Autologous iliac crest bone grafting is an integral part of many orthopaedic surgical procedures. Several studies have documented morbidity and prolonged pain following iliac crest bone graft harvesting in adults; however, in children there is a paucity of information. The purpose of the present study was to quantify the degree of pain and morbidity associated with anterior iliac crest graft harvesting in children undergoing non-spinal orthopaedic surgery.Patients were prospectively enrolled prior to orthopaedic surgery. A patient self-reported visual analogue score was used to record pain at specified time points following surgery. In addition, the patients were reviewed at 2 and 6 weeks, 3 months and 1 year after surgery to record any complications.Data was collected on 33 patients (34 graft sites). Only one patient (2.94 %) had a complication, namely an injury to the lateral femoral cutaneous nerve. This resolved 3 months after surgery. 89 % of patients had no pain at the iliac crest graft harvest site 3 months after surgery. The three patients who had pain at 3 months had visual analogue scores of 1.0, 1.1 and 1.3, respectively.This series reveals a very low complication rate and minimal iliac crest graft harvest site pain in children undergoing non-spinal orthopaedic surgery. In addition, the pain experienced is short-lived. Bone grafts are used in orthopaedic surgical procedures to provide support, fill voids and promote healing. The iliac crest remains the preferred donor site when an autograft is used, as it provides good quantities of cortical and cancellous bone, is easy to access and possesses osteogenic, osteoconductive and osteoinductive properties , 2.The morbidity associated with harvesting iliac crest bone grafts in adults is well documented , 4. PoteIn children there is a paucity of data. A few studies have reported the complications associated with harvesting iliac crest bone grafts for spinal procedures, although they used the posterior crest as a donor site, which has slightly different morbidities associated with it. In addition, it is more difficult to evaluate pain when the posterior iliac crest is used as the donor site in spinal surgery , 13–15.Reports examining the anterior iliac crest have focused on facio-maxillary surgery , 17.Furthermore, the majority of studies in both the adult and paediatric populations have been retrospective and do not provide a true representation of the complications and pain levels associated with harvesting anterior iliac crest bone grafting.In view of this, we undertook a prospective evaluation of the morbidity associated with harvesting anterior iliac crest bone grafts in children undergoing non-spinal orthopaedic surgery.After obtaining local ethics committee approval, we undertook a prospective review of all patients requiring anterior iliac crest bone grafting as part of their orthopaedic surgical procedure at the Sheffield Children’s Hospital between August 2012 and October 2013.Patients who were due to have iliac crest bone grafting as part of their surgical treatment were identified from the surgical waiting list. The patients and their parents were then approached by one of us (AC) at the pre-operative assessment clinic and considered for entry into the study. Exclusion criteria included patients who were aged <7 years, had previous iliac crest graft harvesting, a history of congenital insensitivity to pain and learning difficulties.Children aged <7 were excluded on the advice of the pain management team based on evidence that they would not be able to fill in the visual analogue scale (VAS) correctly. Out of 43 patients identified, 33 met the inclusion criteria and agreed to participate in the study. The patients consented after being provided with verbal and written information on the study. There were 11 females and 22 males with ages ranging from 7 to 16 years (mean 12 years).A 10-cm VAS questionnaire was given to the patients on the morning of their surgery. They were expected to fill it in before surgery and then again at several specified time points afterwards, up to and including 3 months after surgery. The scale ranged from ‘0 = no pain at all’ to ‘10 = worst pain ever’. Two scales were provided for each time point: one for the hip and one for the recipient site . The anaesthetic administered and the medication for managing post-operative pain were similar for all patients.The iliac crest bone graft was harvested utilising a skin incision along the ‘bikini line’ and a standard apophyseal splitting approach. The donor site was infiltrated with local anaesthetic and adrenalin prior to harvesting. The graft harvested depended on the indication. Wound closure was with deep dermal and sub-cuticular absorbable sutures. No drains were used.Patient demographics including age, sex, body mass index (BMI), diagnosis, presence of co-morbidities, procedure requiring bone graft, type of graft harvested, length of iliac crest wound, intra-operative complications and length of hospital stay were recorded.On discharge from hospital the patients were given a week’s supply of pain-relieving medication and were seen in the outpatient clinic at 2 and 6 weeks and 3 months after surgery. At these visits any complications and their progress were recorded. They were asked about the need for additional pain medication. Their questionnaires were collected for analysis after their 3-month review.All 33 patients (34 iliac crest sites) recruited were available for review at the final follow-up, though only 27 questionnaires were fully completed, giving a response rate of 81.8 %. One patient had bilateral non-simultaneous surgery.p values was used to compare the pain recorded over time to the baseline measurement.The results were analysed statistically using IBM SPSS Statistics for Windows, version 19.0. A Friedman analysis followed by post-hoc Wilcoxon signed-rank tests using Bonferroni-adjusted The relationship between pain at the iliac crest and pain at the recipient site was also investigated using Pearson’s product moment correlation coefficient, following verification of assumptions.The mean length of hospital stay in all patients was 1.5 days (range 1–5 days) and the mean length of the iliac crest wound was 4.88 cm . All wounds had healed by the 2-week outpatient review.Out of the 33 patients (34 iliac crest sites) included in the study, only one patient had a complication (2.94 %). This patient had numbness over the lateral aspect of the thigh, in keeping with lateral femoral cutaneous nerve (LFCN) injury. The numbness resolved 3 months after surgery.In this patient, like all other patients, the graft was harvested using a standard apophyseal splitting approach through a ‘bikini-line’ incision over the iliac crest. The graft was required for a lateral column lengthening procedure to correct flat foot deformity.The VAS score at the iliac crest (donor site) increased from baseline before peaking 2 days after the operation and then decreasing. Figure Further analysis was undertaken to provide a time to VAS = 0 or ‘no pain at all’. All patients who did not record a VAS score of 0 were censored at the 3-month point (11 % of patients). The results of the analysis showed a median time to VAS = 0 of 21 days .2  = 161.907, p = 0.00.Neither the results nor the residuals of the VAS scores at the various time points were normally distributed. A non-parametric Friedman test was therefore used to investigate the change in VAS score from the baseline to the different time points used in the study. The results of this analysis showed there was a statistically significant difference in VAS score for the iliac crest across the various measurement points: Xα value was used (p = 0.00625) to control for Type 1 errors , 6 weeks after the operation  and 3 months after the operation .The table shows there was no statistically significant difference between pain at the hip (iliac crest) at baseline and at 4 weeks after the operation  for which the graft was harvested.n = 16), other corrective osteotomy and fixation (n = 4) and other lower limb procedures requiring bone grafting (n = 7). The mean VAS was significantly lower for patients undergoing corrective osteotomies and fixation compared to those undergoing a flat foot procedure or other lower limb procedure requiring a bone graft.The procedures were grouped into three categories: flat foot procedure   complications in 6449 adults requiring iliac crest bone grafts [The rates of minor complications in the adult population are documented at between 6 and 39 %, while major complications are between 0.7 and 25 % [The incidence of lateral femoral cutaneous nerve (LFCN) injury has been reported to range between 1.7 and 31 % following iliac crest graft harvesting , 20–22. Bierne et al. documented a 1.3 % incidence of LFCN injury in 137 patients (age 8–29 years). The low incidence led them to recommend the use of a ‘bikini-line’ incision (placing the skin incision 1 cm behind the anterior superior iliac spine) . This meThe mean surgical scar length of 4.8 cm in our study is intermediate to that reported in other series using anterior iliac crest grafting. Cohen et al. reported a mean scar length of 4.0 cm, Swan et al. 6.0 cm and Laurie et al. 7.0 cm , 21, 24.The visual analogue scale is a validated and commonly used pain scale, suitable for children aged 7 years and over –27, hencThe current study found that severe pain outside the immediate post-operative period was not common. Only three (11.1 %) patients had pain at 3 months and of these three none reported pain >1.3 on the VAS. No patient had pain 4 months after surgery. This is extremely favorable compared to other reports in the paediatric literature , 14, 17.Retrospective reviews by Skaggs et al. noted that 24 % of patients reported pain up to 4 years after harvesting a posterior iliac crest graft for spinal surgery while Swan et al. observed that 7 % of their patients had pain that resolved 6 months after an anterior iliac crest graft was harvested , 17.Though Kager et al. in a prospective review using posterior iliac crest graft for spinal surgery reported that none of the patients had a pain score of more than 3, they stated that 13 % had pain at 1 year, 6 % at 2 years and 12 % at 3 years .Our results also suggest that paediatric patients are pain-free on average sooner than adult patients. Whilst none of the patients in our study had pain at 4 months, reports in the adult literature quote pain levels in 39 % of patients at 3 months, 38–42 % at 6 months and 19–21 % at 2 years after surgery , 28.The positive correlation between pain at the iliac crest and that at the recipient site could be due to the patient’s own perception of pain. It is known that during surgery pain signals generate a secondary inflammatory response, which contributes to post-operative pain. This so-called ‘spinal wind-up’ process can result in a state of post-operative hypersensitivity to pain, due to a combination of peripheral sensitisation due to surgical trauma and central sensitisation due to increased activity of spinal neurons. This could explain the findings of this study, as patients with an increased sensitivity to pain following surgery would be likely to report this at all sites , 29. ThiInherent issues with the retrospective studies quoted mean that the results need to be interpreted with a degree of caution considering the potential impact of bias and other confounding factors. The prospective nature of the current study means that pain can be assessed more reliably without the recall bias that retrospective studies are prone to.The limitations of this study are that the numbers are small and increasing the study size would increase confidence in its findings. Like all previous studies on this subject, the patient’s ability to accurately record pain is also a limitation, especially in younger patients, as pain is a subjective phenomenon that can only be characterised by the patient.The low post-operative pain level and complication rate of this study supports the continued use of anterior iliac crest bone grafts in children undergoing non-spinal orthopaedic surgery requiring bone grafting. In addition, the results of this study are a useful guide in the consenting process for bone graft surgery.


Our objective was to conduct a pilot study of a 9-week group compassion cultivation intervention in chronic pain to examine its effect on pain severity, anger, pain acceptance and pain-related interference. We also aimed to describe observer ratings provided by patients’ significant others and secondary effects of the intervention.The emergence of anger as an important predictor of chronic pain outcomes suggests that treatments that target anger may be particularly useful within the context of chronic pain. Eastern traditions prescribe compassion cultivation to treat persistent anger. Compassion cultivation has been shown to influence emotional processing and reduce negativity bias in the contexts of emotional Pilot clinical trial with repeated measures design that included a within-subjects wait-list control period. Twelve chronic pain patients completed the intervention (F= 10). Data were collected from patients at enrollment, treatment baseline and post-treatment; participant significant others contributed data at the enrollment and post-treatment time points.In this predominantly female sample, patients had significantly reduced pain severity and anger and increased pain acceptance at post-treatment compared to treatment baseline. Significant other qualitative data corroborated patient reports for reductions in pain severity and anger.Compassion meditation may be a useful adjunctive treatment for reducing pain severity and anger, and for increasing chronic pain acceptance. Patient reported reductions in anger were corroborated by their significant others. The significant other corroborations offer a novel contribution to the literature and highlight the observable emotional and behavioral changes in the patient participants that occurred following the compassion intervention. Future studies may further examine how anger reductions impact relationships with self and others within the context of chronic pain. Chronic pain affects an astounding 100 million Americans - causing suffering for the individuals afflicted, their families, and significant others. Chronic pain also exerts a significant financial burden on the U.S. economy, costing over half a trillion dollars annually ,3. As suAnger is an important emotional correlate of chronic pain ,14–25, wCompassion is the experience of perceiving suffering and wishing to alleviate that suffering. We selected compassion meditation because compassion – which this meditation is meant to train – is shown to increase psychological well-being and interpersonal relationships. Compassion is linked to less judgmental views of others , greaterStrengthening compassion is not a new concept in Eastern contemplative traditions, which have meditation practices devoted specifically to cultivating feelings of loving-kindness and compassion. Through the recognition of a common humanity, these practices involve the development of feelings of love and compassion that are directed to the self, others, and ultimately towards all beings . DespiteCompassion meditation is based on broader, general meditation practices, which have been shown to be effective for reducing a wide variety of negative cognitive and emotional state–and psychopathology such as anxiety and depression ,39. MediIn compassion meditation training participants learn to experience feelings of compassion while meditating on various relationships . Accordingly, the intention of compassion meditation training is to increase a person’s capacity to experience compassion for themselves, others, and the world . Compassdepressed individuals and those with chronic pain [Indeed, prior work on interpersonal relationships has shown heightened distress and marital dissatisfaction in the spouses of people with chronic pain . The marnic pain . As suchWe found only one study that examined the effect of a compassion-based intervention – loving-kindness meditation training—on chronic pain . In thisa would be corroborated by significant other report [The purpose of this pilot study was therefore to investigate whether a general compassion cultivation intervention—devoid of pain didactics – would improve pain, anger, and pain acceptance in individuals with chronic pain, and to test whether improvements would be corroborated by the 3rd person observation of their significant others. Our primary hypothesis was that compassion cultivation in individuals with chronic pain would result in reduced pain intensity and anger. We also hypothesized that the intervention would associate with reduced pain-related interference in various life domains and increased pain acceptance. Finally we hypothesized that reductions in anger and pain interference in individuals with chronic painr report .In this pilot study we used a within-subjects, wait-list control with repeated measures design to characterize the effects of a compassion meditation intervention on chronic pain patients and their significant others. A link to an online questionnaire was emailed to all patients at three time points: at enrollment, after a 5-week post-enrollment waiting period (treatment baseline), and again after completion of the 9-week compassion training course (post-treatment); see During the 5-week waiting period, patients were instructed to simply “live their lives as they normally would”. This design allowed patients to serve as their own wait-list controls. Lack of significant differences between enrollment and treatment baseline time points would lend confidence that any observed post-treatment changes would be attributable to the compassion intervention rather than to time effects . To produce a rich and maximally informative dataset, we utilized a mixed-methods approach including both quantitative questionnaire data and qualitative interview and survey data.Interviews were conducted in-person at the enrollment visit and surveys were administered online at treatment baseline and post-treatment following the last compassion class (described below). The patients’ significant others completed interviews at the same time points as the chronic pain patients. Significant others were not allowed to attend the compassion cultivation intervention because we were specifically interested in the observer reports of the significant others, and in any secondary effects of the compassion intervention. The study was approved by the Stanford University Institutional Review Board (IRB). All patients and patients’ significant others provided written, informed consent as approved by the IRB.Patients with chronic pain (N = 119) were contacted from a database of individuals with chronic pain that had previously expressed interest in research participation at the Stanford Systems Neuroscience and Pain Lab. Patients were asked to identify a significant other to participate with them in the study – someone with whom they had a close relationship and interacted with frequently . Patients then asked their significant others to contact the lab to be screened over the phone and schedule a time to attend an initial information session with their chronic pain study partner. Significant others were included if they were 18 years of age or older and excluded if they were diagnosed with a major psychiatric disorder, reported having a substance abuse problem in past 24 months, or had prior compassion meditation training. All significant others of the enrolled patients were eligible and provided informed consent . Only the significant others of patients who were retained in the study were included in the final analysis . Significant others’ demographics and relationships to the patients are shown in The significant others did not receive the compassion cultivation intervention. Rather, the role of the patients’ significant others was to provide pre- and post-treatment observer information about their chronic pain patient partners.All enrolled chronic pain patients and their significant others each received $35 at the initial information session and were mailed $50 checks after completion of the last battery of questionnaires and final post-course survey questions. In addition, the chronic pain patients received the Compassion Cultivation Training (CCT) course at no cost to them.Chronic pain patients attended a standardized 9-week CCT course developed by Stanford’s Center for Compassion and Altruism Research and Education (CCARE). The intervention was delivered to all patients simultaneously in a single class cohort. An experienced CCT instructor who was certified through CCARE’s instructor training program taught the course. To ensure that no pain didactics were delivered during the class, the instructor selected for the study had no formal pain training or background delivering the intervention to patients with chronic pain.not allowed to attend the course with the patients, and patients were asked to not share with their significant other any material from the class .The course involved weekly 2-hour class meetings that included didactics specific to compassion meditation practices, in-class meditation practice, and small and large group discussions. Patients were also given a CD containing all of the guided meditations. A class website provided an optional forum for patients to discuss their experiences involving their in-class or at-home practice. The instructor posted on the website audio recordings of meditations that were themed for the week and any materials that were discussed in class. The website was available only to the patients and no data were collected from their in-class or online discussions. Significant others were As a foundation for compassion meditation training, the first 2 classes involved basic instruction in mindfulness meditation. The compassion meditation training began in week 3 with a practice centered on cultivating feelings of compassion for someone with whom they had a close relationship. Weeks 4 and 5 were devoted to developing self-compassion, week 6 to developing compassion for strangers, and week 7 focused on cultivating compassion for difficult people through the recognition of a common humanity. In week 8, chronic pain patients were taught a “Tonglen” meditation practice, in which they learned to imagine taking in suffering  on the in-breath and release suffering on the out-breath. The class closed in week 9 with suggestions on how to continue to integrate compassion practices into their daily lives. Over the 9-week period, patients were asked to keep a daily online record tracking the number of minutes of meditation they practiced. Patients were provided additional, optional homework exercises related to the compassion theme each week (e.g. writing a compassionate letter to oneself).The Patient Reported Outcomes Measurement Information System (PROMIS) Anger Scale [short form, All pain-specific measures are validated and widely used in chronic pain research. Pain severity was calculated as an average of four questions of the Brief Pain Inventory short form BPI,  in whichPain Interference was also measured by the Brief Pain Inventory Short Form . Seven iPain acceptance was measured with the Chronic Pain Acceptance Questionnaire , a 20-ithttp://www.qualtrics.com/) which meets the Health Insurance Portability and Accountability Act (HIPAA) compliance standards.Patients and significant others were asked to refrain from discussing their survey responses with one another. All questionnaires were presented in random order for all patients. Questionnaires were distributed and completed through the Stanford University online survey system The significant others were asked to rate how much they expected the course would improve their partner’s pain  and their partner’s quality of life . Open-ended questions asked significant others about their past meditation experience and any current meditation practices.Immediately following the last class, all patients were emailed a link to the online post-treatment survey that consisted of both quantitative and open-ended questions. Patients were asked to rate on a 0–10 scale how much they thought the course improved their pain and quality of life . If they rated > 0 improvement, patients were then asked open-endedly which aspects of their quality of life they felt were changed as a result of the compassion intervention. Additionally, patients were asked whether they thought the intervention changed the way they relate to themselves, to their significant others, and to the outside world, and if so, to provide examples.Immediately after their partner completed the compassion intervention, each significant other received a link to the post-treatment survey. Significant others were asked to rate how much they thought the course improved their chronic pain partner’s pain and quality of life . If they rated > 0 improvement, they were asked open-endedly which aspects of their partner’s life were improved by their chronic pain partner having participated in the compassion intervention. Finally, they were asked whether they observed changes in the way their patient partner related to themselves, to them (the significant other), or to the outside world, and if so, to provide examples.One-way repeated measures analysis of variance (RM-ANOVA) tests were conducted for each questionnaire using SAS Version 9.4  with time as the repeated measures factor. Where significant main effects were found, post hoc paired t-tests were calculated to determine which time points differed significantly . The primary outcome measures were BPI Pain Severity and PROMIS Anger, with BPI Pain Interference and Pain Acceptance as secondary outcomes. Pearson correlation was used to examine relationships between time spent in compassion meditation and the change in score from pre-course to post-course of the primary and secondary outcomes. In regression analyses, time spent in compassion meditation was examined as a predictor (process) variable. Secondary outcomes were corrected for multiple comparisons using a False Discovery Rate correction . All other measures were exploratory and were not corrected for multiple comparisons given the small sample size. Technical difficulties prevented the Pain Acceptance questionnaire from displaying properly in the online system at baseline for half of the patients. Therefore, a paired t-test was conducted to determine changes in pre- to post-course Pain Acceptance because data was available for all 12 patients at both of these time points.No differences were found between participants who completed the study and those who withdrew or were withdrawn in terms of our primary measures .Change scores were calculated for the primary and secondary outcomes by subtracting pre-treatment scores from post-treatment scores. Subsequently, Pearson product–moment correlation coefficients were computed to assess the relationship between total minutes spent in compassion meditation and the change scores See . A positDuring the enrollment interview, 50% (N = 6) of chronic pain patients reported having some past meditation experience (ranging from listening to meditation podcasts to attending a meditation course or retreat), 42% (N = 5) reported having other experiences they considered to be related to meditation , and 8% (N = 1) reported having no previous meditation experience. No patients reported having a consistent formal meditation practice at the time of the interview. For the treatment expectancy measure, patients reported moderate expectations for improvement in pain  and quality of life . Expectations for improvement in pain were significantly correlated with the change in pain acceptance score  and the change in PROMIS Anger score . In addition, expectations for improvement in quality of life were correlated with the change in PROMIS Anger score  See .Patients reported that the course improved their pain to a moderate degree  and quality of life to a similarly moderate degree . Patient responses to open-ended post-treatment survey are summarized in Fifty percent (N = 6) of patients’ significant others reported having some past meditation experience (ranging from meditating at the end of yoga classes to studying with Tibetan and Japanese Buddhist priests for 3 years). Similar to the patients, on average the significant others had moderate treatment expectations for their chronic pain patient partners for improvement in pain  and quality of life .Overall the significant others observed moderate improvement in their partner’s pain  and quality of life  post-treatment. The significant others’ ratings for post-treatment improved quality of life in their chronic pain partner was correlated with the change in PROMIS Anger score . No other correlations between significant other’s ratings for post-treatment improved quality of life in their chronic pain partner and outcomes were significant.Our results indicated that greater change in anger for the chronic pain patients’ correlated with significant others’ ratings for post-treatment improved quality of life in their chronic pain partners .In chronic pain, anger has been shown to have negative effects on pain severity ,16, painThe study yielded some unique preliminary findings. First, we found that the compassion intervention was associated with post-treatment reductions in pain severity for chronic pain patients that were moderate in effect size and clinically important in magnitude . Our smaWe also found that the compassion intervention was associated with a 25% reduction in anger (p = 0.01); IMMPACT guidelines for clinical importance classify this level of reduction as important but in the minimal range . It is pWe found that people who underwent the compassion intervention had increased pain acceptance at post-treatment, and highlight this as a variable for consideration in larger studies that may allow for modeling and mediational analyses.Unlike prior compassion intervention research , the CCAPatient reported reductions in anger at post-treatment were qualitatively corroborated by several of the significant other statements. While none of the significant other questions specifically asked about anger, it emerged as a major theme with significant others offering unsolicited descriptions about anger in their chronic pain partners in the open ended interview/survey. For example, several significant others mentioned the anger of the chronic pain patients in the baseline interviews . In the post-treatment survey several significant others commented on anger reductions in their chronic pain partners . As stated earlier, the spontaneous observer reports for reduction in anger lend strength to the associations detected in the patient quantitative data.Another strength of the study was the repeated measures design, with patients serving as their own wait-list controls. A clear lack of change in our variables of interest over the wait period (baseline compared to pre-course ratings) coupled with significant changes observed after the intervention (baseline compared to post-course ratings) lend confidence that the post-course changes were related to the intervention rather than regression to the mean.Several limitations merit consideration. First, this was a small pilot study and thus we were likely underpowered to detect some effects that might emerge in a larger study. Another limitation was the lack of an active control group. We were therefore not able to distinguish the effects of compassion intervention from non-specific effects, such as positive effects of social interaction, social support or learning a new skill. For greater generalizability, future studies will also benefit from a larger and more representative sample size with a more balanced gender and ethnic distribution among patients and their significant others. Our relatively high attrition (50%) may be related to the unique challenges faced by people with chronic pain. Compared to those with other disorders , patients with chronic pain have been shown to be less likely to complete similar 8-week meditation programs . We founChronic pain imparts substantial psychosocial burdens to the individuals and their loved ones, thus underscoring the need to develop treatments that address these factors. Results from this pilot study provide preliminary evidence that a compassion cultivation intervention may reduce pain severity and anger and increase pain acceptance in patients with chronic pain. Despite the rich history of these established practices in contemplative traditions, compassion training is a relatively new area of study in the Western world –57,69–75


Pain or fears about future pain is one of the main reasons for medical consultation. Patients and families use to believe that Cobb angle and back pain are linearly related. The relationship between scoliosis magnitude, HRQL and Self Perception of Trunk Deformity is not clear. To better understand this, a prospective data collection including age, main thoracic and lumbar or thoracolumbar Cob angle, Trunk Asymmetry Perception Scale TAPS, SRS-22 and current treatment was started involving all patients with idiopathic scoliosis attending a rehabilitation clinic, 10 years of age or older at the time of consultation. The data have been retrospectively analyzed and are presented in several studies. This is the study I.The aim of this study was to analyze the relationship between back pain (SRS-22 Pain), curve magnitude and TAPS.N=240; mean age 19.3 y + 10.3 (10-62), mean Cobb thoracic 33.7º + 13.8, lumbar or thoracolumbar 29.7 + 12.7. At the time of consultation patients were untreated or treated . The sub-population of untreated patients was also analyzed, N=76, mean age 19.6 y + 11.6, mean Cobb thoracic 28.2º + 14.8, lumbar 25.2º + 14.7. SPSS was used for statistics.In the whole sample there was no correlation between SRS-22 Pain and the Cobb angle of the main thoracic curve; a significant but weak correlation was found between SRS-22 Pain and Cobb Lumbar (r= -.22 p< .005), TAPS (r= .36 p<.001) and age (r=-.49 p<.001). In the sub-population of non-treated patients, SRS-22 Pain correlated with Cobb Thoracic (r= -.35 p= .01), TAPS (r= .43 p<001) and age (r= -.62 p>.001), but not with Cobb lumbar.Back pain is multi-factorial. Age and subjective perception of trunk deformity show both a stronger linear relationship with back pain than the Cobb angle. The weak linear relationship existing between back pain and thoracic Cobb angle in untreated patients disappear in the whole sample (untreated and treated patients) and the opposite for the Lumbar Cobb. Interpretation is complex trough out study I.


The treatment of patients with chronic pain disorders is complex. In the rehabilitation of these patients, coping with chronic pain is seen as important. The aim of this study was to explore the meaning of attachment and mindfulness-based cognitive therapy (CT) among patients with chronic pain and psychiatric co-morbidity. A phenomenological approach within a lifeworld perspective was used. In total, 10 patients were interviewed after completion of 7- to 13-month therapy. The findings reveal that the therapy and the process of interaction with the therapist were meaningful for the patients’ well-being and for a better management of pain. During the therapy, the patients were able to initiate a movement of change. Thus, CT with focus on attachment and mindfulness seems to be of value for these patients. The therapy used in this study was adjusted to the patients’ special needs, and a trained psychotherapist with a special knowledge of patients with chronic pain might be required. The treatment of patients with chronic pain disorders is complex  implies a patient-centered approach . Of those, 13 patients completed the therapy, one of those patients declined recording, one patient did not turn up at the interview, and one recording failed, resulting in 10 recorded interviews (nine women and one man). Those who did not complete the therapy only attended therapy session a few times, and were therefore not interviewed. The 10 patients interviewed were diagnosed with: Fibromyalgia (1), chronic wide spread pain (3), whiplash trauma (5), and chronic regional pain (1). Additionally, a psychiatric diagnosis according to DSM IV was present in these patients and the most common diagnoses were anxiety, mixed anxiety and depression, and maladaptive stress reaction. Earlier traumatic experiences were found in seven of the patients. The patients were aged between 32 and 60 years, with a mean age of 44, and all but one who worked 25% were on full-time sick-leave.The duration of the therapy was 7–13 months with individual sessions every second week as a rule. The therapy was carried out by the therapist/physician. The therapy focused on the patients’ experiences. In the therapy the patients were encouraged to narrate their life stories and their illness experiences. The physician/therapist listened attentively and when needed confirmed their stories in order to legitimize the patients’ feelings and thoughts about his/her illness. By means of open and Socratic questions the patients were guided to discover new perspectives and to restructure his/her thoughts D'Elia, . An actiQualitative semi-structured interviews were used for data gathering . We have complied with standards for the ethical conduct of research, including confidentiality and anonymity, and the study conforms to the Declaration of Helsinki. The participants filled in an informed consent before the start of the therapy, and their participation in the interview was voluntary and did not affect their future treatment or follow-up. After the interview, a further follow-up with the therapist was a rule.The essential meaning of participating in the therapy was an experience of creating meaning in life with chronic pain. In the interaction with the therapist the patients could gain trust and put words on difficult experiences and strange feelings, as well as to get an understanding of one's own situation. The therapy became a starting point for changes and managing life with pain in a meaningful way. In the therapeutic sessions the patients had an experience of being listened to and of being acknowledged. Depending on the individual's situation and circumstances, different strategies to handle and manage everyday life were found with support and trust from the therapist. To manage life with pain was hard but possible when there was a will to change. In the therapy the past was linked to the present and a movement toward something new could start. Living with chronic pain had been an experience of chaos. Before the therapy the patients experienced that they had reached a limit where they had no more strength to go on although they also had a desire to feel better. During the therapy the patients could find meaning in life with pain. The therapy and the process of interaction with the therapist were experienced as meaningful for the patients’ well-being and the management of their pain. The phenomenon and its essence is illustrated by its three meaning constituents: finding meaning in life with pain; feeling empowered when learning to let go and leave things behind; and building an understanding of one's body and symptoms.Living with chronic pain had negative consequences for the patients’ everyday life. When not being able to manage the pain, the patients gradually lost earlier roles and identity, and their pain had restricted their daily living. The experience of pain was something existential involving feelings and emotions difficult to manage and to express. In different ways the patients experienced the therapy as a way back to life. They could go from earlier chaos and despair back to a life they could cope with. By opening up for one's own feelings and to other persons, negative experiences and stressful thoughts could change. This was experienced as important in the patients’ way back to a more meaningful life.There was grief when I lost my roles, my professional role. I feel like a failure. I can't cope with that either. Somewhere inside you feel ashamed.Anne was born of a young mother and grew up with her grandparents. She always had high demands on herself. After a car accident 1999 when she was in her thirties she suffered from a whiplash trauma with persistent severe symptoms leading to disability pension. In the interview Anne described a way from having no foothold and being in the dark towards retrieving her previous roles as a mother, a wife, and a professional.I reacted strongly to certain situations, triggered by things that happened in my childhood. And I could see the associations between what happened and the way I have handled my life and my feelings. It was nothing wrong. I was brought up to be an independent person.She had long been a victim of her feelings, lacking tools to handle them. During the therapy she was able to narrate the story of her life, and in connection with her past experiences, her present feelings about not being able to handle her problems were more understandable for her.I had the answer how to do it but I could not take hold of it myself … I needed someone who pushed me in the right direction.Anne had a motivation and desire to find a way back to her previous life. She had many of the answers about how to do it but not the ability.At first it was very hard work, like throwing away your mask. I can now put words on feeling abandoned and deserted. My husband prefers that to just snubbing and hissing.And she began to feel free to open up also outside the therapy room to herself and to others.I see now that I will never get rid of my pain … it can be less or more. It is important to be allowed to talk and that you feel someone is listening. It is nothing odd to come here. It is, so to say, part of my health care and part of my way back. We have talked about focusing and breathing in order not to panic when travelling by car and sitting tensely on guard.John's life was also changed in a car accident more than 10 years ago. He was then 24 years old. Like Anne, he had a strong desire to get back to life as it was before the accident but in his case he gradually had to accept that it would not be the same and he needed to put words on these feelings. In doing so, he also had to work with his traumatic memories of the car accident when his car got hit by another car running out of control in bad road conditions. He had to handle his anxiety when driving or going by car.Like before I didn't know the limits of my body … and you were … you were active and then you felt frightfully ill and in pain perhaps a whole week. … You don't have to do that.John experienced pain as something restraining his freedom of movement. Pain was an obstacle that forced him over and over again to change direction.If someone just touches you with a cart when shopping you get angry and there is a misunderstanding. I have learned to stop and think a little. I can tell people, but more calmly.Also John found himself more open to his own feelings and towards other people. Instead of getting angry and building up tension inside his body it was easier to open up and communicate his feelings.Yes it is like a huge backpack and you can unload some bricks here and there … you leave them and it becomes much easier. You don't have to … I don't have to. It is a nice feeling. But now I think I don't have to do it today and maybe not even tomorrow.Before the therapy the patients had experienced that their former strategies to handle life had not worked, having difficulties to cope with their pain and problems. That made them feel confused and powerless. Before the therapy they had not been able to handle their situation, and the pain had restricted their life in various negative ways. In the therapy they were able to put words on their experiences, thoughts, and feelings. The interaction with the therapist was experienced as a secure base. Experiencing a mutual relation with the therapist seemed to give them strength and motivation. They were then able to find strategies to change their old patterns and to try something new. Leaving old things behind made their burden lesser. Mary experienced herself as captured in a spiral motion of pain, stress, and exhaustion; working with mentally retarded children. In leisure hours she always had been very active at home and helping others. After taking care of her parents before they died she felt exhausted and her brothers and sisters even accused her of being unfair and greedy. Still she went on working with disabled children until after a year or two she could not manage her pain in her back, arms, and neck. And she felt she was in need of help. “I told my doctor that I had to be referred for treatment with CT. He would not agree to that at first but I stood up for myself.” Until then she had not paid attention to herself. Her focus had been on the needs and wishes of other people. Earlier it was natural for her to finish her work and not leave anything for tomorrow but now she had learned to think in a different way.Those meetings with her, I think we have fun. It has given me something. My pain is still there but I can get rid of this stress and the heavy weight on my back and the whole body, there is a light ahead.Trying these new strategies gave her new hope and joy.In some patients, the pain along with illness and traumatic memories from childhood or later in life has disturbed the balance and natural flow of life, for example, feeling rigid or immobile. The patients experienced being strengthened when body and mind as well as past and present was integrated. There was a need of setting one's account and to accept life as it had become, which became possible in the therapy. From that base, the patients could view themselves in a new way and from there go on with their lives.I saw a person … being stuck in a certain way of thinking … yes … and I think that after that I have like started trying to look at myself in another way. I think that I have been self-destructive … yes … having a need to oppress … to push myself down in a way.Christine, a married woman 60 years old, had traumatic memories of her childhood and as a teenager, and she realized that those memories still affected her.In a way I think that the right questions are important in order to be able to move on. She has played things down … like everybody sometimes faces difficulties. And it will be no catastrophe if I leave the old things behind, even if it is sort of a safety. I must dare to try something new.In the therapy, she could feel a normalization of her earlier experiences and that it was safe to test new strategies leaving the old things behind.BP saw that I was depressed and wanted me to start medication … and she has said the whole time that I should start going for a walk … many had said so and I thought I had no energy … but when I started this medication I suddenly had the energy for walking.In addition to chronic pain, Christine also needed treatment for Parkinson's disease, and a moderate depression. There was a need for a comprehensive view of her situation and she experienced a new physical and mental flexibility and movement in her life.When the patients experienced that they could understand their body and symptoms in a meaningful way they could start a journey where to go from chaos to comprehensibility and manageability. Some of the patients had a varying degree of burnout in addition to their chronic pain. This often brought about a variety of bodily symptoms as well as bodily and mental exhaustion and anxiety. Their symptoms had become overwhelming and there was a need of explanation and to sort things out in order to manage their pain and to live a meaningful life. For some patients, their understanding of somatic symptoms was an important part in the therapeutic process.I lost my foothold and sense of reality … lost everything. I didn't think it would happen to me. I am used to always keep going … Everything happened all at once … millions of symptoms.Kate is in her late forties and is a mother of four children. Her youngest son is autistic, and two of the other children, like herself, suffer from multiple sclerosis. She had a traumatic childhood and always took responsibility for her brothers and sisters and now for her own family. A few years ago she was burnt out and lost control of her life. In addition to wide spread pain she was mentally and bodily exhausted. Before that, during her whole life, she had not taken notice of her bodily symptoms and not allowed herself to rest when she was tired.Thanks to her [the therapist] … such as … everything was straightened out. I can fit in all the facts … as to speak … so that there is nothing that suddenly appears … because then I lose control immediately … and that can't happen. I must be able to live a fairly good life anyway … as normal as possible with all symptoms in my body. I must face it, read about it and understand it. I feel good about coming here. Nothing has been negative and I haven't been told I am an idiot.Gradually Kate was able to get knowledge of her symptoms and sort them out and thereby started a process of normalization and acceptance. In the therapy, the control of her life was regained when being able to understand her body and symptoms.I don't have to go down to the basement when it is dark. I can do it the following day when it is light for example. I work with alternatives.She described that she has become more observant of signals from her body in her daily life vis-á-vis herself and others.I didn't dare go out for a walk or something … was afraid of collapsing. I wanted to talk to someone who knew about these symptoms and who could explain.Helen talked about her experiences of anxiety that had increased after she had to stop taking Tramadol, and her difficult social situation living with an alcoholic, her child's father. Her pain had started after a whiplash trauma 10 years earlier when she was in her thirties. When she started in therapy her anxiety and panic attacks prevented her from living a normal life.And I have been sitting here saying the same thing tens of times: Can you die from it? At first she told me that she did not think it was serious but she always checked it up in order to reassure me and I was satisfied with that. I had to do something myself in order to get better. But I have had to fight for more than a year and a half, but now it is worth it.In the therapy, Helen was able to talk about her anxiety and to get explanations and investigations of bodily symptoms. As she eventually felt safer and stronger, she was motivated to fight for a better life.Yes, we could go to bed without feeling afraid of him coming in and waking us up. The physical pain is not as painful as the pain in your soul. I think that I am more healthy now … and I could manage a half time job.When Helen managed to move with her child, away from the child's father, to her old apartment, she experienced a gradual improvement of her health. She then started to hope for a normal life even if she experienced a lack of trust in close relations.The CT used in the current study was found to be meaningful for the patients in everyday life and their well-being. The patients described it as meaningful to be seen and listened to, and that there was time for them to tell their story. In the narratives the patients’ experiences from the past were linked with the present and transformed into a new understanding. There was also a need for time and to find a secure base in the therapy from where to go from old to new strategies. Earlier these patients had not benefited from conventional pain treatment. In this study, the therapy was adjusted to their special needs, and led by a trained therapist and physician specialized in treating patients with chronic pain. The therapy used in this study was experienced as meaningful for the patients in finding ways to manage life with pain.In the present study many of the patients felt a lack of control and being in a chaotic situation because of lack of explanation of the origin of pain and other physical symptoms. They had a need to tell their story in order to handle the situation. In the literature, narrative construction can be a way for people to feel well in illness Frank, . In thisThe results revealed that patients with traumatic experiences might be very incoherent in their narratives and they needed time to gain trust. The therapist initially had a role of holding and normalizing feelings and symptoms. A majority of the patients had an insecure attachment pattern and many had traumatic experiences in childhood or as adults. This fact implied demands on the therapist to try to create a secure base in therapy from where the patient could feel safe to try new strategies, just like the small child exploring the world with its mother as a secure base Bowlby, . An adulFor all patients the therapy sessions also involved mindfulness training to learn to let go of stress and negative thoughts by focusing on breathing and presence in the moment. Hereby it can be possible to become an observer instead of a victim Kroese, . In the In the beginning of the therapy several patients reported that they had reached a limit where they had no strategies or means of handling their situation. They described a loss of power and energy. Former strategies to act and to achieve no longer worked. Those patients who left therapy prematurely mostly had lacked motivation and energy. Patients who carried through with their therapy had a need for time to make a change at their own rate. It was a question of holding and timing where the patients could feel safe and take their time to find the power and motivation for change. Similar to results in our study, Steihag et al.  have poiThe outcome of this study elucidates the experiences of this special group of patients with chronic pain and psychiatric co-morbidity. The strength of this study is that there is not much research done on this special group of patients with chronic pain and the results are supported by existing knowledge about treatment of patients with trauma and vulnerability. All patients did not complete the therapy. Of those who did, 12 were interviewed and 10 of these interviews were recorded. The interviews were rich in meanings and a phenomenological approach was found to be well suited. The analysis was performed by researchers with a multi-professional background with a broad experience of chronic pain and/or qualitative research, a fact which might have contributed to a holistic approach. In the interview group 9 of 10 were women, a gender distribution that is not uncommon in chronic pain patients (Fillingim, The patients in the current study had not benefited from conventional pain treatment. The primary aim of the therapy was to improve their well-being and ability to cope with their symptoms. The therapy was adjusted to the patients’ special needs. In line with Malterud and Hunskaar  we argueThe study concluded that the therapy and the process of interaction with the therapist were meaningful for the patients’ well-being and for a better management of pain. During the therapy the patients were able to initiate a movement of change. In the current group of patients, mainly women, life with chronic pain was experienced as a chaos and a loss of control and integrity. Many had reached their limits where they had no more strength to go on and old strategies were unsuccessful. In this phase it was important to them to feel that there was someone who listened to them, confirmed the legitimacy of their experiences, and that there was time to gain trust. For those who had strength and motivation, the therapy started a movement of change and this process looked somewhat different for each individual. There was a change in attitude towards oneself, pain, and relations to other people; meaningful for their well-being in everyday life. The CT used in this study was adjusted to the patients’ special needs and a trained psychotherapist with a special knowledge of treatment of patients with chronic pain might be required.


To determine the vision-related quality of life (VR-QOL) after surgery for macula-off rhegmatogenous retinal detachment (RRD) in relation to visual acuity, contrast acuity, and color vision.In a prospective observational study, we included 55 patients with a macula-off RRD. Best corrected visual acuity (BCVA), color vision (saturated and desaturated color confusion indices (CCI)) and contrast acuity were measured at 12 months postoperatively in both the RRD eye and the fellow control eye, and the 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25) was filled out.Operated and fellow control eyes differed significantly in mean LogMAR BCVA (P<0.0001), median Log contrast acuity (P<0.0001), saturated CCI (P = 0.009), and desaturated CCI (P = 0.016). Significant correlations were observed between the NEI VFQ-25 overall composite score and postoperative LogMAR BCVA , contrast acuity , saturated CCI , and desaturated CCI .A lower VR-QOL was highly correlated to a worse postoperative BCVA and contrast acuity and to a lesser extent to color vision disturbances. Rhegmatogenous retinal detachment (RRD), which refers to a detachment of the neurosensory retina from the underlying retinal pigment epithelium due to a defect in the retina Not only best corrected visual acuity (BCVA) is compromised in these cases, other aspects of central visual function are also compromised after macula-off RRD Previous studies identified a strong relation between postoperative visual function and post-operative vision-related quality of life (VR-QOL) as measured by the National Eye Institute Visual Functioning Questionnaire-25 (NEI VFQ-25) in patients operated on for various vitreoretinal disorders, including RRD We could not find previous studies addressing post-operative quality of life specifically in macula-off RRD patients in relation to BCVA, contrast acuity and color vision. Therefore, the purpose of the present study is to determine the postoperative VR-QOL after macula-off RRD one year after successful reattachment of the retina, and to assess which aspects of postoperative visual function  are most closely related herewith. In addition, we evaluated whether pre-operative, intra-operative, and postoperative factors are associated with a difference in postoperative VR-QOL.We conducted a prospective observational study in patients with a first presentation of macula-off RRD who had an attached retina at 12 months after the first surgical procedure. Reattachment was obtained by one or more surgical procedures. The research protocol was approved by the University Medical Center Groningen (UMCG) review board ethics committee, and was carried out in accordance with the tenets of the declaration of Helsinki. The study was registered with the Dutch Trial Register (NTR839). All patients were operated on at the ophthalmology department of the UMCG. The study was carried out over a three-year period .Adult patients visiting the ophthalmology department of the UMCG with a first presentation of unilateral macula-off RRD of 24 hours to 6 weeks duration were invited to participate in this study. Included in the study were patients of 18 years and older who had given their written informed consent. Patients had to be able to pinpoint their drop in VA to a specific 24-hour period in case of a 24-hour to 1 week macular detachment, and to a period of less than one week in case of a macular detachment of one to six weeks. The cut-off point of ≤1 week or >1 week is conform the available literature We acquired the following patients' characteristics: age, gender, affected eye, ophthalmic history and family history for RRD. In addition, we scored the number of retinal quadrants detached at presentation, and the presence, and grade of PVR Duration and height of macular detachment were determined using the following scoring system. Macula-off RRDs of less than one week duration were scored per day, and of more than one week duration they were scored as 11 days (1–2 weeks duration), 18 days (2–3 weeks duration), 25 days (3–4 weeks duration), 32 days (4–5 weeks duration), and 39 days (5–6 weeks duration), respectively.To measure the height of the detachment at the position of the central macula by ultrasonography the relative positions of the central macula and the optic nerve head were determined before performing a ultrasonography. For this purpose, digital fundus photographs of both eyes were made using the TRC-50 IX fundus camera (Topcon 9B ltd. UK). On both fundus photographs, the distance between the optic nerve head and fovea was measured using the software package IMAGEnet2000 2.53. The measured distance in the affected eye was used to determine the central position of the macula and at this position the height of the macular detachment was measured by ultrasonography. In those cases , in which the measurement of the distance between the macula and optic nerve head could not be performed on the photograph of the affected eye, the measurement of this distance in the fellow eye was used Based on clinical presentation, patients were either operated on by an external procedure (i.e. encircling band and/or buckle) or by 20 Gauge PPV (with or without an encircling band). In PPV cases, either a short acting tamponade (i.e. sulfur hexafluoride gas (SF6)) or a long acting tamponade was used (i.e. octafluoropropane (C3F8) or silicone oil). Collected data refer to the first surgical procedure in all cases.At 12 months postoperatively, we measured BCVA using the ETDRS chart At 12 months postoperatively, patients were requested to self-administer the validated Dutch version Because of an increased risk of cataract development after PPV, which may influence postoperative measurements, we scored the level of cataract using the lens opacities classification system III (LOCS III) in both eyes at pre-determined post-operative intervals Data were analysed using SPSS software package, version 16.0 . A one-tailed paired Student's t-test  or Wilcoxon signed rank test was used to explore statistical differences in visual function parameters between operated and fellow control eyes depending on the distribution of the variable. Spearman's correlation coefficients were calculated to explore significant correlations between the different postoperative visual function parameters. The relationships between age, preoperative factors, postoperative visual function tests  and the NEI VFQ-25 scores were examined using Spearman's correlation coefficients. To determine differences in NEI VFQ-25 OCS and subscores in subgroups we used a Mann-Whitney U test in case of two groups or a Kruskal-Wallis test in case of more than two groups. In the latter case post-hoc analyses were performed for pairwise comparisons between subgroups. All tests were considered statistically significant at a p-value of less than 0.05, except for the Kruskal-Wallis post-hoc analysis, for which a significance threshold of 0.05 divided by the number of groups was used.A total of 56 patients gave their written informed consent and were included. In 46 patients retinal re-attachment was obtained after one surgical procedure, whereas ten patients had one or more re-detachments. One patient died during the study period and was therefore excluded from analysis. In all remaining 55 patients, the retina was still surgically attached twelve months after the initial surgical procedure. Missing data further consisted of: visual function tests at 12 months (n = 1), saturated (n = 2) and desaturated (n = 3) CCI, because of color blindness (n = 2) and unknown reasons (n = 1).Postoperative BCVA, Log contrast acuity, saturated and desaturated CCI in operated eyes were significantly worse than in fellow control eyes . We obseIn summary, even though only small differences existed between vision related quality of life OCS and subscale scores, lower scores on vision related quality of life may be related to more extensive surgery, long-term intraocular tamponades and re-detachment. Patients with a more extensive retinal detachment had lower scores on the subscales ocular pain (i.e. experienced more ocular pain) and vision specific role difficulties. Primary surgical success was associated with higher scores on the subscale near activities and OCS. A higher number of re-detachment surgeries was associated with lower scores on ocular pain (i.e. more pain) and vision specific mental health. Patients operated on by PPV had lower scores on vision specific role difficulties, and patients in whom a PPV was combined with an encircling band scored higher on vision specific mental health. Patients receiving a shorter acting gas tamponade (SF6) instead of longer acting gas tamponade (C3F8) or silicone oil were observed to have higher scores on general vision, ocular pain, near activities, vision specific mental health, driving and on the OCS. Preoperatively pseudophakic patients (RRD eye or fellow eye) had higher scores on the vision specific mental health subscale than phakic patients.In our study on patients with macula-off RRD, NEI VFQ-25 OCS and subscale scores were relatively high with a mean OCS of 88.5. The best possible score on each question was 100 and the second best 75 or 80. This means that most patients scored between the best and second best score. Although the scores were somewhat lower than those in a normal working population and in a population with posterior vitreous detachment (PVD) For example, Okamoto et al. We observed correlations between NEI VFQ-25 OCS, and subscale scores and postoperative BCVA, contrast acuity and post-operative CCI. All tested postoperative visual function parameters were highly correlated with each other. This suggests that BCVA, contrast acuity, and color vision represent interdependent aspects of macular function. However, our observations suggest that - of all tested variables - postoperative BCVA and contrast acuity in the RRD-eye are the most important determinants of postoperative VR-QOL.In contrast to postoperative visual functioning, other patient and surgery related aspects showed very few correlations with NEI VFQ-25 outcomes. Correlations observed related to more extensive surgery, long-term intraocular tamponades and re-detachment. We identified that preoperatively pseudophakic patients (RRD eye or fellow eye) had higher scores on the vision specific mental health subscale than phakic patients. The mental health subscale consists of questions about troubling thoughts about the future and the eyesight. Perhaps, patients with a history of cataract extraction do not have to worry about undergoing a cataract extraction anymore.We observed a significant correlation between post-operative BCVA and NEI VFQ-25 OCS and the subscale scores general vision, ocular pain, near activities, distance activities, mental health, role difficulties and driving. In contrast, Okamoto et al. did not find such a relationship Generally, VA is considered as a major determinant of VR-QOL. This has been suggested in studies on macular hole, epiretinal membrane and diabetic retinopathy In line with the study by Okamoto et al., we observed a significant correlation between contrast acuity and NEI VFQ-25 OCS Although we observed significant correlations between reduced CCI and VR-QOL parameters, we did not find any papers on a possible relation between both aspects. The observed correlations were small, and we therefore assume that unilateral, mild color vision defects have less impact on patients' well-being and visual functioning than unilateral defects in VA and contrast acuity. Also, it could be that the fellow eye compensates better for the defect in color vision in the affected eye than it does for the other two aspects of visual functioning.Previously, we observed that both the duration and the height of macular detachment have a profound effect on the postoperative recovery of visual function, particularly BCVA and CCI Our study highlights important aspects of the postoperative VR-QOL in macula-off RRD patients. Some limitations include a possible selection bias towards highly motivated patients, because they would have been more likely to have participated in this study. In addition, the studied population is modest. Our sample size is considered adequate for overall analyses At 12 months postoperatively, BCVA, contrast acuity, and CCI's in macula-off RRD eyes were still significantly worse for the operated eyes compared to their fellow control eyes. A lower VR-QOL (OCS and subscores) had the highest correlation with a worse postoperative BCVA and contrast acuity (in the RRD-eye). Although less pronounced, postoperative color vision disturbances (saturated and desaturated CCI) were significantly correlated with the NEI VFQ-25 OCS.


Involvement of the skeleton can cause an excruciating pain in two-thirds of terminal patients with a history of malignancy. Due to several limitations of other therapies, such as analgesics, bisphosphonates, chemotherapy, hormonal therapy and external beam radiotherapy; bone-seeking radiopharmaceuticals have an important role in palliation of pain from bone metastases. Although these kinds of therapies have many advantages including the ability to treat multiple sites of tumoral involvement simultaneously, no significant confliction with other treatments, ease of administration and the potential to be used repetitively; in Iran using of this modality is not widely practiced. In this study we evaluated the clinical usefulness of Sm-153 lexidronamfor pain management of bone metastases.28 patients  aged 38-77 years with a history of painful bone metastases caused by different cancers, not responding to conventional treatments were included in the study. All patients had a recent whole body bone scan indicating multiple bone metastases. 1 mCi/Kg Sm-153 lexidronam was injected intravenously to the patients. Whole body scintigraphy was done 3 or 18 hours post injection. Pain relief and quality of life have been evaluated by analog pain scale and Karnofsky index every week, respectively. Also, all patients were evaluated for hematological toxicity every two weeks. Active follow ups were performed.43% of patients showed the presence of the flare phenomenon during the first three days after Sm injection with a mean duration of 2.2 days. The pain relief began between 2 and 16 days post injection and the duration of pain palliation was in the range of 4 to 32 weeks (mean±SD=15.22±7.8). 64.3% of patients showed complete relief of pain and 21.4% achieved partial response to therapy. . The lowest amount of peripheral blood cells was detected in the fourth week for RBCs and in the 6th week for WBCs and PLTs. No one experienced hematological toxicity induced problems.Sm-153 lexidronam is an effective treatment for painful bone metastases. The complication rate is low and the quality of life of the patients after treatment would be significantly improved. Bone metastasis is the common consequence of many malignancies including prostate, breast and lung cancers. One of the most unfavorable complications of metastatic bone involvement is skeletal pain, which can be seen in two-thirds of terminal patients. The paiGenerally usage of non-steroidal anti-inflammatory drugs (NSAIDs) is the first step towards pain relief, which may be replaced by narcotics with the progression of the disease. Narcotic usage itself is commonly accompanied by complications such as over sedation, constipation and severe nausea which strongly reduce the life quality of the patients. Other systemic treatments such as chemotherapy and hormonal therapy have their own limitations as well. On the other hand, some treatment modalities such as external beam radiotherapy and surgery, because of their localized nature, are not optimal solutions for patients with widespread bone metastasis.Bone pain palliation using beta emitter radioisotopes plays a pivotal role in patients with osteoblastic or mixed bone metastasis. This kind of therapy has some unique advantages including the potential ability for simultaneous pain relief in multiple sites of bone involvement, no confliction with other treatments, facility of administration and the potential to be used repetitively. Despite these valuable attributes, unfortunately in Iran use of this method has been very limited.153Sm-EDTMP) is one of the most practical radiopharmaceuticals for bone pain palliation with the ability to concentrate in the areas with increased osteoblastic activity. As Samarium emits both gamma and beta particles, it is possible to confirm bone accumulation of the radiotracer after administration. The average range of its beta rays is about 6 millimeters in soft tissue and its physical half life is nearly 46 hours. Reported response rate of 153Sm-EDTMP administration is up to 92%, Nuclear Science and Technology Research Institute (NSTRI), Tehran, Iran) with the dose of 1mCi/kg was injected intravenously followed by rapid infusion of 10cc saline 0.9%.28 consecutive patients  aged 38 to 77 years (mean age ± SD=59±12) who had painful skeletal metastases were included in the study. Each patient had at least two sites of severe bone pain due to osteoblastic or mixed bone metastases (according to a recent bone scan) with no evidence of any contraindications for radionuclide therapy. The exclusion criteria included pregnancy and breast feeding, any evidence of Disseminated Intravascular Coagulation (DIC), super scan pattern in the latest bone scintigraphy, any emergency problems such as acute compression on the spinal cord and pathologic fractures, neurologic origin as the source of bone pain, hemi body radiotherapy during the last three months and long acting chemotherapy during the last four weeks. After taking a comprehensive medical history and giving written and oral instructions to patients regarding the treatment and suitable hydration, 153Sm-EDTMP, urinary catheter was inserted for the patients with urinary incontinence and remained in place for 24 hours. Whole body scan was performed 3 and/or 18 hours after 153Sm-EDTMP administration for evaluation of drug distribution and confirmation of radiotracer accumulation in the lesions.The patients were observed in the first 4 hours post injection for appropriate hydration, control of symptoms and social radiation protection. Before injection of 153Sm-EDTMP injection and then every week post treatment.The patients were followed up every three days during the first two weeks and then every week for the next 16 weeks. The severity of bone pain  ruler), as welTherapeutic response was defined as pain palliation after samarium injection based on the VAS ruler. The VAS scores less than 3 points after treatment was considered a complete response. Delta VAS (∆VAS) was defined as the difference between pre-treatment and post treatment VAS scores. No response was defined as ∆VAS less than 3. Other conditions were considered as partial response.Analgesic usage was categorized in to two groups; non-steroidal anti inflammatory agents (NSAIDs) and narcotic drugs and the average usage of both was recorded before and after the treatment. In our study, the number of NSAIDs was seen equivalent to the same number of Ibuprofen tablets (400 mg) and the narcotic drugs were considered equivalent to 10 mg of morphine in intra muscular injection form.Assessment of bone marrow function was done every 2 weeks by evaluation of peripheral blood cell counts for 12 weeks and the grade of bone marrow toxicity was obtained based on the National Cancer Institute Common Toxicity Criteria (NCI-CTC).The data was finally analyzed by the SPSS 16 software. Univariate analysis was done for description of frequency of different variables. Comparison of quantitative variables before and after therapy was done using a paired t-test.43% (12 out of 28) of the cases had breast cancer, 29% (8 cases) prostate cancer, 11% nasopharyngeal carcinoma and 5 cases (17%) were involved with one of the following; lung, rectum, bladder or gastric carcinomas. The treatment was explained to the patients and then an informed written consent was obtained. All patients suffered severe pain in at least two points of the skeleton and 75% of them (21 patients) had severe bone pain in three or more foci. Consistent with the VAS ruler, the mean severity of bone pain was 9.75 in the first site, 9.10 in the second site and 8.66 in the third site of the skeleton.Bone pain intensified in 43% of cases between the first and the third days post injection with the mean duration of 2.2 days (Mean±SD =2.2±0.83) and was considered as the flare phenomenon.Pain relief began between 2 to 16 days post injection (Mean±SD =8.4±4.3) and the response lasted for 4 to 32 weeks with a mean duration of 15.2 weeks. (Mean±SD =15.2±7.8). Complete and partial response was observed in 18 and 6 cases (64.3% & 21.4%) respectively and 4 cases (14.3%) had no response to therapy.There was no significant difference between patients with breast, prostate & others cancers in terms of treatment response. (p=0.118)153Sm-EDTMP injection.The general health status improved in 46% of patients, 25% reported no change and 29% had worse condition post The amount of analgesic consumption was significantly reduced post injection (p<0.001). 153Sm-EDTMP uptake in the following scintigraphies. No abnormal soft tissue uptake was noted in samarium scans.  is a well known universal treatment for patients with severe metastatic bone pain-6.153Sm-EDTMP on metastatic bone pain due to breast and prostate cancers specifically, showed 81 and 92% over all response rate with 51 and 36.5% complete response respectively; however 39% also showed some degrees of pain relief. This results in an 85% over all response. Also the duration of pain palliation by RnT showed a wide range (4 to 32 weeks) which makes the prediction of response duration difficult. Although our patients showed a higher rate of complete response compared to the study of Baczyket al . A large well-designed review showed a pooled range of 70-90% response rate with 30-40% complete response according to the previous studies. Two impopectively. Two othpectively-14. BaseAs there was a possibility that the patients continued narcotic usage despite the pain palliation, we evaluated NSAIDs and narcotic usage separately. Interestingly, both pharmacologic groups showed significant reduction in usage following the onset of decrease in patients VAS scores.The study showed significant reduction in all three types of blood cell counts , but the RBC reduction had some differences with WBCs and PLTs in both severity and time of onset. Grade 3 bone marrow toxicity was not observed for RBCs. This suggests more concern for WBCs and PLTs. At ten weeks post treatment the blood cell count was similar to the pre-treatment count although there are some studies which suggest longer time for blood cell count reversibility.153Sm-EDTPM injection makes administration of this radiotracer more favorable. In this aspect, our results were congruent with the results of other similar studies(Absence of life threatening events as a result of r studies-18.We faced some limitations during our study. First of all, our study was limited to only 28 cases; therefore, sub groups analysis was not possible. We suggest further clinical trials with larger groups of patients in each kind of malignancy. Secondly, evaluation of specific serum markers and follow up bone scintigraphy were not done post treatment, so the response assessment was based only on patient’s reports.Samarium-EDTMP therapy is an effective and safe solution for metastatic bone pain palliation with no fatal complications. We hope this favorable therapy becomes a common and frequent procedure in Iran in the near future.


Postoperative pain was assessed with the verbalnumeric scale and with five variables of emotional state: anxiety, sweating,stress, fear, and crying. The Chi-squared test, Student's t test or ANOVA and amultivariate logistic regression analysis were used for the statistical analysis. the prevalence of immediate postoperative pain was 28%. Anxiety was the mostcommon emotional factor (72%) and a predictive risk factor for moderate to severepostoperative pain . Age exerted a protective effect .  preoperative anxiety and age are predictors of postoperative pain in patientsundergoing orthopedic and trauma surgery. Second, postoperative analgesia remains inadequate and exposes patients tosevere postoperative pain. This situation can lead to significant patient discomfort and negativephysical and psychological effects as well as a major socio-economic impact byincreasing the postoperative morbidity and hospital stay. Timely prevention, detection and treatment may help reduce health problemsassociated with the high prevalence and intensity of postoperative pain.Orthopedic and trauma surgeries are often associated with severe postoperative pain fortwo main reasons. First, the surgery often causes intense nociceptive stimulation of themusculoskeletal tissue-2. Seive pain. This stal stay. Timely. In this regard, knowing the emotional factors that influence theoccurrence of postoperative pain would be an important contribution to a moreappropriate treatment for each patient. It has been shown that certain emotional statessuch as anxiety and fear can influence individual responses to surgical intervention andto the need for analgesia(-). In the last decade, there has been increasing interest in analyzing theinfluence of preoperative anxiety on postoperative pain and recovery, but the data comefrom heterogeneous studies that vary in their sociodemographic characteristics and thetype of surgery(-). Furthermore, studies on patients undergoing orthopedic surgery, one of themost painful procedures, are even scarcer. Confirming the relationship between preoperative anxiety and postoperativepain is significant because if one exists, patients with high anxiety should beidentified before surgery and should expect individualized strategies for pain treatmentafter surgery. Patient expectations regarding surgery have changed, and the lack ofpostoperative pain is an important indicator of satisfaction with hospitalcare.Although postoperative pain is predictable and there are various ways to prevent andtreat it, the correct approach widely varies from one patient to another in similarsurgical procedures. In thinalgesia-7. Inurgery-. Furthe scarcer. Confirurgery,. Patientalcare,12.In Spain, there are no recent data showing the prevalence of immediate postoperativepain following orthopedic or trauma surgery or the relationship between emotionalfactors and postoperative pain in these surgeries. This study was undertaken to analyzethe relationship between preoperative emotional state and the prevalence and intensityof postoperative pain in patients undergoing orthopedic or trauma surgery as well as toexplore potential predictors of postoperative pain..This analytical and retrospective observational study was conducted in the postoperativecare unit (PCU) of a university hospital in Barcelona (Spain) between January and March2011. The study protocol was approved by the Clinical Research Ethics Committee of thecenter (Code 36/2010), and the guidelines of the STROBE Statement were followed forobservational studies.The study analyzed a convenience sample, selecting all patients who underwent traumasurgery  or prosthetic surgery and met the inclusion and exclusion criteria. We included patients older than 18 yearswith a minimum stay of 4 hours in the PCU. This interval was chosen because at leastfour pain assessments were guaranteed during the immediate postoperative period, as painis determined at least every hour during this period in routine clinical practice.Patients who could not perform the pain self-assessment  were excluded. These patients were easilyidentifiable because for the pain assessment of patients who were not able to describepain, we used behavioral scales; the results from this assessment are included in themedical records. During the study period, 568 orthopedic and trauma surgery patientswere included. In total, 171 were eligible, and 44 were excluded due to a PCU stay ofless than 4 hours (16), cognitive impairment (14), mechanical ventilation (5) andincomplete data in the medical record (9). The final study sample consisted of 127patients. This number allowed achieving the study objectives, assuming that thecorrelation coefficients of 0.2 with the calculation of Spearman's rank correlationcoefficient would be significant and that this number could generate a multivariateanalysis. A reasonable percentage of losses valued at 15% was recorded. A notebook wasdesigned for specific data collection.The primary endpoint was immediate postoperative pain (within the first hour of PCUadmission), and the following secondary endpoints were assessed: emotional state; maximum postoperative pain in the PCU,maximum pain within the first 24 hours, average pain during the PCU stay, pain withinthe first 12 hours and 24 hours; demographic variables: age and gender; previous physical condition: low-risk patients (American Society ofAnesthesiologists [ASA]: I or II) and high-risk surgical patients (ASA > II);presence of comorbidity ; operating time ;surgical indication ; type ofanesthesia ; and pain treatment .. This validated scale ranges from 0 (no pain) to 10 (maximum pain). Forthis study, two standardized pain intensities were established: mild pain (NRS≤3) andmoderate-to-severe pain (NRS≥4). In cases where there was more than one record ofimmediate pain, its average value was calculated. In routine clinical practice, thesurgical nurse who meets the patient in the preanesthesia area evaluates thepreoperative emotional state.Pain intensity was assessed using the Numeric Rating Scale (NRS). This vPreoperative emotional state was assessed with the routine clinical practice tool. It isa dichotomous scale (absent=0 / present=1) of 5 items: anxiety, sweating, stress, fearand crying. With these items, the total score for emotional state, which may range from0  to 5 , was obtained. For the purpose of thisstudy, no levels of intensity of preoperative emotional state alterations wereestablished.Regarding the categorical variables, the results were presented as the number of casesand percentages. Concerning the quantitative variables, they were expressed as means ±standard deviations. The comparison of emotional state variables with immediatepostoperative pain was performed with the Chi-squared test. Student's t test or ANOVAwas used for quantitative variables, and calculation of Spearman's rank correlationcoefficient was used with ordinal variables. With clinically relevant results thatshowed statistically significant differences in the bivariate analysis, a multivariatelogistic regression analysis was performed. To validate this model, the Hoshmer-Lemeshowgoodness-of-fit test was used. Additionally, as a discrimination index, the area underthe curve (AUC) of the receiver operating characteristic (ROC) was used. The statisticalanalysis was performed using SPSS (version 19.0). The probability of making a Type Ierror at 5% (α=0.05) with a bilateral approach was set.The general characteristics are summarized in ). Nostatistically significant difference was observed in pain intensity by gender, number ofcomorbidities or duration of surgery.Regarding the analysis of maximum pain during the PCU stay, the results showed that 58patients (45%) had moderate-to-severe maximum pain with an average intensity of 6±1.7 and that within the first 24 hours, 84 patients (66%) hadmoderate-to-severe maximum pain with an average intensity of 5.8±1.7 . During prosthetic surgery, the maximum pain intensity during the PCU stay andwithin the first 24 hours was statistically higher than that during the trauma surgery. Patients who underwent general anesthesia experienced more pain duringtheir PCU stay than did patients who underwent combined or regional anesthesia . Nevertheless, several authors agree on the need to improve paintherapy. These shortcomings have been mentioned in this study, which reveals aprevalence of postoperative pain in trauma and prosthetic surgery ranging between 28%and 61%, with episodes of moderate-to-severe pain in 45% of patients during their PCUstay and 66% within the first 24 hours of the postoperative period. These findings areconsistent with those of other studies where between 22% and 67% of patients of traumasurgery had pain within the first 24 hours of the postoperative period and 64% on the previous day. However, the authors did not report whether itwas immediate postoperative pain. Although the studies have reported a high prevalence of postoperativepain, comparing their results is difficult, hence the need to determine the influence ofsocio-demographic, clinical and psychological factors as predictors of postoperativepain.In the last fifteen years, various clinical guidelines have been published withrecommendations for treating postoperative pain,-16. Ntherapy,17. Te period,18 anive pain. Althoupain,,-23., but they disregarded gender as a consistent predictor. In another study,with a cohort of 1,990 patients, anxiety and depression were predictors of pain, butneither age nor gender were associated with pain. Some authors have described a higher prevalence of pain among youngpeople, while others report a higher prevalence in older patients. There are also mismatches in the prevalence of pain among men and women.Some authors observed more pain in women and younger patients while others found ahigher prevalence in men. Our results are consistent with some studies and differ from others. Youngpatients experienced more pain during the immediate postoperative period, but nodifferences according to gender or other factors such as operating time or comorbiditieswere observed. Another factor associated with a greater prevalence of pain is the typeof surgery. Our patients undergoing prosthetic surgery reported a greater intensitycompared with that reported by trauma surgery patients. However, these results are notcomparable to those of other studies, which compare different types of surgeries but nottrauma with prosthetic surgery. Regarding pain treatment, although most postoperativepatients receive some form of analgesic treatment, they continue to feel pain. In ourstudy, the presence of postoperative pain during the PCU stay was a factor associatedwith the increased consumption of analgesics. The prescription of analgesics was similarto other studies, with NSAIDs and/or acetaminophen  as the mostused. Morphine was used as rescue analgesia in almost a quarter of patients,similar to other studies . These data support the conclusion that pain remains inadequately treatedwith the current guidelines and that there is significant room for improvement.Patient characteristics such as age, gender, type of patient, previous experiences ortype of surgery may help explain the large variability in the prevalence ofpostoperative pain. However, the literature is rather contradictory in these respects.In a systematic review of 23,000 patients, the authors highlighted preoperative pain,anxiety, age and type of surgery as the most significant predictors of postoperativepain and analgesic consumption, but thith pain. Some apatients,22. Te in men, 23.  surgery. Our paostused, 17. . Some authors have analyzed anxiety/depression or preoperative anxiety aspredictors of postoperative pain. Others have reported on the association between anxiety andpain; although all of the investigators agree there is an association betweenthese factors, it is unclear whether anxiety causes pain or pain causes anxiety. Ourresults point to other emotional factors besides anxiety. However, in the literature,there is no evidence of these aspects, which would enable a proper comparison. In ourstudy, the results regarding anxiety are consistent with those of previousinvestigations and show that anxiety is a predictor of postoperative pain. However,these data are correlated with the immediate postoperative period. Additionally, theresults of published studies are for the first 24 hours or 48 hours of the postoperativeperiod or are the follow-up data of patients monthly or at one year after surgery.Furthermore, there is a significant degree of variability in the type of tools used toassess anxiety and pain, once more making it difficult to compare the data.Increasingly, emotional factors play an important role in postoperative pain. Hence,different authors have examined these factors in isolation, as predictors ofpostoperative pain during interventions of orthopedic and trauma surgeries-,,-25. Sive pain,24. Odpain-, 25; In reference to the study limitations, although this is a retrospective study, theoutcomes are an updated approximation of the predictors of a high prevalence ofpostoperative pain. These data may serve as a starting point to encourage furtherresearch. A possible bias may exist due to the data and patient selection. However, thedata obtained from the medical records was complete, without losses due to a lack ofinformation in the main study variables. The use of our scale may limit the comparisonof our results with those of other researchers because they used psychologicalassessment tools, while we preferred to use an instrument of routine clinical practicein our study. This instrument is a widely used tool to assess emotional factors, but itis not an instrument for a complete psychological evaluation, and its use cannot beinterpreted in this regard. However, the available evidence on predictors ofpostoperative pain does not assess emotional factors such as fear, stress, tearing orsweating. Therefore, our data further elucidate the results published so far and showthat the use of simple routine methods during the preoperative period may help identifypatients with an increased risk of postoperative pain, with the possibility ofindividualized interventions when deemed necessary. Finally, the retrospective nature ofthe study may limit the interpretation of the results, but in our opinion, the presentfindings are a good first approximation to the issue. In conclusion, the present investigation identified two predictors of immediate painduring the postoperative period: age and preoperative anxiety. Consequently, werecommend that young and anxious patients have customized analgesic regimens to betteralleviate their postoperative pain within the first hours after surgery. Theestablishment of protocols with specific instruments for assessing and treating anxietyas a predictor of postoperative pain is encouraged. This intervention would help healthprofessionals understand and improve the perception of their patients' pain and optimizepain treatment.