Post-operative pain following anterior cruciate ligament reconstruction remains an important challenge. Steroids are used in various surgical procedures to decrease post-operative nausea, vomiting and pain. However, only a few studies have reported the effect of systemic administration of steroids in controlling postoperative pain after anterior cruciate ligament surgery.We have conducted a prospective randomised trial with 109 patients divided into two groups to determine if administration of dexamethasone in the perioperative period improves pain in the post-operative period. The patients were divided into two groups: D, treatment (dexamethasone) and P, control placebo . Patients in the D treatment group were given the first dose of 10mg of intravenous dexamethasone intravenously intraoperatively and the second dose on transferring of the patient to the inpatient department. The patients in the placebo P group, were administered normal saline in the perioperative period in a similar manner.Post-operative pain was significantly less in the dexamethasone group at rest and on walking (p<0.001) for the first 24 hours after surgical procedure. Subsequently, the VAS pain scores were almost similar in both groups at 48 and 72 hours. The administration of dexamethasone resulted in less requirement of antiemetic and rescue analgesia medication There was no difference in range of motion and wound complications rate during the follow-up period at six months. No adverse side effect, like osteonecrosis of the hip, was detected.The pain following anterior cruciate ligament reconstruction is severe during the first 24 hours and perioperative administration of dexamethasone can decrease the post-operative pain substantially. Though pain after arthroscopic procedures is lower as compared to open surgical procedure it is still an important barrier in initiation of early rehabilitation programme with delay in achieving quadriceps contractions and movement at the knee joint. Few studies have advised regarding the use of steroids in nausea and vomiting after surgical interventions. However, their role in post-operative pain especially in arthroscopic surgery is still not well defined.Inadequate pain relief after surgical procedure delays recovery, increases duration of stay in hospital and reduces satisfaction among patients3. A single or sometimes two doses of dexamethasone are commonly employed to prevent nausea, vomiting and decrease post-operative pain6. Despite its good analgesic and antiemetic effects in the post-operative period, there is reluctance amongst surgeons in the use of steroids due to its possible side effects.Steroids inhibit the cyclooxygenase signalling pathway leading to decrease in local and systemic inflammatory responses and thus decreasing pain. Dexamethasone is a commonly used steroid in clinical practice for this purpose due to its high potency and low mineralocorticoid effectThe present study was designed to determine (1) the efficacy of dexamethasone in reducing post-operative pain after anterior cruciate ligament reconstruction (ACLR), (2) whether the administration of dexamethasone improves range of motion, (3) whether the use of dexamethasone increases the risk of surgical site wound complications.The study protocol was approved by the institutional review board before patient enrolment. The study was reported as per Consolidated Standards of Reporting Trails (CONSORT) 2010 requirement. Written informed consent was obtained from patients. From June 2017 to March 2020, all patients with anterior cruciate ligament injury were included in the study. Patients aged below 18 years and above 80 years, and those with severe heart disease, liver or renal failure, diabetics, peptic ulcer disease, history of glucocorticoid intake during the past three months, and contraindication to spinal anaesthesia, were excluded from the study.6, a sample size of 41 patients in each group was required to demonstrate a difference of eight points in VAS score (0 to 100) at an alpha level of 0.05 and a power of 0.09 with significance level set at 0.05. Assuming a 10% exclusion rate, the minimum sample size in each group was calculated to be 46. So, we had decided to include 50 patients in each arm of the trial.Sample size: based on previous study in knee surgeryStudy design: the patients recruited in the study were randomly divided into two groups; Dexamethasone (D) and Placebo (P). The randomisation was carried out with study participants on a 1:1 ratio of two study groups using a computer-generated list of random numbers. A staff with no further involvement in the study generated allocation sequence and concealed the allocation results in sealed opaque envelopes that were given to the research coordinator. The envelopes were opened just before surgical procedure. The patients in dexamethasone D group were administered two doses of 10mg dexamethasone while in placebo P group two doses of 2ml of normal saline were administered. The first dose was given by anaesthesiologist in the operative room and the second dose was given by the nursing staff following shifting of patients to the inpatient ward. The anaesthesiologists administering the drug and nurses were not included in the study. The surgeons, physical therapist, patients, data collector and analyst were blinded to the allocation.Surgical procedure: all anterior cruciate ligament reconstructions were performed by the senior surgeon (DB) in the same laminar operating theatre. Spinal anaesthesia using 15mg of 0.5% bupivacaine was administered in all the patients. After examination under anaesthesia and diagnostic arthroscopy, hamstring grafts were harvested from the ipsilateral knee. The femoral and tibial tunnels were created with the help zigs. The femoral end of the graft was fixed with end button and tibial end with BIORCI screws .Post-operative protocol: the patients were kept under observation for three hours in the post-operative care unit and then transferred to the inpatient ward. They were advised to apply ice packs on shifting to inpatient department for the next 24 hours. Patients were administered oral diclofenac sodium 50mg 12 hourly after resumption of oral intake. Intravenous nefopam 20mg was added whenever a patient had complained of pain greater than 40 on visual analogue scale (0 to 100). Additional dose of intravenous tramadol 100mg was administered in case patients reported pain greater than 60 on VAS scale. The patients were given metoclopramide in case of two or more episodes of postoperative nausea and vomiting (VAS > 4). Ondansetron 5mg was used in case of severe nausea or vomiting not relieved with metoclopramide.The visual analogue scale with corresponding numerical value was completed by patients at the time of each assessment by the nursing staff. After surgical procedure, the patients underwent identical rehabilitation programme with deviations in cases with associated meniscus and other ligament injuries. The patients with associated meniscal injuries who underwent repair for the same were subjected to extended partial weight bearing protocol by three weeks. The patients with medial collateral ligament injuries were prescribed specific range of motion brace for four weeks. A long knee brace was applied in all the cases. Patients were advised to perform knee bending, active straight leg raise and isometric quadriceps exercises as per pain tolerance on the day zero after the wearing-off of motor blockade of spinal anaesthesia. They were allowed to fully bear weight with a knee brace in extension as per pain tolerance.7. VAS was recorded at rest (patient should have rested in bed for at least 20 minutes before assessment) and during walking . The number of episodes of nausea and vomiting along with doses of antiemetic drugs were recorded. Nausea was assessed using VAS scale with zero denoting no nausea and ten means severe nausea. Fatigue among patients was assessed using Identity Consequence Fatigue Scale (ICFS)8 before and three days after anterior cruciate ligament reconstruction. Other parameters recorded were length of stay in hospital and wound infection.Outcome measurement: Before the surgical procedure, demographic details, medical history, and concomitant medications taken by patient were recorded. The dexamethasone administration is known to increase the blood sugar levels so change in blood sugar levels were recorded before and after surgery in both the groups. The subjective assessment of pain was carried out by the nurses not involved in the study. Pain was assessed using visual analogue scale at 6 hours , 12, 24, 36, 48 and 72 hours after the operative procedure. The visual analogue scale used was a straight 100mm line with one extreme being no pain (zero) and the other extreme being severe pain (100)Student t test or Wilcoxon Mann Whitney U test was used to analyse quantitative data and Pearson Chi Square test was used to analyse qualitative comparative data. Two-way ANOVA was applied to test for significance within the groups. The statistical significance was set at p<0.05. The data analysis was performed with SPSS version 18 software [SPSS inc. USA].Patient Demographics: Between June 2017 to March 2020, 109 patients were scheduled for anterior cruciate ligament surgery in the institution. Among these five patients refused to participate and three patients were ineligible for inclusion in the study. Thus, 101 patients were included in the intent to treat analysis. Fifty-one patients were randomised into group D and 50 patients were randomised into group P . HoweverPain and rescue medication: Patients in the dexamethasone group had experienced lesser pain than the placebo group after anterior cruciate ligament reconstruction (ACLR) both at rest and while walking at 12, 18 and 24 hours , 3. The The number of patients who required nefopam in the dexamethasone group were smaller than the placebo group (p = 0.003). The overall tramadol consumption was also lower in the dexamethasone group (p = 0.021) . Post-opPost-operative fatigue and range of motion: the postoperative Identity Consequence Fatigue Scale (ICFS) score was lower in the dexamethasone group in comparison to placebo group . In paraTolerability: at the time of last follow-up at six months, no major side effects were recorded which could be attributed to administration of dexamethasone. No case of deep-seated infection was noted in either group. There was no sign of avascular necrosis detected in the hip joints. There were two cases of stitch abscess which were treated with oral antibiotics. Three cases required knee manipulation to gain range of motion in the placebo group. There were no cases of deep vein thrombosis or pulmonary emboli.9. The success of the programme depends upon the pain relief provided to the patient after surgery. So, multimodal approach is used in the pain management of these cases and multiple drugs are used to achieve the desired outcome. Inflammation at the operative site is an important factor leading to pain and drugs like steroids are known strong anti-inflammatory drugs10. Steroids have been used in varying proportions in orthopaedic surgeries to decrease the inflammatory response, lower chances of post-operative nausea and relieving post-operative pain15. In the current randomised placebo-controlled trial, administration of dexamethasone resulted in decrease in post-operative pain, fatigue, and nausea.The accelerated rehabilitation programme following anterior cruciate ligament surgery is currently the post-operative protocol followed at various institutes worldwide3. Steroids inhibit peripheral nerve terminals at the point of tissue injury and prevent transmission of pain signals across synapses in the spinal cord. It is however not clear whether the analgesic effect with dexamethasone is the end product of anti-inflammatory effect or inhibition of central or peripheral pain receptors along the pain pathway.The glucocorticoids have strong evidence to support analgesic effect6, they are not routinely used due to possible side effects. The complications like delayed wound healing, adrenal suppression and osteonecrosis of hip are associated with steroid intake in high doses and for prolonged periods. The studies conducted in arthroplasty patients administered a single or two doses of glucocorticoid had not shown increased risk of either infection or bleeding. Salerno et al3 in their meta-analysis on assessment of perioperative risk with methylprednisolone in surgical patients had observed no adverse event. There was no difference in number of cases experiencing wound complications or gastrointestinal bleeding. Kardash et al16 in their study on hip arthroplasty had reported improvement in VAS pain scores at 24 hours with a single dose of dexamethasone and reported no adverse event at 12 months. In our study there was no case of surgical wound infection which supports the safety of glucocorticoids during the perioperative period.Despite various studies showing clear benefits of steroids with analgesic and antiemetic effectset al17 in their study had reported that there should be a minimum of 33% reduction in VAS scores to be clinically significant for pain evaluation. Based on this criterion, reduction in VAS pain scores at 12 hours should be at least by 1.53 points at rest and 1.74 points while walking in our study. However, the reduction was less than 33% at 12 hours in both cases. But the reduction was greater than 33% at 24 hours after anterior cruciate ligament reconstruction surgery. So, the maximal effect of dexamethasone in pain reduction can be observed at post-operative day one after surgical intervention. Moreover, there is significantly less consumption of additional analgesic agents which further supports its use in the perioperative period.In the present study, statistically significant reduction in VAS pain scores were noted within 24 hours after surgical intervention both at rest and while walking. Jensen et al13 on multiple surgical procedures, it was reported that dexamethasone in dosage of more than 0.11mg/kg is required for decreasing postoperative pain. The dose administered was 0.36mg/kg (mean weight in study was 63.5kg) in the current study and we concluded that with two doses of 10mg dexamethasone there is reduction in pain scores after ACLR. In addition, there was reduction in events like post-operative nausea and vomiting with the same dose.In a meta-analysis by Lunn et al18 in their study in cases of knee arthroplasty reported decrease in post-operative fatigue using ICFS tool specifically designed to measure fatigue and get back to normal life in surgical patients. The components which included the outdoor activities were not covered in the current study. Lunn et al13 in their meta-analysis had also reported a decrease in post-operative fatigue. The results of our study were consistent with previous studies.Xu There are a few limitations of our study. First, the clinical effects of dexamethasone were evaluated only for a short period and long-term effects need to be assessed. Second, the two doses of dexamethasone were administered within the first three hours of operative procedure, so safety and necessity of the drug after 24 hours or 48 hours remains unknown. Third, the trial lacked stratification which would have ensured equal distribution of prognostic variables. However, the demographic characteristics of the patients were comparable as described in The administration of dexamethasone in the perioperative period can decrease inflammatory response and hence reduce post-operative pain, nausea, and fatigue but it does not improve range of motion after anterior cruciate ligament reconstruction. Moreover, two doses of steroids in the perioperative period do not increase the risk of surgical site complications or gastrointestinal haemorrhage.


This randomized clinical trial of women with breast cancer assesses whether short-term acupuncture reduces long-term aromatase inhibitor–related joint pain compared with sham acupuncture or a waiting list control. Does short-term acupuncture confer long-term reduction of joint pain related to aromatase inhibitors among women with breast cancer?In this multicenter randomized clinical trial of 226 women with early-stage breast cancer, patients in the true acupuncture group who received 12 weeks of acupuncture, compared with those in the sham acupuncture group or the waiting list control group, had statistically significant reductions in joint pain scores at 52 weeks.Acupuncture was associated with a statistically significant decrease in aromatase inhibitor–related joint pain that persisted at 40 weeks after discontinuation of the intervention, suggesting long-term benefits of this therapy. Aromatase inhibitors (AIs) have proven efficacy for the treatment of hormone-sensitive breast cancer; however, arthralgias (pain and stiffness) contribute to nonadherence with therapy for more than 50% of patients.To examine the effect of acupuncture in reducing AI-related joint pain through 52 weeks.A randomized clinical trial was conducted at 11 sites in the US from May 1, 2012, to February 29, 2016, with a scheduled final date of follow-up of September 5, 2017, to compare true acupuncture (TA) with sham acupuncture (SA) or waiting list control (WC). Women with early-stage breast cancer were eligible if they were taking an AI and scored 3 or higher on the Brief Pain Inventory Worst Pain (BPI-WP) item . Analysis was conducted for data received through May 3, 2021.Participants were randomized 2:1:1 to the TA (n = 110), SA (n = 59), or WC (n = 57) group. The TA and SA protocols were composed of 6 weeks of intervention at 2 sessions per week , followed by 6 additional weeks of intervention with 1 session per week. Participants randomized to WC received no intervention. All participants were offered 10 acupuncture sessions to be used between weeks 24 and 52.In this long-term evaluation, the primary end point was the 52-week BPI-WP score, compared by study group using linear regression, adjusted for baseline pain and stratification factors.P = .01) and were 0.99  points lower in the TA compared with the WC group (P = .03). In addition, 52-week BPI pain interference scores were statistically significantly lower in the TA compared with the SA group . Between 24 and 52 weeks, 12 (13.2%) of TA, 6 (11.3%) of SA, and 5 (10.6%) of WC patients reported receipt of acupuncture.Among 226 randomized women , 191 (84.5%) completed the trial. In a linear regression, 52-week mean BPI-WP scores were 1.08  points lower in the TA compared with the SA group (In this randomized clinical trial, women with AI-related joint pain receiving 12 weeks of TA had reduced pain at 52 weeks compared with controls, suggesting long-term benefits of this therapy.NCT01535066ClinicalTrials.gov Identifier:  Subsequent systemic reviews and meta-analyses5 have confirmed this effect.Aromatase inhibitors (AIs) have proven efficacy for the treatment of hormone-sensitive breast cancer.5 of acupuncture trials with longer-term follow-up suggested that treatment effects persist for up to 12 months. Specifically, the authors reported only a 10% reduction in the long-term beneficial effect of TA when compared with usual care and a 50% reduction in effect when compared with SA.5 The trials were heterogeneous in terms of design, condition, and duration of treatment. To address the sustained benefit of acupuncture among women with AI-induced arthralgias, we now report the 52-week results from SWOG S1200.The duration of persistent benefit of acupuncture after a course of treatment is uncertain. A meta-analysis6 In brief, eligible study participants were postmenopausal women with stage 1 to 3 breast cancer taking a third-generation AI for 30 days or more before registration. Race and ethnicity, as reported by the study team, are provided to interpret the generalizability of the results. Inclusion criteria included a score of 3 or higher  on the Brief Pain Inventory Worst Pain (BPI-WP) item. From May 1, 2012, to February 29, 2016, a total of 226 patients were randomly assigned to TA (n = 110), SA (n = 59), or WC (n = 57), with a final date of follow-up of September 5, 2017  reporting guideline.Details of the study have been previously reported.Study participants were randomized 2:1:1 to TA vs SA vs WC, with randomization dynamically balanced by study site. Both TA and SA consisted of twelve 30- to 45-minute sessions administered during 6 weeks (2 sessions per week) followed by 1 session per week for 6 more weeks. For TA, stainless steel, single-use, sterile, and disposable needles were used and inserted at traditional depths and angles. The SA protocol consisted of a core standardized prescription of minimally invasive, shallow needle insertion using thin and short needles at nonacupuncture points. The SA protocol also included joint-specific treatments and an auricular sham based on the application of adhesives to nonacupuncture points on the ear. The WC group received no acupuncture during the initial 24 weeks of study participation. At 24 weeks, all patients received vouchers for 10 TA sessions to be used before the 52-week visit.7 The short-form version of the BPI was administered at 6, 12, 16, 20, 24, and 52 weeks. For this long-term analysis, the primary end point was the 52-week assessment of BPI-WP (which was not previously reported), examined using multivariable linear regression. Secondary end points for this long-term evaluation included the BPI average pain, pain interference, pain severity, and worst stiffness scores at 52 weeks. All BPI scores range from no symptoms to worst on a 0- to 10-point scale (with higher scores indicating worse symptoms). In addition, we evaluated pain using the PROMIS Pain Interference–Short Form (PROMIS PI-SF), which has scores ranging from 6 to 30.8 This instrument was also administered at 6, 12, 24, and 52 weeks and has 5 response levels , with higher scores reflecting worse symptoms.The original protocol-specified primary end point was the BPI-WP score at 6 weeks.9 Patients were asked to make 3 maximal voluntary contractions with 1 minute between each. The maximum contraction was used. The Timed Get Up and Go test is a physical function assessment tool of speed that is an estimate of impairments in balance and gait.10We examined 2 functional measures: grip strength and Timed Get Up and Go test. Grip strength was measured with a digital hand grip strength dynamometer  in kilograms.3 In brief, 208 eligible patients provided 82% power to compare TA with SA and, separately, with WC with 2-sided α = .025 tests to account for 2 independent comparisons. For this long-term evaluation, the primary hypothesis was that TA would decrease joint pain associated with the use of AIs compared with SA or WC at 52 weeks. No adjustments for multiple comparisons were made for all secondary or post hoc analyses, which are considered exploratory. Under intention-to-treat, all evaluable 52-week assessments were used, even if control group patients received TA after 24 weeks. The 52-week BPI-WP scores were compared by group using multivariable linear regression adjusting for the baseline score and indicator variables for study sites, with 2 indicator variables to represent the different intervention groups. In addition, we examined BPI-WP scores at 6, 12, 16, 20, and 24 weeks using multivariable linear regression. Other BPI domains and the PROMIS PI-SF scores were evaluated at individual assessment times using linear regression. Longitudinal analyses using all assessments for each patient-reported outcome domain through week 52 were conducted using linear mixed models, with individuals considered random effects; assessment time (as both a linear and quadratic function) and its potential interaction with treatment were considered fixed effects. Regression analyses included covariate adjustment for the baseline score, indicator variables for study sites, and 2 indicator variables for intervention group. The proportion of patients by group who discontinued use of AIs or who used any pain medications  after the initial on-study assessment was tested using a χ2 test. Two-sided α = .05 tests were deemed statistically significant. Statistical analyses were conducted using SAS software, version 9.4 (SAS Institute Inc).11The sample size determination for the protocol-specified primary end point at 12 weeks was previously described.A total of 226 women were randomized , of whom 205 (90.7%) completed the trial. A total of 111 patients (49.1%) had received prior chemotherapy, and the median time receiving AI therapy was 1.1 years . Patient characteristics were well balanced by group .P = .01) and 0.99 points  between the TA and WC groups (P = .03) (P < .001) (eTable 1 in P = .85).In total, 91 of the 110 patients (82.7%) assigned to TA, 53 of the 59 (89.8%) assigned to SA, and 47 of the 57 (82.5%) assigned to WC had both baseline and 52-week BPI-WP scores available for analysis. For patients with 52-week scores, the mean (SD) baseline BPI-WP was 6.77 (1.51) in the TA group, 6.38 (1.55) in the SA group, and 6.40 (1.54) in the WC group. Compared with baseline, the observed BPI-WP was 2.72 points lower (reduced pain) at 52 weeks in the TA group, 1.46 points lower in the SA group, and 1.55 points lower in the WC group, with differences in adjusted 52-week mean BPI-WP scores of 1.08 points  between the TA and SA groups (P = .03) . Of noteP < .001) and 0.64 points lower for TA compared with SA  (P = .10).In longitudinal analysis, there was no evidence of an interaction of assessment time and intervention assignment, and the best model included assessment time as a linear variable (eTable 2 in P = .02) . There wP = .89). The main reason for noncompletion was patient refusal . Fifty-two–week BPI pain interference scores were statistically significantly lower in the TA compared with the SA group . In addition, compared with SA, adjusted PROMIS PI-SF scores for those in the TA arm were statistically significantly lower (less pain interference) at 52 weeks . No other statistically significant differences between arms at the 52-week assessment for any other pain or quality-of-life domains were observed  of TA, 6 (11.3%) of SA, and 5 (10.6%) of WC patients reported receipt of acupuncture. Among all enrolled patients, there was no difference by group in completion of intervention , and 16 of 24 (66.7%) in the WC group (P = .09). Taken together, pain medication use was less likely for patients in the TA compared with the SA or WC groups combined . No differences were observed between groups in assessments of grip strength . To examine incident use of pain medications during the study, we also evaluated patterns among patients who did not report pain medication use at baseline (n = 91 [40.3%]). Among these patients, new use of pain medications during the study occurred in 20 of 44 patients (45.5%) in the TA group, 16 of 23 (69.6%) in the SA group  for patients with early-stage breast cancer and AI-related joint pain, statistically significant improvements in pain scores were seen at 52 weeks compared with SA and WC. The maximal adjusted between-group difference between TA and WC at 12 weeks (at the end of the study intervention) was 1.97 points; at 52 weeks, the mean (SD) difference remained at 0.99 points and was also statistically significant. The maximal adjusted mean between-group difference between the TA and SA groups occurred at 52 weeks and was 1.08 points. This difference was relatively constant during the follow-up period. Although there is some uncertainty about the clinical meaning of this between-group difference,17 testosterone,18 ω3 fatty acids,19 and vitamin D20) and nonpharmacologic interventions (exercise21) have been studied to treat AI-associated arthralgias with mixed results. Most of these trials did not assess or did not find long-term benefits. In addition, the 4 prior studies of acupuncture for AI arthralgias did not evaluate the maintenance or durability of effect.25 Our results support findings from prior studies of sustained effects of acupuncture. Mechanisms that may underlie these effects have been proposed, including the suggestion that acupuncture works by stimulating the vagal-adrenal axis and reducing inflammation.26 A meta-analysis of acupuncture trials for other painful conditions with longer-term follow-up suggested that treatment effects persist after completion of the intervention.5 Acupuncture is appealing to some patients because the adverse effects are generally limited compared with medications; however, this treatment is not covered by many insurance plans and is currently only covered for Medicare beneficiaries with low back pain. Ongoing trials are evaluating personalized approaches to acupuncture protocols.28Both pharmacologic , there are also limited data on the effect of AI arthralgias on these specific measures, and most patients did not have functional impairments at baseline.Interventions to assess strategies for controlling pain can be challenging to perform and interpret. First, pain is subjective and can vary depending on multiple factors other than the AI medication and the study intervention. Second, there is no accepted single definition of meaningful improvement in pain despite considerable deliberations by experts in the field.In this randomized clinical trial, we found that among postmenopausal women with early breast cancer who experienced AI-related arthralgias, a 12-week intervention of TA compared with SA or WC resulted in statistically significant sustained reduction in joint pain at 52 weeks. This study highlights the durability of the acupuncture response through 1 year, as well as the importance of having both SA and WC groups to fully evaluate the effect of the acupuncture intervention.


The median operation time was also significantly lower in the hydrogen peroxide group . Meanwhile, the visual analogue scale (VAS) scores were significantly higher in the hydrogen peroxide group . The topical application of hydrogen peroxide as a hemostatic agent effectively decreases the operation time and intraoperative blood loss. Thus, hydrogen peroxide can be used as a routine hemostatic agent for bleeding control in tonsillectomy.This study aimed to further evaluate the benefit of topical hemostasis agents in tonsillectomy. We compared the clinical effects of topical application between hydrogen peroxide and adrenaline in tonsillectomy. Overall, 60 patients (120 tonsils) were prospectively enrolled for tonsillectomy between February 2018 and December 2020. The patients were randomly assigned to either the hydrogen peroxide or adrenaline group. Then, tonsillectomy was performed using hydrogen peroxide as a hemostatic agent on the assigned side, while adrenaline was applied to the other side. All procedures were performed by a surgeon who was blinded to the randomization. The outcome measurements of operation time, intraoperative blood loss, postoperative pain, and hemorrhage events were analyzed. The intraoperative blood loss was significantly lower in the hydrogen peroxide group than in the adrenaline group (9.99 ± 4.51 mL vs. 13.87 ± 6.32 mL;  Tonsillectomy is one of the most common surgical procedures in otolaryngology. Despite improvements in anesthesia and surgical techniques, intraoperative and postoperative hemorrhage remain major concerns in tonsillectomy , with prThe blood supply of the tonsils mainly comes from the lingual and tonsillar branches of the facial artery. The pharyngobasilar fascia, which extends into the tonsils, covers the lateral surface of the tonsils. The complexity of the blood supply of the tonsil and the distanced and limited operation field increase the risk of massive intraoperative bleeding during tonsillectomy. Therefore, a rapid-onset hemostasis agent is essential to avoid major surgical complications. Effective hemostasis contributes to a lower operation time, better outcomes, and uneventful wound healing.Traditional electrocauterization for hemostasis may create thermal injury and result in explosive vaporization, which would lead to severe damage to the surrounding tissue. Topical hemostatic agents help the surgeon to target bleeding sources and reduce tissue damage in non-bleeding regions. In this regard, several topical agents, such as hydrogen peroxide, adrenaline, saline solution, and lidocaine ,5,6, havPost-tonsillectomy pain is another major problem, as it might lead to poor oral intake, dehydration, sleep disturbance, and prolonged hospitalization. Thus, the effect of pain control should be considered when a hemostasis agent is applied. Many local applications, such as bismuth sulfate, oral rinse, lidocaine spray, fibrin glue, and betadine silver nitrate, have been investigated to control postoperative pain .Hydrogen peroxide is an oxidizing agent that is easily degraded by tissue catalase to form oxygen and water. It is a widely available topical antiseptic and nontoxic hemostasis agent that produces oxidative burst and local oxygen production . In the The advantages of both hydrogen peroxide and adrenaline include rapid onset, acceptable duration, easy accessibility, and cost effectiveness. However, to date, there has been no direct, comparative, randomized controlled trial to achieve consensus on the optimal topical hemostasis agent in tonsillectomy. Therefore, this study aimed to compare the clinical effects of the topical application of hydrogen peroxide and adrenaline in tonsillectomy.A total of 60 patients aged 8–68 years were prospectively enrolled for tonsillectomy in tertiary referral centers between February 2018 and December 2020. All subjects fulfilled the American Academy of Otolaryngology Head and Neck Surgery criteria for chronic or recurrent tonsillitis, recurrent tonsil hemorrhage, peritonsillar abscess, or tonsillar hypertrophy with obstructive symptoms. Subjects were excluded if they had tonsillar cancer, underwent combination surgeries, had severe underlying diseases, such as cardiovascular disease, or had bleeding tendency disorder.All surgical procedures were performed via blunt dissection under general anesthesia by the same surgeon. The application of hydrogen peroxide and adrenaline was randomized preoperatively. A local anesthetic injection of 2 cc lidocaine over the peritonsillar area was performed prior to removing each side of the tonsil to reduce pain by blocking peripheral nociceptive excitation. To achieve the best confounding control, we focused on the same subjects, and all patients’ tonsils were randomly assigned to either the hydrogen peroxide or adrenaline group. Then, tonsillectomy was performed using hydrogen peroxide as a hemostatic agent on the assigned side, while adrenaline was applied to the other side. All procedures were performed by a “blind” surgeon. During tonsillectomy, cotton balls soaked with 3% hydrogen peroxide were tightly packed into the tonsillar fossa for hemostasis of mucosal bleeding, and 1% adrenaline was applied on the other side of the tonsillar fossa. We rinsed both cotton balls with 2% lidocaine and then packed them into the tonsillar fossa until complete hemostasis was achieved. Bipolar electrocauterization was used for hemostasis if persistent active bleeding was not controlled.The intraoperative blood loss on each side was measured by weighing the cotton balls and suction bottle before and after the operation. The operation time was calculated as the period between the first incision and the time all bleeding or oozing was secured entirely on the single side, encompassing the time of dissection and hemostasis. We avoided opioid drugs due to nausea and possible respiratory inhibition. In addition, anti-inflammatory drugs, such as non-steroidal anti-inflammatory drugs, were excluded because of their adverse effects on platelet function, which are associated with a tendency to bleed.Postoperative pain in the first 24 h and 48 h after tonsillectomy was recorded. Postoperative pain was assessed by determining the more painful side during follow-up. Pain intensity was evaluated by a blinded physician using a visual analogue scale, with a score of 0 indicating no pain and 10 indicating maximum pain. All patients were blinded to which technique was applied on each side. Postoperative data about pain score, fever, time to oral intake, and bleeding events were collected. All patients received the same dose of acetaminophen four times daily. In general, the patients were discharged 2 days postoperatively after examination of the uneventful surgical wound without oozing.t test was used to analyze postoperative pain score, intraoperative blood loss, and operation time. All statistical analyses were performed using SPSS 20.0 statistical software. p < 0.05 was considered statistically significant.Data on operation time, intraoperative blood loss, postoperative pain, and hemorrhage events were collected and analyzed. Descriptive statistics were presented as the means and standard deviations, and categorical variables were presented as counts and percentages. The 95% confidence intervals (CIs) were determined for the strength of association and intergroup correlation. For the main analysis, the differences in operation time, blood loss and postoperative pain between groups are expressed as means (95% CI). The study had a statistical power of 80% and an effect size of 70%. The paired In total, 60 subjects were enrolled. None of the patients had any hypersensitivity response to the ingredients of the locally applied hydrogen peroxide and adrenaline. No complications or postoperative secondary bleeding were noted after tonsillectomy. The operation time, hemostasis time and intraoperative blood loss for each side are shown in p = 0; The average intraoperative blood loss was significantly higher in the hydrogen peroxide group than in the adrenaline group .The median operation time was 8.85 ± 4.04 min in the left group and 8.39 ± 3.49 min in the right group, with no significant difference  . Our resA 2017 meta-analysis revealed that the application of local anesthetic, either by infiltration or the topical method, could provide a modest reduction in post-tonsillectomy pain and hemorrhage . The metElectrocauterization for hemostasis can significantly decrease the operation time and intraoperative blood loss; however, it can also increase postoperative pain ,17. FurtIn our study, the intraoperative blood loss was small (median volume < 15 mL) in both the hydrogen peroxide and adrenaline groups. Topical hemostatic agents that have the benefit of rapid onset, easy accessibility, cost effectiveness and analgesic effect are highly beneficial. We performed blunt dissection and applied topical hemostatic agents. Topical application of a hemostatic agent can treat all potential bleeding sites, not only focusing on an active bleeding area, but also on hard-to-access bleeding areas, such as the low pole of the tonsil. Thus, a topical hemostatic agent may be a feasible method to control hemorrhage. Hemostasis with the compression of a cotton ball may also cause lower postoperative pain than bipolar cauterization and ligation . TopicalHydrogen peroxide is widely used for wound irrigation, owing to its hemostatic and antimicrobial effects. Chang et al. and Al-Abbasi et al. reported that the use of hydrogen peroxide significantly reduced the operation time in tonsillectomy by 35% and 31%, respectively . In our For intraoperative blood loss, the median volume was significantly lower in the hydrogen peroxide group than in the adrenaline group. We found that both hydrogen peroxide and adrenaline could decrease intraoperative hemorrhage. However, although the effect size of 3.88 mL of intraoperative blood loss may be significantly different, this little change may not have clinical significance. In addition, we also found that the mucosa and soft tissue turned white after hydrogen peroxide was pressed tightly. The chemical burns and bitter taste of hydrogen peroxide might explain the higher 24 h postoperative pain score in the hydrogen peroxide group (4.98 ± 1.94) than in the adrenaline group (4.27 ± 1.97).There are three main applications of hydrogen peroxide: antiseptic, hemostasis and wound healing. Reactive oxygen species (ROS) defend the host from invading microbes by damaging microbial DNA. When hydrogen peroxide is degraded, reactive oxygen species are released, causing DNA strand breakage by DNA oxidization . ROS indIn addition to the antiseptic benefit, we also found a decrease in operation time. Further analysis of the decreased operation time in the hydrogen peroxide group showed that the “bubble effect”, due to oxidation in the early stage, rapidly turned the bleeding area to white. This helped the surgeon to easily localize the bleeding source requiring cauterization and clarify the visual field. It also shortened the operation time. Applying hydrogen peroxide to the wound at the late stage can kill fibroblasts and promote re-epithelialization . HydrogeThere are numerous theories regarding the hemostatic effects of hydrogen peroxide, including thermal injury of the vascular ends, oxygen embolization of vessels, and reactive vascular spasms . More reCurrently, hydrogen peroxide is used clinically not only as a hemostatic and antiseptic agent, but also as a wound-healing agent . HydrogeHatton et al. reported that topical adrenaline is an effective hemostatic agent in tonsillectomy . The appWe combined lidocaine and adrenaline in this study because lidocaine could stabilize the neural membrane by inhibiting voltage-gated sodium channels, resulting in the suppression of impulse conduction, affecting local anesthetic action. To prevent the systemic circulation and adverse effects of central nervous system toxicity, tachycardia, convulsion, respiratory obstruction  and vocaThis study has some limitations. The number of subjects enrolled in our study was too small to draw a definite conclusion. In the absence of a control group in this study, where no topical agents are used, it is difficult to interpret the absolute benefit of each other’s hemostatic agents. Previous studies measured pain before and after the administration of supplemental analgesia; however, there may still have been some residual analgesic effect on subsequent measurements in the early period. Meanwhile, we assessed the pain score at 24 h postoperatively, when the anesthetic effect may have little residual activity. Furthermore, we found that it was difficult for some patients to precisely discriminate the exact pain score on each side, possibly resulting in bias. Further studies should investigate the effects of hemostatic agents over a longer duration with a larger set of participants.The topical application of hydrogen peroxide is beneficial for reducing the operation time and intraoperative blood loss, with minor complications, in tonsillectomy. Thus, hydrogen peroxide can be used as a routine topical hemostatic agent in tonsillectomy. Meanwhile, the topical application of adrenaline provides significant pain relief on the first day compared to hydrogen peroxide.


CNR1) gene. In this study, we examined the association between three-nucleotide repeats (AAT) polymorphism located in the 3′UTR non-translational region of CNR1 and the patient’s quality of life after total hip arthroplasty. Our study examined the degree of pain sensation, hip function, and the patient’s performance at defined intervals after elective hip replacement due to degenerative changes. The study included 198 patients (128 women and 70 men). The average age was 67 years. PCR genotyping assay was used to identify the (AAT)n triplet repeat polymorphism in the CNR1 gene. The (AAT)n repeat number was determined by sequencing using a standard sequencing protocol. Our study found no statistically significant association between the degree of pain, hip function, and the change in the degree of disability and the (AAT)n polymorphism in the CNR1 gene, no statistically significant correlations between clinical symptoms, the patient’s age, and the number of AAT repeats, no association between the length of the allele and the degree of pain, hip function, and the change in disability.Genetic factors may predispose persons to decreased pain excitability. One of the interesting modulators affecting pain perception may be polymorphisms of the cannabinoid receptor type 1 ( Osteoarthritis (OA) is one of the more common causes of disability in the elderly. Pain and progressive loss of function are the most important clinical signs warranting the initiation of both pharmacological and surgical treatment ,2. The rCNR1) gene on chromosome 6 (6q14-q15) ; 2 pmol fluorescent labeled primer forward; 2 pmol primer reverse and 0.6 U AmpliTaq 360 DNA polymerase [Applied Biosystems]. PCR was performed in a Mastercycler Gradient [Eppendorf] and included a three-minute initial denaturation at 94 °C followed by 26 cycles of the 20-second denaturation at 94 °C, primer annealing at 58 °C for 30 s, extension at 72 °C for 30 s, and a final extension at 72 °C for 30 min. Fluorescent analysis of PCR products on ABI PRISM® 3100-Avant [Applied Biosystems] were used for length and allele determination. Additionally, (AAT)n repeat number was confirmed by sequencing in randomly selected homozygous samples using a standard sequencing protocol, performed on an ABI PRISM® 3100-Avant [Applied Biosystems]. For the purpose of the analysis, alleles were subsequently classified as short (<11) or long alleles ≥ 11 (AAT)n, which is consistent with the research by Comings et al., [The day before surgery, a 2 mL whole blood sample for genetic testing was drawn. Genomic DNA was isolated using GeneMATRIX Quick Blood DNA Purification Kit . Our study used a PCR genotyping assay to identify the (AAT)n triplet repeat polymorphism in the y Dawson . PCR was et al., .p < 0.05, Shapiro-Wilk test); thus, a non-parametric test was used in the calculations. Parameters and their changes were compared between genotypes using the Mann-Whitney test. The correlations between the number of AAT repeats in the shorter and longer allele, the average number of AAT repeats from two alleles, and measurable parameters were analyzed using Spearman’s rank correlation coefficient. Statistical calculations were performed using Statistica 10. In this case, p < 0.05 was used as the threshold for statistical significance.The accordance of genotype distributions with Hardy-Weinberg’s equilibrium was analyzed using the exact test. In most cases, the distributions of measurable parameters—pain perception, degree of disability, and hip function—were significantly different than normal  and 6 months after surgery. Hip function using the HHS and the degree of disability using the ODI were also performed. The results of these measurements are shown in CNR1) gene with pain intensity, hip function, and the degree of disability. The frequency of CNR1 (AAT)n alleles in the study group is presented in The study evaluated the association of the AAT polymorphism of the cannabinoid receptor type 1 .At the same time, CNR1 genotypes were found to be consistent with Hardy-Weinberg’s equilibrium (p = 0.50). The study group’s short allele (S) frequency was 35%; here, there were no statistically significant differences in CNR1 allele frequencies between genders. Similarly, the frequency of the three genotypes  of CNR1 was similar in women and men—as shown in Alleles with less than 11 AAT repeats were classified as short (S), while those with AAT number of repeats of 11 and above were described as long (L). Based on this classification, the patients were divided into three groups: those with 2 short alleles (S-S), those with 2 long alleles (L-L), and those with 1 short and 1 long allele (S-L). The distributions of CNR1 gene polymorphism with pain intensity, hip function, and the degree of disability in patients at defined intervals after surgery. There were no statistically significant correlations between the degree of pain sensation assessed according to the VAS scale and the L-L, S-L, and S-S genotypes at defined intervals, i.e., six weeks and six months after hip replacement)—The study aimed to analyze the association of the cannabinoid CB1 receptor There were also no statistically significant differences between hip function and the change (improvement) in hip function measured according to the Harris scale, L-L, S-L, and S-S genotypes at defined time intervals —In addition, no statistically significant correlation was found between the degree of disability and the change in the degree of disability measured by the ODI, L-L, S-L, and S-S genotypes at defined intervals, i.e., one week, six weeks, and six months after the surgical treatment—There were no statistically significant correlations between the clinical symptoms and their changes, as measured by the VAS scale, Harris scale, Oswestry Disability Index, and the number of AAT repeats in the shorter allele and in the longer allele, as well as the average number of AATs from both alleles at defined time intervals .The average number of AAT repeats for each patient was calculated based on the following formula: .CNR1 gene, i.e., a microsatellite polymorphism of the number of three-nucleotide repeats (AAT).The endocannabinoid system is involved in several physiological and pathological processes; hence, attempts to use it for therapeutic purposes seem justified. Since the effect of this system, and especially the use of drugs affecting this system, may be subject to genetic variations, we chose to study one of the most frequently described variations within For the evaluation of the quality of life in patients after hip replacement, the Visual Analog Pain Scale (VAS) was used to assess pain, and the Harris Hip Score (HHS) and Oswestry Disability Index (ODI) were used to assess the performance of the patients after hip arthroplasty. Other authors have also used similar tools ,43.CNR1 gene encoding the cannabinoid receptor (CB1) on the patient’s quality of life after hip replacement, the variable number of trinucleotide repeats (AAT)n within the CNR1 gene encoding the CB1 receptor was determined in all patients. To identify (AAT)n, the method of Comings et al. [CNR1 alleles were subsequently classified into two groups according to the criterion of the number of repeats of the AAT sequence, distinguishing the short allele (S)—containing less than 11 repeats, and the long allele (L)—containing 11 and more repeats. This was used as the basis for a division of patients into 3 genotypes , whose frequency distribution among the patients qualified for our study was similar to the results obtained by other authors [To analyze the effect of the polymorphism of the s et al.  was used authors . A correCNR1 gene encoding cannabinoid receptor type 1 and the pain sensation of the patients after hip arthroplasty. Other authors have also looked at the role of genetic variation in the CB1 receptor in pain perception. The Brazilian analysis [CNR1 gene may be associated with FM, obesity, irritable bowel syndrome, migraine, and post-traumatic stress disorder. On the other hand, Gerra et al., [CNR1). This indicates that FM is not a homogeneous disorder. Spanish researchers [CNR1 G1359A, rs12720071) in a similar area to the AAT microsatellite polymorphism, i.e., the 3′UTR of exon 4. The pain threshold and pain tolerance were determined based on the cold-pressor test, which involved immersion of the non-dominant hand in 4 °C water by young, healthy participants. Perceived pain was also assessed using the VAS scale. However, none of the variables were found to be statistically significantly associated with the studied polymorphism, regardless of the participant’s assessed mood. Furthermore, in another study [CNR1 mRNA expression did not differ among chronic low back pain patients. Researchers from Japan [CNR1 gene, peripheral pain sensation, and analgesia-related features in postoperative pain management in patients who underwent open abdominal or orthognathic cosmetic surgery. In that study, no statistically significant associations were found between (ATT)n repeats in the CNR1 gene and peripheral pain sensation. However, short tandem repeats in the CNR1 gene were associated with the frequency of fentanyl use, fentanyl dose, and the VAS scores 3 h after orthognathic cosmetic surgery. Similar observations were obtained in the study of patients with irritable bowel syndrome, in which no association between the (ATT)n repeats of the CNR1 gene and pain sensation was found [In our study, we did not find an association between the (AAT)n polymorphism of the analysis  found 30 et al.,  found noearchers  analyzeder study , CNR1 mRom Japan  performeas found . Based oCNR1 gene in patients after hip arthroplasty. As measured by the Harris scale, there was also no statistically significant relationship between the CB1 receptor CNR1 gene polymorphism and hip function. Furthermore, there was no statistically significant correlation between the degree of disability and the change in the degree of disability as measured by the ODI. However, it is important to note that this has been groundbreaking research and that more research is needed. The first observations linking the endocannabinoid system to postoperative pain after hip replacement and to functional disability in arthrosis patients were only made a few years ago [The intensity of pain perception assessed using the visual analogue scale (VAS) was not found to be statistically significantly correlated with the (AAT)n polymorphism of the CB1 cannabinoid receptor ears ago . Studiesears ago ,53,54. SSome researchers have shown that single-stranded miRNAs bound in the RNA-induced risk complex (RISC) silencing complex bind to non-coding 3′-untranslated regions (3′UTR) of mRNA, leading to decreased translation, increased transcript degradation, or both . TherefoCNR1 gene and the degree of pain, hip function, and change in disability in patients who underwent elective hip arthroplasty. However, due to the relatively small group size, larger studies are needed in order to confirm the value of the present study observations, as the research on the cannabinoid system may open new perspectives for individualizing therapy and evaluating the effectiveness of treatment for patients with hip osteoarthritis. Considering the undeniable role of the cannabinoid system in nociception, further research in this area would be advisable.In conclusion, the aim of our study was to find a potential association between one of the genetic factors—(ATT)n polymorphism—and the perception of pain, hip function, and performance in patients after hip arthroplasty. The analysis of the results showed that there was no association between the length of the allele of the CB1 cannabinoid receptor


Total knee arthroplasties are the second most common surgery in Canada. Most patients recover well, but 20% or more still suffer from persistent pain and opioid use. Though opioids are an important part of perioperative pain management, their potential for long-term adverse effects is well recognized. Limiting opioids may be insufficient to overcome the issue of opioid overuse. Pain and opioid use are highly linked, so an effective alternative needs to address both issues.The principal objective of this pilot trial is to assess the feasibility. The clinical objectives are to determine the effects of a multicomponent care pathway on opioid-free pain control, persisting pain and opioid use, functional knee outcomes, quality of life, and return to function.We will include adult patients scheduled for primary elective total knee arthroplasty. Patients in the intervention group will undergo a multicomponent intervention pathway that will be facilitated by an intervention coordinator linking each patient and their surgical/ perioperative team. The interventional pathway will include (1) preoperative education on pain and opioid use, (2) preoperative risk identification and mitigation using cognitive behavioral skills, (3) personalized postdischarge analgesic prescriptions, and (4) continued support for pain control and recovery up to 8 weeks. Patients in the control group will receive the usual care at their institution.The overarching goal is to implement and evaluate a coordinated approach to clinical care to improve pain control and reduce harms, with an emphasis on patient-centered care and shared decision making.Trial Registration Number: NCT04968132 (informed consent/ research ethics board statement). Trial Registration Number: NCT04968132.


An increasing number of patients require outpatient and interventional pain management. To help meet the rising demand for anesthesia pain subspecialty care in rural and metropolitan areas, health care providers have used telemedicine for pain management of both interventional patients and those with chronic pain.In this study, we aimed to describe the implementation of a telemedicine program for pain management in an academic pain division in a large metropolitan area. We also aimed to estimate patient cost savings from telemedicine, before and after the California COVID-19 “Safer at Home” directive, and to estimate patient satisfaction with telemedicine for pain management care.This was a retrospective, observational case series study of telemedicine use in a pain division at an urban academic medical center. From August 2019 to June 2020, we evaluated 1398 patients and conducted 2948 video visits for remote pain management care. We used the publicly available Internal Revenue Service’s Statistics of Income data to estimate hourly earnings by zip code in order to estimate patient cost savings. We estimated median travel time and travel distance with Google Maps’ Distance Matrix application programming interface, direct cost of travel with median value for regular fuel cost in California, and time-based opportunity savings from estimated hourly earnings and round-trip time. We reported patient satisfaction scores derived from a postvisit satisfaction survey containing questions with responses on a 5-point Likert scale.Patients who attended telemedicine visits avoided an estimated median round-trip driving distance of 26 miles and a median travel time of 69 minutes during afternoon traffic conditions. Within the sample, their median hourly earnings were US $28 (IQR US $21-$39) per hour. Patients saved a median of US $22 on gas and parking and a median total of US $52 (IQR US $36-$75) per telemedicine visit based on estimated hourly earnings and travel time. Patients who were evaluated serially with telemedicine for medication management saved a median of US $156 over a median of 3 visits. A total of 91.4% (286/313) of patients surveyed were satisfied with their telemedicine experience.Telemedicine use for pain management reduced travel distance, travel time, and travel and time-based opportunity costs for patients with pain. We achieved the successful implementation of telemedicine across a pain division in an urban academic medical center with high patient satisfaction and patient cost savings. Chronic pain is the most common reason for seeking medical care, with a prevalence of 50% and 10% of localized and generalized chronic pain, respectively, in the United States. Chronic pain is associated with significant occupational, functional, and psychological morbidity and accounts for an estimated annual US $61 billion in lost productivity in the United States [However, pandemic policies discouraging direct in-person contact forced pain practices to use alternative methods to deliver care to chronic and interventional patients, which led to the rapid adoption of telemedicine. To encourage telemedicine use, governments eased regulations, and Medicare  and otheClinical consultations using telemedicine have been associated with patient cost savings, without a difference in clinical outcomes compared to in-person visits , and witPrior to the pandemic, we initiated telemedicine-enabled pain clinics for interventional patients with chronic pain at our academic medical center and community practices to reduce wait times and no-show rates and to increase patient satisfaction. During the onset of the pandemic, the majority of outpatient pain visits at the University of California, Los Angeles (UCLA) rapidly shifted to telemedicine visits. This paper focuses on the structure, implementation, and patient cost savings and satisfaction associated with our pain division’s telemedicine program. We aimed to (1) describe the UCLA Comprehensive Pain Center’s telemedicine implementation for comprehensive pain management; (2) estimate the travel time, travel distance, and time-based opportunity savings for patients using telemedicine; and (3) describe patient satisfaction using telemedicine.This was a retrospective, observational case series study of telemedicine use in a pain division at an urban academic medical center comprising the UCLA Comprehensive Pain Center and Community Pain Clinics.The UCLA Comprehensive Pain Center is a multidisciplinary pain management practice in Santa Monica, California. The practice is staffed by four attending physicians, a physician assistant, and a licensed clinical social worker. In addition to performing consults and follow-up visits, providers can perform procedures without image guidance, including trigger point injections, joint injections, and nerve blocks. The UCLA Comprehensive Pain Center has 10 examination rooms equipped with an examination bed and a computer with a camera for electronic medical record (EMR) access via Epic (Epic Systems Corporation) and telemedicine use. The majority of procedures are done on an outpatient basis at the Santa Monica UCLA Outpatient Surgery Center. Typical outpatient procedures include epidurals, nerve blocks, radiofrequency ablations , joint injections, kyphoplasties and vertebroplasties, and placement of spinal cord stimulators and intrathecal pain pumps.The UCLA Community Pain Clinics are community extensions of the UCLA Comprehensive Pain Center. There are currently nine attending physicians operating out of six office locations in the Greater Los Angeles Metropolitan Area. The community sites provide the same quality of care at a variety of geographical locations distributed throughout the Los Angeles Metropolitan Area. Outpatient procedures are performed at nearby surgery centers within the community. Patient demographics, diagnoses, procedural interventions, and telemedicine use closely resemble those seen at the Santa Monica UCLA Comprehensive Pain Center.For both the Santa Monica UCLA Comprehensive Pain Center and the UCLA Community Pain Clinics, patients are generally referred from their primary care or surgical providers. All pain management providers perform a thorough evaluation, including a history and physical, and review all the labs, imaging, and other pertinent data. Management may involve additional diagnostic studies, medication, multidisciplinary therapy, and interventional procedures. Patients already on opioid medication constitute a significant portion of the referrals. Given the opioid epidemic and US Centers for Disease Control and Prevention guidelines for opioid management, many prescribing physicians emphasize weaning opioid usage, especially for patients on more than 60 morphine milligram equivalents. If the pain management provider agrees to manage the patient’s opioid regimen, regular follow-up is usually required every 4 weeks.We extracted demographic data from the EMR for all video visit encounters within the anesthesiology pain division from August 1, 2019, to June 30, 2020. Telemedicine visits for patients residing in California were included for analysis. During the COVID-19 pandemic in California, a “Safer at Home” directive was ordered on March 18, 2020. Before the COVID-19 era, patients used telemedicine prior to the “Safer at Home” directive; during the COVID-19 era, patients had their first telemedicine visit for pain management following the directive.To measure patient satisfaction, we used data from a patient satisfaction survey sent to patients after their video visit. UCLA Connected Health emails each patient a patient satisfaction survey after completion of their video visit. The survey has 11 questions with responses on a 5-point Likert scale and a section for comments. From March 24 to April 22, 2020, UCLA Connected Health transitioned its survey platform from REDCap (Research Electronic Data Capture) to Qualtrics; during this period, patient satisfaction surveys were not distributed, and no patient satisfaction survey data are available for this period. All survey responses from August 1, 2019, to March 23, 2020, and from April 23 to June 30, 2020, were included for survey analysis.The UCLA Comprehensive Pain Center implemented telemedicine for use in clinical care in July 2019, and we report on the period from August 1, 2019, to June 30, 2020. The UCLA Pain Division uses telemedicine for initial consultations, medication management, and postprocedural follow-up visits. In Clinical use cases for telemedicine:New patients for postoperative pain medication managementNew patients that have been referred by a spine surgeon for a specific injectionPosthospitalization follow-up of patientsPatients on medication management who need a medication refill or adjustment in medicationPatients who need to discuss imaging results and next steps in their managementPatients with recurrent pain who may need a repeat injectionPostprocedural  follow-up of patientsOur group’s clinical experience thus far with telemedicine is that it offers a convenient care delivery option to the patient and that, generally, adequate clinical assessments can be made during a telemedicine visit. In all telemedicine use cases, the need for an in-person physical exam is made on a case-by-case basis. An abbreviated physical examination is documented in the EMR. If the source or nature of pain is unclear during the telemedicine visit, the clinician may request for the patient to come for an in-person evaluation. Other reasons the clinician may request an in-person evaluation include the following: if physical examination is required by the patient’s insurance company for procedural authorization, though many, including Medicare, do not require authorization for procedures; if there are concerning lesions on a patient’s magnetic resonance imaging scan necessitating a more comprehensive physical examination; and if urine drug screening is requested, for instance, if a substance misuse disorder is suspected. Overall, in our experience, about 10% of telemedicine visits are converted to in-person visits.For initial telemedicine consultations, the physician elicits a history from the patient, and an abbreviated physical exam is performed remotely by asking the patient to do certain maneuvers and eliciting feedback on pain in response to these movements. Further management is decided based on the history and the abbreviated physical examination. Should a procedure be recommended, a complete physical examination is performed in the preoperative area on the day of the procedure.The UCLA Anesthesiology Pain Division also offers the option for telemedicine visits for medication management as an alternative to in-person visits. During a telemedicine visit for medication management, the patient provides the physician with an update regarding pain levels and functionality while on the current medication regimen and reports any adverse side effects associated with the medication regimen. The physician may review pertinent imaging and diagnostic studies or order additional studies and referrals. The physician also assesses for any aberrant drug-related behaviors and checks CURES  reports before prescribing scheduled medications. Prescriptions are primarily e-scripted to the patient’s preferred pharmacy, and patients are generally prescribed up to a 30-day supply of medication, with additional refills as appropriate.Our institution has also used telemedicine for postprocedural follow-up. Depending on the procedure, patients are offered the option to follow up with their pain physician using telemedicine as early as 2 to 3 days to 3 to 4 weeks after the procedure. For patients who seek radiofrequency ablation, most insurance payors require two diagnostic medial branch nerve blocks to be completed with significant improvement  before proceeding with radiofrequency ablation. This requires a follow-up evaluation between these staged procedures, for which we offer a telemedicine follow-up visit. For most other nonstaged procedures, procedure follow-ups can also be completed via telemedicine. During a postprocedural follow-up telemedicine visit, the clinician will inquire about any improvement after the procedure and any adverse side effects associated with the procedure. The patient will be asked to comment on improvement in functionality, if any, as a result of the procedure. The patient and the physician would discuss the next steps in clinical management, including medications, the potential for repeat procedures, additional procedures, and referrals to other specialists.UCLA Health uses Vidyo videoconferencing software  for its telemedicine video visits. Telemedicine visits are scheduled within Epic, and providers log in to the video visit from the Epic clinic schedule. UCLA Health uses a mobile-only option for patients who use the Epic MyChart app (Epic Systems Corporation) on their smartphone or tablet to log in to the myUCLAhealth patient portal. After logging in to the Epic MyChart app, patients are prompted with a “begin visit” button at the top of the opening webpage. Patients wait in a virtual “waiting room” until the provider logs on to the video interface. We evaluated patient cost savings and satisfaction associated with telemedicine use in our patient population. To calculate patient costs saved by using telemedicine for care as opposed to an in-person visit, the patient’s total cost for an in-person visit was estimated by calculating and totaling the total fuel cost for travel by car to a clinic visit, parking cost, and time-based opportunity cost, based on previously published methods ,13. The To estimate patient earnings per hour by zip code based on the IRS SOI, total annual earnings within a zip code were first calculated as the sum of two income categories: (1) business or professional income and (2) salaries and wages. We defined earnings to include wages and income from running a business, a more comprehensive definition of labor earnings. In contrast, wages listed in employer databases do not reflect patients’ income from running a business. For individual returns, annual earnings per person can be calculated by dividing total annual earnings by the number of individual returns within the zip code. For joint filings, earnings per person must be calculated by dividing total earnings by twice the number of filings, since each filing reflects two people’s combined earnings. Within each zip code, annual earnings per person are calculated using a denominator that reflects the share of filings that were individual versus joint returns ,20. In pFinally, to estimate earnings per hour, we divided the estimated annual earnings per person by 2000 hours per year. We assumed 2000 working hours per year, which equals 40 hours per week times 50 weeks per year. This is similar to the annual work hours assumption used by the BLS when it estimates hourly wages from surveys of employers: the BLS uses an estimate of 2080 hours per year . NotablyTo estimate the time-based opportunity savings, we multiplied the round-trip travel time by the patient’s estimated hourly earnings by zip code; for this pain population, the median hourly earnings were US $28 per hour. Sensitivity analyses were conducted by varying the fuel cost , the median round-trip distance (5-200 miles), and the fuel economy  to characterize the range of travel costs, round-trip travel distance, and hourly earnings. A subset of our patients had serial visits for chronic pain management, and we conducted a sensitivity analysis varying hourly earnings and number of visits to understand savings with telemedicine over chronic care management.t test for continuous variables (2-tailed) and the chi-square test for categorical variables . P values less than .05 were considered statistically significant.Patient characteristics and study variables were summarized using mean (SD), median (IQR), or frequency (%), unless otherwise noted, using the Python programming language (Python Software Foundation ). In ordInstitutional Review Board (IRB) approval was obtained but given exempt status for the purposes of analyzing and retrospectively reporting our results for quality improvement (IRB #20-000573).P<.001). There was no significant difference in the distribution of race between cohorts from the pre–COVID-19 era and the COVID-19 era. Additional patient demographic characteristics are presented in We completed 2948 telehealth video visits with 1398 patients. The mean age of the total patient sample was 56 (SD 16) years. Patients from the pre–COVID-19 era were, on average, younger than patients from the COVID-19 era  no-shows and 2948 (98.1%) successfully completed telehealth visits.Of the 2192 video visit encounters for which a patient experience survey was emailed, there were 313 completed patient experience surveys (response rate of 14.3%). Patient satisfaction for using telehealth for pain management was high. Out of 313 survey responders, 286 (91.4%) either “agreed” or “strongly agreed” that they were satisfied with a video visit for care management, and 293 (93.6%) survey responders either “agreed” or “strongly agreed” that they felt confident in meeting with their provider via a video visit. Out of 313 survey responders, 271 (86.6%) said that they either “agreed” or “strongly agreed” that they would prefer future video visits for pain management care. We present the results of the patient experience survey in P=.002). As calculated from the patients’ home zip codes to their pain providers’ clinics, the median round-trip travel distance was 26 miles (IQR 13-51). The median round-trip travel time in afternoon traffic conditions was 69 minutes (IQR 46-101). Patients from the pre–COVID-19 era experienced longer travel times than patients from the COVID-19 era  and experienced greater estimated total savings than patients from the COVID-19 era (P<.001). Sensitivity analyses were conducted to reflect the value of a telemedicine encounter based on hourly earnings  per hour, with subsequent median time-based opportunity savings of US $32, bringing the estimated median total savings per telemedicine video visit to US $52 (IQR US $36-$75). Patients from the pre–COVID-19 era had higher hourly earnings  were satisfied with their telemedicine experience.We introduced our telemedicine program for all the patients seen in our health care system meeting our eligibility criteria, and not for a narrow subset of patients, improving the generalizability of our findings to a general pain management population. Inclusion in our study of patients seen in both academic and community-based practices also improved our findings’ generalizability. Our study included a relatively high number of patients, making the findings more robust. Our use of IRS SOI data to estimate hourly earnings by zip code, rather than using citywide median incomes, likely strengthened the accuracy of our cost savings estimate.Other studies have established the significant increase in telemedicine adoption since the beginning of the COVID-19 pandemic ,24 as weOur methods only took into account the use of cars as a transportation mode. We did not look at other means of transportation  when calculating travel costs. Furthermore, ideally, our time-based opportunity cost analysis would quantify patient savings at the individual level. While our approach provided a more refined way of calculating time-based opportunity cost, our approach was limited in that even within a zip code, earnings varied for particular patients, and our method did not, therefore, perfectly capture patient earnings. Our time-based opportunity cost analysis also did not consider patients who may be unemployed, unable to work, or retired, which may represent hourly earnings of $0 per hour and for whom total savings may only reflect travel costs. We also compared the observational cohorts on a few characteristics that we could abstract from the EMR, leaving the potential for unmeasured confounding factors.Patient savings are an essential component of the financial benefits of telemedicine. These savings should ideally be quantified at an individual patient level to reflect heterogeneous populations of patients with different opportunity costs associated with travel for in-person visits. Opportunity costs are typically estimated based on hourly wage rates or hourly earnings, but such individual income data are not collected by health systems. In this study, we estimated the earnings of our sample of patients with pain using a novel approach that used publicly available IRS SOI data, which allowed us to estimate hourly earnings by zip code. Earnings estimated based on patient zip codes are more accurate than using citywide or national median incomes or wages, which is the measure used in previous studies ,26,27. TP<.001). Telemedicine offers value for patients in the form of time-based opportunity savings, especially for patients who must travel long distances, experience traffic, or have high time-based opportunity costs from missed work. A subset of patients had multiple video visits for medication management. Figure S4 in Our data suggest that patients who stood to benefit the most from adopting telemedicine—because they have higher hourly earnings and, therefore, higher time-based opportunity costs of in-person visits—were early adopters of telemedicine. Patients from the pre–COVID-19 era had higher total savings compared to the patients from the COVID-19 era (Patient satisfaction as a measure of quality of care is also a key part of value-based care. It has been associated with the success of telemedicine initiatives , patientConsensus recommendations from panels of adult chronic pain health professionals have identified the value of telemedicine to manage pain ,32, but Finally, challenges with using telemedicine at the patient level have begun to come to light since the COVID-19 pandemic. Access to telemedicine involves different economic and social factors, and chronic and interventional patients will need access to telecommunications technologies  as well In this study, we aimed to describe the implementation and evaluation of our adult anesthesia pain division’s standardized telemedicine practice guidelines for adult chronic and interventional patients with pain and to estimate total patient cost savings and satisfaction with telemedicine. We found that per visit, patients saved US $52, on average, taking into account both actual cost and time-based opportunity cost and that a high proportion of patients surveyed were happy with their telemedicine experience. Chronic pain causes significant suffering and a reduced quality of life, especially in the setting of a pandemic, but telemedicine provides efficient and cost-effective care to patients with chronic pain. Our telemedicine initiative was built on our academic hospital’s comprehensive pain center and the community clinics’ capacity to treat and care for patients with pain needs; our findings suggest that expanding the use of telemedicine for pain management may save patients time, reduce costs, and provide high patient satisfaction. Following the COVID-19 pandemic, we anticipate that telemedicine management for patients with pain will continue to evolve as health care systems strive to improve population health and improve care access for patients with pain needs.


The TYMO® device is a portable posturography platform that monitors the tilting of the body’s center of mass and reports the results of the rehabilitation process. (2) Objective: To evaluate the effect of therapy based on neurophysiological methods (proprioceptive neuromuscular facilitation (PNF), neurodevelopmental treatment according to the Bobath concept (NDT-Bobath)) and the SPIDER system on body weight transfer shifting, in post-stroke patients in the chronic phase, compared to therapy based on neurophysiological methods , without the use of the SPIDER system. (3) Methods: This is a randomized controlled trial in which patients  were assigned to one of two groups: study, n = 60 ; and control, n = 60 . In patients in both groups, before and after the training (2 weeks of therapy), body weight distribution was measured on the TYMO® platform. (4) Results and Conclusions: The results of the statistical analysis demonstrated a greater reduction in the tilt of the body’s center of mass in therapy using the SPIDER system, compared to therapy in which the system was not used.(1) Background: The Strengthening Program for Intensive Developmental Exercises and Activities for Reaching Health Capability (SPIDER) system is dedicated to patients with motor deficits resulting from damage to the peripheral or central nervous system (including post-stroke patients). It enables the conduct of forced-weight-bearing therapy to the lower limb affected by the paresis. In this study, the TYMO Of the 15 million people worldwide who suffer a stroke each year, 5 million are permanently disabled and need ongoing care ,3,4. TysThe above-mentioned topic of imbalance and asymmetric gait is related to the investigation of the pattern of walking . Clinicians use qualitative analysis and observation-based balance scales  because these tests do not require equipment input and are easy to perform. However, quantitative analysis is more accurate and provides more information about the patient’s functional status. Posturographic platforms are used to quantitatively measure the center of the body’s mass tilts in standing, which interpret standing stability and postural control strategies ,19. Commn = 300) residing at the center at that time, patients meeting the inclusion criteria were selected  , in cooperation with the NORMAN Neurological Rehabilitation Center in Koszalin. The study was conducted from August 2021 to August 2022. From a group of all post-stroke patients (vention) . All patInclusion criteria  were det-Change from sitting to standing (d4103)—the patient performs a transition from sitting with feet placed on the floor to standing (without any assistance);-Holding the standing position (d4154)—the patient stays in the required standing position for a specified period of time (without any assistance);-Test to assess the risk of falls in walking (TUG—d4500)—the patient stands up from a sitting position  and walks a distance of 3 m, then turns around and returns to the starting point by sitting down again. The time is measured from standing up to taking up a sitting position again. Norms: healthy people—less than 10 s, elderly people—14 s, patients at risk of falling—more than 30 s ,23.ICF-based functional testing:Modified Ashworth Scale: a six-point numerical scale used to assess increased muscle tone (spasticity). Muscle tension in the lower limbs is tested in the supine position, symmetrically on both sides. The speed of passive movement, which should last approximately 1 s in full flexion or extension, proves to be important ,24.Barthel scale: an international scale for assessing a patient’s functional abilities and care needs. The index assesses the patient’s level of dexterity and independence in ten basic areas: eating, moving and sitting, maintaining personal hygiene, using the toilet, washing and bathing the entire body, moving on flat surfaces, going up and down stairs, dressing and undressing, controlling feces and anal sphincter, controlling urine and bladder sphincter. Interpretation of scores: 0–20 pts.—complete dependence, 21–80 pts.—help from others needed, 81–100 pts.—patient can function independently with support from others .Rankin scale: a six-point scale assessing the level of disability of a neurological patient  ,26.NIHSS scale: an international scale to assess the state of consciousness, orientation, response to commands, associated gaze, visual field range, facial and limb muscle paresis, sensation and language function of the stroke patient. Scores range from 0  to 42 points  .MMSE scale: a mental status evaluation scale that allows quantitative assessment of many aspects of cognitive function: orientation in time and place, memory, attention and counting, remembering, language function, repetition, following complex oral or written instructions and visuospatial ability. The maximum score that can be obtained in the test is 30 points (a score below 24 points is indicative of varying degrees of Dementia) .FMA-LE test: an index to assess lower limb sensorimotor dysfunction in post-stroke patients. The scale includes an assessment of: reflex activity, voluntary movements within and beyond synergies, ability to perform isolated movements, speed and coordination. A total score of 34 points indicates normal lower limb function ,30.Mirror test: a test used to investigate deep sensation .Berg Balance Test: a quantitative test to assess balance and fall risk. It focuses on static and dynamic balance. It includes 14 tasks with a maximum score of 56 points. A score of 0–20 points suggests total wheelchair dependence; 21–40 points are assigned to a patient who moves with assistance, 41–56 points—independent patient ,32.® platform. The study group’s training lasted 2 weeks: 4 × 45 min per day of therapy based on neurophysiological methods and 1 × 45 min per day of therapy using the SPIDER system. In contrast, training of the control group lasted 2 weeks: 5 × 45 min per day of therapy based on neurophysiological methods, without the use of the SPIDER system.The physiotherapeutic treatment of both groups was based on manual therapy, balance training and postural control, sensory and functional techniques using neurophysiological methods , and exercises on equipment . In addition, the study group was treated using the SPIDER system. Before and after two weeks of the rehabilitation program, active body weight distribution (COFT) analysis was performed on the TYMO® is a device for analyzing the transfer of the body’s center of mass; it compares the symmetry of the active weight distribution and quantitatively assesses balance and postural control in the standing position  that balance can be maintained;-The range of motion (ROM) exceeded;-The center of force track (COFT), or the total length of the center of force track (COF) during each measurement. Medio-Lateral indicates the total range of lateral sway of the body (right-mid-left), and Anterior-Posterior indicates the total range of forward and backward sway of the body (front-mid-backward);-The COF movement area ;-The Stability Dynamics Index (STDI), which analyzes the relationship between the distance traveled by the COF and the area of ROM. The higher the value, the more unstable the patient;-An average speed and the ratio of maximum speed to average speed. The speed value describes the number of fast movements that need to be made to maintain balance;-A posture, viz., the distribution of weight and/or force from front to back and left to right .TYMOposition . The TYM® platform . Prior to the test, each patient was instructed to distribute their body weight symmetrically on both lower limbs during the test. The test of maintaining the above-described position lasted 30 s , is based on elastic cords, which are the stimulating elements. The cords are attached to a support belt, which in turn is placed around the patient’s waist. The force generated depends on the type of expander (two types of cords are used) and the height of attachment on the cage of the SPIDER device (height of expander attachment—center of gravity angle)  34,35,3,335,36.The advantage of the SPIDER system is the ability to work with the patient in a standing position. The patient is off-loaded if the point of attachment of the cords to the cage is above the level of the support belt (above the transverse plane and therefore above the center of mass). Conversely, the patient is loaded if the cords are attached below the level of this belt (below the transverse plane). This quick way of changing the load and unloading is a useful possibility in the training . In patiIn the present study, therapy using the SPIDER system consisted of forcing the body weight onto the affected lower limb to inhibit the mechanism of learned disuse of this limb . This ren > 30, the t-test could be used . Indeed, the t distribution can be approximated by a normal distribution because the sample size in this case (n = 60) is large. Descriptive statistics were performed using the Student’s t-test. Data management and analysis were performed in two programs: Microsoft Excel 2007  + add-ons and StatSoft Statistica V12 Advanced Package . The statistical significance level was set at p < 0.05 (one-tailed).Tests of normality were performed using the Shapiro–Wilk Test. These tests did not indicate the normality of the distribution. However, since p > 0.05)  . Accordi > 0.05) .® platform, after rehabilitation with the SPIDER system (2.14 cm) is significantly smaller than the mean tilt before rehabilitation (4.29 cm), measured in the same way (the t Stat parameter is less than 0 (−13.6542), and P(T ≤ t) one-sided (3.22093 × 10−20) is less than 0.000001 and is therefore smaller than the assumed α = 0.05)  .® platform before (3.55 cm) and after rehabilitation (3.47 cm) using therapy without the SPIDER system are close to each other; the result is not statistically significant (t Stat parameter is less than 0 (−0.5883), and P(T ≤ t) one-sided (0.2792) is greater than the assumed α = 0.05)  .® platform after rehabilitation and measurements before rehabilitation is significantly greater if the SPIDER system was used during rehabilitation (t Stat parameter is less than 0 (−9.8534), and P(T ≤ t) one-sided is less than 0.000001, thus less than the assumed α = 0.05) (The mean difference in tilt measured in centimeters using the TYMO = 0.05) .® platform, before and after rehabilitation, with the use of the SPIDER system, is (−2.15 cm). The difference in the tilt of the patient’s mean center of mass, measured on the TYMO® platform, before rehabilitation and after rehabilitation, using therapy without the SPIDER system, is (−0.08 cm). The larger negative difference indicates that, with the use of the SPIDER system, the recorded tilts decreased to a larger extent during rehabilitation compared to the tilts recorded before rehabilitation, compared to not using the SPIDER system in the training.The difference in the mean tilt of the patient’s center of mass, measured on the TYMOThe following graphs  illustra® measurement platform, which enabled an objective, direct, quantitative assessment of the patient. Such an assessment can convert into significant physiotherapy efficiencies and consequently an improvement in the patient’s quality of life, as well as contributing to lower rehabilitation costs and a shorter period of abstinence from work. Platforms used to quantitatively measure the body’s center of mass while standing interpret standing stability and postural control strategies [Impaired gait ability after stroke significantly limits patients’ ability to participate in many social activities. Gait speed is considered a predictor of disability severity ,38,39. Hrategies . Roerdinrategies . Similarrategies . De Haarrategies . The resrategies . In addirategies . It shourategies . Thereforategies ,48. Studrategies ,49,50. Trategies ,51. Thusrategies ,52, wherThe above results indicate the effectiveness of physiotherapy treatment using the SPIDER system, with regard to the symmetry of body weight distribution in post-stroke patients, compared to therapy in which the system was not used. In the study group, there was a marked reduction in the tilt of the body’s center of mass to the unaffected side.