "bladder or bowel dysfunction",
            "gait disturbance",
            "limb weakness",
            "immediately contact",
            "within 24 hours",
            "within 1 week",
            "do not do MRI",
            "back heat",
            "localized heat",
            "localised heat",
            "localized warmth",
            "localised warmth",
            "warmth",
            "burning",
            "skin temperature",
            "temperature"
          ],
          "sectionsRead": [
            "Recommendations 1.3.1-1.3.6 and Box 1: recognising spinal metastases or MSCC",
            "Recommendations 1.5.1-1.5.6: radiologist involvement and MRI assessment",
            "Rationale and impact: recognising spinal metastases or MSCC",
            "Rationale and impact: imaging investigations — radiologist involvement and MRI assessment",
            "Full 77-page document search for thermal wording"
          ]
        }
      },
      "verifiedPassages": [
        {
          "passageId": "PV-NG234-RECOGNITION-FRAME",
          "locator": {
            "recommendation": "1.3.1",
            "box": "Box 1",
            "pdfPages": [
              18,
              19
            ],
            "section": "Recognising spinal metastases or MSCC"
          },
          "evidenceLayer": "guideline-recommendation",
          "analyticParaphrase": "The recognition frame joins three distinct elements: past, current, or suspected cancer; specified back-pain characteristics; and specified symptoms or signs of cord compression. The listed pain patterns are severe unremitting, progressive, mechanical, strain-aggravated, sleep-disturbing nocturnal pain, localised tenderness, or exertional leg claudication. The cord-compression list comprises bladder or bowel dysfunction, gait difficulty, limb weakness, neurological signs of cord or cauda-equina compression, numbness, paraesthesia or sensory loss, and radicular pain.",
          "allowableUse": "Describe the exact cancer, pain-pattern, and neurological dimensions that change concern, without collapsing the three lists or omitting qualifiers.",
          "notSupported": "Treating a vivid sensory adjective, isolated recurrent back heat, or burning without the listed context as evidence of spinal metastases or cord compression."
        },
        {
          "passageId": "PV-NG234-CANCER-CORD-COMPRESSION-EMERGENCY",
          "locator": {
            "recommendation": "1.3.2",
            "pdfPage": 19,
            "rationalePdfPage": 52,
            "section": "Recognising spinal metastases or MSCC"
          },
          "evidenceLayer": "guideline-recommendation-and-rationale",
          "analyticParaphrase": "Immediate contact with the MSCC coordinator and treatment as an oncological emergency apply when a person with a past or current cancer diagnosis presents with a Box 1 symptom or sign of cord compression. The rationale ties immediate action to that combined cancer and neurological constellation and to prevention of instability and neurological harm.",
          "allowableUse": "State the immediate cancer-context redirect only with the past/current cancer qualifier and a named cord-compression symptom or sign.",
          "notSupported": "Immediate oncological referral for isolated back heat, for back pain alone, or for a person without the specified cancer and neurological context."
        },
        {
          "passageId": "PV-NG234-CANCER-PAIN-WITHIN-24-HOURS",
          "locator": {
            "recommendation": "1.3.3",
            "pdfPage": 20,
            "rationalePdfPages": [
              52,
              53
            ],
            "section": "Recognising spinal metastases or MSCC"
          },
          "evidenceLayer": "guideline-recommendation-and-rationale",
          "analyticParaphrase": "For a person with a past or current cancer diagnosis whose pain has a Box 1 characteristic suggesting spinal metastases, NICE directs advice through the MSCC coordinator within 24 hours. This pathway is distinct from the immediate emergency pathway for cord-compression signs.",
          "allowableUse": "Preserve the cancer history, qualifying pain pattern, 24-hour advice route, and distinction from the neurological emergency pathway.",
          "notSupported": "Using any back sensation, any back pain, or heat quality alone to trigger the 24-hour MSCC pathway."
        },
        {
          "passageId": "PV-NG234-SUSPECTED-CANCER-URGENT-ONCOLOGY",
          "locator": {
            "recommendation": "1.3.5",
            "pdfPage": 20,
            "rationalePdfPage": 53,
            "section": "Recognising spinal metastases or MSCC"
          },
          "evidenceLayer": "guideline-recommendation-and-rationale",
          "analyticParaphrase": "For a person without a past or current cancer diagnosis, urgent oncology assessment is directed only when a Box 1 pain characteristic is present and cancer is suspected, with a cross-reference to the separate suspected-cancer guideline.",
          "allowableUse": "State that absence of known cancer does not erase concern when cancer is independently suspected and the specified pain pattern is present.",
          "notSupported": "Inferring suspected cancer from isolated recurrent back heat or from an unqualified burning descriptor."
        },
        {
          "passageId": "PV-NG234-KNOWN-CANCER-NEGATIVE-CLINICAL-EVIDENCE",
          "locator": {
            "recommendation": "1.3.6",
            "pdfPage": 20,
            "rationalePdfPage": 53,
            "section": "Recognising spinal metastases or MSCC"
          },
          "evidenceLayer": "guideline-recommendation-and-rationale",
          "analyticParaphrase": "When a person with past or current cancer has low-back pain but no clinical evidence of spinal metastases or MSCC, for example after previous imaging, the guideline calls for tailored information about Box 1 changes and urgent contact if symptoms change or worsen. It does not treat one prior negative assessment as permanent reassurance.",
          "allowableUse": "Preserve safety-netting, change-over-time, and prior-assessment context.",
          "notSupported": "Claiming that a prior negative image rules out later disease, or applying cancer-specific safety-netting as a generic explanation for back heat."
        },
        {
          "passageId": "PV-NG234-MRI-TIMING-AND-EXCEPTIONS",
          "locator": {
            "recommendations": [
              "1.5.2",
              "1.5.3",
              "1.5.4",
              "1.5.6"
            ],
            "pdfPage": 22,
            "rationalePdfPages": [
              55,
              56,
              57
            ],
            "section": "Imaging investigations — MRI assessment"
          },
          "evidenceLayer": "guideline-recommendation-and-rationale",
          "analyticParaphrase": "Suspected MSCC under recommendation 1.3.2 leads to MRI as soon as possible and always within 24 hours, ordinarily at a local or directly accessible imaging centre. Clinical suspicion of spinal metastases without suspected MSCC under recommendation 1.3.3 leads to MRI within one week to guide treatment. Overnight MRI is reserved for circumstances in which an urgent diagnosis is needed for immediate treatment. Screening MRI solely to detect early cord compression is not recommended for people with diagnosed spinal metastases who lack cord-compression symptoms or signs.",
          "allowableUse": "Show that imaging timing follows a clinically qualified pathway and that the guideline contains explicit limits on transfer, overnight scanning, and asymptomatic screening.",
          "notSupported": "Routine or urgent MRI for isolated recurrent back heat, imaging based on a thermal adjective alone, or use of the one-week timing outside suspected spinal metastases."
        },
        {
          "passageId": "PV-NG234-EVIDENCE-BASIS-AND-UNCERTAINTY",
          "locator": {
            "recognitionRationalePdfPages": [
              52,
              53
            ],
            "imagingRationalePdfPages": [
              55,
              56,
              57
            ],
            "sections": [
              "Rationale — recognising spinal metastases or MSCC",
              "Rationale — imaging investigations"
            ]
          },
          "evidenceLayer": "guideline-rationale-and-evidence-limit",
          "analyticParaphrase": "The recognition recommendations draw on comparative and undiagnosed-cancer symptom evidence together with committee experience; the guideline states that cancer history was a strong indicator in the context of back pain but provides no diagnostic-accuracy estimate in the recommendation PDF. Imaging recommendations draw on a large imaging evidence base plus expertise; the rationale reports that plain radiographs combined with neurological assessment had very low sensitivity, and that a randomized screening-MRI trial in high-risk people did not materially improve major clinical outcomes. These statements support pathway boundaries, not diagnosis from any single symptom.",
          "allowableUse": "Qualify the guideline as authoritative pathway evidence while retaining its evidence layers and the distinction between recognition factors and diagnostic tests.",
          "notSupported": "A sensitivity, specificity, likelihood ratio, prevalence, or causal estimate for any Box 1 factor or for back heat; proof that a listed factor independently diagnoses malignancy."
        },
        {
          "passageId": "PV-NG234-THERMAL-NONFINDING",
          "locator": {
            "scope": "Entire 77-page PDF",
            "searchTerms": [
              "back heat",
              "localized heat",
              "localised heat",
              "localized warmth",
              "localised warmth",
              "warmth",
              "burning",
              "skin temperature",
              "temperature"
            ]
          },
          "evidenceLayer": "structured-negative-finding",
          "analyticParaphrase": "Targeted full-document searches found none of the thermal terms. The recognition pathways use cancer context, named pain characteristics, neurological symptoms and signs, progression, function, and change or worsening rather than heat, warmth, burning, or temperature language.",
          "allowableUse": "Record that NG234 does not establish isolated recurrent localized back heat as a recognition or referral criterion and identify the dimensions it actually uses.",
          "notSupported": "Proof that isolated back heat is benign, proof that malignancy or cord compression cannot include a thermal complaint, or a conclusion about other guidelines or populations."
        }
      ],
      "interpretation": {
        "evidenceRole": "Authoritative but indirect safety-boundary source.",
        "clusterUse": "NG234 supports a discriminating safety framework in which cancer history or suspicion, specific pain behavior, neurological signs, functional change, and tempo determine the next pathway. It cannot convert the focal thermal complaint itself into a metastatic-spine or MSCC signal.",
        "safetyBoundary": "Any later redirect language must reproduce the relevant population, constellation, and timing. The source-specific absence of thermal wording is neither reassurance nor disease exclusion.",
        "relationshipToNG127": "NG234 adds an oncology-specific pathway to NG127's neurological boundaries. The sources should remain complementary and must not be merged into an unqualified generic red-flag list."
      },
      "claimsNotEstablished": [
        "Isolated recurrent heat or burning confined to the back suggests spinal metastases, MSCC, cancer, or cauda-equina compression.",
        "Heat or burning is equivalent to the listed pain characteristics, numbness, paraesthesia, sensory loss, or radicular pain.",
        "Any Box 1 factor independently diagnoses cancer, spinal metastases, instability, or cord compression.",
        "The recommendation PDF supplies diagnostic-accuracy, prevalence, causal, or prognostic estimates for the focal thermal phenotype.",
        "Absence of thermal wording establishes benignity or excludes malignant, neurological, dermatological, vascular, autonomic, or other causes.",
        "NG234 establishes Korean referral logistics, coordinator availability, or jurisdiction-specific timing.",
        "The guideline evaluates objective skin temperature, deep temperature, spontaneous warmth, or subjective-objective thermal discordance."
      ],
      "unresolvedBlockers": [
        "The companion NG234 evidence reviews were not independently reconstructed in this bounded unit; evidence-detail claims must remain limited to what the official recommendation PDF and its rationale state.",
        "NG234 is UK guidance and does not by itself establish Korean care pathways, MSCC-coordinator access, service configuration, or jurisdiction-specific implementation.",
        "Two frozen Tier 1 research candidates remain passage-unverified: T1-QST-SR-23711482 and T1-NP-COMPARATOR-28902951."
      ],
      "verificationDecision": "verified-for-qualified-cancer-and-cord-compression-safety-boundaries-and-source-specific-thermal-negative-finding",
      "nextWorkUnit": "Verify T1-QST-SR-23711482 as one bounded passage-verification unit from the frozen abstract and lawful-access state, focusing on thermal-QST subgroups, pooled associations with pain or disability, heterogeneity, sparse outcomes, and claims that remain unavailable without full text."
    },
    {
      "artifact": "passage-verification-t1-descriptor-sr-32609541.json",
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        "pmcid": null,
        "doi": "10.1080/03007995.2020.1790349",
        "title": "Sensory descriptors which identify neuropathic pain mechanisms in low back pain: a systematic review.",
        "eligibilityDecision": "include-as-indirect-descriptor-validity-and-counterevidence-source",
        "eligibilityReason": "The review directly asks whether subjective pain descriptors distinguish neuropathic from nociceptive low-back pain and preserves conflicting evidence for temperature-related descriptors. Its population has low-back pain, often with referred leg pain, rather than recurrent focal subjective back heat, and its mechanism classifications do not establish temperature, diagnosis, or cause."
      },
      "sourceVerification": {
        "acceptedManuscript": {
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          "accessHistory": "The retrieval-stage publisher route returned HTTP 403 and was not bypassed. This later claim-specific check found a lawful public author-affiliated repository copy, superseding the earlier unresolved full-text state without overwriting that historical access record."
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        },
        "targetedRead": {
          "searchType": "Claim-specific search for a lawful full text, followed by targeted full-manuscript section and table verification; no broad retrieval or ranked pagination.",
          "exactQueries": [
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          "queryTermsWithinFullText": [
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            "hot",
            "burning",
            "cold",
            "thermal hyperalgesia",
            "heterogeneity",
            "common method bias",
            "gold standard",
            "limitations"
          ],
          "sectionsRead": [
            "Abstract",
            "Methods: search strategy, eligibility, selection and extraction, synthesis, and risk of bias",
            "Results: study selection, risk of bias, study characteristics, and temperature pain",
            "Discussion: summary, equivocal evidence, data-gathering methods, and reference standards",
            "Relevance to practice",
            "Strengths and limitations",
            "Conclusion",
            "Tables 2-4"
          ]
        }
      },
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          "passageId": "PV-32609541-ELIGIBILITY",
          "locator": {
            "section": "Methods — Eligibility Criteria",
            "acceptedManuscriptPages": [
              5,
              6
            ]
          },
          "evidenceLayer": "review-method",
          "analyticParaphrase": "Eligible studies had to collect verbal symptom descriptors from people with neuropathic low-back pain, with or without spinally referred leg pain; provide descriptor analyses or analysable data; and use a reference test to distinguish neuropathic from other pain mechanisms. Questionnaire-based reference tests were accepted. Eligible designs included diagnostic-accuracy-appropriate cohort, cross-sectional, longitudinal, Delphi, and case-series studies; animal studies, certain serious or specific spinal populations without a confirmed neuropathic mechanism, and studies lacking a neuropathic-pain reference test were excluded.",
          "allowableUse": "Define the review's population, descriptor source, and permissive reference-standard rule.",
          "notSupported": "Eligibility for isolated recurrent focal back heat, a requirement for objective thermal measurement, or use of a uniform neurological reference standard."
        },
        {
          "passageId": "PV-32609541-EVIDENCE-BASE",
          "locator": {
            "section": "Results — Study Selection and Study Characteristics",
            "acceptedManuscriptPages": [
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              8
            ]
          },
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          "analyticParaphrase": "The review assessed 94 full texts and included eight studies encompassing 3,099 participants classified as having neuropathic low-back pain with or without referred leg pain. Five studies compared 849 neuropathic cases with nociceptive low-back-pain groups; one clustered descriptors in 2,094 neuropathic low-back-pain participants against other neuropathic conditions; two described descriptor consistency or frequency in 156 participants. Seven studies were cross-sectional and one used mixed methods. No included study reported sensitivity, specificity, or likelihood ratios for individual sensory descriptors, and heterogeneity precluded meta-analysis, so findings were narratively synthesized.",
          "allowableUse": "Describe the small and heterogeneous evidence base and why study counts are not pooled diagnostic-accuracy estimates.",
          "notSupported": "A meta-analytic effect, pooled accuracy, prevalence, prospective validation, or direct evidence about people whose main symptom is localized back heat."
        },
        {
          "passageId": "PV-32609541-RISK-OF-BIAS",
          "locator": {
            "section": "Results — Risk of bias across studies; Table 2",
            "acceptedManuscriptPages": [
              7,
              26
            ]
          },
          "evidenceLayer": "review-method-and-observation",
          "analyticParaphrase": "Two reviewers applied QUADAS-2, with moderate item-level agreement (kappa 0.42). Three of eight studies had the most favorable profile, each with five low-risk and two unclear judgments. Index-test and reference-standard domains were the recurring sources of risk. Table 2 shows high risk in at least one bias domain for four studies and unclear judgments in every study; several studies also had high reference-standard applicability concerns.",
          "allowableUse": "Qualify all descriptor findings with the review's recurring index/reference-standard risks and reviewer-judgment uncertainty.",
          "notSupported": "That the included studies were uniformly high quality or that QUADAS-2 validates any individual descriptor."
        },
        {
          "passageId": "PV-32609541-CONSTRUCT-SEPARATION",
          "locator": {
            "section": "Results — Temperature pain",
            "acceptedManuscriptPages": [
              10,
              11
            ]
          },
          "evidenceLayer": "review-method-and-construct-definition",
          "analyticParaphrase": "The review explicitly separates evoked thermal hyperalgesia from pain quality described as hot, burning, or cold. Two painDETECT-based studies asked whether cold or heat in an area was painful and separately asked about burning pain. Five other studies used wording about pain that felt hot, burning, or cold. Because these questions address different constructs and were phrased differently, the review analyzed them in separate subsections.",
          "allowableUse": "Support the distinction among pain triggered by temperature, a hot/burning/cold pain descriptor, subjective warmth, and measured temperature.",
          "notSupported": "Combining all temperature-related questionnaire items into one heat-sensation variable or equating any item with objective skin temperature."
        },
        {
          "passageId": "PV-32609541-THERMAL-HYPERALGESIA",
          "locator": {
            "section": "Results — Thermal Hyperalgesia",
            "acceptedManuscriptPage": 11
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          "evidenceLayer": "review-observation",
          "analyticParaphrase": "In one included study, thermal pain thresholds did not differ between neuropathic and nociceptive low-back-pain groups; within the neuropathic group, heat hyperalgesia did not differ between back and leg, while cold hyperalgesia was reported more often in the back. A second study found that its thermal-pain item did not meet the stated item-discrimination threshold. The review later summarized that neither thermal-hyperalgesia study found discrimination between neuropathic and nociceptive low-back pain.",
          "allowableUse": "Retain null counterevidence for evoked thermal-pain items and the isolated within-person region finding as distinct results.",
          "notSupported": "A conclusion about spontaneous warmth, objective back temperature, or recurrent focal heat episodes."
        },
        {
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              12,
              15
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          "evidenceLayer": "review-observation-and-author-synthesis",
          "analyticParaphrase": "Four studies reported that hot, burning, or cold pain descriptors discriminated neuropathic from nociceptive low-back pain; two studies did not; and one reported discrimination for hot but not cold pain. Selected questionnaire studies reported large within-study frequency differences, but descriptor groupings and reference classifications varied. The authors therefore treated temperature-related pain-quality evidence as conflicting or equivocal rather than diagnostically settled.",
          "verifiedDetails": {
            "supportingStudies": 4,
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            "mixedHotPositiveColdNegativeStudies": 1,
            "selectedReportedFrequencies": {
              "ElSissiThermalPain": {
                "neuropathicPercent": 83,
                "nociceptivePercent": 38
              },
              "SivasDN4": {
                "burningNeuropathicPercent": 64,
                "burningNonNeuropathicPercent": 23,
                "painfulColdNeuropathicPercent": 48,
                "painfulColdNonNeuropathicPercent": 11
              }
            }
          },
          "allowableUse": "Show that burning or temperature-related pain wording is neither uniformly discriminating nor safely interpretable without the questionnaire, comparator, and reference standard.",
          "notSupported": "Using a hot or burning descriptor alone to diagnose neuropathic pain, infer a lesion, identify etiology, or classify localized subjective back warmth."
        },
        {
          "passageId": "PV-32609541-METHOD-HETEROGENEITY",
          "locator": {
            "section": "Discussion — descriptor gathering and reference standards",
            "acceptedManuscriptPages": [
              15,
              16,
              17
            ]
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          "evidenceLayer": "author-limit-and-source-criticism",
          "analyticParaphrase": "Descriptor collection varied between offered questionnaire choices and participant-generated language; the availability of a no-match response was unclear. Three studies used the same questionnaire both to classify neuropathic pain and to analyze its component descriptors, creating common-method bias. Temperature questions differed in construct and timeframe across tools. The review notes no gold-standard reference test for neuropathic low-back pain, divergent classification methods, and evidence that studies likely compared non-identical groups.",
          "allowableUse": "Explain why study counts favoring a descriptor do not amount to independent validation and why wording, recall window, and classification method matter.",
          "notSupported": "Treating questionnaire-item association as proof of mechanism or assuming different tools measure the same temperature sensation."
        },
        {
          "passageId": "PV-32609541-REVIEW-LIMITS-CONCLUSION",
          "locator": {
            "section": "Strengths and limitations; Conclusion",
            "acceptedManuscriptPages": [
              18,
              19
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          },
          "evidenceLayer": "author-limit-and-conclusion",
          "analyticParaphrase": "The authors identify English-only inclusion as a possible publication-bias source, note that most primary studies were not designed chiefly to validate sensory descriptors for neuropathic low-back pain, and acknowledge that descriptor data often had to be extrapolated. Their conclusion states that current evidence is insufficient to support or refute sensory descriptors as identifiers of neuropathic low-back pain, although evidence was stronger for allodynia and numbness and remained conflicting for other descriptors.",
          "allowableUse": "Use the review as counterevidence against single-descriptor mechanism classification and as a source for bounded hypothesis generation only.",
          "notSupported": "A clinical diagnosis, safety redirect, treatment decision, or confident mechanism inference from localized heat or burning language."
        }
      ],
      "interpretation": {
        "reviewObservations": [
          "Eight heterogeneous studies contributed 3,099 participants classified as having neuropathic low-back pain, but none reported sensitivity, specificity, or likelihood ratios for individual descriptors.",
          "Evoked thermal hyperalgesia and pain described as hot, burning, or cold were distinct constructs in the review.",
          "Temperature-related pain-quality findings conflicted across studies, while both thermal-hyperalgesia studies failed to discriminate neuropathic from nociceptive low-back pain.",
          "Risk of bias centered on index tests and reference standards, and three studies reused the same questionnaire for classification and descriptor analysis."
        ],
        "authorInterpretation": "The authors consider allodynia and numbness the relatively stronger subjective indicators and dysesthesia suspicion-raising, but conclude that evidence is insufficient to support or refute sensory descriptors generally and that consensus is poor for other descriptors, including temperature-related pain qualities.",
        "reviewerInterpretation": "For this cluster, the source is most valuable as counterevidence: a person saying hot or burning may be describing pain quality, pain on thermal stimulation, perceived skin-temperature change, or another construct. Even in selected low-back-pain cohorts, hot/burning/cold wording did not classify mechanism consistently, and circular questionnaire use weakens some positive associations.",
        "hypothesesForLaterSynthesis": [
          "A localized back complaint described as heat should be disambiguated into spontaneous warmth, burning pain, temperature-evoked pain, perceived surface-temperature change, and objective temperature before mechanisms are considered.",
          "Co-occurring numbness, allodynia, dysesthesia, neuroanatomical distribution, and examination findings may be more informative than heat language alone, but this review does not validate a diagnostic rule for the cluster phenotype.",
          "Differences in Korean and English wording, prompted versus volunteered responses, and recall windows may materially change classification and require explicit provenance."
        ],
        "clinicalImplicationStatus": "No diagnostic or treatment implication is established for recurrent localized back heat. The source supports better questioning and construct separation, not a neuropathic label. Any clinical assessment or safety redirect requires separate verified evidence and examination context."
      },
      "claimsNotEstablished": [
        "Hot, burning, cold, thermal hyperalgesia, subjective warmth, paradoxical heat, and objective skin temperature are equivalent constructs.",
        "A hot or burning descriptor alone identifies a neuropathic pain mechanism, lesion, disease, diagnosis, or cause.",
        "The included populations represent people with isolated, recurrent, skin-normal localized back heat.",
        "The study counts constitute pooled diagnostic accuracy or a prevalence estimate.",
        "Temperature-related descriptor findings generalize across questionnaires, languages, recall periods, anatomical sites, or back-versus-leg distributions.",
        "The review supports imaging, referral, urgency, treatment, or safety-redirect decisions for this cluster.",
        "The accepted manuscript is the publisher version of record or has been independently re-reviewed by this workflow."
      ],
      "unresolvedBlockers": [
        {
          "id": "descriptor-primary-study-dependence",
          "status": "bounded-source-limitation",
          "detail": "Study-level effect estimates, exact item wording, reference classifications, and anatomical attribution vary and would require verification in the eight primary studies before making any quantitative or tool-specific claim. This does not reopen broad retrieval."
        },
        {
          "id": "language-and-construct-transfer",
          "status": "bounded-cluster-limitation",
          "detail": "The English-only low-back-pain review cannot establish equivalence with Korean 배열 or 화끈거림, spontaneous back warmth, objective temperature, or historical terms. Preserve the terminology crosswalk and sampling provenance."
        }
      ],
      "verificationDecision": {
        "status": "verified-with-material-limitations",
        "evidenceRole": "Indirect descriptor differentiation and counterevidence against single-descriptor mechanism classification.",
        "stageDecision": "Retain passage-verification. Seven frozen Tier 1 objects remain, including both authoritative safety objects; passage-verification exit criteria are not met.",
        "transitionCount": 0
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      "nextWorkUnit": "Verify T1-TRUNK-QST-24525274 as one bounded passage-verification unit, focusing on back-versus-limb thermal thresholds, reliability and site effects, population and test protocol, null or discordant findings, and the limits of evoked QST for spontaneous localized back heat, while recording the lawful full-text access state."
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        "doi": "10.2340/00015555-2789",
        "title": "Brachioradial Pruritus and Notalgia Paraesthetica: A Comparative Observational Study of Clinical Presentation and Morphological Pathologies.",
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          "sectionsRead": [
            "Abstract",
            "Introduction",
            "Methods: Subjects, Set-up, Scales and questionnaires, Intraepidermal nerve fibre density determination, Statistical analysis",
            "Results: Subjects, Magnetic resonance imaging, Skin status and scratching behaviour, Intraepidermal nerve fibre density, Clinical outcomes",
            "Table I",
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              83
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              "Results: Subjects"
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          "evidenceLayer": "study-design-sampling-and-case-definition",
          "analyticParaphrase": "The authors retrospectively analysed routine clinical data from successive adults considered for inclusion at one German chronic-pruritus centre. They included 58 people, 29 labelled brachioradial pruritus and 29 labelled notalgia paraesthetica. Diagnosis used symptom onset location and quality, the ice-pack sign, absence of primary dermatosis, and objective MRI or CT and local nerve-fibre findings. The article does not report the sampling dates, exclusions, number considered but not included, or an independently applied operational case definition.",
          "verifiedDetails": {
            "design": "retrospective single-centre observational analysis of routine clinical data",
            "totalN": 58,
            "brachioradialPruritusN": 29,
            "notalgiaParaestheticaN": 29,
            "samplingLanguage": "successive adult patients considered for inclusion",
            "diagnosticInputs": [
              "history and symptom quality",
              "ice-pack sign",
              "absence of primary dermatosis",
              "MRI or CT pathology",
              "reduced local intraepidermal nerve-fibre density"
            ]
          },
          "sourceCriticism": "Because imaging and nerve-fibre findings were diagnostic inputs and later compared as morphological outcomes, incorporation and selection effects are possible. The study is not a diagnostic-accuracy design.",
          "allowableUse": "Describe the selected comparator cohort and its composite clinical-plus-objective case assignment.",
          "notSupported": "Population prevalence, incidence, unbiased consecutive capture, independent diagnostic validity, or representativeness of people reporting localized back heat."
        },
        {
          "passageId": "PV-28902951-BURNING-AND-ELICITATION",
          "locator": {
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              85
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            "sections": [
              "Methods: Scales and questionnaires",
              "Results: Clinical outcomes"
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            "table": "Table I"
          },
          "evidenceLayer": "questionnaire-based-comparative-observation",
          "analyticParaphrase": "Clinical pruritus properties were recorded with the Neuroderm questionnaire. At the first visit, burning was recorded for 19/28 assessed brachioradial-pruritus participants and 9/27 assessed notalgia participants; the table reports p=0.01 from a chi-square comparison. The narrative separately states that itch and burning co-occurred in 16/28 brachioradial-pruritus participants, but gives no parallel notalgia co-occurrence count. Seven of 28 assessed notalgia participants were described as having pure itch. These are overlapping symptom descriptors in itch-defined groups, not measures of warmth or temperature.",
          "verifiedDetails": {
            "instrumentNamed": "Neuroderm questionnaire",
            "burning": {
              "brachioradialPruritus": "19/28",
              "notalgiaParaesthetica": "9/27",
              "reportedP": 0.01,
              "reportedTest": "chi-square"
            },
            "itchAndBurningCooccurrence": {
              "brachioradialPruritus": "16/28",
              "notalgiaParaesthetica": "not reported"
            },
            "pureItchInNotalgia": "7/28",
            "multiResponseStructure": true
          },
          "elicitationLimit": "The article names the questionnaire but does not reproduce the exact prompt, response options, whether descriptors were offered or volunteered, language handling, coding rules, assessor process, or missing-data mechanism.",
          "allowableUse": "Show that burning was not uniform across two selected neuropathic-itch groups and was less often recorded in the notalgia group in this study.",
          "notSupported": "Prevalence of burning or warmth in notalgia, spontaneous patient wording, a validated diagnostic threshold, equivalence of burning with heat, or applicability to a heat complaint without itch."
        },
        {
          "passageId": "PV-28902951-NOTALGIA-LOCATION-TIME-AND-CONTEXT",
          "locator": {
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            "printedPage": 85,
            "section": "Results: Clinical outcomes",
            "table": "Table I"
          },
          "evidenceLayer": "selected-cohort-phenotype-observation",
          "analyticParaphrase": "All 29 notalgia participants had recorded upper-back involvement spanning C6-T8, and nine also had lower-back involvement spanning T9-T12. Disease duration of at least six weeks was reported for 28/28 assessed participants. Fourteen participants reported itch peaks and 14/28 continuous symptoms; these categories are not presented as mutually exclusive. Bed warmth was recorded as a trigger in 4/26, which is contextual provocation rather than a spontaneous localized warmth descriptor.",
          "verifiedDetails": {
            "upperBackInvolvement": "29/29; C6-T8",
            "additionalLowerBackInvolvement": "9/29; T9-T12",
            "durationAtLeastSixWeeks": "28/28 assessed",
            "itchPeaks": 14,
            "continuousSymptoms": "14/28",
            "bedWarmthTrigger": "4/26"
          },
          "allowableUse": "Retain an itch-defined upper-back dysesthesia phenotype and distinguish its time and trigger fields.",
          "notSupported": "A recurrent isolated back-heat phenotype, objective surface heat, deep heat, a mutually exclusive episodic-versus-continuous classification, or general population frequency."
        },
        {
          "passageId": "PV-28902951-MRI-RESULT-AND-DENOMINATOR-CONFLICT",
          "locator": {
            "source": "publisher PDF",
            "printedPages": [
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              84,
              86
            ],
            "sections": [
              "Methods: Set-up",
              "Results: Magnetic resonance imaging",
              "Discussion"
            ]
          },
          "evidenceLayer": "study-observation-with-internal-reporting-conflict",
          "analyticParaphrase": "The results say 25 brachioradial-pruritus and 21 notalgia participants underwent MRI. The notalgia pathology-category counts sum to 21, including seven with no pathology. Yet symptom-location concordance is reported as 24/25 for brachioradial pruritus and 11/22 for notalgia, with p<0.001. The article does not reconcile the 21-versus-22 notalgia denominator. Imaging was obtained only in a subset and was also part of the reported diagnostic process.",
          "verifiedDetails": {
            "reportedMRICompleted": {
              "brachioradialPruritus": 25,
              "notalgiaParaesthetica": 21
            },
            "notalgiaPathologyCategories": {
              "degenerative": 8,
              "stenosis": 2,
              "combined": 4,
              "noPathology": 7,
              "sum": 21
            },
            "reportedSymptomLocalizationConcordance": {
              "brachioradialPruritus": "24/25",
              "notalgiaParaesthetica": "11/22",
              "p": "<0.001"
            },
            "unresolvedConflict": "The notalgia concordance denominator is 22 although only 21 MRIs and 21 pathology classifications are reported."
          },
          "allowableUse": "Use only as selected-cohort comparative evidence that exact scan-to-symptom correspondence was not uniform, while reporting the denominator conflict.",
          "notSupported": "A precise notalgia concordance rate, causation, diagnostic accuracy, an imaging indication, or inference that a normal or discordant scan proves a peripheral mechanism."
        },
        {
          "passageId": "PV-28902951-IENFD-METHOD-RESULT-AND-CAUSAL-LIMIT",
          "locator": {
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            "printedPages": [
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              84,
              86
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            "sections": [
              "Methods: Intraepidermal nerve fibre density determination",
              "Results: Intraepidermal nerve fibre density",
              "Discussion"
            ]
          },
          "evidenceLayer": "local-paired-biopsy-method-observation-and-author-hypothesis",
          "analyticParaphrase": "Four-millimetre biopsies were taken from symptomatic and asymptomatic skin at C6 on the forearm for brachioradial pruritus and on the back for notalgia. PGP 9.5-stained fibres crossing the basement membrane were counted at 400-fold magnification in three specimens per biopsy and averaged per epidermal length. The paper reports lower lesional than non-lesional density for brachioradial pruritus (6.0 versus 12.2 fibres/mm; p=0.01) but no paired difference for notalgia (11.2 versus 9.6 fibres/mm; p=0.47, n=24). No healthy controls were used. The authors' central-versus-peripheral compression explanation is explicitly a hypothesis, not a demonstrated mechanism.",
          "verifiedDetails": {
            "biopsyDiameter": "4 mm",
            "marker": "PGP 9.5",
            "counting": "fibres crossing basement membrane divided by epidermal length; mean of three specimens",
            "brachioradialPruritus": {
              "lesional": "median 6.0 [4.9, 8.4], n=27",
              "nonLesional": "median 12.2 [9.7, 15.3], n=18",
              "p": 0.01
            },
            "notalgiaParaesthetica": {
              "lesional": "median 11.2 [7.9, 17.5], n=25",
              "nonLesional": "median 9.6 [6.3, 17.6], n=24",
              "pairedAnalysisN": 24,
              "p": 0.47
            },
            "healthyControlGroup": false
          },
          "sourceCriticism": "The unequal brachioradial lesional and non-lesional counts do not disclose the exact paired analytic denominator. Biopsy findings were diagnostic inputs, and no link between burning and individual biopsy values was reported.",
          "allowableUse": "Retain the null local paired notalgia result and the between-syndrome morphological contrast as bounded counterevidence.",
          "notSupported": "Causality, a generalized small-fibre neuropathy diagnosis, diagnostic accuracy, a mechanism for burning, or any measurement of subjective or objective heat."
        },
        {
          "passageId": "PV-28902951-DESIGN-LIMITS-AND-COMPARATIVE-UNCERTAINTY",
          "locator": {
            "source": "publisher PDF",
            "printedPages": [
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              87
            ],
            "sections": [
              "Discussion",
              "Conclusion"
            ]
          },
          "evidenceLayer": "author-limit-and-reviewer-source-criticism",
          "analyticParaphrase": "The authors identify routine clinical data and unequal diabetes frequency as a limitation and call for prospective studies excluding neuropathy-producing diseases. Across the paper, available denominators vary by measure, follow-up is incomplete, no healthy or non-neuropathic comparator is included, and many group comparisons are presented without adjustment for multiple testing. Baseline diabetes is reported as 8/29 versus 1/29 in Results but described as seven versus one in Discussion. These issues prevent a clean causal or diagnostic interpretation of the group differences.",
          "verifiedDetails": {
            "authorNamedLimitation": "higher diabetes frequency in brachioradial pruritus",
            "diabetesReportingConflict": "Results: 8/29 versus 1/29; Discussion: 7 versus 1",
            "authorRequestedNextDesign": "prospective studies excluding diabetes and other neuropathy-producing diseases",
            "additionalReviewerLimits": [
              "retrospective routine-care design",
              "variable missing denominators",
              "no healthy or non-neuropathic comparator",
              "no reported multiplicity adjustment",
              "diagnostic incorporation of MRI and IENFD"
            ]
          },
          "allowableUse": "Bound any comparison by confounding, missingness, reporting inconsistency, and design limitations.",
          "notSupported": "A causal ranking of central versus peripheral compression, confirmation of neuropathic origin, treatment efficacy, prognosis, or a diagnostic pathway for localized back heat."
        }
      ],
      "interpretation": {
        "studyObservations": [
          "Burning was recorded in both selected itch-defined groups and less often in the notalgia group.",
          "Notalgia location was uniformly upper-back in this selected cohort, but the symptom construct was itch with possible paraesthesias rather than isolated heat.",
          "Exact MRI concordance was not uniform and its notalgia denominator is internally inconsistent.",
          "The local paired IENFD comparison was null in notalgia and different in brachioradial pruritus."
        ],
        "authorInterpretation": "The authors argue that brachioradial pruritus has a more pronounced neuropathic component and hypothesize central versus more peripheral compression differences; they call for prospective confirmation.",
        "reviewerInterpretation": "The study supports a discriminator: burning alone does not define a single syndrome, even within selected neuropathic-itch diagnoses. It also supplies counterevidence to simple scan or local nerve-fibre attribution in notalgia. Incorporation, confounding, missingness, and reporting conflicts make it unsuitable for prevalence, diagnosis, or causal inference.",
        "hypothesesForLaterSynthesis": [
          "In recurrent localized back-heat research, burning should be elicited separately from warmth, itch, pain, bed-warmth provocation, touch temperature, and visible skin change.",
          "A comparison framework should prespecify how imaging and sensory tests are evaluated independently of the case definition to avoid incorporation bias."
        ],
        "clinicalImplicationStatus": "No direct clinical recommendation is established. The source cannot justify diagnosis, reassurance, imaging, biopsy, treatment, or safety redirection for isolated recurrent back heat."
      },
      "verificationDecision": {
        "status": "fulltext-verified-with-reporting-limitations",
        "evidenceRolesSatisfied": [
          "comparative burning-frequency and elicitation boundary",
          "itch-defined upper-back phenotype context",
          "MRI concordance counterevidence and reporting conflict",
          "local nerve-fibre method, null notalgia result, and causal boundary"
        ],
        "evidenceRolesNotSatisfied": [
          "spontaneous warmth characterization",
          "objective skin or deep temperature",
          "exact questionnaire prompt and coding",
          "diagnostic accuracy or independent causal attribution"
        ],
        "tier1SetAudit": {
          "frozenTier1Objects": 12,
          "objectsWithBoundedPassageVerificationDecisions": 12,
          "remainingPassageUnverifiedTier1Objects": 0,
          "residualAccessAndReportingGaps": "carried as explicit limitations; none requires broad retrieval or blocks synthesis"
        },
        "stageTransition": true,
        "stageTransitionReason": "All 12 frozen Tier 1 objects now have auditable passage-verification decisions; authoritative safety passages, counterevidence, negative yields, construct boundaries, access limitations, and reporting conflicts are explicit. The remaining gaps constrain claims but do not prevent competing syntheses."
      },
      "claimsNotEstablished": [
        "Prevalence or diagnostic value of burning, warmth, or recurrent localized back heat.",
        "That burning was spontaneous wording rather than a prompted questionnaire response.",
        "That burning, warmth, bed warmth, touch warmth, paradoxical heat, evoked thresholds, and measured temperature are equivalent.",
        "A precise notalgia MRI-concordance estimate because the source reports 21 MRIs but a 22-person concordance denominator.",
        "That MRI abnormalities or local nerve-fibre findings caused symptoms or distinguish diagnoses independently.",
        "That the reported notalgia IENFD null proves absence of neuropathy or another mechanism.",
        "Any imaging, biopsy, treatment, safety, prognosis, or referral recommendation for localized back heat."
      ],
      "unresolvedBlockers": [
        {
          "id": "t1-np-comparator-reporting-limits",
          "status": "bounded-source-limitation",
          "detail": "The article does not provide exact Neuroderm prompts or coding, reports 21 notalgia MRIs but uses 22 as the concordance denominator, gives unequal brachioradial biopsy counts without the paired denominator, and conflicts on the brachioradial diabetes count. Do not silently reconcile these values. They limit dependent claims but do not block competing synthesis."
        }
      ],
      "nextWorkUnit": "At competing-syntheses, create one bounded evidence matrix contrasting subjective dysesthesia/itch, objective local temperature, evoked thermoception, and conditional safety/context framings, with passage locators, counterevidence, discriminating predictions, and unsupported claims."
    },
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        "pmcid": "PMC11146484",
        "doi": "10.1097/PR9.0000000000001162",
        "title": "Quantitative sensory testing in notalgia paresthetica reveals small fiber-type-specific differences in non-pruritic sensitivity: a pilot study.",
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        "eligibilityReason": "The study directly compares symptomatic and contralateral back sites and reports thermal QST and paradoxical sensations, but the recruited phenotype is dermatologist-diagnosed unilateral subscapular itch rather than recurrent localized subjective back heat."
      },
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          "accessState": "not-acquired",
          "result": "The ordinary public PMC file request returned an HTML proof-of-work preparation page rather than the PDF. No challenge was solved or bypassed. The official PMC OA API listed an OA package and article PDF, but the returned package HTTPS locator gave HTTP 404 and the exact FTP locator denied directory change in this environment.",
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          "consequence": "The main article verifies that DFNS-standardized QST was used and reports paradoxical-heat outcomes, but the exact stimulus sequence, trial count, response rule, and scoring procedure remain unverified."
        },
        "targetedRead": {
          "queryTerms": [
            "notalgia paresthetica",
            "subscapular",
            "QST",
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            "cold",
            "paradoxical heat",
            "hot",
            "alloknesis",
            "limitations"
          ],
          "searchType": "Targeted search within the acquired article; no new bibliographic search or broad retrieval."
        }
      },
      "verifiedPassages": [
        {
          "passageId": "PV-38835743-PHENOTYPE",
          "locator": {
            "section": "2. Methods",
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          },
          "evidenceLayer": "study eligibility and phenotype",
          "verifiedContent": "Fifteen adults were recruited from a university dermatology clinic after dermatologist confirmation. Operational diagnosis required unilateral localized pruritus on the subscapular back without primary skin disease; probable or diagnosed neuropathy, spinal injury, and other clinically relevant sensory deficits were exclusions. The article states that standard diagnostic criteria for notalgia paresthetica do not exist.",
          "supports": "This is an itch-defined, selected clinic sample with a specific dorsal distribution and explicit exclusions.",
          "doesNotSupport": "It does not define or validate recurrent focal back warmth, burning without itch, objective skin heating, prevalence, or diagnostic accuracy."
        },
        {
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          "verifiedContent": "DFNS-standardized QST was applied at the patient-rated itchiest area inferior to the medial scapular border and at the mirror location on the contralateral back at the same dermatomal level. Comparisons were paired within participants and separately made against published age-, sex-, and trunk-site-matched reference data after transformation. Mechanical-evoked itch was separately rated.",
          "supports": "The affected-versus-contralateral comparison is anatomically aligned, and the study distinguishes evoked itch from the other QST modalities.",
          "doesNotSupport": "The main text does not verify the detailed paradoxical-heat stimulus sequence. The published reference comparison is not an internally recruited healthy-control comparison."
        },
        {
          "passageId": "PV-38835743-COHORT",
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            "section": "3. Results",
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          "evidenceLayer": "sample description",
          "verifiedContent": "The pilot included 15 people: 12 women, 9 White participants, mean age 64.0 years, and mean symptom duration 12.0 years with a 1-to-33-year range. Nine cases were right-sided. Itch severity bands were mild in 9 and moderate in 6; no participant was in the little or severe band.",
          "supports": "The observed findings arise from a small, chronic, predominantly female clinic cohort with mild-to-moderate itch burden.",
          "doesNotSupport": "The sample cannot establish population frequency, representativeness, or findings in people whose principal complaint is heat rather than itch."
        },
        {
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            "section": "3. Results",
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          "verifiedContent": "The symptomatic and contralateral asymptomatic sites did not differ on the reported sensory measures at P greater than 0.10, except that mechanical-evoked itch was higher at the symptomatic site (mean 4.0 versus 0.8; Z 2.67; P 0.008).",
          "supports": "This is direct counterevidence to assuming that a symptomatic back site must show a site-specific thermal QST abnormality.",
          "doesNotSupport": "A null difference in this pilot does not prove equivalence of the two sites or exclude localized physiological differences not captured by this protocol."
        },
        {
          "passageId": "PV-38835743-REFERENCE-COMPARISON",
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            "section": "3. Results",
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          "evidenceLayer": "external-reference comparison",
          "verifiedContent": "Against published trunk reference data, both the symptomatic and contralateral sites showed lower sensitivity to warm-to-cold-to-warm changes, lower pinprick pain sensitivity, and greater repeated-pinprick wind-up. Cold sensitivity was lower at both sites but reached the study threshold only at the symptomatic site.",
          "supports": "The reported deviations were substantially bilateral rather than confined to the itchy side.",
          "doesNotSupport": "These evoked sensory thresholds do not measure spontaneous felt heat or skin temperature, and the external-reference comparisons may be vulnerable to false-positive findings."
        },
        {
          "passageId": "PV-38835743-PHS",
          "locator": {
            "section": "3. Results",
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            "table": "Table 2"
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          "evidenceLayer": "paradoxical sensation result",
          "verifiedContent": "Table 2 reports paradoxical heat sensations on at least one trial in 4 of 15 symptomatic sites and 2 of 15 contralateral sites. Its footnote states that one participant counted in the contralateral cell described cold during skin warming, which the authors say is not technically paradoxical heat. The article does not supply a corrected table cell after this qualification.",
          "supports": "Paradoxical responses were observed on both sides and were not unique to the symptomatic site.",
          "doesNotSupport": "The table does not establish spontaneous back heat; the exact PHS protocol is in the unacquired supplement, and the footnoted classification ambiguity must not be silently recalculated."
        },
        {
          "passageId": "PV-38835743-DESCRIPTOR",
          "locator": {
            "section": "4. Discussion",
            "htmlSectionId": "s4",
            "localHtmlLine": 1585
          },
          "evidenceLayer": "author-reported symptom descriptor",
          "verifiedContent": "The authors state that Hot ranked third among Short-Form McGill Pain Questionnaire sensory descriptors, after Sharp and Tender, in this cohort.",
          "supports": "Heat-related language can occur within an itch-defined notalgia paresthetica cohort.",
          "doesNotSupport": "The article does not report the count, frequency, timing, depth, touch-temperature relation, or primacy of Hot in the main text; this discussion statement cannot establish a back-heat phenotype or prevalence."
        },
        {
          "passageId": "PV-38835743-LIMITS",
          "locator": {
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          "evidenceLayer": "interpretive limits and counterevidence",
          "verifiedContent": "The authors characterize proposed fiber and central-sensitization mechanisms as plausible or suggestive rather than definitive. They identify the absence of internal healthy controls as the most serious limitation, warn that the external-reference analysis may produce false positives, note uncertain generalization across dermatomal levels and national reference populations, and state that QST alone cannot definitively establish the proposed mechanism.",
          "supports": "Mechanistic interpretation must remain hypothesis-level and the external-reference findings require caution.",
          "doesNotSupport": "The study does not establish etiology, causal spinal impingement, treatment efficacy, or a clinical redirect for isolated recurrent back heat."
        }
      ],
      "interpretation": {
        "directlySupported": [
          "In this 15-person itch-defined pilot, symptomatic and mirrored asymptomatic back sites were broadly similar on QST apart from evoked itch.",
          "Reported thermal and other sensory deviations versus published reference data were mainly bilateral.",
          "Paradoxical sensations occurred on both sides, with a classification caveat in the contralateral table cell.",
          "A heat-related pain descriptor was mentioned in the cohort, but the main article does not quantify it."
        ],
        "hypothesesOnly": [
          "Aδ-pathway dysfunction, reduced cold inhibition, and central sensitization may contribute to notalgia-paresthetica itch.",
          "Any relationship between these findings and spontaneous recurrent localized back heat."
        ],
        "clinicalImplication": "None established for isolated recurrent localized back heat. At most, the study identifies an itch-defined unilateral subscapular phenotype and demonstrates why spontaneous warmth, pain-language Hot, paradoxical heat under QST, and objective temperature must remain separate constructs.",
        "constructBoundary": "Spontaneous localized warmth or burning is not equivalent to evoked paradoxical heat; neither is equivalent to warm-detection threshold, perceived Hot on a pain questionnaire, or measured skin temperature."
      },
      "claimsNotEstablished": [
        "Prevalence, diagnostic accuracy, cause, or treatment efficacy for recurrent localized back heat.",
        "Objective heating of symptomatic skin.",
        "That the symptomatic site has a localized thermal sensory deficit relative to the mirrored back site.",
        "That the reported Hot descriptor was common, primary, spontaneous, recurrent, or specifically localized to the back.",
        "That isolated recurrent back heat is a red flag or indicates notalgia paresthetica, neuropathy, spinal pathology, or central sensitization.",
        "The exact paradoxical-heat stimulus and scoring protocol, because the linked supplement was not lawfully acquired in this environment."
      ],
      "unresolvedBlockers": [
        {
          "id": "t1-np-qst-supplement-access",
          "severity": "bounded-source-limitation",
          "missingWork": "Lawfully acquire and verify the article supplement before making any claim dependent on the exact PHS stimulus sequence, trial count, response definition, or scoring.",
          "stageEffect": "Does not block other Tier 1 passage-verification units or require reopening broad retrieval."
        }
      ],
      "verificationDecision": {
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        "centralClaimEligible": false,
        "permittedUse": "Indirect phenotype differentiation, within-person null/counterevidence, construct separation, and study-limit support with explicit population and measurement qualifiers.",
        "prohibitedUse": "Direct evidence of spontaneous localized back heat, objective temperature elevation, diagnosis, prevalence, mechanism, efficacy, or safety redirection."
      },
      "nextWorkUnit": "Verify T1-NP-BURN-32416719 as one bounded passage-verification unit, focusing on elicited burning language, dorsal distribution, comparator design, radiology association, treatment-result limits, and non-equivalence to recurrent localized heat."
    },
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        "kind": "shared-cluster"
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        "candidateId": "T1-QST-SR-23711482",
        "pmid": "23711482",
        "doi": "10.1016/j.pain.2013.05.031",
        "title": "Relationship between quantitative sensory testing and pain or disability in people with spinal pain-a systematic review and meta-analysis.",
        "eligibilityDecision": "retain-as-abstract-verified-indirect-qst-counterevidence-source",
        "eligibilityReason": "The review pools associations between evoked QST measures and self-reported pain or disability in spinal-pain populations and reports thermal-stimulus and thermal-temporal-summation findings. It informs construct limits but does not study spontaneous recurrent localized back heat, objective skin temperature, or diagnostic performance, and lawful full text was not available in the frozen access state."
      },
      "sourceVerification": {
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        },
        "lawfulAccessState": {
          "frozenPublisherCheck": "The priority access audit records HTTP 403 at the LWW publisher route; no access control was bypassed.",
          "fallbackLocators": [
            "https://pubmed.ncbi.nlm.nih.gov/23711482/",
            "https://doi.org/10.1016/j.pain.2013.05.031"
          ],
          "boundedDecision": "This unit used the current public PubMed abstract and did not reopen broad retrieval or attempt to bypass publisher controls."
        },
        "targetedRead": {
          "sectionsRead": [
            "PubMed unstructured abstract in full"
          ],
          "sectionsNotAvailable": [
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          "verifiedDetails": {
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            },
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            },
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              "QST site: primary pain versus remote",
              "pain condition: back versus neck",
              "pain type: acute versus chronic",
              "induction stimulus: mechanical versus thermal"
            ]
          },
          "allowableUse": "Support the limited statement that pooled threshold associations with pain and disability were weak and that the abstract did not report evidence of moderation by the named categories.",
          "notSupported": "Equivalence of subgroups, a null thermal-specific association, thermal subgroup estimates or study counts, heterogeneity magnitude, prediction, diagnostic accuracy, causal direction, or an individual-patient decision rule."
        },
        {
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          "evidenceLayer": "sparse-meta-analytic-results-and-author-interpretation-as-reported-in-abstract",
          "analyticParaphrase": "Pain intensity had an abstract-reported correlation of 0.26 with thermal temporal summation and -0.30 with pain tolerance, but the authors cautioned that only a few studies contributed. They interpreted the overall findings as compatible either with pain threshold being a poor marker of central sensitization or with sensitization not playing a major role in patient reports of pain and disability; the abstract does not adjudicate between these alternatives.",
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              "confidenceInterval95Percent": [
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              "studyCount": "not reported; described only as a few studies"
            },
            "painIntensityVersusPainTolerance": {
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              "confidenceInterval95Percent": [
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                -0.13
              ],
              "studyCount": "not reported; described only as a few studies",
              "thermalSpecificity": "not stated in the abstract"
            },
            "authorAlternatives": [
              "pain threshold may be a poor marker of central sensitization",
              "sensitization may not play a major role in reported pain and disability"
            ]
          },
          "allowableUse": "Retain the two sparse outcome estimates, label thermal temporal summation explicitly, avoid labeling pain tolerance as thermal-specific, and attribute the unresolved alternative explanations to the authors.",
          "notSupported": "Stable thermal-temporal-summation inference, an exact contributing-study count, causation, proof against sensitization, a mechanism for localized back heat, or a clinical threshold."
        }
      ],
      "interpretation": {
        "reviewObservations": [
          "Across the review corpus, pain-threshold correlations with pain intensity and disability were weak.",
          "The abstract did not report evidence that the threshold relationships were moderated by the named testing, region, duration, or stimulus categories.",
          "Thermal temporal summation and pain-tolerance correlations were based on only a few studies, without exact counts in the abstract."
        ],
        "authorInterpretation": "The authors offered two alternatives: pain threshold may poorly mark central sensitization, or sensitization may contribute little to patient reports of pain and disability.",
        "reviewerInterpretation": "This is counterevidence against treating a single evoked QST threshold as a close proxy for reported spinal pain or disability. It is not evidence that spontaneous localized heat is unrelated to thermoception, because the review did not study that phenotype and the abstract withholds thermal subgroup estimates, heterogeneity, and study-level details. The moderator result is absence of demonstrated moderation, not proof that mechanical and thermal tests are equivalent.",
        "hypothesesForLaterSynthesis": [
          "A study of recurrent localized back heat should prespecify spontaneous sensation, evoked detection or pain thresholds, temporal summation, and objective skin temperature as separate constructs rather than using one as a surrogate for another.",
          "Weak group-level threshold correlations make individual-level discordance plausible as a measurement problem worth testing, but this review does not establish its frequency, cause, or clinical meaning."
        ],
        "clinicalImplicationStatus": "No direct clinical recommendation is established. The abstract cannot support diagnosis, reassurance, safety redirection, treatment, imaging, or an individual-patient QST decision rule for recurrent localized back heat."
      },
      "verificationDecision": {
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        "evidenceRolesSatisfied": [
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          "thermal-stimulus moderator boundary at abstract level",
          "sparse thermal-temporal-summation finding and evidence limitation"
        ],
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        ],
        "stageTransition": false,
        "stageTransitionReason": "Eleven of 12 frozen Tier 1 objects now have bounded passage-verification decisions. T1-NP-COMPARATOR-28902951 remains passage-unverified, so passage-verification exit conditions are not met."
      },
      "claimsNotEstablished": [
        "That any included participant reported recurrent heat or burning localized to the back.",
        "Any relationship between spontaneous localized back heat and evoked warm detection, heat pain, temporal summation, paradoxical heat, or objective skin temperature.",
        "Thermal subgroup definitions, contributing-study counts, pooled thermal threshold estimates, subgroup-specific heterogeneity, prediction intervals, or small-study effects.",
        "That mechanical and thermal induction methods are equivalent; the abstract reports no evidence of moderation, not equivalence.",
        "That the pain-tolerance estimate was thermal-specific.",
        "That the sparse thermal temporal summation correlation is stable, generalizable, causal, or clinically actionable.",
        "That weak group-level correlations rule out sensitization in an individual or prove that pain thresholds are invalid.",
        "Diagnostic sensitivity, specificity, likelihood ratios, prevalence, prognosis, treatment effect, imaging indication, or safety redirect.",
        "Equivalence among evoked QST, objective skin temperature, spontaneous warmth, burning pain, paradoxical heat, Korean 배열/화끈거림, or Literary Sinitic 背熱."
      ],
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        }
      ],
      "nextWorkUnit": "Verify T1-NP-COMPARATOR-28902951 as one bounded passage-verification unit, focusing on group denominators, symptom elicitation, burning frequencies, pathology methods, imaging concordance, comparative uncertainty, lawful full-text access, and claims that remain unavailable without full text."
    },
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        "doi": "10.3390/sports10030041",
        "title": "Effects of Unilateral Muscle Fatigue on Thermographic Skin Surface Temperature of Back and Abdominal Muscles—A Pilot Study",
        "eligibilityDecision": "include-as-indirect-objective-temperature-method-and-counterevidence-source",
        "eligibilityReason": "The study measures back-specific objective skin-surface temperature before and after a unilateral trunk-fatigue provocation, but it does not recruit people with spontaneous recurrent localized back heat or measure felt warmth or burning."
      },
      "sourceVerification": {
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        },
        "targetedRead": {
          "queryTerms": [
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            "skin surface temperature",
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            "area",
            "treatment side",
            "non-treatment side",
            "acclimatization",
            "room temperature",
            "humidity",
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            "DOMS",
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            "precision",
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            "emissivity",
            "repeatability"
          ],
          "searchType": "Targeted search and section-level reading within the already acquired article; no new bibliographic retrieval or broad pagination."
        }
      },
      "verificationDecision": {
        "status": "verified-with-reporting-and-design-limits",
        "centralClaimEligible": false,
        "permittedUse": "Indirect support for controlled back thermography methods, transient post-exercise surface-temperature asymmetry, temporal variability, and the need to distinguish relative side difference from absolute pre-post change.",
        "prohibitedUse": "Direct evidence of spontaneous localized back warmth or burning, a patient-level subjective-objective association, deep-muscle temperature, diagnosis, injury detection, clinical screening, prevalence, mechanism, safety redirection, or treatment selection."
      },
      "verifiedPassages": [
        {
          "passageId": "PV-35324650-SAMPLE-DESIGN",
          "locator": {
            "section": "Abstract and 2. Materials and Methods",
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            "table": "Table 1"
          },
          "evidenceLayer": "sample and design",
          "verifiedContent": "The one-group pre/post/follow-up pilot enrolled 41 participants (22 male, 19 female), aged 19 to 34 years with mean age 22.63 years. The reported power calculation targeted at least 31 participants, but only 33 of the initial 41 were retained for final analysis after exclusions for protocol performance, premature termination, image obstruction by a sports bra, or failure to attend all three measurements. The article does not report a control group or substantive health-status eligibility criteria.",
          "supports": "The source concerns a small, young volunteer sample under an experimentally imposed exercise condition.",
          "doesNotSupport": "It does not characterize patients with recurrent localized back heat, establish population representativeness, or separate the effect of exercise from secular or repeated-measure effects using a non-exercising control group."
        },
        {
          "passageId": "PV-35324650-CONTROLS",
          "locator": {
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          "evidenceLayer": "pre-measurement and environmental controls",
          "verifiedContent": "Participants were instructed to avoid intense activity and substances described by the authors as drugs, with caffeine and alcohol as examples, for 48 hours and to avoid large amounts of food or water for 2 hours. After upper-body clothing removal, they acclimatized seated for 10 minutes. The room was set to 20 degrees Celsius, with relative humidity 40%, wind speed 0 metres per second, and solar radiation 0 watts per square metre. Body composition was measured during acclimatization.",
          "supports": "Back thermography was obtained under specified laboratory and preparation conditions that materially constrain comparison with uncontrolled real-world measurements.",
          "doesNotSupport": "The instructions do not verify adherence, control daily oscillation, or establish that the same conditions would hold during a spontaneous symptom episode."
        },
        {
          "passageId": "PV-35324650-PROVOCATION-TIMING",
          "locator": {
            "section": "2. Materials and Methods",
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          "evidenceLayer": "experimental provocation and timing",
          "verifiedContent": "Participants performed Roman-chair side bends in 20-repetition sets at a metronome-controlled one second up and one second down. The treated side was contralateral to handedness, and exercise continued until prespecified performance-failure or exertion criteria, including an OMNI score of at least 8. Thermograms were taken before exercise, 10 minutes after exercise, and approximately 24 hours later. Sweat was removed when it occurred and about every two minutes before imaging.",
          "supports": "The observed temperature pattern is tied to a deliberate, intense unilateral trunk-exercise challenge and a specific 10-minute post-exercise window.",
          "doesNotSupport": "The protocol does not model an unprovoked, recurrent, variably timed heat or burning sensation, and the study did not image the immediate period before 10 minutes or the reported 48-hour soreness peak."
        },
        {
          "passageId": "PV-35324650-ROI-MEASUREMENT",
          "locator": {
            "section": "2. Materials and Methods",
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            ],
            "figure": "Figure 2"
          },
          "evidenceLayer": "regions of interest and measurement reporting",
          "verifiedContent": "A NEC TVS-200 ISS camera and InfReC Analyzer NS9500 Lite software were used. Cork markers at Th12, both posterior superior iliac spines, both costal arches, and both iliac crests supported repeat placement. Four rectangular dorsal regions represented upper and lower treatment-side and non-treatment-side back; four analogous ventral regions were also defined. Mean skin temperature per region per image was analysed, and left-handed participants' data were inverted to align treatment-side categories. The article does not report camera accuracy, thermal sensitivity, image resolution, emissivity, camera distance or angle, calibration, assessor blinding, measurement repeatability, or a smallest detectable or clinically meaningful difference.",
          "supports": "The paper defines regional mean surface-temperature comparisons anchored to anatomical markers and harmonized by treatment side.",
          "doesNotSupport": "It does not establish measurement precision, within-person repeatability, a diagnostic asymmetry threshold, exact symptom localization, or bilateral anatomical side effects because handedness inversion removes native left-right direction."
        },
        {
          "passageId": "PV-35324650-BACK-RESULTS",
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            "table": "Table 2"
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          "evidenceLayer": "objective back-temperature results and counterevidence",
          "verifiedContent": "All four back-region means were lower at 10 minutes post-exercise than at baseline and approximately 24 hours, while baseline and follow-up did not differ in post hoc testing. Table 2 reports upper treatment-side means of 31.48, 30.42, and 31.44 degrees Celsius at pre, post, and follow-up versus 31.48, 29.88, and 31.48 on the upper non-treatment side; lower treatment-side means were 31.38, 30.04, and 31.22 versus 31.43, 29.72, and 31.26 on the lower non-treatment side. Thus, the treated back was relatively warmer than the untreated back at 10 minutes, by 0.54 degrees Celsius upper and 0.32 degrees Celsius lower from the reported group means, despite both sides being cooler than baseline. Post-exercise upper and lower side comparisons were reported as statistically significant, while no side asymmetry was reported before exercise or at follow-up.",
          "supports": "A transient relative side asymmetry can coexist with an absolute bilateral temperature fall after exercise, and the asymmetry was absent at the other measured times.",
          "doesNotSupport": "Relative warmth of one exercised side does not mean objective heating above baseline, subjective warmth, deep-muscle heating, persistence, pathology, diagnostic localization, or clinical importance. The 0.54 and 0.32 degree differences are transparent calculations from reported group means, not author-defined thresholds."
        },
        {
          "passageId": "PV-35324650-SUBJECTIVE-DISCORDANCE",
          "locator": {
            "section": "2. Materials and Methods, 3. Results, and 4. Discussion",
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          "evidenceLayer": "subjective measures and temporal discordance",
          "verifiedContent": "The study collected general POMS fatigue and seven-point delayed-onset muscle soreness rather than localized warmth or burning. It reports average exercise exertion and fatigue/soreness scores but no participant-level or region-level association between those ratings and thermographic back temperature. The authors note that soreness was highest at 48 hours, whereas thermography was not performed then; at about 24 hours, back temperature had returned near baseline.",
          "supports": "The subjective and objective constructs and their measurement times were not aligned well enough to establish a symptom-temperature relationship.",
          "doesNotSupport": "The paper cannot show that felt fatigue, soreness, warmth, or burning covaries with back skin temperature or that a normal thermogram excludes a subjective symptom."
        },
        {
          "passageId": "PV-35324650-LIMITS",
          "locator": {
            "section": "3. Results, 4. Discussion, and 5. Conclusions",
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          "evidenceLayer": "interpretive, reporting, and generalizability limits",
          "verifiedContent": "The authors explicitly state that infrared thermography measures body-surface temperature, which is shaped by skin blood flow and sweat activity, and that temperature change cannot be directly inferred from the activity of deep trunk muscles. They identify body-fat distribution, training condition, daily oscillations, possible exercise-form error, and laboratory-to-real-world transfer as limitations. The reported final-analysis count is 33, yet the post-exercise asymmetry tests report n=35 for back and n=34 for abdomen without explaining the discrepancy. The conclusion proposes possible diagnostic and rehabilitation applications and calls for comparison with EMG, but the study supplies no clinical comparator, diagnostic-accuracy analysis, injury outcome, or validated threshold.",
          "supports": "Surface, depth, context, precision, analysis-denominator, and external-validity limits must accompany any use of the observed asymmetry.",
          "doesNotSupport": "The authors' proposed applications do not establish diagnostic validity, screening benefit, causal muscular localization, injury prevention, rehabilitation efficacy, or clinical use for recurrent localized back heat."
        }
      ],
      "interpretation": {
        "directlySupported": [
          "Under controlled laboratory conditions, a unilateral trunk-fatigue challenge produced a transient side difference in mean back skin-surface temperature 10 minutes later.",
          "Both treatment and non-treatment back regions were cooler than baseline at the post-exercise measurement; the treatment side was only relatively warmer than the non-treatment side.",
          "No back asymmetry was reported at baseline or approximately 24 hours, when region means were near baseline.",
          "The study measured general fatigue and delayed soreness, not spontaneous localized warmth or burning, and did not test their association with regional temperature."
        ],
        "hypothesesOnly": [
          "Skin-blood-flow, sweat-gland, systemic inflammatory, cross-training, training-status, body-fat, or exercise-form explanations for the observed pattern.",
          "Any relationship between experimentally provoked surface-temperature asymmetry and recurrent spontaneous localized back heat or burning.",
          "Any diagnostic or rehabilitation value of the observed asymmetry."
        ],
        "clinicalImplication": "None established for isolated recurrent localized back heat. The study is useful chiefly as a measurement caution: objective skin-surface temperature depends on preparation, environment, timing, region definition, exercise, sweating, and body composition, and relative side difference must not be confused with heating above baseline or with subjective sensation.",
        "constructBoundary": "Objective infrared skin-surface temperature is not deep-muscle temperature, spontaneous perceived warmth, burning pain, evoked thermal threshold, fatigue, soreness, or a diagnosis. A statistically significant group side difference is not a validated individual abnormality threshold."
      },
      "claimsNotEstablished": [
        "That recurrent localized back heat or burning is accompanied by elevated skin-surface temperature.",
        "That subjective warmth, burning, fatigue, or soreness tracks regional thermographic temperature.",
        "A normal range, repeatability estimate, precision bound, clinically meaningful difference, or diagnostic asymmetry threshold for back thermography.",
        "Deep-muscle temperature, causal muscular localization, injury detection or prevention, diagnostic accuracy, treatment selection, rehabilitation efficacy, prevalence, or safety redirection.",
        "Persistence beyond the measured 10-minute post-exercise window or a 48-hour thermographic pattern.",
        "Native left-right asymmetry, because data were reoriented into treatment-side categories.",
        "That the reported post-exercise inferential denominators are consistent with the stated 33-person final analysis."
      ],
      "unresolvedBlockers": [],
      "nextWorkUnit": "Verify T1-SAFETY-NG127 as one bounded passage-verification unit from the frozen official guideline PDF, focusing on exact population and symptom context, associated neurological findings, urgency and referral wording, exceptions, evidence basis, and the explicit non-finding that isolated recurrent back heat is not itself an established redirect."
    }
  ]
}