Improvements in daily functioning were also obtained (p < 0.0001). Multiple regression was performed to estimate the effect of selected variables on patients’ level of functioning. Burn area (p = 0.0126), pain level (questionnaire part B: p = 0.0004 and questionnaire part C: p = 0.0208) and gender (p = 0.0413) had a significant impact on the level of daily functioning. Pain complaints are the most crucial predictor affecting the functional status and depression levels in burn wound patients. Increased levels of depression promote dissatisfaction with one’s appearance.Burn wounds most often occur on visible parts of the body. They therefore cause fear of disfigurement and rejection by those around them. In addition, they cause pain. The main aim of this study was to analyse factors affecting the functioning of patients hospitalised for burns. The study included 57 patients hospitalised for burns. Each person was surveyed twice: on day seven after admission and on the day of discharge from the hospital. The following research tools were used: a personal questionnaire to collect clinical data and the scales of the Katz Activities of Daily Living (ADL), the short-form McGill Pain Questionnaire (SF-MPQ), the Beck Depression Inventory (BDI) and the Satisfaction with Appearance Scale (SWAP). On the discharge day, compared to day 7, there was an improvement in the patient’s level of functioning in all areas analysed. Pain intensity ( The way people function depends on many factors. The most frequently mentioned are state of health, limitations due to disability and increased symptoms of illness, mood, depression and financial situation. In addition, in the psychosocial sphere, self-esteem has a significant influence. How one perceives oneself, including one’s appearance both by oneself and by those around one, is essential in the construction of one’s own identity ,2. PeoplDuring hospitalisation, the focus is on wound healing and life-saving measures. At the same time, the patient’s emotional needs are often overlooked or not given sufficient attention ,12. FurtIt is important to involve patients as early as possible in basic activities of daily living . Their increased participation in self-care activities leads to increased self-esteem and independence .The most common psychological problems faced by patients with burn wounds include depression, anxiety, post-traumatic stress disorder, fear of disfigurement, social isolation, pain and the financial burden that follows the lengthy hospitalisation and necessary treatment .It is worth noting that there are few research papers on patient functioning during hospitalisation. Reports mainly concern the post-hospitalisation period and show how patients with a burn scar cope psychologically, physically and socially after such a harrowing experience. Knowledge paucity on how a burn patient functions during hospitalisation has revealed the need to learn more about the problems in this group of patients.The main aim of this study was to analyse the factors affecting the functioning of patients hospitalised for burns. In addition, the aim was to compare patients’ functioning on day seven after admission to the burn unit and the day of discharge.The study included 57 patients hospitalised for burns at the Burns Treatment Unit of the Department of Trauma, Burns Treatment and Plastic Surgery of the Poznan University of Medical Sciences at the Józef Strusia Multi-Specialist City Hospital in Poznan between September 2018 and February 2020.All scales and the interview questionnaire were aimed at adults who gave informed consent to participate in the study. Before the study, the purpose was explained, and patients were informed that their answers would remain anonymous. All questionnaires were completed in the presence of one nurse observer.Patients hospitalised for burns and whose hospital treatment lasted a minimum of 14 days were included in the study. The following patients were excluded from the study: those with current and past psychiatric disorders, alcohol dependence syndrome, cancer and those in a pharmacological coma. Each person was examined twice: on day seven after admission and on the day of discharge from the hospital.In the first stage of the study, a personal questionnaire was used (sociodemographic data were collected), and clinical information was collected . In addition, the scales of the Katz Activities of Daily Living (ADL) scales, the short-form McGill Pain Questionnaire (SF-MPQ), the Beck Depression Inventory (BDI) and the Satisfaction With Appearance Scale (SWAP) were used. In the second stage, clinical information in a personal questionnaire was completed, and the scales from the first stage were used again.Wallace’s rule of nines was used to determine the burn area of the body: total body surface area (TBSA).In conjunction with the aim of the study, variables were identified, and appropriate research tools were selected. The dependent variable was the functioning of patients with a burn wound: daily functioning—ADL scale, mental functioning—Beck Depression scale.Independent variable—sociodemographic characteristics, wound characteristics, pain intensity—the short-form McGill Pain Questionnaire (SF-MPQ) and satisfaction with one’s appearance—Satisfaction With Appearance Scale (SWAP).A survey to collect sociodemographic and clinical data.The Katz Activities of Daily Living (ADL) Scale—assesses the performance of basic activities such as getting out of bed and moving to a chair, dressing and undressing, bathing, using the toilet, eating independently and controlling bowel movements. The patient can earn 1 point for each activity performed independently. The maximum is 6 points. The following criteria are distinguished: able-bodied 5–6 points; moderately able-bodied 3–4 points; severely disabled 2–0 points ,15. All The Polish version of the short-form McGill Pain Questionnaire (SF-MPQ)—provides a qualitative and quantitative measurement of pain sensations. It consists of three parts. The first refers to 15 adjectives describing pain experienced during the past week, including 11 sensory and four affective pain items. The patient rates each item on the following pain intensity scale: 0—no pain, 1—mild pain, 2—moderate pain and 3—severe pain. A maximum of 45 points can be given to the patient (SF-MPQ—part A) ,17,18. TThe Beck Depression Inventory (BDI)—Polish version—a screening tool. Used to assess the presence of depressive symptoms resulting from adjustment disorders. This scale contains 21 items. Each item consists of four statements describing how the patient felt during the last day of the past week or month. The subject selects one of the four affirmative statements and scores on a scale from 0 to 3 points. The total score is the sum of the points obtained from the 21 statements . There aSubjective satisfaction with appearance, highlighting facial features (elements 4–7);Subjective satisfaction with appearance, emphasising other parts of the body (elements 8–11);Social discomfort due to appearance (elements 1–3);Social impact related to appearance (elements 12–14) ,26.Satisfaction With Appearance Scale (SWAP)—the scale contains 14 items relating to patients’ thoughts and feelings about their appearance following a burn. Each of these items is scored by the patient in a range of 0 points (strongly disagree) to 6 points (strongly agree). The total score is the sum of all the points scored. Questions 4–11 are scored inversely. The higher the score, the greater the dissatisfaction with one’s appearance and body image. A maximum of 84 points can be scored ,24,25. TU test.Count (N) and percentage (%) present statistical descriptions for qualitative variables. The mean and standard deviation (SD) present quantitative variables. For these variables, the conformity of their distribution to the normal distribution was checked using the Shapiro–Wilk test. This test did not confirm consistency with the Gaussian curve for most variables, so in this paper, all analyses were performed using non-parametric tests. The non-parametric Wilcoxon test was used to compare the results of the level of functioning obtained on day seven of hospitalisation and those obtained on the day of hospital discharge. A comparative analysis of the level of functioning according to gender, place of residence, occupational status, burn area and occurrence of burn wound infection was performed using the non-parametric Mann–Whitney On the other hand, the Kruskal–Wallis test was used for comparative analysis of the level of functioning according to education, marital status, degree of burn and location of the scar. Further analyses were performed with multiple comparison tests (post hoc tests) if the test detected any differences. Relationships between selected variables were analysed using the non-parametric Spearman rank correlation test.p < 0.05.In this study, multivariate regression analysis was performed to test the effect of selected independent variables on psychophysical variables. In addition, descriptive statistics and comparative analysis were performed using the statistical programme STATISTICA, version 13 . Results were considered significant if The mean age of the entire study group was 48.5 ± 13.7 years . The preThe most common areas of burn for 70.2% of the study participants were the head, face, hands and neck. Hospitalisation of patients for burns lasted an average of 28 ± 10 days. According to TBSA , the average burn area was 16.56 ± 9.46%. Almost half of the patients (45.6%) took one antibiotic during their hospital stay. Symptoms of burn wound infection during the entire hospitalisation occurred in 18 patients, representing 31.6%.When analysing the patients’ level of independence in basic activities of daily living , it was found that on day seven of the hospital stay, there was a predominance of able-bodied  and moderately non-disabled patients . The mean ADL scale score was 4.39 points. . On discThe independent variable included in the study was a pain in the wound area. On day seven, the mean score obtained in the pain intensity part (questionnaire part A) of the SF-MPQ scale was 17.51 points, in questionnaire part B—64.11 points and questionnaire part C—1.49 points. It decreased significantly on the day of discharge.More than half (56%) of the subjects had a lowered mood corresponding to BDI scale level—mild depression on day 7 of hospitalisation, while 30% of the patients had a lowered mood on the day of hospital discharge .As assessed using the SWAP scale, satisfaction with appearance averaged 31.47 points on day 7 and 26.46 points on the day of discharge. Women were significantly less satisfied with their appearance than men in the first and second study periods. Only in men did satisfaction with appearance increase on the day of discharge compared to day 7 of hospitalisation.p = 0.0091)—men showed greater efficiency, and place of residence (p = 0.0236)—patients living in rural areas were more efficient than city dwellers. The depressive symptoms correlated only with gender but in both study periods (p = 0.0016 and p < 0.0001) more depressed mood occurred in the first period in men and on the day of discharge in women.The following sociodemographic factors influenced the level of daily functioning only in the first period of hospitalisation: gender (p = 0.0126); ADL functioning worsened with increasing burn area. On the other hand, the number of hospitalisation days negatively correlated  with the level of daily functioning and positively with the severity of depressive symptoms. The rule was that as the number of days spent in the hospital increased, patients’ levels of self-efficacy decreased statistically significantly, and levels of depression increased .Of the clinical factors , there was a correlation in the first period of hospitalisation between the level of daily functioning and burn area (p = 0.0394). There were lower levels of depression among patients without infection symptoms. Our study outlined a statistically significant difference between appearance satisfaction depending on the degree of burn and the area of the burn in period one. In the case of burn severity, a significant difference between full-thickness and partial-thickness burns was evident. Patients with partial-thickness burns (p = 0.0335) were more dissatisfied with their appearance. When assessing the area of the burn, it was noted that on day seven of the study, patients were more dissatisfied with their appearance when burned in areas such as the head, face, hands or neck than the rest of the body (p = 0.0147).A difference in the severity of depressive symptoms was in patients with and without wound infection  and depression level  in both study periods, indicating that the more intense the patient’s pain level, the greater the dissatisfaction with their appearance and the higher the level of depression.The analysis also showed positive correlations between the level of pain assessed by the SF-MPQ scale and the SWAP and BDI scale scores. In addition, positive correlations were obtained between pain level  and satisfaction with appearance , and all predictors together explained 34% of the dependent variable. In addition, burn area (TBSA), pain level (quantitative measure of pain experienced during the last week—questionnaire part B and measure of pain experienced at the time of the survey-questionnaire part C) and gender had a significant effect on the level of daily functioning (Multivariate regression results showed that the model for ADL proved significant (ctioning .p = 0.0001), and all predictors explained 46% of the dependent variable together. The level of pain experienced (quantitative measure of pain experienced during the last week—questionnaire part B) significantly affected the level of depression  and actual appearance ,27. VisiA consequence of the healing process of burn wounds may be the formation of hypertrophic scars, which are less flexible and worsen the appearance of the person . Hence, Hospitalisation time is a difficult time for people with burn wounds. When the lesions occur over a larger body area, including the face or hands, such a location makes it challenging to perform self-care activities. Patients additionally struggle with emotions due to family separation, a long break from work, and the need to adjust to the rhythm of work in the ward . AnalysiIn conclusion, this study highlighted that psychological and affective reactions to pain, such as anxiety, anorexia, fear, fatigue, helplessness, hopelessness and depression, cause increased pain. Furthermore, any situation that exacerbates one of these reactions results in increased pain. Therefore, by analysing emotional factors, it can be concluded that they can influence pain experience and behaviour . FurtherIn the available literature, the most common predictors of pain were age ,38 and bOur study showed no significant correlation between satisfaction with appearance and depression. Perhaps there was a measurement in too short a time since the injury. Different results were obtained by other authors . They shMoreover, the hands are the part of the body that we look at often during daily activities and whose efficiency affects the level of independence. Throughout their hospitalisation, burn patients struggle with the pain associated with the burn wound and with dressing changes, surgery, rehabilitation and the newly formed scar. Therefore, in addition to monitoring pain levels and the wound healing process, more time should be spent talking, counselling and providing emotional support. The cooperation and education of the family is also an essential element.Pain complaints are a significant factor influencing functional status and levels of depression in patients with a burn wound. Dissatisfaction with one’s appearance promotes the development of depressive symptoms. Early recognition of worsening pain symptoms can prevent or reduce symptoms of depression. During hospitalisation, a plan for scar treatment and rehabilitation after hospitalisation should be discussed with the patient. Such measures increase patients’ awareness of wound healing and therapy and promote the strengthening of self-care. In addition, patients receive a positive signal that they can always count on professional help during hospitalisation. They also know what help they need and where they can access it after hospitalisation. If depressive symptoms are identified, the patient should be given appropriate support as soon as possible.Reports on the post-hospitalisation period preoccupy the available literature. In our study, we referred to assessing the patient’s functioning during hospitalisation. The hospitalised patient faces completely different problems during hospitalisation than those who have completed their treatment and have been discharged home. Therefore, future research should consider patient functioning during and after hospitalisation. Such a research model will make it possible to determine whether the studied variables change during hospitalisation and how they affect the patient’s life after leaving the hospital. A final limitation was that the number of people included in the study needed to be more significant. Undoubtedly, the small burn unit (11 beds) where the study was performed limited access to a more significant number of patients. In addition, the inclusion and exclusion criteria disqualified a large group of patients.


IntroductionPain represents up to 78% of emergency department (ED) appointments, and an average of 16% of patients that consume ED resources have chronic pain. ED overuse could be an indicator of poor pain management. We are not aware of any study that has ever been carried out to understand the incidence of patients followed up at a multidisciplinary pain clinic (MPC) who overuse the ED. We aim to characterize patients in our MPC who overuse the emergency department, comprehend our percentages, and develop effective methods to reduce these numbers in the near future.Materials and methodsWe reviewed the medical records of patients observed in our MPC in 2019, selected patients with more than six ED visits from 2019 to 2021, and registered their ED visit diagnosis and evolution. We followed up on these patients and characterized them according to demographic aspects, chronic pain diagnostics, comorbidities, chronic medication, number of chronic pain department appointments, and patients that underwent invasive pain treatment.ResultsIn 2019, 1892 patients were evaluated at our MPC, and only 1% were classified as overusers of the ED. The average number of episodes per patient was 10 in 2019, seven in 2020, and four in 2021. 70% of episodes were due to pain, and 94% were discharged immediately. The majority were women, and 69% were under the age of 69. Seventy-three percent had psychiatric disorders, and 95% and 89% were medicated with opioid and antidepressant medication, respectively, prior to the ED evaluation. Chronic primary pain was the most common diagnosis (47%), followed by chronic secondary musculoskeletal pain (21%). In 2019, most of these patients had only one appointment at our MPC, and in 2021, 79% had no appointments at all.ConclusionOur findings emphasize the particularities of patients with chronic pain who are followed in an MPC and misuse the ED. We observe the predominance of middle-aged people, which raises concerns about the impact of chronic pain in the active population. Issues like the predominance of patients with a diagnosis of primary chronic pain, psychiatric disorders, and being polymedicated with antidepressants and opioids are also a concern. We also realized that a high percentage of patients who overuse EDs lost follow-up at MPC over the past three years, which may reinforce the idea that they were misguided in the treatment of their chronic pain.We recognized the need to improve teamwork with primary care in the follow-up of these patients as well as sensitize emergency service professionals to refer this patient rather than medicate acutely so that follow-up could be carried out in the appropriate places to reduce the percentage of ED overuse. Chronic pain is a common, complex, and distressing problem that has a significant impact on society and individuals . It is dUp to 78% of all emergency department (ED) visits have been pain-related, and chronic pain accounts for 10%-16% of these visits . PatientSince the ED is not considered an appropriate setting for chronic pain management and ED visits cost about five times as much as a general practice visit, their use for non-urgent medical conditions such as chronic pain puts the health care system's resources under great strain . The mosMaladaptive pain coping strategies, such as pain catastrophizing, not only lead to disability but also increased pain intensity, decreased quality of life, and increased use of acute care services .Chronic pain management is beyond the scope of an intervention in the ED . HealthcAlthough the definition of ED overuse is still not entirely clear, we consider it a strong indicator of poor pain management in patients with chronic pain . In our Following the premise that overuse of emergency services is an indicator of poor management of chronic pain, especially in patients followed up in dedicated units, in this study we aim to identify the incidence of ED overusers, characterize these patients, and identify the factors that contribute to their ED presentation. We intend that these aspects will allow us to create, in the near future, a good foundation to evaluate the effectiveness of intervention in our multidisciplinary pain clinic (MPC) for the reduction of ED overuse.To identify ED overusers and determine the incidence of ED overuse, we selected all patients with consultations at our MPC from 2019 and followed their attendance at the emergency department for three years consecutively.Study design and time period This was a cross-sectional study consisting of a health record review of the list of patients with medical appointments at the MPC at Hospital Pedro Hispano, Matosinhos, Portugal, in 2019. This study was approved by the institutional research ethics board, and all informed consent was requested and approved. ).Setting and PopulationThe study was conducted at an MPC in the north of Portugal. We chose all patients who had six or more ED visits during the year from the 1892 patients who still had one appointment at our center in 2019. ProceduresWe obtained the list of patients with six or more ED visits during 2019 from the hospital's administrative database. Each ED visit was classified as pain-related, trauma-related, or other. We recorded the total number of ED visits in 2019, 2020, and 2021, the Manchester sorting grade, the post-discharge destination, as well as the diagnosis for ED visits. The following data were collected: age, gender, address, chronic pain classification ), comorbidities, chronic medication, the total number of appointments at the chronic pain department, and the patients that underwent invasive pain treatment.Statistical analysis We used IBM Statistical Package for the Social Sciences (SPSS) software to analyze the data. Descriptive and univariate analyses were performed. Continuous variables are presented as means and standard deviations (SDs), and categorical variables are presented as percentages and counts.Among the 1892 patients who were evaluated in our MPC, only 19 patients (1% of the entire population) had six or more ED visits during 2019. This group had 409 emergency episodes during 2019, 2020, and 2021, and the average number of episodes per patient was 10 in 2019, seven in 2020, and four in 2021. The main diagnosis in the ED was pain (70%) and 94% were discharged immediately without any intervention. On the Manchester screening, 44% of patients were classified as yellow, 36% as orange, and 18% as green. All events resulted in 94% of patients being discharged, 5% being hospitalized, and 1% being referred to medical specialty areas.Characterizing the overuser group, 80% were female, and the mean age was 65. According to their age, 69% of these patients were less than 69 years old. All patients had several chronic diseases and were on chronic medication. At 73%, psychiatric disorders were the most prevalent disease, and cardiac pathologies such as heart failure and ischemic disease, in parallel with respiratory pathologies such as obstructive sleep apnea syndrome, chronic obstructive pulmonary disease, and asthma, were the second and third most frequent diseases, respectively. We also discovered that 21% of patients who overused the emergency department had an oncological disease. The main etiological diagnoses for why these patients are followed up in an MPC, according to the ICD-11 classification of chronic pain, are primary chronic pain (47%) and musculoskeletal pain (21%). Also, chronic cancer-related pain, as well as chronic neuropathic pain and chronic postsurgical or posttraumatic pain, were other prevalent diagnoses, each with 11. 95% of the overusers were medicated with opioids prior to the emergency episode, and 33% were medicated with both weak and strong opioids. Relatively to the antidepressant medication, 89% of these patients were taking this kind of medication, and we also found that five patients were taking simultaneously two different types of antidepressants and that two patients were taking simultaneously five types.The mean and standard deviation of ED overuse appointments in our center during 2019 were 1.16 ± 0.37, and only one patient underwent invasive procedures as part of a multimodal approach. In 2020, eight of these patients had no pain unit appointments, and the remaining patients were only followed up on two occasions. In 2021, the number of patients who had no follow-up in our MPC rose to 15, and only one had two appointments that year. In the end, there were two patients that were discharged from our MPC and three patients that passed away.In the following table, we characterize the group of patients who overused the ED in 2019, 2020, and 2021.Pain is one of the main reasons that leads patients to the emergency department, where poorly controlled or acute chronic pain accounts for 16% of the events. The percentages of patients with chronic pain who overuse the ED are known, but the incidence of ED overusers in units dedicated to the treatment of chronic pain is still unknown.Since clinicians in emergency services do not have enough time to explore the management of chronic pain effectively and safely, the use of this service among this population brings an unnecessary use of resources and serious risks for the patients. We believe that misuse of the emergency department is an indicator of poor pain management, whether in terms of insufficiently treated pain or the inability of MPC to respond to these patients.According to our data, only 1% of the 1892 patients evaluated in our MPC during 2019 were considered to have overused the ED. This percentage is most likely the result of a multimodal approach to the contribution of biological, psychological, and social or environmental factors to pain problems, which is critical in the management of chronic pain patients. Pain can have various etiologies, from physical to emotional, so a merely physical approach is clearly ineffective. We are also a center that favors targeted invasive procedures, implying a redoubled effort in carrying out the correct chronic pain diagnoses to obtain success with the invasive techniques. In our study population, on average, one in two patients was submitted to invasive procedures, but in the overuser group, the procedures were carried out on only one in every 20 patients, approximately. These results corroborate the importance of regional invasive techniques in chronic pain management, which may be one of the reasons for the low number of overusers in our center.The combination of these measures and the open channel of communication with our MPC are probably responsible for the success of the treatment of these patients and the lower recurrence of ED visits.Regarding demographic characteristics, these 19 patients were characterized, and they followed the descriptions found in the literature, with a predominance of female gender patients and the sixth decade of life. Regarding age groups, we found a predominance of ages below 69 years, with a higher incidence in patients between 40 and 49 and 60 and 69 years. Other aspects, such as work absence at this age and the socioeconomic impact of this illness behavior, will reflect this fact. The predominance of older ages, above 80 years, on the other hand, likely reflects the presence of severe musculoskeletal structural disease unresponsive to pharmacological therapies, as well as the difficulty of articulation in this age group when contacting MPC either by phone or e-mail.The main diagnosis was primary chronic pain, given the absence of a well-defined etiological factor and the increasing challenge of managing these situations. In fact, an approach other than pharmacological treatment is truly required for this type of diagnosis. Associated with this major chronic pain diagnosis, a large percentage of patients have a history of psychiatric pathology, and almost 90% are chronically medicated with antidepressants. This factor corroborates what the literature shows: that these patients are unable to create strategies to cope with pain, leading to the recrudescence of pain, depression, and an inability to adapt psychologically, and consequently the recurrence of medical care, especially in the ED.  MoreoverAlmost 100% of patients were medicated with opioids and a higher percentage with both weak and strong opioids. This brings us to the question about the use of opioids for the treatment of non-cancer pain, especially in situations of chronic primary pain, whose treatment is more dependent on a holistic approach. According to the literature, patients with primary pain syndromes may be less responsive to opioids due to higher endogenous opioid levels and more susceptible to the worsening of hyperalgesia by opioids, so this kind of treatment is clearly advised against. Furthermore, the potential for dangerous side effects, physical tolerance, misuse, or addiction increases the risk of their use in the treatment of this kind of pathology.  In the sequence of our analysis, during the three years under study, patients who overused the ED lost follow-up at the MPC, and in 2021, only four (20%) patients were consulted. Because these patients were not well followed up on in the MPC, they had to visit the ED more frequently, and the lack of follow-up meant that they continued to overuse the ED in the years that followed. In these cases, ED physicians should be educated to refer these patients back to primary health care or to MPC, where the achievement of pain control can be most effective and lasting, and to avoid prescribing opioids indiscriminately.Primary health care has a key role in managing chronic pain patients, mainly by maintaining follow-up, prescribing chronic medication, or facilitating referrals to specialist departments. However, literature shows that chronic pain patients do not feel confident about managing their pain with a primary health assistant, and general practitioners do not feel secure in the approach to more complex chronic pain situations. ,10In the Manchester screening, we observed that although most episodes were classified as yellow or orange, a great proportion of patients were discharged after receiving intravenous medication or an opioid prescription. These episodes can also be avoided by articulating with the MPC. The ease of accessing the emergency room and the administration of drugs with a quick effect on reducing pain are identified as two of the main reasons that lead chronic pain patients to the emergency room.  LimitationsWe did not statistically study the impact of the SARS-CoV-2 pandemic on reducing emergency department utilization, which significantly reduced the influx of patients and probably influenced the results for 2020 and 2021. Another limitation of the study is the restriction of the evaluation of emergency episodes to our institution, knowing the possibility of patients having resorted to other institutions.The lack of a control group of chronic pain patients without follow-up in our MPC makes comparing our population to the general population difficult. However, it allows us to build a fundamental knowledge base that could enable us, in the future, to design an effective study of our approach. Despite being in its early stages, our work has significance and can serve as a jumping-off point for others because there is no comparable study in the literature.Noting the dynamics of the ED overuse group at our center, it turns out that chronic pain is a public health problem with an important economic impact. It is primordial to improve collaboration with primary health care in the follow-up of these patients, as well as sensitize emergency service professionals to refer these patients instead of medicating them acutely. This will allow for follow-ups to be carried out in the appropriate places and the reduction of ED overuse. This strategy will minimize the number of patients who get lost in the system, as happened with the pandemic, and will avoid indiscriminate prescriptions of opioids in the ED.The importance of realizing that patients overuse resources is crucial to reducing costs and improving patient safety. We believe that the development of more studies on this topic is essential to improving the quality of care provided to patients with chronic pain.


After treatment, patients in the control group had a low back pain NRS score (4.00 ± 0.85), lower extremity NRS score (3.87 ± 0.78), ODI score (58.25 ± 2.53), and low back pain NRS score (2.00 ± 0.54), while the study group had a lower extremity NRS score (2.00 ± 0.50) and ODI score (58.25 ± 2.53) that were statistical significance . In conclusion, treatment with LTEB can effectively reduce the pain and improve the functional impairment of patients with low back pain with radicular pain, which is clinically important.Lumbar transforaminal epidural block (LTEB) is a minimally invasive interventional method, and the interventional effect of LTEB on the treatment of low back pain with radicular pain is not yet clear; therefore, a total of 100 patients with low back pain with radicular pain treated in our hospital from January 2021 to December 2021 were included in this study, and they were divided into two groups of 50 each using a digital double-blind method. The control group was treated conservatively, and the study group was treated with LTEB. Patients' pain was assessed using the numerical rating scale (NRS), and the degree of functional impairment was assessed using the Oswestry disability index (ODI). The results of the study showed comparable differences in NRS scores for low back pain, NRS scores for lower extremities, and ODI scores of patients before treatment ( Low back pain and leg pain are common symptoms among lumbar diseases. The occurrence of symptoms may be associated with lumbar disc herniation or spinal stenosis compressing the nerve root, resulting in pain and dysfunction in the innervated area of the nerve root of lower extremities. Opioids are often used for relieving pain, but the use of these medicines can have a serious impact on the quality of life of patients with this disease . With thP > 0.05). The study has been approved by the Ethics Committee of the hospital.A total of 100 patients with low back pain with radicular pain treated in our hospital from January 2021 to December 2021 were included in the study, which were divided into two groups, including control and research groups, with the digital double-blind method, with 50 patients in each group. Basic data are shown in Inclusion criteria are as follows: (1) patients with low back pain with radicular pain in lower extremities and imaging findings suggesting lumbar degeneration; (2) patients who did not respond well to conservative treatment; and (3) patients who volunteered to join the study and signed the informed documents after being informed of the contents of the study by medical staff with their family members.Exclusion criteria are as follows: (1) patients with lumbar tumor, ankylosing spondylitis, lumbar tuberculosis, abnormal coagulation function, diabetes, and gastrointestinal ulcer and (2) patients with a history of lumbar operation, mental and intellectual diseases, communication disorders, and incomplete basic information.The control group was given with conservative treatments. After the patients were admitted, medical staff gave conservative treatments such as massage, acupuncture, and pharmacological intervention.The contents of conservative treatments for the research group were consistent with those for the control group, accompanied by LTEB . The responsible nerve root was judged according to the preoperative imaging examination results and symptoms. For patients with bilateral symptoms, the heavier side was selected for treatment. The surgical puncture route was performed according to the preoperative imaging design, and the posterolateral Kambin triangle approach was selected. Before operation, Kirschner wires were adopted to locate the puncture path and the entry points on the skin were marked. The area around the puncture point was sterilized with iodophor, and sterile drapes were routinely laid down. Local anesthesia was performed with 40 ml of 2.235 mg/ml ropivacaine methanesulfonide, of which, 5 ml was injected into the skin and subcutaneous tissues, 10 ml was injected into the deep fascia, and 10 ml was injected into the periarticular process. Of the remaining 15 ml, 10 ml was reserved for later use and 5 ml for epidural block. The 22G needle was selected for puncture. During the operation, the end point of the needle in the imaging fluoroscopy was located below the pedicle of the affected side in the anteroposteric film, below the foramina in the lateral film, and the end point of the anatomical puncture was located in the ventral epidural region of the axillary nerve root as the outlet of the responsible nerve root. After no reflow after withdrawal, the iodohyalcohol contrast agent  was injected locally. Patients were asked if they had the same numbness, inductance, and swelling in the pain area before operation. Meanwhile, the intraoperative imaging fluoroscopy was used to determine the location and understand drug dispersion. After no reflow after withdrawal again, 5 ml of 2.235 mg/ml ropivacaine methanesulfonide and 0.5 ml of Diprospan were mixed and then injected slowly. After the needle was removed, the puncture point was disinfected with alcohol and covered with the sterile dressing. After checking for 10 min, patients were asked about the pain changes, and patients with no adverse reactions were escorted back to wards. After operation, patients could get out of bed for simple activities after lying flat for 6 h, with the waist fixed by 3D.Patients' pain was evaluated with NRS. NRS is a common self-evaluation scale on patients' pain in clinical practice, which is simple and quick to apply, with no special equipment . During The degree of patients' dysfunction was evaluated with ODI scale. ODI scale is a self-management questionnaire commonly used by patients in clinic. This qut-test, and P < 0.05 indicated that the difference was statistically significant.Data were analyzed with the statistical software SPSS20.0. Clinical baseline data measurements were expressed as (P > 0.05), and after treatment, both of NRS scores in the research group were lower than those in the control group. The differences between two groups were statistically significant (P < 0.001), as shown in The differences in NRS scores of low back pain and lower extremities before treatment were comparable (P > 0.05), and after treatment, ODI score in the research group was lower than that in the control. The differences between two groups were statistically significant (P < 0.001), as shown in The difference in ODI score before treatment was differential , and after treatment, NRS scores of low back pain and lower extremities in the research group were lower than those in the control group. The difference between groups was statistically significant (P < 0.001). The results suggested that during the treatment of LTEB in patients with low back pain with radicular pain, drugs dispersed around the articular process and blocked the nerve root, dorsal root ganglion, and dorsal rami of spinal nerves; therefore, the symptoms of low back pain and radicular pain were effectively relieved. The data in this study showed that the difference in ODI score of patients before treatment was differential (P > 0.05), and after treatment, ODI score in the research group was lower than that in the control group. The difference between groups was statistically significant (P < 0.001). The results suggested that LTEB given to patients with low back pain with radicular pain can be conducted by injecting a large number of drugs into the pain on the ventral side of the dura through the transforaminal approach, which could spread widely; therefore, the effect of the transforaminal approach is more prominent in reducing the pain and improving the dysfunction. However, there are still some defects in this study, such as the small number of included samples and the imperfect standards. We look forward to expanding the samples for analysis in the next step.NRS score is often used clinically to evaluate the degree of pain in patients, which has a high sensitivity, and is simple and easy to be understood and easy for patients to grasp . HoweverIn conclusion, LTEB for patients with low back pain with radicular pain can effectively reduce the pain and improve the dysfunction, which has positive significance in clinical practice.


We conducted a systematic review of the effectiveness of local preemptive analgesia for postoperative pain control in women undergoing vaginal hysterectomy.MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews were searched systematically to identify eligible studies published through September 25, 2019. Only randomized controlled trials and systematic reviews addressing local preemptive analgesia compared to placebo at vaginal hysterectomy were considered. Data were extracted by two independent reviewers. Results were compared, and disagreement was resolved by discussion. Forty-seven studies met inclusion criteria for full-text review. Four RCTs, including a total of 197 patients, and two SRs were included in the review.Preemptive local analgesia reduced postoperative pain scores up to 6 h and postoperative opioid requirements in the first 24 h after surgery.Preemptive local analgesia at vaginal hysterectomy results in less postoperative pain and less postoperative opioid consumption. Hysterectomy for benign indications is one of the most common operations in gynecology. Multiple guidelines and reviews favor the vaginal approach for benign hysterectomy, if feasible –5. In GeMany Enhanced Recovery After Surgery (ERAS) protocols in gynecology recommend multimodal analgesia using different agents addressing different pathways to reduce intra- and postoperative opioid requirements, speed recovery and reduce complications , 3, 7. TWe performed this systematic review (SR) because of the clinical relevance of postoperative pain control in a frequently performed procedure.The primary aim was to systematically review the literature on vaginal hysterectomy with any form of local preemptive analgesia according to postoperative pain reduction. Secondary outcomes were defined as postoperative opioid requirements, readmission rates, perioperative pain management and quality of life measured by validated questionnaires as well as opioid-related side effects.https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020144709. PRISMA guidelines were followed [The systematic review was restricted to the use of local preemptive analgesia in vaginal hysterectomy; other modes of hysterectomy and other forms of analgesia interventions were excluded. The protocol was registered at PROSPERO and is available under followed . No apprTwo gynecologists systematically searched MEDLINE (1946 to present), EMBASE (1974 to present), the Cochrane Central Register of Controlled Trials (CCTR) and the Cochrane Database of Systematic Reviews (CDSR) to identify relevant randomized controlled trials (RCT) and SR. Subject headings and keywords for vaginal hysterectomy were suitably combined with those for local preemptive analgesia or local anesthetics as well as filters for randomized controlled trials or systematic reviews. No restrictions for the date of publication were made, and all full text articles that were published in either English or German were included while those written in other languages were excluded. Reference lists of eligible studies and review articles were included in the search.Two reviewers (N.T. and A.-M. S.) screened the identified abstracts and removed duplicate entries. Subsequently, all full texts of potentially relevant abstracts were retrieved and screened in the same way. Any discrepancies were resolved by consensus. The screening process and its results were documented in a spreadsheet.The two reviewers used prespecified extraction templates to independently extract the data. Extracted data included information on the study type and methodology, country/place of the study, inclusion and exclusion criteria, participant demographics, number of participants and measured outcomes and effects. Disagreement was resolved by discussion between the reviewers.The review focused on RCTs and SRs of local preemptive analgesia given prior to vaginal hysterectomy for all indications with the goal of reducing postoperative pain, peri- and postoperative opioid use as well as readmission rates. The search was through 25 September 2019. The intervention had to be compared to another regime or placebo. We excluded laparoscopic or laparoscopically assisted vaginal hysterectomies. For more homogeneous data we also excluded systemic interventions and spinal interventions. Studies including vaginal hysterectomy done for prolapse were included. No restrictions were made on the basis of sample size, country or date of publication.The quality of the RCTs was assessed with the current version of the Cochrane Risk of Bias Tool , which cA total of 731 abstracts were identified, and after removal of the duplicates, 539 were screened and 47 full-text manuscripts were selected for further evaluation. As our review focused strictly on preemptive local analgesia in vaginal hysterectomy, we identified 4 RCTs with a total of 197 patients and 2 SRs for inclusion in the SR  or a verbal analogue pain score from 0 to 10 at different predefined time points between 30 min (min) and 32 h (h) after surgery. Two studies evaluated postoperative pain at rest, one while resting and during coughing and one defining the primary outcome of postoperative pain as pain intensity while coughing.Both studies which evaluated pain at rest showed a significant reduction in pain for 30 min up to 6 h after surgery. Pain during coughing was also significantly reduced at 1 and 4 h postoperatively in the treatment groups in the two studies that assessed this Table .Our predefined secondary outcomes in the four studies included blood loss, length of hospitalization, adverse events, duration of surgery, postoperative nausea and vomiting, and time to first mobilization. These outcomes did not differ between the two groups with or without preemptive analgesia. None of the four RCTs measured quality of life (QoL), readmission rate or perioperative care, so no results to these predefined secondary end points of our protocol can be reported.None of the four included RCTs reported any adverse events regarding the use of preemptive local anesthesia.The studies which defined pain at rest or during movement or pain at other evaluated time points as secondary outcomes found also a significant decrease in pain between 1 and 8 h. One secondary outcome all four studies had in common was postoperative morphine consumption. Although the results regarding opioid use in post-anesthesia care were different in two studies, all studies showed a significant reduction in morphine-controlled patient analgesia and/or overall opioid requirements in the treatment group in the first 24 h.Using the Cochrane Risk of Bias Tool , we asseA meta-analysis was planned but due to the heterogeneity of time points and conditions under which the outcomes were measured, the results of the studies were analyzed descriptively.Our systematic review of preemptive local analgesia at vaginal hysterectomy yielded four RCTs with a total of 197 randomized patients –26. To oAll four RCTs showed a significant decrease in postoperative pain with the use of preemptive analgesia at different measurement points up to 8 h after surgery and a decrease in morphine use over the first 24 h after surgery. However, the effect on postoperative pain reduction is only seen up to 8 h postoperatively, which means that the effect is only measurable on the day of surgery. This is consistent with the half-life of widely used local anesthetic agents. This explains the lack of difference in length of hospital stay , 24. AlsRegarding postoperative pain and opioid consumption, the effects were statistically significant and clinically measurable, but the total number of patients investigated was small. However, besides the pain scores reported by Hristovs.ka et al., all postoperative pain score means and medians were under 45 mm on the VAS scale.There are different VAS cutoffs for mild, moderate and severe pain for the VAS scale ranging from 30, 70 and 100 mm  to 44, 7Athanasiou et al.  studied The largest study in this review  randomizThe earliest study in our review, published in 2003 , has theThere has been much debate about what amount of VAS change is clinically important. A prospective observational study enrolling 224 patients suggested the minimal clinically important difference (MCID) to be 10 in the postoperative setting measured by the VAS scale . HoweverThe postoperative pain scores in the present review indicate that patients undergoing vaginal hysterectomy have good postoperative pain control even without preemptive analgesia. With medians and means of 3.1, 4.5, 3.6 and 3.3 points between 3 and 4 h after surgery, most of the patients had postoperative pain scores that can be considered acceptable . NeverthAll four trials in this review found reduced postoperative opioid requirements during the first 24 h after surgery –26. ManyThis is a systematic review of a simple intervention in a frequently performed operation with a clear result. An inexpensive and simple intervention – i.e., preoperative infiltration with a local anesthetic agent, improves patient outcomes.The results of our SR are limited by the studies available. Our review yielded four RCTS with < 200 patients overall. A meta-analysis was not possible because of heterogeneity of end points as well as the use of different local analgesics and the small number of studies included. Also, a sub-analysis according to the indication for vaginal hysterectomy was not possible because of heterogeneity.The data from four RCTs, with three of them being of good quality, indicate that local preemptive analgesia in the form of a paracervical block is a simple procedure, which results in lower postoperative pain scores and opioid consumption of patients undergoing vaginal hysterectomy. Another systematic review has already described the need for further evidence in minimally invasive hysterectomies . NationaGiven its easy implementation and low cost, local preemptive analgesia in vaginal hysterectomy is a simple but effective procedure to improve postoperative pain control.None of these studies used a long-acting, liposomal-bound agent, and this might be a topic for future research. Only one RCT has compared liposomal bupivacaine vs. placebo in posterior vaginal wall surgery and found no significant decrease in postoperative pain or narcotic medication .


Additionally, the mean (SD) score of the pain acceptance was 46.44 (11.16), which significantly increased to 73.61 (15.65) in post-intervention (p < 0.001). Furthermore, the mean (SD) score of headache disability was 73.55 (19.48), which significantly decreased to 23.33 (19.88) in post-intervention (p < 0.001). Finally, headache intensity was 7.33 (0.98) and 5.78 (1.83), which significantly decreased to 2.77 (2.04), and 1.38 (1.48) after the intervention based on the Diary Scale for Headache and McGill Pain Questionnaire (SF-MPQ-2), respectively (p < 0.001). In conclusion, the results show that mindful hypnotherapy is a feasible and effective treatment for chronic migraine.This study was a randomized controlled design and examined the feasibility and effectiveness of mindful hypnotherapy on psychological inflexibility, pain acceptance, headache disability, and headache intensity in patients with chronic migraine headaches. The sample consisted of 38 females with chronic migraine who were randomly assigned to mindful hypnotherapy and medical treatment as usual groups. Psychological inflexibility pain scale (PIPS), chronic pain acceptance questionnaire-revised (CPAQ-R), headache disability inventory (HDI), diary scale for headache, and short-form McGill pain questionnaire 2 (SF-MPQ-2) were administered at baseline and post-treatment in both groups. The psychological inflexibility mean (SD) score was 81.00 (12.15) at baseline, which significantly decreased to 53.28 (17.06) after the intervention ( Migraine is a common neurological disease, a highly debilitating disorder, so debilitating that it ranks second regarding years lived with a disability according to the World Health Organization and the Global Burden of Disease Study ,2,3. MorChronic migraine (CM) is a migraine headache that occurs 15 or more days per month for more than 3 months and affects approximately 1.4–2.2% of the global population ,7. CM isOne of the important key processes underlying the impact of headaches is psychological inflexibility , which iAdditionally, other psychological factors, such as negative emotional states, can be related to the likelihood of attack onset, headache severity, performance, and treatment prognosis . Many stIn medical treatments, many pharmaceutical treatment options for migraine patients often result in side effects, poor tolerability, and limited effectiveness, which leads to high levels of unmet need, and a high number of patients report discontinuing or switching to alternative treatment options ,23. For In addition to pharmacological therapies, other treatment options exist, including psychological interventions . PsycholThe results of the review study by Hammond  has showMindfulness-based treatments also represent an avenue to investigate effects in patients with chronic migraine . The priMindful hypnotherapy (MH) tries to create a deeper level of change in patients by integrating mindfulness and hypnosis. This integration has critical clinical contemplation for improving intervention efficiency and effectiveness ,41,42. IDespite considerable advances in treating migraine headaches, it remains the second most common cause of disability in the world . It can This study is a randomized controlled design that was conducted as a doctoral dissertation in clinical psychology in 2022 at Shahid Beheshti University of Medical Science, Tehran, Iran. The Research Committee of Shahid Beheshti University of Medical Sciences  and the Iranian Registry of Clinical Trials (IRCT code No: IRCT20201009048974N2) have approved this study.The assistant researcher, who was not aware of the study objective, generated the random number sequence using the random number generator function in SPSS. Then, the assistant researcher opened the envelope that was kept sealed, opaque, and numbered in sequence and then assigned the participants to the groups.Participants included female adults with chronic migraine headaches without aura who were referred by an expert neurologist, Neurology Clinic, Moheb Mehr Hospital, Tehran, Iran. The sample size was calculated using G-Power software using an analysis of covariance considering effect size = 0.50 , a = 0.0Inclusion criteria: the diagnosis of chronic migraine headaches without aura according to the International Headache Committee (IHS) and the Third International Classification of Headache Disorders (ICHD-3); a history of migraine for at least one year; having informed consent to participate in the study and sign a written consent form; age range of 18 to 50 years; availability for nine weekly sessions; in the case of receiving medications, the dosage and type of medication should be stable in the last months before the start of the study and remain stable during the study period.Exclusion criteria: another chronic pain or headache diagnosis; having medication overuse headache (MOH); recent substance abuse; diagnostic indicators or a history of borderline personality disorder, bipolar disorder, psychosis, or schizophrenia due to contraindication with hypnosis; received psychological interventions in the last six months, or participated in another psychological intervention at the same time as the study.All participants provided informed consent to participate in the study and signed the written consent form. In addition to their right to withdraw to participate from the study, concerning the dropout rate from the study, a complete explanation was given regarding treatment conditions, the number of sessions, and randomization between treatment and control groups. Moreover, the participants have been thoroughly examined in terms of having enough time to attend the intervention sessions and the possibility of presence during the weekly seasons in the clinical psychology clinic in Taleghani hospital. Participants were randomly assigned to intervention  and control  groups by randomization method. The intervention group consisted of nine weekly, 1-h sessions of mindful hypnotherapy. Participants in the MTAU group used the regular descriptive drugs and did not receive any psychological intervention during treatment but were given the opportunity to complete the intervention after participating in the study. The psychological inflexibility pain scale (PIPS), chronic pain acceptance questionnaire-revised (CPAQ-R), headache disability inventory (HDI), diary scale for headache, and short-form McGill pain questionnaire 2 (SF-MPQ-2) were conducted at baseline and post-intervention.The patients in the mindful hypnotherapy group were treated for nine weekly 1-h individual sessions of mindful hypnotherapy by using the mindful hypnotherapy protocol  adopted Psychological Inflexibility in Pain Scale (PIPS): The PIPS is a 16-item scale used to assess the psychological inflexibility of people with chronic pain. The two main components of PIPS include avoidance of pain and fusion with painful thoughts. Items are rated on a 7-point Likert scale that ranges from 1 (never true) to 7 . Higher scores meant greater levels of psychological inflexibility. The PIPS demonstrated good internal consistency as measured by Cronbach’s alpha, with 0.90, 0.75, and 0.89 for avoidance, fusion, and total scale, respectively .Chronic pain acceptance questionnaire–Revised (CPAQ-R): The CPAQ-revised is a 20-item and rated on a 7-point scale from 0 (never true) to 6 (Always true). CPAQ-R has 2 subscales, including activity engagement (pursuit of life activities regardless of pain) and pain willingness (recognition that avoidance and control are often unworkable methods of adapting to chronic pain). A total score is calculated by summing all items, and higher scores indicate higher levels of acceptance. Internal consistency was reported with an alpha of 0.82 for activity engagement and 0.78 for pain willingness ,47.Headache Disability Inventory (HDI): HDI is a 25-item scale created by Jacobson et al.  for asseDiary Scale for Headache: This scale (38) was used to measure headache frequency and intensity. Patients record a diary of headache frequency and intensity on a rating scale from zero (absence of pain) to ten (most intense disabling headache) in a week. The mean headache intensity in one week was calculated by dividing the sum of severity scores by the number of headaches per week. The minimum headache intensity is zero, and the maximum score is ten. The reliability coefficient is estimated at 0.88 .Short-form McGill pain questionnaire 2 (SF-MPQ-2): This questionnaire is used to measure the quality and intensity of the pain . It const-Tests were used to identify baseline differences between the intervention and control groups in clinical characteristics , 34 (18 in the intervention group and 16 in the MTAU control group) completed the post-test, and their data were included in the final analysis. Those who did not complete the intervention were excluded from the study.p > 0.05). The Independent t-Test (see p > 0.05). The results of Levene’s test of equality of variances (see p > 0.05).Test see  also shonces see  also revp < 0.001). The effect size for the avoidance of pain, fusion with pain thought, and total psychological inflexibility subscales were 0.53, 0.33, and 0.48, respectively.p < 0.001), with the effect size of 0.66, 0.44, and 0.65, respectively . The effect size for emotional, functional, and total scores were 0.70, 0.62, and 0.67, respectively.p < 0.001). Furthermore, the result of the McGill pain questionnaire (see p < 0.001). The effect size for total pain intensity was 0.62, and for continuous, intermittent, neuropathic, and affective pain was 0.72, 0.45, 0.41, and 0.67, respectively.Finally, headache frequency and headache intensity based on the diary scale for headache see  have a caire see  shows thThis study examines the feasibility and efficacy of mindful hypnotherapy, a novel intervention that incorporates elements of both mindfulness and hypnosis for treating headache disability and intensity alongside improving psychological inflexibility and pain acceptance in females with chronic migraine. Results from severe migraine patients showed statistically significant changes in outcome variables after treatment, including improvements in psychological inflexibility and pain acceptance compared with control groups. Furthermore, the mindful hypnotherapy group had a statistically significant decrease in headache disability and headache intensity after treatment compared with the control group.These findings were similar to those of a previous study of mindful hypnotherapy. The results of the study by Olendzki et al.  show thaThe effectiveness of mindful hypnotherapy can be explained by the mechanisms underlying migraine headaches and related components and processes of the treatment. One of the most important treatment principles is mindfulness. Manipulating attention with mindfulness techniques can affect the affective and sensory aspects of pain perception. Also, nonjudgmental awareness of bodily sensation with acceptance increases body awareness, and parasympathetic activity leads to improved body mechanisms and reduces pain ,55. MindMoreover, both mindfulness and hypnosis have neuroplasticity effects ,61,62,63Based on this study, mindful hypnotherapy is recommended as a feasible and effective psychotherapy for improving psychological inflexibility, pain acceptance, headache disability, and headache intensity in patients with chronic migraine headaches. These results also support the potential utility of the MH model for chronic headaches. Mindful hypnotherapy can be combined with other medical treatments that are helpful to this population. This approach provides a promising basis for further therapy development and challenges us to reconsider the pain experience.The main limitation of this study was the gender of the study sample. The participants were female, and this led to the limited interpretation and extrapolation of results to other genders. Future investigations should attempt to replicate and extend these results and tests of generalizability to another gender. Moreover, another limitation of the study is that the results of the study rely on subjective measures. Other limitations included the lack of an active control condition and a relatively small sample size. Therefore, further research could be conducted with an active control group and a larger sample size. Additionally, future research is needed to examine the impact of mindful hypnotherapy delivery in a group format. Both mindfulness and hypnotherapy can be performed in a group context and could be very beneficial, enabling many individuals to be treated at the same time. Research is also needed to investigate the feasibility, efficacy, and effectiveness of MH for chronic tension-type headaches, other chronic pain conditions, irritable bowel syndrome, and psychological issues in chronic conditions such as cancer and MS.The results of the current study show that mindful hypnotherapy is promising as being an effective intervention for improving psychological inflexibility, pain acceptance, headache disability, and headache intensity in females with chronic migraine. Given that the results in psychological inflexibility and pain acceptance were conducted in both mindfulness and hypnosis contexts, this novel intervention shows the potential for being a unique and valuable contribution to chronic migraine interventions. However, because of the subjective measures, it is unclear if the subjective improvement that we found is down to the design of the study or to the treatment under investigation. In conclusion, this study suggests that mindful hypnotherapy is a very effective way of alleviating the symptoms of headache, and given the promising findings for MH, neurologists and psychotherapists may wish to give serious consideration to mindfulness in combination with hypnosis as a treatment option when working with patients with headache.


To explore how patients in biopsychosocial pain rehabilitation perceive encounters with interprofessional teams. The focus of this article is to explore how interactions can perpetuate or diminish chronic pain stigma.An ethnographic approach was applied to the study. Participant observation of interprofessional encounters and clinical encounters in a pain rehabilitation ward was undertaken in 2016 (19 weeks). Interviews with 12 professionals and seven patients were conducted. Data were analysed in an abductive process using thematic analysis.The patients perceived their encounters with interprofessional teams as supportive, with implications for pain stigma. This is presented as two themes: (1) being seen as credible, involving patients being believed in and a concept of being overactive at the expense of their own health, and (2) being helped to see their situation in a new light, which involves enthusiasm about changing and challenging views in a process with professionals who were supportive and united across professions.Interprofessional biopsychosocial pain rehabilitation can be an intervention for diminishing internalised pain stigma in patients.Knowledge on how encounters with professionals induce personal learning processes among people with chronic pain.Interprofessional biopsychosocial pain rehabilitation may be an intervention that can diminish internalised stigma in patients suffering from chronic pain. The study contributes to increased understanding of patient perceptions of positive encounters with professionals during a learning process in rehabilitation and of the imbued influence on power relations. This appears to be fundamental to diminishing pain stigma, as the occurrence of stigma is dependent on differences in power. In modern society, people with chronic pain suffer from stigmatising attitudes ,2. HealtPatients with chronic pain have been found to invest much work and energy in being perceived as credible by professionals . At the For the purpose of this study, we find Link and Phelan’s , p.367 cInternalising stigma is not a necessary consequence of social stigma ,3. Some Research has found multiple consequences of social stigmatising attitudes towards people with chronic pain. Internalisation of pain stigma is associated with low self-esteem and low self-efficacy . PerceptInterprofessional biopsychosocial pain rehabilitation is often defined as rehabilitation programs delivered by a team of at least two separate professions which communicate extensively about patient management, targeting at least two of the following aspects to meet the complexity of chronic pain: physical, psychological, social and work-related factors. The service can be provided in rehabilitation centres, pain clinics or outpatient settings ,11–13. AAccording to Wade , learninProfessionals across professions in health care have been found to have stigmatising attitudes towards patients with chronic pain ,4. IncreThe study is based on findings from an overall qualitative study using an ethnographic approach to explore social processes characterising interprofessional collaboration in pain rehabilitation ,26. The The setting for the study was a biopsychosocial pain rehabilitation in-patient ward in a hospital in Norway. Overall, 19 professionals and 26 patients participated in the observation and interviews in the study. Two intertwined interprofessional teams provided the rehabilitation program, in a close-knit team setting . We seleThe teams consisted of registered nurses, physiotherapists, occupational therapists, psychologists, medical doctors, and social workers. The two teams in the ward were intertwined, as some shared office space across teams and some held functions in both teams. Their approach had a cognitive focus combined with patient education about topics such as pain physiology, and physical activities such as strength training. Adjusting medication or introducing invasive pain treatment was not part of the program. One team provided an individual program with more use of one-on-one appointments with each profession. The other team facilitated a group-based program with more use of group education, counselling, and training sessions. This team also had some individual admissions.The patients suffered from chronic pain with basis in a wide range of causes such as physical trauma or hypermobility syndrome or with no biomedical findings explaining the pain. Diagnosis was not included in the criteria for admission. To qualify for the rehabilitation programme, patients had to have complex pain conditions with a severity that led to significant dysfunction in daily activities and reduced quality of life. They had to have completed investigation into the cause of the pain. Moreover, patients had to be evaluated as motivated for a biopsychosocial approach and in need of interprofessional rehabilitation. The patients stayed in the hospital unit for approximately four periods lasting from one to four weeks during a time span of one year.The first author conducted participant observation between February and June 2016 on 40 unique days of approximately 5 h. The observational role varied from more to less participation, which is common in participant observation . The firThe first author observed encounters between patients and professionals from all the six professions involved. In encounters between patients and professionals, attention was given to the actions and accounts of both parties. These encounters could take the form of counselling (seven occasions), discharge meetings (four occasions), patient education (12 occasions), physical activities (four occasions) and informal encounters. Interprofessional encounters such as team meetings, informal conversations and written reports were observed. The focus of the observations intentionally interchanged between aspects such as the content of stories, the non-verbal social atmosphere or the words used. For example, in a meeting between an occupational therapist and patient, focus was placed on the exact words used because the conversation appeared to be substantial and to flow well. During group patient education sessions, where professionals could hold a monologue for some time, focus might be placed on the patients’ changing non-verbal signals of being concentrated, bored or in pain. Field notes  were written during observation or as soon as possible afterwards.During the observation phase, the first author conducted semi-structured individual interviews (19) with patients (7) and professionals (12). Patient interviews had an average length of 41 min and interviews with professionals an average length of 54 min. Interview guides with open-ended questions were used. Examples of questions in the interview guide for patients include “What was it like to meet the professionals who work here?”, “Can you tell me about an experience of meeting the professionals here that has been especially rewarding for you?”, “Can you tell me about an experience of meeting the professionals here that has been particularly challenging?” and “What is your experience of telling the professionals about your pain?” The interviews were undertaken to obtain accounts to broaden the understanding of the observed social processes . None ofWe selected the patients with the aim of representing a diversity of perspectives based on pain background, gender, experiences from group-based or individual admissions in the unit, and on being perceived by professionals to vary in their perspectives on the rehabilitation process. A nurse from one of the observed teams helped recruit potential patient participants. Three of the patients interviewed were also observed. Among the 12 professionals who were interviewed, two participants from each of the six professions were represented. They were recruited by the first author during fieldwork in the hospital unit, with the aim of obtaining varying accounts from all professions. Professionals were selected based on convenience, when there for instance were only two employed psychologists, or on experience or distinct perspectives needed to expand the data.The hospital’s data protection officials approved the study on behalf of the Norwegian Data Protection Authority, which cooperates with the Regional Committee for Medical and Health Research Ethics. All participants received written information about the study and signed an informed consent letter. At the start of the fieldwork, the first author presented herself and informed the two teams about the study in interprofessional meetings. This was also done before observing groups of patients. Before observing one-on-one encounters between patients and professionals, an agreement was made with the professional, who then asked and informed the patient. If the patient consented, the first author informed the patient about the study at the start of the observation. The first author was present for dialog with all participants during the fieldwork. Interview settings were selected to ensure confidentiality, and sensitive information was deleted in publications.We used thematic analysis ,31 to deAnalysis began during fieldwork with writing notes about patterns and ideas. Influenced by these notes, the first author generated an unrefined map of codes and themes across the data . The staWe addressed the trustworthiness of the study in several ways, which according to Lincoln  can be dJournaling also strengthens the dependability of the research process . In addiThe participating professionals and patients were sampled in such a way as to represent a variety of perspectives and broaden the understanding of the phenomena, which reinforces confirmability. The concept of confirmability can be explained as the extent of the researchers’ prior understanding of the phenomenon shaping what is found, where the researcher should aim to use data gathering procedures that confirm findings as also shaped by participants . CompariWe identified two themes showing the patients’ perceptions of their encounters with interprofessional pain rehabilitation teams, with implications for pain stigma: (1) to be seen as credible, and (2) being helped to see their situation in a new light.Tom was sitting in his room when I came to talk to him. He had struggled with chronic pain stealing his time and energy for years. He experienced a wide gap between his current situation and his longing to spend time with family and friends and do sports. Exhausted from pain after performing chores such as vacuum cleaning, he would have to lie on the coach for the rest of the day. He felt that he had to tiptoe around people who wrongly assumed him to be in good health and expected him to behave in ways he could not. The rehabilitation ward was for him a free space where he could finally relax in a social dimension, although the rehabilitation was hard work and he went through one disappointment after the other on his journey.[…] you feel safe when you come here. You can relax, you can be yourself. You don’t have to tiptoe and sort of: ‘is anyone looking down on me for parking in the handicap space? It… he looks healthy, so he doesn’t need to park there!’ Even though I’m allowed to. The patients feared others misinterpreted them as lazy or slackers for working fewer hours or not at all or for not being there for their family and friends because they needed a lot of rest. These others did not see how the patients gave all they had, did too much, wanted to achieve too much and did not think enough about their own needs. This was expressed in interviews, in patient education sessions and in one-to-one meetings between professionals and patients.Through meeting the professionals, the patients found they were finally seen as credible, which was followed by a new or strengthened positive self-understanding. Especially the concept of “overactivity” appeared to make them feel understood and credible by the professionals. This concept was about them exerting themselves in the wrong way, often driven by the fear of being negatively and stereotypically misinterpreted. This exertion led to more pain and exhaustion. All the patients talked about this in the interviews, and five of them also linked it to their perception of the professionals understanding them in the right way:There’s a fear, it’s … a protection mechanism that makes you exert yourself completely wrong and do even more. So, all those things, the inner things, let go [through rehabilitation]. I was left with only the real pain. And the fear was somehow gone. Trying to protect themselves from stereotypical views, at the expense of their own health, implies that the patients were aware of and cared about negative perceptions in society. They appeared to be balancing between believing in the negative perceptions and taking care of their own needs. The need to be careful not to be overactive on good days resonated well with the patients. They needed to work on overactivity so that they could live a better life with less pain and participate in everyday life. When passing on this view to the patients, the professionals referred to how it was a widespread problem among people with chronic pain, and visualised their message using hand drawings and metaphors. Such interactions were observed in one-to-one meetings and patient education sessions, and can be illustrated by a meeting between an occupational therapist and a patient:Patient: ‘I have a long list of things I want to do on a good day. Yesterday, I talked to the physiotherapist about doing as little on a good day as on a bad day. To gain energy … For the past six months, the normal days have been completely gone!’ Occupational therapist: ‘Many with long-term pain talk about such a pattern.’ She draws a line with large wave crests and deep troughs on a sheet of paper. ‘It alternates between the good days where a lot is done, followed by very bad days.’ The patient recognizes the pattern and says: ‘In those troughs, the bad days, I just lie all day.’ The occupational therapist draws a line with smaller waves that run through the middle of the big waves and says: ‘It’s important to live a life which is more like this.’ Patient: ‘I have to slow down on the good days.’ The patients were taught about the problem of having too many rules for not participating in everyday life in order to avoid pain, and about balancing their activities so as not to be overactive. Still, through interactions between patients and professionals concerning the right balance between not being overactive and not having pain rules, most patients expressed a perception of being understood as first and foremost overactive.In five of the interviews, patients talked about how they did not tend to whine and complain about pain. They avoided talking about illness because they believed it might become worse. They did not want to appear to others as sick or be a burden by making people feel sorry for them. The pain was not what they wanted to talk about with the professionals.I'm not the kind of person who talks that much about illness. Eh … in general. So … I think it’s too much. I think it … becomes negative somehow. Instead, I want to focus on the nice weather outside and that I want to go for a walk, because it … does something more to you than to… [focus on illness] (laughs a little) yes. In three interviews, patients expressed relief at being believed when they talked about their pain with the professionals in the rehabilitation unit:The first time [he told the rehabilitation professionals about his pain] it was … uncomfortable … Because I had experiences from the health care system, I was not completely believed by everyone [he takes a deep breath] … And I was just a like ball being thrown around in a system, back and forth in the hospitals for many years. New examinations and . yes … But when I came here and … feeling safe after the first conversation … You can drop your shoulders and: ‘Oh, finally! Finally, there’s someone who has … believes in me.’ Only to a small extent was pain observed to be directly discussed between patients and professionals in pain rehabilitation, although it could be a topic in their first encounters. Rather, several patients expressed a wish to communicate with the professionals about what affected the pain and what could be done. There appeared to be a widespread wish to receive help with seeing their demanding life with chronic pain in a new light.There was widespread enthusiasm among the patients about the biopsychosocial approach. According to talks between patients and accounts given in six of the interviews, many appeared to have strong positive emotions connected to their new insights and how the professionals in the rehabilitation program were outstanding and could be trusted more than elsewhere. In interviews, such accounts dealt with being privileged to receive such good treatment or with how the professionals’ input and tools had helped them to see their situation in a new light. Sarah, a woman in her forties who had suffered from pain all her life due to hypermobility syndrome, expressed great enthusiasm about how her views had been changed through a process in which she needed time alone to digest the information:When he drew it up and, I didn’t get it right away, but when I read it afterwards in the evenings and sort of looked at it a bit… because there’s a lot of information to take in and you become like, wow. And then there’s another worldview … I don’t know about … I will use a word called paradigm, it’s a small paradigm shift in your own thinking! Because you have been there, and you feel like the pain has had catastrophic consequences. Been a lot of illness, pain and all. And you’re a patient and you’re almost a victim and … and then suddenly: yes, but we can separate something away here! The accounts from patients could deal with experiencing the professionals as fellow human beings who listened to what they said while giving clear advice. Five patients expressed in the interviews that the professionals collaboratively acted on the information they provided. Sarah was very pleased with how she had been met interprofessionally:And you meet real people before you meet the professional […] And what’s really surprising is that when you say something, they actually listen to you. And you get good answers back. And they come back to you afterwards and say: ‘Sarah, you said that, now we have thought a bit and discussed in the team, because they have such interdisciplinary meetings, and we have found out … how does that sound to you?’ And I think that’s good and professional, I like that. Two patients said they had heard different stories from other patients in the unit who had negative perceptions of the help given. The negative perceptions were explained as being due to prior experiences with the health care system or to not understanding what the rehabilitation program was about.I'm more naïve; this [rehabilitation] worked really well! Or it may not be naive, but I think the experiences from when we have met the health service … I have had them [health care professionals] in my life for a short period, while they [other patients] have often had them a long while. So that’s why I also think that I see it with different eyes, and when it works, it works so well because … I don’t have that negative ballast with me. The patients talked about how hard it was to trust whether it was safe to do as professionals said due to earlier experiences of how professionals approached chronic pain in different ways and gave contrary information or advice concerning the pain. This is illustrated by the following observed talk between patients about their earlier experiences with professionals elsewhere:One patient said: ‘They work in such different ways. Different healthcare professionals say different things. I'm going crazy. In the end, you don’t trust yourself .’ Another patient replied: ‘After these experiences, it becomes difficult to trust whether it is safe to do what health professionals say. It’s best to do what you think yourself. You have to be a bad patient or friend or mother.’ The patients talked about how they feared that family or friends did not understand the rehabilitation program and thought the patients would come home cured or that the program implied that the pain was psychological. Many patients therefore feared that people believed it possible to think the pain away, implying that the patients complained and shirked their duties due to an “unreal” problem. Three of the patients talked about this in the interviews. This also emerged in a patient education session, where a patient started talking about worries concerning the next-of-kin day, where patients could invite relatives or other close ones to visit the rehabilitation unit and get information about the program:‘They [her relatives] are here for just one and a half hours, and I’m afraid that she’ll leave here thinking that this is something you can get rid of by changing your thoughts, that you can pull yourself together, then it goes away and you’re healthy. We’re here for four weeks and get a thorough introduction, we get to ask questions. When they’re here for such a short time, they can easily go home with a simplistic conception.’ As frequently observed when patients were gathered in education sessions, the patients in this session appeared to have similar experiences. Many of them agreed with the first patient’s perception and felt strongly about it:There’s an impassioned atmosphere in the group about this topic. The conversation moves fast. Another patient says she has decided not to invite anyone here. She has a lot of experiences showing that those closest to her don’t understand. The social worker who led this session shifted the focus by being supportive while urging the patients that they could not expect anyone to fully understand what they were experiencing:The social worker says that you cannot make others understand to a full extent: ‘If you have held a yellow lemon in your hand and tasted it, and are going to describe how it tastes to someone who has never even touched one, you will not be able to get that person to acquire exactly the same knowledge of the lemon.’ In the patient education sessions, the professionals often acknowledged the patients’ experiences of not being believed or of not being understood regarding their pain. As in the example above, this acknowledgement could be given without directly referring to the concrete experiences of individual patients. Rather, they drew general conclusions about these phenomena while offering a possible way of challenging them.When professionals conveyed specialised knowledge about chronic pain, it could provoke patients into disagreeing with what was said. One such instance occurred in a patient education session, when a physiotherapist described persistent pain as a false alarm, and received reactions from the audience.The physiotherapist asks the patients what acute pain is. They suggest burns, that it is pain that passes. The physiotherapist explains that pain is an alarm signal to warn about danger. She asks the patients: ‘If chronic then?’ It is suggested that then it does not go away. The physiotherapist says that then it is a false alarm. A patient reacts to this and does not agree. The physiotherapist explains that what she means by false alarm is that with chronic pain the appropriate response is not to withdraw as in the case of acute pain. .Most of the patients in our study seemed to perceive their encounters with interprofessional teams as supportive. The patients expressed their impressions of the professionals as more knowledgeable and less prejudiced than professionals elsewhere. The patients perceived the encounters as supportive in that they were seen as credible while receiving help to see their situation in a new light.Our findings show that patients with chronic pain can experience a clear duality between being negatively misinterpreted outside versus positively understood and helped inside a biopsychosocial pain rehabilitation unit. In this discussion we emphasise the social meaning of the positive perceptions of encounters and how it can influence pain stigma. Regarding the patients’ perceptions of negative misinterpretations experienced elsewhere, these are consistent with earlier research showing experiences of disbelief from professionals about patients’ pain ,5 and peWe found that patients in biopsychosocial pain rehabilitation can express positive perceptions about themselves, and about how they perceive to be seen by professionals in the unit. Earlier research has shown that patients with chronic pain can perceive themselves as strong individuals and prefer to avoid complaining about their pain . Such poThe patient process can be viewed as a learning process due to changes in dispositions and capabilities  concerniTo diminish the internalisation of stigma in patients, one key element appears to be to clarify and help them to see life with chronic pain in a new light. Doing so can enhance the patients’ ability to reject widespread negative cultural beliefs about people with chronic pain. Clarifying misconceptions and demystifying concepts can dissolve anxiety and resistance to deviating from the previously known and embraced reality . A way oOur findings show that patients can perceive professionals in interprofessional teams as being in continuity in communication across professions. Building further on what other team members have said can strengthen patient perceptions of the professionals as being in interprofessional continuity, which Hoving et al.  found toFor the present, we have discussed a personal learning process promoting a reduction in stigma beliefs. However, while beliefs about a group of patients is one component in the unfolding of stigma, there needs to be a relational power situation in which the less powerful can be exposed to discriminatory consequences for the stigma to occur .Controlling access to health care is one concrete way of having power that can result in stigmatisation, since perceptions about a patient group can entail serious discriminatory consequences . When adLearning about contrary interpretations of stigma can be a process in which the relational power situation between patients and professionals can be transformed through their social encounters. We find a power transition in two different dimensions. One dimension is the empowerment of patients towards believing in their own ability to handle their situation through perceiving to be understood by professionals in ways that counter the social stigma beliefs discussed above. This can be explained as power (or capacity or empowerment) to do something, which is one part of the concept of power . The extThe other dimension of the transition in power can be seen through how patients in biopsychosocial pain rehabilitation perceive themselves to understand knowledge in a new “paradigm” together with the professionals, and one which outsiders do not understand. This perception places patients in a new favourable “we,” or in-group, with the professionals. We find this to be a change from the “us” and “them” situation, where people have been placed in distinct categories . The patAlthough we find a transition in the power relation, we urge an awareness of the potential challenges for patients facing a trade-off with regard to their own needs in the quest to become the good and acknowledgeable patient in order to fit into the in-group. For instance, in our findings, patient’s experiences of pain or suffering were directly discussed to a small extent only, and several statements expressed a will to avoid this kind of focus. Our findings may be due to patients trying to refute the stigma of being complainers. It can be a way of downplaying the condition, as an attempt to be normal in order to become part of the group ,42. ThisWe find that an interprofessional biopsychosocial pain rehabilitation program can be an intervention to reduce stigma without expressing the reduction of stigma as an explicit goal. The environment in the rehabilitation unit in which patients are involved with others in a similar situation and with professionals from multiple professions can be defined as what De Ruddere and Craig  term an There are some limitations to the study, one of which is that the patients in this pain rehabilitation program where all considered to be motivated by a biopsychosocial approach as part of gaining admission to the program. Had we included people with chronic pain who were considered not to be motivated by this approach, their perceptions would differ. A large majority of the patients in the pain rehabilitation unit comprised women, and this is reflected in the sample of participants in interviews, where only one man was included. Men’s perceptions are therefore poorly represented in the study. Moreover, had we included patients who had completed the rehabilitation program and had experienced day-to-day life afterwards, we may have found their perceptions to be different.Interprofessional biopsychosocial pain rehabilitation can be an intervention to diminish internalised stigma in patients suffering from chronic pain. The study shows that patients can perceive encounters with professionals from multiple professions in pain rehabilitation as supportive. The encounters are perceived as positive due to the continuity of the professionals’ communication, while facilitating a personal learning process where patients feel they are seen as credible and helped to see their situation in a new light with contrary interpretations of social stigma beliefs. The study adds new knowledge by conceptualising how admission to rehabilitation and support from being part of an in-group with professionals in a learning process can be a transition of power in the dimensions of both “power over” and “power to.” This appears to be fundamental to diminishing pain stigma, as the occurrence of stigma is dependent on differences in power. We believe the results can be transferred to biopsychosocial pain rehabilitation settings and to other health care settings that provide treatment to patients with chronic pain, by increasing understanding of patient perceptions of encounters with professionals across professions in health care and the impact of a personal learning process on power relations and pain stigma.