Adolescent smartphone users have developed a variety of musculoskeletal conditions due to their use of smartphones. ELDOA (Elongation longitudinaux avec decoaption osteo-articulaire) is based on maximizing facial and spinal stretching by assuming specific posture for 1 minute and post facilitation stretching is also a type of muscle energy technique that is used for chronically shortened or tight muscles. This aimed to compare the effects of post-facilitation stretching technique and ELDOA on neck pain and functional disability in mobile users experiencing Text neck syndrome during COVID-19.t test was used, and a paired sample t test was used to find the difference within each group.This single-blinded randomized control trial with a parallel group design was conducted at the Department of Physiotherapy Safi Hospital  from September 2021 to April 2022. Forty smartphone users between the ages of 18 and 35 who had a Neck Disability Index score of >10 due to neck pain without unilateral arm symptoms participated in the study. Of the 40 participants, twenty were randomly assigned to the ELDOA group and twenty were assigned to the post facilitation stretching group, and each group received 3 weekly sessions of treatment for 6 weeks. The Numeric Pain Rating Scale (NPRS), Neck Disability Index (NDI), and Smartphone Addiction Scale (SAS) were used to measure pain intensity, functional disability, and smartphone addiction at baseline and after 18 sessions of treatment. SPSS version 22 was used to enter and analyze the data. To find comparisons between groups an independent sample P < .03) with 95% CI  and functional disability (P < .05) with 95% CI  at 6th week. There was no statistically significant difference (P = .35) with 95% CI  between the two groups regarding smartphone addiction. The NPRS, NDI, SAS scores were significantly different within each group with P < .05.Post-treatment values showed statistically significant difference between groups. ELDOA group showed greater improvement in pain (The study concluded that ELDOA method and post-facilitation stretching both were effective in treating neck pain and functional disability. However, ELDOA method was superior to post-facilitation stretching effects on neck pain and functional disability among patients with text neck syndrome. The current era has seen a pandemic situation caused by the Coronavirus Disease 2019 (COVID-19), which has resulted in erratic challenges around the world. To limit the spread of the virus and protect people from the harmful effects of the disease, a “lockdown” has been chosen as the first line of defense, along with other measures such as social distancing and restricting gatherings in society. This scenario has created a rise in the use of smartphones by people of all ages, creating an immense influence on education, the health sector, business sector, and social life as well. Teenagers are using cellphones more frequently, which is causing a rise in musculoskeletal issues. With the increasing size of cell phones and more screen time, postural abnormalities are becoming more prevalent.The term “text neck” was first used by Dr Dean L. Fishman to describe neck injuries caused by long periods of bending the neck forward. These injuries are caused by repeated stress on the neck.Text Neck Syndrome is also called turtle neck posture and is caused by watching mobile phones or tablets in a flexed position for long periods of time. Text neck syndrome can cause serious damage to the cervical spine, such as inflammation of the ligaments, irritation of the nerves, and a more curved spine if it is not treated. With the growing use of technology in the modern lifestyle, this syndrome has become a new health concern. A smartphone user’s neck can suffer from this syndrome due to repetitive stress injury and sustained cervical flexion.,6Studies indicate that mobile phone usage is very common among people between the ages of 18 and 44. It has been reported that 79% of the population keeps their smartphones with them almost most of the time.,8 A common symptom of text neck syndrome is neck pain or discomfort, soreness, with other symptoms including shoulder discomfort, increased spinal curvature, and chronic headaches. Moreover, it can cause chronic low back pain in the upper back, characterized by dull pain to severe pain and muscle spasms.The improper and prolonged use of smartphones has led to a cluster of symptoms commonly known as “text neck syndrome.”,10 Several other factors can lead to neck pain such as neoplastic disease, inflammatory conditions, infectious conditions and congenital problems. Growing evidence reports that persistent neck pain in young age leads to chronic pain in adults.–14 This condition is a growing concern in young population as they use smartphones or electronic gadgets for simple tasks.Text neck syndrome can also be considered as 21st century syndrome due to numerous reporting cases. Musculoskeletal pain especially neck pain is a public health condition in modern time.Outpatient physiotherapy provided by physical therapists during the COVID-19 pandemic was an important part of physical rehabilitation for patients with different Musculoskeletal, neurological, and respiratory conditions.,17 Physiotherapy includes manual techniques used by skilled clinician to diagnose and treat soft tissues and joint structures. As part of this approach, increasing range of motion is achieved by enhancing the repair and extensibility of the surrounding tissues, facilitating movement, and decreasing disability levels by improving musculoskeletal function pertaining to daily activities. Post facilitation stretching is also type of muscle energy technique that is used for chronically shortened or tight muscles. It involves relaxation of muscle and lengthening of fascia.In this application, the patient was instructed to contract at or near patient’s maximum voluntary capacity for 5 to 10 seconds and then relax as quickly as possible. The researcher would aggressively stretch the muscle at barrier.Warm-up exercises, stretches, rest, ice/heat, massage, posture correction, and lifestyle changes may help acute text neck symptoms. Chronic cases may benefit from physical therapy, medication, injections, manipulation, and acupuncture. Myofascial ELDOA (Elongation longitudinaux avec decoaption osteo-articulaire) technique was first described by Guy Voyer in 1979, which is also called LOADS . It is based on maximizing fascial and spinal stretching by assuming specific posture for 1 min. It targets spinal strengthening and decompression. ELDOA has originated from a variety of treatment approaches and creates local and general effects. It allows decompression of zygopopheasal joints, more absorption of fluids in disc, increase circulation, improve tone and end range. It also allows correction of impaired posture, improving respiration and proprioceptive facilitation of concerned segment. It has also secondary benefits on organ system.,21A number of conditions have been treated with ELDOA, including prolapsed intervertebral discs, piriformis syndrome, chronic low back pain, cervical radiculopathy, active trigger points, and forward head posture.–25In text neck syndrome pain is caused by mostly by stiff trapezius and levator scapulae.This syndrome has become a new health concern worldwide and affects the huge population. Adolescent smartphone users increase day by day and have a lot of musculoskeletal conditions. The size of cell phones become bigger day by day and demands more screen time. Prolonged duration of flexed posture while looking down on a screen leads to pain intensity and disability in cervical spine. Few studies have been conducted on the physical therapy management of text neck syndrome than those on prevalence and awareness. Hence, this study aimed to examine the effects of post-facilitation stretching versus ELDOA treatment on mobile users experiencing text neck syndrome during the COVID-19 pandemic.This single-blinded randomized clinical trial was conducted at the Physical Therapy department of Safi Hospital, Faisalabad and was registered in the WHO Registry clinicaltrials.gov with number. NCT05048992 and ethical approval (REC/RCR & AHS/21/0116) was granted by Research and ethics committee of Riphah International University and this trial followed the Declaration of Helsinki.The study recruited 40 patients  with Text neck syndrome through consecutive sampling, and in this single-blind study, one of the groups received post-facilitation stretching, and the other received ELDOA. The study flow diagram is shown in Figure Forty patients with acute neck pain without unilateral upper extremity symptoms, 18 to 35 years of age, using smartphone since past 1 year and neck disability index (NDI) score > 10 were included in the study. Participants having any congenital cervical abnormalities, history of whiplash injury within the last 6 weeks, history of spinal neoplastic disease, spinal infection, cervical spine fracture, or previous surgical neck procedure and cervical radiculopathy were excluded from the study. Taking into account the above-mentioned inclusion and exclusion criteria, subjects were recruited in this study through consecutive sampling and then participants were randomly assigned to both groups by the researcher. After taking informed consent, subjects assigned to Group A and group B by lottery method. All participants had equal choice of group allocation and asked to draw one chit from a box. Participants with an odd number were assigned to group A and participants with even number assigned to group B. with 0.80 power of study, 5% margin of error and 95% confidence interval with 10% attrition rate.Sample size of 36 was calculated with effect size 0.99 by using G power analysis software, version (3.1.9.2)Treatment was given to both groups for 6 weeks with 3 sessions per weeks on alternate days of the week with 45 minutes duration of each session and treatment session was conducted during the daytime. A pre-assessment was conducted before treatment commenced, and a post-treatment assessment was conducted at the last session, using the Numeric Pain Rating Scale (NPRS), NDI and Smartphone Addiction Scale (SAS). All patients in both groups were advised to take frequent breaks during Smartphone use and avoid static posture as a home plan.Before each session, both groups received a 10-minute hot pack session.group A was treated with ELDOA which is myofascial stretching technique of the cervical spine. Patients were asked to adopt desired position to target intervertebral segments. Breathing is also important factor in ELDOA stretch. Patients were instructed to not to hold or strain breathing through promoting diaphragmatic breathing.The patient was inside lying with bottom limb place below the head along with neutral cervical spine. Bottom leg was bent to stabilize the trunk. Progression of this posture was made through lengthening of neck and rest of the spine. Patients were asked to maintain this position for 1 minute. After that Patients were asked to extend top arm over head with palm placed on the ground. Foot of top leg placed anterior to the knee by keeping hip in vertical position. Patients were asked to maintain this position. In the final step, Patients were asked to protrude their tongue and move their eyes towards head.The starting position of patients was supine lying with both arms placed on the sides. Patients were asked to move to both knees towards chest until tension reaches the sacrum region. Then Patients were asked to raise their head from floor to produce further tension. Progression of this position was made through extension of both arms along with external rotation at shoulder. Patients were asked to maintain this position for 1 minute.This is the progression of level C4-C5. For targeting C5-C6, patients were asked to rotate both arms toward ceiling by keeping in parallel direction. Tension was maintained for 1 minute. Every posture was maintained for 1 minute with 15 seconds rest and each session consists of 5 repetitions.This is the progression of level C5-C6. Patients were asked to abduct both arms in coronal plane up to 45 degrees. Tension was maintained for 1 minute.Post facilitation technique was used to treat tight trapezius and levator scapulae. At first patient was instructed to contract at or near patient’s maximum voluntary capacity for 5 to 10 second and then relax as quickly as possible. The researcher was aggressively stretch the muscle at barrier.Each patient was in supine position. Patients were asked to place their affected hand under the thigh in order to produce shoulder depression. Therapist was standing towards the head of patient and placed hand on non-affected side. Therapist attempted to flex, contra-laterally side flexion and rotation until tissue resistance was felt. After that therapist placed the muscle in mid-range and lengthened aggressively beyond tissue resistance with 15 second hold. After that new barrier was achieved and same procedure repeated.Each session consists of 5 repetitions. Treatment was given to both groups for 6 weeks with 3 sessions per weeks. All patients were advised to take frequent breaks during smartphone use and avoid static posture as a home plan.Patients were asked to place their affected hand under the thigh in order to produce shoulder depression. Therapist was standing towards the head of patient and placed hand on non-affected side. Therapist attempted to flex, contralaterally side flexion and ipsilateral rotation until tissue resistance was felt. After that therapist placed the muscle in mid-range and lengthened aggressively beyond tissue resistance with 15 second hold. After that new barrier was achieved and same procedure repeated.The primary outcomes were:• It consists of 11 points. In which 0 means no pain and 10 means severe pain.The intensity of pain was assessed using the NPRS, which is valid, reliable, and universally accepted scale.• It is scale of ten sections with each section of 5 marks. Interpretation of this scale is as 0 score indicates no activity limitation and 5 score indicates complete activity limitation. Score ranges from 0 to 50 in which 0 indicates no disability and 50 means maximum disability. A higher score indicated greater level of activity limitation.This study measured functional neck disability using NDI, which is widely used and well validated.The secondary outcome was:•An assessment of smartphone addiction was performed using the SAS, which has been proven to be a reliable and valid instrument. Total score of SAS ranges between 33 to 198 and higher score indicates more disability.The study was single blinded as only the assessor was blinded during treatment, and patients and the clinical therapist were not blinded due to the nature of the treatment protocol.t test was used independent sample t test was applied to measure difference between two groups. To find difference within each group Paired sample t test was used.The data analysis was done by using SPSS version 22 for Windows software. For descriptive statistics frequency tables and bar charts were used. Parametric test was used to compare two population at different various intervals. To find between group comparison independent sample P value .67. The body mass index of participants in ELDOA group was 21.29 ± 4.14 and in post–facilitation stretching technique group 22.05 ± 4.24 with P value .56. The Pre-NPRS score in ELDOA group was 4.80 ± 1.36 in post-facilitation stretching group was 4.4 ± 1.18 with P value.32. The Pre-NDI score in ELDOA group was 16.20 ± 5.18in post–facilitation stretching group was14.65 ± 4.71with P value .32. The Pre-SAS score in ELDOA group was 111.7 ± 35.7 score in post–facilitation stretching group was 118.4 ± 20.25 with P value .47. The independent t test and levene’s test for equality of variances was used to evaluate homogeneity of among two groups  and SAS (P > .05).The finding of the current study revealed that there was a significant difference between the groups on NPRS and NDI pre- and post-treatment for pain and functional disability with a P value of (P < .03) with 95% CI  and (P < .05) with 95% CI , respectively, and ELDOA group showed greater improvement in functional disability (P < .05). However, between group comparison of SAS score reported no significant difference (P = .35) after treatment with 95% CI   and between group comparison showed no significant results (P > .05). In our study ELDOA which was type of manual soft tissue approach was found more superior than post-facilitation stretching. Another study conducted on the effects of modified ELDOA and ELDOA on cervical radiculopathy reported that both interventions were effective in improving posture and disabilities; however, no significant difference was found.ELDOA method is basically postural exercises that could be taught to the patients. These exercises separate the vertebral spaces by generating facial tension at targeted vertebral segment. Separation causes increase in blood flow, disc hydration. Muscles strengthening, improvement in proprioception also achieved through these postural exercises. Retamal et al conducted a clinical trial in 2021 to compare the effects of fascial therapy and manual therapy among patients of chronic neck pain. In the past literature fascia targeted therapy grabs the attention of physiotherapists as it has beneficial effects on chronic neck pain. This study was conducted on three groups, Fascial therapy group, Manual therapy group and no treatment group. Subjects were allocated to three groups and assessed by using, visual analogue scale and Neck pain and disability scale. Results reported large effect size of fascial therapy and manual therapy in chronic neck pain. As in this study, both interventions reported improvement in neck pain and disability. The difference between this study and our study is that we have two groups whereas this study conducted on three groups.Brück et al performed a RCT to determine the effectiveness of yoga poses and deep cervical fascial therapy on mechanical neck pain. Patients were recruited and assessed on NPRS, patient specific functional scale and neurodynamic test. They concluded in favor of deep cervical fascial approach and yoga as a promising treatment protocol for mechanical neck pain. Fascia is an important factor in treating musculoskeletal problem and in this study, results supported that ELDOA method  are more effective as compared to post- facilitation stretching. Due to the pandemic, patients were reluctant to participate so it was more difficult to instruct those regarding different ELDOA postures and giving verbal and tactile cues to hold postures. More research may be necessary to determine the longevity effects of interventions with follow-up sessions and objective measures, as well as on other symptoms of text neck syndrome. More studies with a larger sample size and adding patient with chronic condition should be conducted in the future by the researchers. It is recommended that clinicians use the ELDOA method in routine practice since it provided better results than post-facilitation stretching in reducing neck pain and functional disability among patients with Text Neck Syndrome.In 2021 Raja et alThe study concluded that the ELDOA method and post-facilitation stretching were both effective in treating neck pain and functional disability. However, the ELDOA method provided superior results to post-facilitation stretching for neck pain and functional disability among patients with Text Neck Syndrome. Furthermore, no significant difference was found between groups in smart phone addiction outcomes.Conceptualization: Maryam Farooq, Muhammad Salman Bashir.Data curation: Maryam Farooq, Muhammad Kashif.Formal analysis: Maryam Farooq.Funding acquisition: Maryam Farooq, Abida Arif, Nosheen Manzoor, Farwa Abid.Investigation: Maryam Farooq, Abida Arif, Nosheen Manzoor.Methodology: Maryam Farooq, Abida Arif, Muhammad Kashif, Farwa Abid.Project administration: Muhammad Salman Bashir.Resources: Maryam Farooq, Abida Arif, Nosheen Manzoor, Farwa Abid.Software: Abida Arif, Nosheen Manzoor, Farwa Abid.Supervision: Muhammad Salman Bashir.Validation: Muhammad Salman Bashir, Muhammad Kashif.Visualization: Maryam Farooq, Muhammad Salman Bashir, Muhammad Kashif.Writing – original draft: Maryam Farooq, Muhammad Salman Bashir, Muhammad Kashif.Writing – review & editing: Maryam Farooq, Muhammad Salman Bashir, Muhammad Kashif.


To describe the types of analgesic medications administered to patients who were attended by ambulance on recreational trails while mountain biking or hiking and report on the reduction in pain by these agents.This is a retrospective cohort study of patients attended by ambulance (2015–2021) after mountain biking or hiking, on Western Australia (WA) trails. All data were extracted from electronic patient care records created by ambulance personnel who attended the patient. We compared patient and case characteristics between mountain bikers and hikers and the reduction in pain scores achieved by different analgesics.A total of 717 patients were included. Paramedics reported traumatic aetiology for mountain bikers in 92 % of cases and hikers in 58 % of cases. A pain score out of 10 was recorded for 538 (75 %) patients. The median (inter-quartile range) initial pain score was 6 (2–8) and the median final pain score was 3 (1–5). Around 48 % of these 538 patients reported ≥25 % reduction in their pain score. A reduction of ≥25 % in their pain score was greatest in those patients who received intravenous fentanyl (81 %), followed by patients administered multiple analgesics (72 %) and methoxyflurane only (52 %). Even 37 % of 134 patients who received no analgesia still reported ≥25 % reduction in their pain score by hospital arrival.Trauma was the most common reason mountain bikers and hikers on trails called an ambulance and a large proportion of these patients were in pain on ambulance arrival. Further work assessing the effectiveness of safe, non-opioid analgesics, additional to methoxyflurane, is needed to ensure non-registered practitioners such as first aid providers and event medical teams can offer suitable safe analgesics to these patients. Additionally, among patients given no pharmacological analgesic agent, almost half still achieved a >25 % reduction in their pain scores which reiterates the importance of non-pharmacological pain reduction strategies. A descriptive study of analgesic agents administered by ambulance personnel to mountain bikers and hikers on trails in Western Australia. Common acute traumatic injuries in mountain biking have been reported to be predominantly lacerations and abrasions with more serious injuries being mainly upper extremity fractures . ParticiWithin Western Australia (WA), the ambulance service utilises four analgesics for the treatment of acute non-cardiac origin pain. The analgesics are (1) oral acetaminophen , (2) inhalational methoxyflurane , (3) fentanyl in intravenous (IV) and intranasal (IN) preparations  and (4) IV/intramuscular (IM) ketamine  . These aTreatment of pain in the prehospital setting is often reported as being suboptimal, despite similar analgesic agents to those used in a hospital setting being available . Where pA review of analgesics in mountain rescue situations, not specifically mountain bikers or hikers, recommended the use of a range of medications including acetaminophen, methoxyflurane, fentanyl and ketamine . These rThe aim of this study was to describe the types of analgesic agents used amongst trail users transported by ambulance within WA and report the changes in pain scores after administration of these agents.22.1We conducted a retrospective cohort study of all people transported to hospital by ambulance due to a mountain biking or hiking injury/medical event within WA between January 1, 2015 and December 31, 2021.Approval was obtained from the Curtin University human research ethics committee under approval numbers HR128/2013-63 and HR128/2013-73., 2015 and December 31st, 2021. Cases were identified using St John WA (SJWA) electronic Patient Care Records (ePCR) completed by the attending ambulance personnel at the time of the incident. These ePCR records are formed by a systematic collection of patient health data and administrative information of the incidents . Cases were identified through a four-stage process. Initially, a geographical delineation was applied between metropolitan Perth and surrounding areas. All cases outside the metropolitan area and those in Kalamunda, Mundaring and Gosnells, which are inside the metropolitan area but have many recreational mountain biking and hiking trails, were included. All mountain biking and hiking trails available from the Trails WA website were downloaded and overlayed onto the non-metropolitan area already delineated by local government boundaries  and significantly (p < 0.001) more likely to be male(84 % for mountain bikers vs 39 % for hikers) .Table 1D3.2Of all patients attended by ambulance a total of 538 (75 %) had pain scores recorded, 179 (25 %) patients had no pain scores recorded and 134 (19 %) patients had pain scores recorded but with no analgesia administered. The initial pain scores of mountain bikers and hikers were significantly different. A higher proportion of hikers reported no pain [114 patients (36 %)] when compared with mountain bikers [65 patients (16 %)] . The pro3.3In total, 1557 separate doses of analgesia were given to 439 (61 %) patients. Of the patients given analgesia, inhalational Methoxyflurane was the most common analgesic given to patients , followed by IV Fentanyl , acetaminophen , IN fentanyl , and ketamine .A total of 199 patients had fractures or dislocations recorded by the treating ambulance personnel. For patients with fractures and/or dislocation, the most common analgesic given was methoxyflurane in 137 (47 %) patients, followed by IV fentanyl in 71 (24 %) of patients. For 519 patients without a reported fracture, almost half of the patients received no analgesic agent  and 147 (24 %) received methoxyflurane . Of the 3.4Overall, 536/717 (75 %) patients had a pain score recorded at the scene and another at hospital arrival. The median initial pain score was 6 (out of 10) (IQR 2–8)  Fig. 1)Fig. 1). 4We described the characteristics of a cohort of trails-based mountain bikers and hikers transported to hospital via ambulance focusing on the analgesics administered. In investigating prehospital analgesics used by the WA ambulance service we identified that for patients reporting pain either IV fentanyl or a combination of multiple analgesics achieved the highest proportion of minimum clinically important difference (MCID) pain reduction with 81 % and 72 % of patients reported a MCID in their pain score by arrival at hospital respectively .We found mountain bikers were more likely to be male and hikers female. This is supported by previous work which indicated that injured mountain bikers were approximately 70–92 % male . There iMountain bikers had significantly shorter prehospital intervals at 87 (64–114) minutes compared with 115 (80–182) minutes for hikers. To our knowledge no previous work has reported on the prehospital intervals of mountain bikers or hikers, so we are unable to make comparison with other regions. It is possible the difference between the prehospital interval in these cohorts is due to hiking trails being less centralized without direct access points and often being further away from metropolitan areas.Over half of the patients (n = 390) described in this study reported moderate to severe initial pain and over 93 % of mountain bikers and 58 % of hikers called an ambulance due to trauma-related injuries. Whilst more mountain bikers than hikers reported medium to severe initial pain this is likely due to the greater proportion of call outs being for trauma related cases. More mountain bikers than hikers had the presence of a fracture reported by the attending clinician at 32 % compared with 22 %. Previous work found fractures constituted between 30 % and 43 % of reported injuries in mountain biking, consistent with our findings ,29,30. WPatients receiving multiple analgesics reported a slightly higher median initial pain score of 8 (IQR 7–9) when compared with IV fentanyl, with a median of 7 (IQR 6–8) and a slightly higher final pain score than IV fentanyl with 4 (3–6) compared to 3 (2–5). Previous findings of a large retrospective analysis comparing prehospital analgesic use in New South Wales, Australia found a multiple analgesic approach to be no different in effectiveness to fentanyl alone . SimilarPatients who received only methoxyflurane reported a MCID in their pain 52 % of the time, meaning almost one in two patients did not receive a meaningful reduction in their pain score by hospital arrival. Patients given methoxyflurane had initial median pain scores of 7 (5–9), similar to both IV and IN fentanyl, but final pain scores for patients given methoxyflurane were higher than all other analgesics, with a median of 5 (3–7) compared with IV fentanyl with a median of 3 (2–5) or a multiple analgesic approach having a median pain score of 4 (3–6). This finding was congruent with a previous retrospective Australian prehospital study which found methoxyflurane to be effective in 59 % of the 19,235 of patients . A prospInitial pain scores for the nil analgesia group were lower than those of the fentanyl, multiple analgesic and methoxyflurane groups at 4 (2–6). Patients who received no analgesia still achieved a MCID in their reported pain scores 49 % of the time, and these patients may have received pain relief from non-pharmacological means. Previous work investigating prehospital analgesia on paediatric patients found children whose pain was managed through non-pharmacological interventions did not differ in their pain score on ED arrival from children administered pharmacological analgesia . The reaTM  a sub-lingual 25 mg racemic ketamine formation and is being made available for ambulance personnel at certain locations where opioid analgesics are unavailable [For patients in this study who did have a fracture reported by a clinician, a multiple analgesic approach was the most common analgesic regime used . Some pavailable . Considevailable . Conside4.1The limitations of this study include being retrospective and observational. A further limitation of this study was that 25 % of mountain bikers and hikers did not have pain scores recorded. Whilst some of these patients may not have been in any pain, a proportion were possibly missing due to noncompliance with ePCR data recording requirements, especially considering some were administered analgesics. A further potential limitation in the retrospective analysis of such a distinct cohort is the potential to miss cases for inclusion leading to a selection bias. To address this, a wide net was cast for initial potential case identification, followed by manually reviewing each case to confirm whether mountain biking or hiking related. The number of patients in the data set did limit the potential for sub-group analyses.5We found mountain bikers and hikers presenting with pain, predominantly from traumatic injuries, reported that fentanyl and multiple analgesics achieved a greater proportion of minimum clinically important difference in pain reduction compared with methoxyflurane or acetaminophen alone. Considering that, of all patients given analgesia, around 50 % achieved a meaningful reduction in their pain scores the analgesics currently in use by the ambulance service may not be appropriate for this cohort of patients. Further research is needed into providing suitable analgesics for this cohort of patients, especially in rural areas where limited medications are available.Data is unavailable for public release due to patient confidentiality.Paul J. Braybrook: Writing – review & editing, Writing – original draft, Validation, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Hideo Tohira: Writing – review & editing, Supervision, Methodology, Data curation. Deon Brink: Writing – review & editing, Supervision. Judith Finn: Writing – review & editing, Supervision, Project administration. Peter L. Buzzacott: Writing – review & editing, Supervision, Project administration.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


Resiniferatoxin (RTX) is an ultrapotent capsaicin analog with a unique spectrum of pharmacological actions. The therapeutic window of RTX is broad, allowing for the full desensitization of pain perception and neurogenic inflammation without causing unacceptable side effects. Intravesical RTX was shown to restore continence in a subset of patients with idiopathic and neurogenic detrusor overactivity. RTX can also ablate sensory neurons as a “molecular scalpel” to achieve permanent analgesia. This targeted  RTX therapy holds great promise in cancer pain management. Intra-articular RTX is undergoing clinical trials to treat moderate-to-severe knee pain in patients with osteoarthritis. Similar targeted approaches may be useful in the management of post-operative pain or pain associated with severe burn injuries. The current state of this field is reviewed, from preclinical studies through veterinary medicine to clinical trials. Euphorbium, a drastic medicinal plant resin known since Roman times . In. In69]. In adult Sprague–Dawley rats, inflammatory pain can be induced by injecting carrageenan 6 mg in 150 µL) into the hind paw. In these animals, perineural RTX (25 to 250 ng in a volume of 50 µL around the sciatic nerve) significantly increased the hind-paw heat withdrawal latency at the ipsilateral carrageenan injection side ,149,150. µL into In a rat model of postoperative pain, perineural RTX prevented the development of incisional hyperalgesia . MoreoveThe monoiodoacetate (MIA) model has become a standard for studying joint disruption in osteoarthritis. Various studies demonstrate that MIA evokes pain and avoidance behaviors in experimental animals that are similar to those reported in osteoarthritis patients. In rats, MIA (8 mg/50 µL injected into the knee joint) induces inflammation and damages cartilage. In rats with MIA-induced osteoarthritis, intra-articular RTX (0.0003% to 0.03%) increased paw withdrawal latency to radiant noxious heat and mechanical stimuli . It alsoIn rats, stereotactic unilateral RTX microinjection (20 or 200 ng in 4 µL) into the trigeminal ganglia blocked both the afferent (capsaicin-evoked eye-wiping response) and efferent (neurogenic inflammation detected by Evan’s blue extravasation) function of TRPV1-positive C-fibers . The antIn Rhesus monkeys, RTX was microinjected into the trigeminal ganglia , whereasIn pigs, periganglionic RTX (2000 ng) reduced TRPV1 mRNA by 66.3% compared to solvent control , with no50 for epidural RTX was determined as 265 ng [Severe cancer pain caused by bone metastasis usually affects more than one dermatome. Such generalized pain can be targeted by intrathecal RTX administration that reaches multiple ganglia via the cerebrospinal fluid . In ratss 265 ng . At thiss 265 ng . At a “ss 265 ng . In the hind paws, intrathecal RTX blocked carrageenan-induced thermal hyperalgesia. In the dorsal horn of the spinal cord, intrathecal RTX deleted most TRPV1/CGRP-positive nerve endings . FurtherImportantly, intrathecal RTX had no effect in normal mechanosensation (von Fey hair or pin prick) or motor coordination . A seconTrpv1 gene [In a murine model of cancer pain, intrathecal RTX produced lasting analgesia , similarpv1 gene . Of notepv1 gene . If the Lastly, intrathecal RTX ameliorated the signs of prostatodynia evoked by the injection of complete Freund’s adjuvant into the rat prostate . These observations imply a therapeutic potential for (1) intraganglionic RTX for orofacial neuropathic hyperalgesia, (2) local/site-specific RTX injections for arthritic pain and burn injury-related pain, and (3) intrathecal RTX administration for cancer pain. Large dogs are prone to developing osteosarcoma in their legs. These animals limp and exhibit behavioral signs of severe pain. In 20 dogs with intractable bone cancer pain, intrathecal RTX (1.2 µg/kg) was given under general anesthesia . The mosIntravenous capsaicin is known to elevate blood pressure by increasing peripheral vascular resistance . Smooth The RTX-induced hypothermic response is easier to explain. Hypothermia is a well-known effect of systemic capsaicin or RTX administration ,69. CapsThe day after intrathecal RTX treatment, dogs appeared to be normal on physical examination . The aniIn a prospective, randomized (RTX or standard-of-care), and blinded trial involving 72 companion dogs with bone cancer pain, RTX (1.2 µg/kg) was injected into the cisterna magna for forelimb tumors or the L5/6 lumbar interspace (lumbar puncture) for hind-limb cancers . “UnblinOf note, three of fourteen beagle dogs died after intracisternal RTX (3.6 µg/kg) treatment . This fiIn summary, intrathecal RTX is a well-tolerated and effective treatment of severe cancer pain in companion dogs, incentivizing the transition to human clinical trials ,176,177.An open-label, single-site, Phase I clinical trial with increasing intrathecal RTX doses (NCT 00804154) was carried out under a Cooperative Research and Development Agreement between the National Institute of Neurological Disorders and Stroke (NiNDS), Bethesda, MD and Sorrento Therapeutics . For thiThis small  study implies that intrathecal RTX may exert a clinically useful analgesic action in cancer patients, with manageable adverse effects. A few patients even became ambulatory after the RTX treatment. At present, this study is recruiting patients for testing the analgesic potential of the 44 µg RTX dose.The intrathecal route of RTX administration requires general anesthesia. Furthermore, it affects both blood pressure and heart rate. Epidural RTX seems to be devoid of these complications .The first-in-human epidural RTX study enrolled 17 participants and employed doses in the range of 0.4 µg to 25 µg given under mild sedation . RTX wasSorrento Therapeutics plans to perform a randomized, blinded, placebo, and standard-of-care controlled Phase II trial with epidural RTX  in 120 patients with advanced cancer (NCT 05067257) ,181.Osteoarthritis is the most common form of arthritis that predominantly affects the knees, hips, and hands. Osteoarthritis involves the whole joint, causing cartilage degradation, bone remodeling/osteophyte formation, and synovial inflammation ,183. SinThe Swiss biotech company Mestex AG has developed an injectable RTX solution (MTX-071) to treat osteoarthritic knee pain. In a Phase IB clinical trial, 40 patients (35 to 85 years old) with moderate-to-severe knee pain caused by advanced osteoarthritis received an RTX dose of 12.5 µg into the knee joint . Side efp = 0.0311). In the one-year follow-up, three patients maintained full response [In the numerical pain rating scale, 83% of the patients reported a significant, clinically meaningful 2.63 decrease in the WOMAC A1 score  acquired Mestex AG. Grünenthal is ready to start a Phase III clinical trial at multiple sites, involving 1800 patients . For thiImportantly, similar relief of osteoarthritic pain was reported by Sorrento Therapeutics  following intra-articular RTX injections .An interesting and controversial clinical use of topical RTX is in treating life-long premature ejaculation ,187,188.Clostrium difficile-associated pseudomembranous colitis [In rats, intra-gastric RTX blocks both basal and stimulated acid secretion . Moreove colitis . In coli colitis . In periodontitis-susceptible Fischer rats, RTX inhibits experimental periodontitis . A similChemoablation by RTX of cardiac afferents protects the rat heart from pressure overload-induced cardiac hypertrophy . IntrathIn dogs and ferrets, RTX exerts a marked antiemetic action ,201.Lastly, RTX was promoted to improve the prognosis of COVID patients .RTX is an ultrapotent capsaicin analog with a broad therapeutic window, allowing for the full desensitization of TRPV1-expressing sensory afferents by means of a single injection . RTX desDesensitization to RTX is by definition reversible . IntraveRTX is a highly lipophilic molecule. Keeping RTX bioavailable in aqueous solutions is challenging. The lack of commercially available intravesical RTX preparations hinders clinical use. Nonetheless, it was stated that the “future of bladder control is a pinch of pepper and gene therapy” . The chaRTX can also ablate sensory neurons, causing permanent analgesia ,176,177.Intra-articular RTX has been given “breakthrough therapy designation” by the US Food and Drug Administration (FDA) to treat moderate-to-severe knee pain in patients with osteoarthritis . SimilarAnimal experiments imply therapeutic utility for site-directed RTX administration in various disease states like periodontitis ,196. TheMost recently, a polymer-coated nanoparticle cream formulation of RTX, Resinizin  , has bee


Objective To investigate the effect of closure types of the anterior abdominal wall layers in cesarean section (CS) surgery on early postoperative findings.Methods The present study was designed as a prospective cross-sectional study and was conducted at a university hospital between October 2018 and February 2019. A total of 180 patients who underwent CS for various reasons were enrolled in the study. Each patient was randomly assigned to one of three groups: Both parietal peritoneum and rectus abdominis muscle left open (group 1), parietal peritoneum closure only (group 2), and closure of the parietal peritoneum and reapproximation of rectus muscle (group 3). All patients were compared in terms of postoperative pain scores (while lying down and during mobilization), analgesia requirement, and return of bowel motility.Results The postoperative pain scores were similar at the 2nd, 6th, 12th, and 18thhours while lying down. During mobilization, the postoperative pain scores at 6 and 12 hours were significantly higher in group 2 than in group 3. Diclofenac use was significantly higher in patients in group 1 than in those in group 2. Meperidine requirements were similar among the groups. There was no difference between the groups' first flatus and stool passage times.Conclusion In the group with only parietal peritoneum closure, the pain scores at the 6thand 12thhours were higher. Rectus abdominis muscle reapproximations were found not to increase the pain score. The closure of the anterior abdominal wall had no effect on the return of bowel motility. The attainment of safe delivery for both mother and baby via cesarean section (CS) is one of the important achievements of modern obstetrics. Cesarean section is one of the most frequently performed operations in the world, and its frequency is increasing.There are various studies comparing outcomes of closure and non-closure of the parietal and visceral peritoneum, and rectus muscle reapproximation and no approximation. In these studies, postoperative pain, need for analgesia, adhesion, infection, fever, endometritis, and duration of hospitalization were examined,In this study, we investigated the effect of closure types of the anterior abdominal wall layers on postoperative pain, need for analgesia, and postoperative return of bowel motility.The present study was designed as a prospective cross-sectional study between October 2018 and February 2019 in patients undergoing their CS at a university hospital. This study was conducted on patients who had standard CS surgical procedures in our clinic and who were eligible for the study. Anterior abdominal wall closure patterns vary from surgeon to surgeon in our clinic. This stage is implemented in three different ways. Group assignments were made by browsing the operation notes. Each patient was randomly assigned to one of these three groups:Group 1:Both the parietal peritoneum and rectus abdominis muscle were left open;Group 2:Parietal peritoneum closure only;Group 3:Closure of the parietal peritoneum and re-approximation of rectus muscle.The inclusion criteria were being at 37 or more weeks of gestation, not having systemic disease, having standard CS procedures under spinal anesthesia. Elective CS patients and patients in labor were included the study. The exclusion criteria included the following: patients with preterm births ; administration of anesthesia besides general anesthesia; fetal distress; maternal hypertensive disorders; maternal systemic diseases; preeclampsia; premature rupture of membranes; chorioamnionitis; pregestational and gestational diabetes; placental invasion anomalies; coagulation disorders; multiple pregnancies; renal, liver, and gastrointestinal disease; history of > 3 previous CS; presence of dense adhesions; and psychiatric disorders.Approval from the institutional local ethics committee was obtained, and each patient provided a signed informed consent for their participation in the study. All staff members (nurses and investigators) were blinded to the study groups, and all postoperative procedures were made while remaining blinded. The health care provider who questioned the patient about pain after the operation and medicated the patient did not know which procedure was applied.As a standard treatment in our clinic, we use intramuscular diclofenac for analgesia for the first 24 hours (1 g every 8 h) and orally 3 times per day thereafter. In the case of patients who describe pain  in spite of the treatment with diclofenac, we administer narcotics as an analgesic instead of diclofenac. All patients receive preoperative prophylactic intravenous antibiotics (cefazolin 2 g). Liquid food intake and mobilization of the patients are performed at the 6th postoperative hour. The nursing staff monitor and record maternal blood pressure, pulse activity, and urinary output hourly during the first 24 hours.nd, 6th, 12th, and 18thhours after surgery with the assistance of nursing staff. Pain scores were recorded at the 2ndhour while lying down, and at other hours, pain scores were recorded both while the patient was lying down and during mobilization. The time to return of bowel function was recorded from the end of the surgery to the times of the first passage of flatus and stool. No medical or mechanical intervention was performed for passing flatus and stool. The patients were discharged at 48 hours postoperatively. No intervention was used for patients who did not pass stool within 48 hours.In the present study, postoperative pain was measured using a VAS (0 = no pain and 100 = worst pain ever). All mothers completed the VAS score at the 2Cesarean section is performed in our clinic as described below. All CSs are performed by the senior assistant. Nearly all surgeries are performed under spinal anesthesia. A standard technique is used in all procedures. All women have a Pfannenstiel-type transverse incision. The subcutaneous tissue layer is dissected using the fingers, and then a small transverse incision is made, medially, with a scalpel and extended laterally using scissors in the fascial layer. The rectus muscles are separated bluntly. The peritoneum is opened with the forefinger. A bladder flap is formed, and a low transverse incision is made in the uterus. The uterine incision is closed using a single-layer continuous locked suture with a Vicryl 1.0 suture . The abdominal cavity is cleaned from amniotic fluid and blood. The closure of the parietal peritoneum and rectus muscle in our clinic varies according to the preference and experience of the surgeon. The parietal peritoneum is closed using a continuous Vicryl 2.0 suture (Ethicon Johnson & Johnson). The rectus muscles ere reapproximated using three loose vertical midline interrupted sutures with Vicryl 2.0 sutures (Ethicon Johnson & Johnson). Sutures are placed about 1 cm from the edge of the incision and 1 cm apart, without excessive tension. Subcutaneous fat is closed when the tissue is thicker than 2 cm. Skin is reapproximated using a continuous subcuticular suture with 2.0 polypropylene (Ethicon Johnson & Johnson). All operative procedures are performed by the same surgeon. The day of CS is considered as day 0.p < 0.05 was considered significant.The G*Power 3.0.10 software  was used for calculating the sample size.A total of 180 women who underwent CS for various reasons, including planned repeated cesarean delivery with up to maximum three previous CSs, were enrolled in the study. All patients were similar in groups with respect to age, weight, and body mass index (BMI).Sixty women were allocated to each group. The most frequent indications for CS were as follows: elective repeat CS, malpresentation, and macrosomia. The demographic and physical conditions of the subgroups are summarized inndpostoperative hour, the VAS was evaluated only while lying down, whereas at the other times, it was evaluated while lying down and during mobilization. The postoperative pain scores were similar at the 2nd, 6th, 12th, and 18thhours while lying down. During mobilization, the postoperative pain scores were different between the groups at the 6thand 12thhours, and the pain scores at the 6thand 12thhours were significantly higher in group 2 than in group 3.The comparison of the groups in terms of the VAS of the subgroups is summarized inThe comparison of the groups in terms of analgesia requirements is summarized inThe frequency of cesarean section is steadily increasing all over the world, as it is in Turkey.When searching the literature, many studies comparing different stages of CS from skin incision to uterine closurend, 6th, 12th, and 18thhours while the patients were lying down. During mobilization, postoperative pain scores were different between the groups at 6 and 12 hours. Pain scores at 6 and 12 hours were found to be significantly higher in the parietal peritoneum closure group than in the group undergoing both closure of the parietal peritoneum and reapproximation of the rectus muscle. The approximation of the rectus muscle did not increase postoperative pain and analgesia requirement.There has been a long-standing hypothesis that there is a relationship between the approximation of the rectus abdominis muscle and pain,Postoperative intestinal dysfunction is a physiologic response to abdominal surgery and is more common in open surgery, such as CS.This prospective cross-sectional study ensured standardization of factors that could affect postoperative pain. All women participating in our study received the same intraoperative anesthesia, followed the same postoperative pain management protocol, and underwent similar surgical techniques so as to reduce the number of potentially confounding variables. Accordingly, we excluded patients with conditions that might influence pain and bowel motility.The limitations of this study include the follow-up of only postoperative short-term results; the long-term results of aspects such as uterine involution, adhesions, and diastasis recti were not studied. Also, the lack of questioning the patients' previous pain conditions, having no data about the duration of surgery, blood loss, and episodes of nausea and vomiting were other limitations. In addition, mobilization times that could potentially affect gastrointestinal motility could not be controlled. The strength of this study is that it is the first to investigate the effect of closure of the anterior abdominal wall on the postoperative return of bowel motility.In the group with only parietal peritoneum closure, the pain scores at the 6th and 12th hours were higher. Rectus abdominis muscle reapproximations were found to not increase the pain score. The closure of the anterior abdominal wall had no effect on the return of bowel motility. Whether or not the anterior abdominal wall is closed has no effect on bowel motility and analgesia requirement. The studies that consider analyzing directly intraabdominal pressures, intestinal motility time, mobilization time of the patient and measuring pain scores more objectively can give more consistent results.


In addition to pain, a significant problem of old age is dementia and depression, which can hinder the diagnosis and treatment of pain. The aim of this study was to analyse the prevalence of pain in patients treated in a geriatric outpatient clinic and the treatment used. (2) Methods: The analysis was based on the records of 937 patients who visited the Geriatric Outpatient Clinic in Dobre Miasto between 2015 and 2020. Based on records containing data dating back to their first visit to the hospital, patients’ experiences of pain, the presence of depressive symptoms and dementia, and the pharmacological treatment used for pain  were analysed. (3) Results: Pain complaints were reported by 311 patients (33.2% of the study group), 76% of the complaints were from females. The mean age of the patients was 78 years (SD = 8.45). At least one analgesic drug was taken by 107 patients (34.4%). The most commonly used analgesics were opioids , especially tramadol. Of the potential coanalgesics, the largest number of patients used an antidepressant. (4) Conclusions: Despite the widespread prevalence of pain among the elderly, only about one-third of them were taking pain medication, mainly in the form of weak opioids. Patients with symptoms of dementia were found to report pain less frequently. One of the medical challenges we face in the 21st century in developed countries is the increasing number of patients over 60 years of age . MultimoBasically, quality of life decreases with age, so elderly age is correlated with less social and leisure activities, household activity engagement, and a higher risk of disability. Quality of life in the elderly population further decreases with the presence of pain symptoms ,16,17. SThe correct diagnosis of pain is also a challenge in elderly patients due to the prevalence of cognitive impairment in this group, and with it the inability to correctly describe pain and its intensity, location, or nature. Communication problems among people with dementia, as well as failure to recognise non-specific manifestations of pain, lead to the neglect of treatment in people with cognitive impairment. Often the ‘disease mask’ of pain in patients with dementia may be the severity or fluctuating course of behavioural disorders . Among oChronic pain is also often a cause of disability in older people. The PolSenior 2 found that chronic pain was more often reported by people who were incapacitated in activities of daily living, had limited mobility, and used mobility aids. A patient’s disability in older age may also be one of the obstacles to diagnosing the cause of pain due to difficulties in accessing tests or specialist consultations .Difficulties also exist in the management of pain in older people. This is due to the presence of physiological changes associated with ageing, chronic diseases, and concomitant polypharmacotherapy, which can make the response to the analgesic treatment used difficult to predict, often resulting in over-caution in the use of effective analgesics, e.g., opioids ,26,27. MThe aim of this study was to assess the prevalence of chronic pain complaints among patients who were referred to a geriatric outpatient clinic in relation to the cognitive functioning of patients and reported symptoms of mood disorders. The analgesic treatment used, which, so far, appears to have been inadequate in this group of patients, was also assessed.Our study was retrospective in nature, and the materials for analysis were collected from the records of 937 patients over 60 years of age who first visited the Geriatric Outpatient Clinic of the Complex of Health Care Institutions in Dobre Miasto (Warmińsko-Mazurskie Voivodeship) between 2015 and 2020.During their first visit, the reason for seeking medical attention was noted in the patients’ records. Of the possible reasons, patients whose main reason for seeing the geriatrician was pain were selected for further analysis, and data on the medications used, both prescription and non-prescription, were collected in the records. Additionally, patients who exhibited symptoms of depression and cognitive decline were screened for further analysis. The study was approved by an ethics committee headed by Tomasz Stompór MD, Ph.D.Information was collected on the intensity of depressive symptoms, as assessed by the Geriatric Depression Scale (GDS-4) and the Geriatric Depression Scale (GDS-15). Patients who scored 1 out of 4 on the GDS-4 or >5 points on the GDS-15 were classified as possibly depressed.Patients’ cognitive functioning was assessed using the following scales: MMSE , CDT , and AMTS . Patients with MMSE scores below 23, CDT ≤ 4 points, and AMTS ≤ 6 points were considered to have probable dementia.The analgesics and co-analgesics taken by patients were also analysed by being divided into drug groups ,31. For p < 0.05.Licensed TIBCO Statistica software  was used to statistically analyse the results. In this paper, all results are expressed as the mean (SD) and median (range). To evaluate the normality of distribution of the variables, the Shapiro–Wilk test was applied. As most of the investigated variables were not normally distributed, the nonparametric Mann–Whitney test was employed. The Shapiro–Wilk test was applied to evaluate the normal distribution of the demographic data. Spearman’s rank correlation analysis and a chi-square test were used to assess the relationships between parameters. The significance level was set to Of the 937 patients (708 women and 229 men) who visited the Geriatric Outpatient Clinic, pain was reported by 311 patients (33.2%), and for all of which, pain was the main reason for their visit.s = −0.08, p < 0.05).There were 237 women (76.2%) and 73 men (23.5%) in the group of patients who cited pain as the main reason for consulting the geriatrician. The mean age of the patients seeking medical attention for pain was 78 years (SD = 8.45). The relationship between age and pain experience among patients was examined, and it was found that younger patients complained of pain more frequently (rn = 937). At least one analgesic medication was taken by 107 of the 311 patients who cited experiencing pain as the main reason for their geriatric consultation (34.4%). It was found that patients seeking help for pain were more likely to take an analgesic than those reporting to a geriatrician for other reasons . Opioids were the most commonly used analgesics, with 63 patients (58.9%) using them for pain treatment; tramadol was the most commonly used opioid (54 patients). Strong opioids were used by only seven patients. Non-steroidal anti-inflammatory drugs (NSAIDs) were taken by 54 patients (50.5%), as shown in Pain medication was taken by 147 patients  were also taking drugs that potentially acted as coanalgesics, such as antiepileptic drugs, selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, quadricyclic antidepressants, and glucocorticosteroids . No correlation was obtained between patient age and medication groups.The relationship between patients’ age and reporting to the doctor for pain complaints was investigated, and it was found that younger patients were more likely to report pain complaints (rp < 0.05) . There were 35 patients with dementia (11.3%) who complained of pain. The relationship between the variable of citing pain as a reason for reporting and CDT, AMTS, MMSE test scores was examined, and it was found that patients with higher test scores were more likely to report pain than patients with dementia  ( < 0.05) . The relFor the 222 patients experiencing pain, the severity of depressive symptoms was assessed using the GDS-4 or GDS-15 test, with 149 of these patients (67.1%) receiving a score indicating the possibility of co-occurring depression. Depressive symptoms were not found to be more prevalent in patients with pain compared to patients without pain.In a retrospective analysis, it was found that, in about one-third of patients, the main reason for visiting the Geriatric Outpatient Clinic was pain. In the PolSenior 2 study, chronic pain was reported by 47.6% of patients in those aged 65 years old and older . In a stDespite this widespread prevalence of pain among the elderly, the analysis presented here found that only about one-third of patients reporting pain take analgesics. This may be due to a number of reasons, including doctors’ fear of potentially harmful side effects after taking the drugs, such as kidney damage or gastrointestinal bleeding, dependence on opioid drugs, fear of worsening patients’ cognitive functioning, an increased number of falls, and/or patients’ own fears of potentially harmful side effects or feeling unwell while taking the drugs ,35,36. UHowever, even when treatment is implemented, it is not always effective. Based on the results of the present study, it was found that patients seeking medical attention for pain were more likely to take an analgesic than others; however, experiencing pain remained the most important reason for hospital visits among the elderly, and pain control was not satisfactory. Evaluating the efficacy of the drug groups used, especially in chronic pain, is difficult due to the multifactorial nature of the complaints, the complexity of the pain syndromes, and the difficulty in designing long-term studies . In shorComparing the results obtained with similar results obtained in Poland, in a study by Podczaska et al. conducted in 2016 among 392 nursing home residents aged between 75 and 102 years, without dividing them into those experiencing pain or not, pain medication was taken by 113 patients (28.8%), but only 84 patients claimed they were taking medication regularly. Of these, 53 patients (63%) were taking non-opioid analgesics, of which 51 patients were taking NSAIDs, two patients were taking paracetamol alone, nine patients were taking tramadol in monotherapy, two patients were taking tramadol with paracetamol, and one patient was taking morphine . CompareIn another study by this author from 2018 , out of 96 patients with pain, only 33 people (34%) were taking analgesics. Overall, 13 people (14%) were taking non-opioid analgesics, of which 3 were taking NSAIDs, and 10 were taking paracetamol. A total of seven people (7%) were taking tramadol with paracetamol, and two people (2%) were taking buprenorphine. A total of 11 people (11%) were taking a non-opioid drug in concert with an opioid. A total of 20 (60%) of the 33 people taking medication were using an opioid . CompareIn studies conducted in other European countries, significant differences in the consumption of analgesics have been observed. In a 2019 observational study focusing on a group of 94, 820 elderly patients in Northern Italy, non-steroidal anti-inflammatory drugs were taken by 36.62% of patients, while opioids were taken by 12.48% of patients . MeanwhiIn our study, we also analysed the potential coanalgesic medications taken by patients presenting with pain. During their first visit to the Geriatric Outpatient Clinic, 44.85% of patients taking an analgesic reported that they were also taking a coanalgesic. However, it is not known whether these were prescribed for pain or for another reason. In the PolSenior 2 study, an analgesic together with a coanalgesic was reportedly taken by 7.5% of patients. Interestingly, despite inadequate pain control, no patients were chronically treated with serotonin-norepinephrine reuptake inhibitors (SNRIs), which are recommended as the standard of care for neuropathic pain, while some patients were taking antiepileptic drugs. In epidemiological studies, the prevalence of depression in people over 60 years of age ranges from between 4.3% and 63% . MoreoveIn our analysis, dementia affected 151 people with pain (16.24%). Among the patients reporting pain, there were 35 people with dementia (11.3%), and it was also shown that those with more severe cognitive impairment reported pain less frequently than those with less severe dementia. Interestingly, a study by Neumann-Podczaska et al. found that patients with dementia were less likely to receive analgesic treatment compared to patients without dementia . A simils = −0.08, p < 0.05). In the PolSenior 2 study, pain complaints were reported most frequently by patients between 85 and 89 years of age. An explanation for these differences may be that, in the study presented in this paper, many patients exhibited cognitive problems, which may have hindered proper communication in reporting pain complaints [The relationship between age and pain perception among patients was examined, and it was found that pain was the most frequently reported reason among younger patients (rmplaints .Diagnosing pain in elderly patients remains a challenge not only due to the multi-morbidity of the elderly but also the difficulty of contact with the patient. Adequate pain treatment should be provided so that older people can maintain the highest possible quality of daily functioning. Bearing in mind that quality of life drops with every decade and even quicker with the coexistence of pain, it is crucial to provide patients with proper pain treatment.


What is the additional value of the comprehensive complication index (CCI) and ClassIntra system (classification for intraoperative adverse events (ioAEs)) in adverse event (AE) reporting in (deep) endometriosis (DE) surgery compared to only using the Clavien–Dindo (CD) system?The CCI and ClassIntra are useful additional tools alongside the CD system for a complete and uniform overview of the total AE burden in patients with extensive surgery (such as DE), and with this uniform data registration, it is possible to provide greater insight into the quality of care.Uniform comparison of AEs reported in the literature is hampered by scattered registration. In endometriosis surgery, the usage of the CD complication system and the CCI is internationally recommended; however, the CCI is not routinely adapted in endometriosis care and research. Furthermore, a recommendation for ioAEs registration in endometriosis surgery is lacking, although this is vital information in surgical quality assessments.A prospective mono-center study was conducted with 870 surgical DE cases from a non-university DE expertise center between February 2019 and December 2021.Endometriosis cases were collected with the EQUSUM system, a publicly available web-based application for registration of surgical procedures for endometriosis. Postoperative adverse events (poAEs) were classified with the CD complication system and CCI. Differences in reporting and classifying AEs between the CCI and the CD were assessed. ioAEs were assessed with the ClassIntra. The primary outcome measure was to assess the additional value toward the CD classification with the introduction of the CCI and ClassIntra. In addition, we report a benchmark for the CCI in DE surgery.A total of 870 DE procedures were registered, of which 145 procedures with one or more poAEs, resulting in a poAE rate of 16.7% (145/870), of which in 36 cases (4.1%), the poAE was classified as severe (≥Grade 3b). The median CCI (interquartile range) of patients with poAEs was 20.9 (20.9–31.7) and 33.7 (33.7–39.7) in the group of patients with severe poAEs. In 20 patients (13.8%), the CCI was higher than the CD because of multiple poAEs. There were 11 ioAEs reported  in all procedures, mostly minor and directly repaired serosa injuries.This study was conducted at a single center; thus, trends in AE rates and type of AEs could differ from other centers. Furthermore, no conclusion could be drawn on ioAEs in relation to the postoperative course because the power of this database is not robust enough for that purpose.From our data, we would advise to use the Clavien–Dindo classification system together with the CCI and ClassIntra for a complete overview of AE registration. The CCI appeared to provide a more complete overview of the total burden of poAEs compared to only reporting the most severe poAEs (as with CD). If the use of the CD, CCI, and ClassIntra is widely adapted, uniform data comparison will be possible at (inter)national level, providing better insight into the quality of care. Our data could be used as a first benchmark for other DE centers to optimize information provision in the shared decision-making process.No funding was received for this study. The authors have no conflicts of interest to declare.N/A. WHAT DOES THIS MEAN FOR PATIENTS?Quality assessment and follow-up are important in any surgical procedure. This study, which focused on endometriosis, investigated whether using the comprehensive complication index (CCI)  and ClassIntra (reports intraoperative complications) classification systems, in addition to Clavien–Dindo (CD) , would give a better view of the total burden of complications (adverse events) that patients may experience during their medical treatments, compared to using CD alone. We found that using the CD system together with the CCI and the ClassIntra provides a complete overview of the adverse events that patients may experience during their medical treatments. This means that doctors and medical professionals can accurately identify, record, and categorize any complications that arise, ensuring that patients receive the best possible care. By using this system, doctors can identify any issues quickly, which can lead to faster treatment and better outcomes for patients. Overall, the use of the CD classification system, together with the CCI and ClassIntra, benefits patients by providing a clear and complete understanding of their medical treatments and any complications that may arise. Comparisons at a national and international level also then become possible, benefiting patients worldwide.Quality assessment and follow-up are important in surgery. Quality assessment and registration of healthcare, including patient-reported outcome measures, could improve healthcare outcomes  system is currently the most used, validated, and accepted standard to classify perioperative AEs . Furthermore, because a weighting system is lacking, it is not possible to compare the impact of multiple minor AEs against one major AE. Additionally, for the ease of handling in AE registration , it is common to capture only the AE with the highest grade  . Intraoperative adverse events (ioAEs) that are solved during surgery cannot be classified by CD. ioAEs are also important to register and classify, as these events are associated with adverse outcomes in the postoperative course , which wFor the classification of poAEs in endometriosis surgery, the Clavien–Dindo and use of the CCI have been recommended since 2016  endometriosis surgery, facilitating comparisons at both national and international levels.This study used prospectively collected data on surgical cases with endometriosis or DE from a Dutch DE expertise center . Data inclusion took place from February 2019 through December 2021 by the EQUSUM application /2 where wC stands for weight of complication. CD Grade I = wC 300, Grade II = wC 1750, Grade IIIa = wC 2750, Grade IIIb = wC 4550, Grade IVa = wC 7200, and Grade IVb = wC 8550. CD Grade V always results in CCI® 100.AEs were documented until 42 days post-procedure according to the CD classification . The valioAEs were classified by the validated ClassIntra reporting system and defined as ‘any deviation from the ideal intraoperative course between skin incision and skin closure, and includes events related to surgery and anaesthesia’ , version 28.0 was used for analysis. Categorical variables were described as frequencies with percentages. For normally distributed or skewed data, data were presented as mean with SD or median with interquartile range (IQR), respectively. The Shapiro–Wilk test was used to determine the distribution of the data. For group comparisons with parametric data, an independent Student’s T-test was performed, while for non-parametric data, the Mann–Whitney test was performed. A two-tailed Ethical approval was given by the Medical Ethics Committee of the Leiden University Medical Centre for the use of the anonymous data in the EQUSUM database (LUMC) (G20.019).2 . The mean age of the women was 36.4 (SD 7.1) years, with a mean BMI of 24.9 (SD 4.5) kg/m2 . Pain waIn total, 11  ioAEs arose and were corrected directly during surgery . These iThis study was performed to advocate uniform registration in the field of AEs in endometriosis surgery, and especially in DE, making use of the CD and CCI as well as the ClassIntra systems. This is one of the largest and most detailed studies on this topic, which could act as a first step toward benchmarking AEs in DE surgery.A high percentage of poAEs were registered, namely 16.7%. Easy discrimination between severe AEs is possible with the CCI (CCI ≥ 33.7). We found only 4.1% of patients with severe AEs, which are interesting to discuss in, for example, morbidity and mortality meetings. Furthermore, with the CCI, it is possible to calculate the total burden of AEs, instead of only reporting the most severe AE (as with CD). If we only used the most severe AE (which is common with the CD), 23 poAEs would not have been used in the total AE calculation . This is a significant part of the total AE burden.As far as we know, there are no endometriosis studies where the CCI is used for the registration of poAEs. In our study, the median CCI was 20.9 (IQR 20.9–31.7) in the total cohort, and 33.7 (IQR 33.7–39.7) in the patients experiencing severe AEs. This is comparable with non-endometriosis literature: The CCI also makes it easy to compare poAE rates over the years, something that is more challenging with an ordinal scale (CD). It was easy to show that the median CCI over the years did not significantly change. In contrast, with the CD alone, it was only possible to detect frequencies instead of comparing the total AE burden.In our cohort, 11 ioAEs occurred, which were treated intraoperatively. These 11 ioAEs would not have been classified if only the CD system was used. For a complete overview in the quality assessment of surgical audits, these 11 ioAEs are also a significant part of the AEs that need to be classified. This is especially important when new surgical techniques are introduced. The ClassIntra could be a good tool in the debriefing period at the end of a surgical procedure. In this way, the registration is directly performed and the whole team could instantly reflect on any ioAE that occurred. Furthermore, the team can discuss strategies aimed at preventing any poAE that may occur as a result of the ioAE, such as increased monitoring for peritonitis in cases with intraoperative intestinal injuries. To highlight the literature gap on ioAE reporting, a critical appraisal of 46 randomized controlled surgical trials on AEs concluded that only 41% of the studies reported ioAEs, with 13% providing a definition and only 9% using a classification for these ioAEs , which is a strength of our study. With this study, we hope to encourage other centers to also adopt these classification systems. Not only will this provide a more accurate and complete overview of AEs but also it will enable data comparison on multiple levels. A limitation of this study is the fact that it was performed in a single center, which limits the number of cases. However, even with a smaller number of cases, this study is able to illustrate how the addition of the CCI and ClassIntra systems would lead to a more comprehensive image of the complications that may arise in surgical endometriosis cases.In AE reporting, we recommend to use the Clavien–Dindo for poAEs, which aligns with international recommendations ;it uses a linear scale instead of an ordinal scale, which is beneficial for research/statistical purposes;there is easy discrimination of severe poAEs when using the cutoff point of CCI ≥33.7;we can compare patients with one poAE to patients with multiple poAEs; andit creates easy and interpretable data for benchmarking.We acknowledge that implementing our recommendations will necessitate additional registration time for doctors, who already devote a significant amount of time to computer-based tasks rather than direct patient care. However, if the IT is properly designed and the registration is performed accurately, it will eventually save time and energy. For example, with the EQUSUM application, it is easy to perform statistics, while the syntax for all the calculations is already there. The CCI will automatically be generated after running the syntax and all other calculations for AE percentages. Proper use of the current and future technologies does have the potential to decrease workload instead of increasing it, even with more registration. Effort should be put into making it as easy as possible for doctors, and ‘reward’ them with easy and automatically generated monthly and annual reports for the morbidity and mortality meetings.This study showcases the advantages of integrating two supplementary systems—the CCI and Classintra system—in the reporting of AEs that occur during endometriosis surgery. Although the Clavien–Dindo classification is a commonly used tool for evaluating postoperative complications, it has limitations in capturing the entirety of AEs, particularly those that arise during surgery. In order to address this limitation, the CCI and Classintra system were developed, providing standardized methods for categorizing and reporting multiple and ioAEs. By utilizing these systems, a more inclusive and thorough summary of all AEs can be generated, leading to a more comprehensive understanding of patient outcomes and the potential to lessen the overall burden of AEs associated with surgery.


Accordingly, patients in the ESP group required less morphine from 60 minutes to 12 hours after surgery, but they required increased non-opioid postoperative analgesia management at 4, 8, and 12 hours after surgery (p from 0.002 to <0.001) compared to the control group. In this study, we found ESP blocks to be a safe, technically simple, and effective treatment for postoperative pain management after elective oncologic abdominal procedures.Patients undergoing abdominal oncologic surgical procedures require particular surgical and anesthesiologic considerations. Traditional pain management, such as opiate treatment, continuous epidural analgesia, and non-opioid drugs, may have serious side effects in this patient population. We evaluated erector spinae plane (ESP) blocks for postoperative pain management following elective oncologic abdominal surgeries. In this single-center, prospective, and randomized study, we recruited 100 patients who underwent elective oncological abdominal surgery between December 2020 and January 2022 at Soroka University Medical Center in Beer Sheva, Israel. We compared postoperative pain levels in patients who were treated with a preincisional ESP block in addition to traditional pain management with intravenous opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and acetaminophen, compared to patients who were only given traditional pain management (control). Patients who were treated with a preincisional ESP block demonstrated significantly lower Visual Analog Scale scores at 60 minutes and 4, 8, and 12 hours following the surgery, compared to the control group ( Regional anesthesia complements and enhances multimodal analgesia for different types of abdominal surgery, with its role increasingly recognized , and mayHowever, traditional pain management in these patients, including opiate treatment, continuous epidural analgesia, and non-opioid drugs, may have serious side effects . OpiatesThe erector spinae plane (ESP) block is one of the newest techniques to be explored . It was In this prospective study, we performed ESP blocks for postoperative pain management for different types of elective oncologic abdominal surgeries. We compared two groups of patients to evaluate the effects of incorporating a preincisional ESP block alongside traditional pain management using intravenous opioids and nonsteroidal anti-inflammatory drugs (NSAIDs). Specifically, we examined the postoperative pain level and incidence of postoperative nausea and vomiting in these groups. One group received both the ESP block and traditional pain management, while the other (control) group received only traditional pain management.NCT05512897.This was a single-center, prospective, and randomized study. This study was approved by the Human Research and Ethics Committee at Soroka Medical Center (RN-0355-19-SOR). In this study, we recruited all patients who underwent elective open oncological abdominal surgery between December 2020 and January 2022 at Soroka University Medical Center, a 1000-bed tertiary-care, level I trauma center and university teaching hospital located in Beer Sheva, Israel. Formal informed consent for the study was obtained on the day before surgery. One hundred patients were included. The study was registered with ClinicalTrials.gov identifier: Informed consent was obtained from participants during the preoperative assessment. For eligible patients who refused to participate in the present study, the standard pain treatment was prescribed.We recruited all patients older than 18 years of age, with an ASA physical status class between I and II, who were undergoing open oncologic abdominal operations .Unconscious or mentally incompetent patients or those who refused to participate in the study were excluded.We collected data from electronic records during the patients' hospital and intensive care unit admission, including demographics of gender, age, underlying medical conditions, and admission diagnosis; Visual Analog Scale (VAS) levels; postoperative opioid and NSAIDs requirements; postoperative incidences of nausea and vomiting and other complications; type of surgery; and length of hospital stay.For this study, we performed the bilateral ESP block technique, which involves the patient sitting with support from a member of the care team or lying in a lateral decubitus position. Before each case, we did a preliminary scan with a linear ultrasound transducer (6–13 MHz) placed vertically on the patient's upper back, 2.5–3 cm lateral to midline. For sensory blockade of the appropriate dermatome, blocks were administered at levels T6–T10 for upper abdominal surgery and levels T8–L2 for lower abdominal incisions. The midline (spinous processes) and transverse processes were then marked bilaterally. Using a sterile technique, an 80 mm 22 G needle was inserted in cranial-caudal direction in-plane to the ultrasound transducer towards the transverse process. The needle crosses three layers of muscle, from posterior to anterior: trapezius, rhomboid, and erector spinae, until it touches the transverse process . Local ahttps://randomization.com.The recruitment of patients was performed at the preoperative clinic visit as part of the first anesthesiology evaluation and preanesthesia examination. Goals of the study and the experimental protocol were explained to the patients along with the possible complications and adverse effects. Informed consent to be enrolled in the study and consent to be randomized into two groups were obtained at the same meeting. Randomization of the participants into two groups was performed using We divided all patients into two groups before the beginning of the surgery . The conControl and ESP patients received standard pain control that included treatment with opioids, NSAIDs, and acetaminophen (paracetamol) . PostopeOur primary outcomes were VAS pain scores at 1, 4, 8, 12, 24, and 48 hours postoperative and opioid analgesic requirements during the first 48 hours of the postoperative period. Secondary outcomes included nausea and vomiting incidence, non-opioid analgesic requirements, and variations in hemodynamic parameters.t-test to analyze age. For the other quantitative variables that were not normally distributed, we used the Mann–Whitney U test and chi-squared test.Assuming an annual admission rate of 500 patients during 1 year of the study enrollment, we planned to achieve a sample size of at least 100 patients. Sample size was calculated for the difference in postoperative cytokine levels. A total of 100 patients were needed for a significance level of 0.05 and a power of 90%. Each study group consisted of 50 patients for a total of 100 patients. To analyze our quantitative variables, we used the Kolmogorov–Smirnov test to determine their distribution. After conducting the test, we found that only age was distributed normally. As a result, we used the p values < 0.05 are considered as statistically significant. For statistical analysis, SPSS software version 26 (IBM) was applied.The quantitative variables are presented by mean and standard deviation and/or median and interquartile range (IQR). The qualitative variables are presented by their distribution by percentage. For multivariate analysis, quantile regression was applied because dependent variables are not normally distributed. We performed quantile regression for the following quantiles: 0.1, 0.25, 0.5, 0.75, and 0.9. After enrollment and the processes of randomization and exclusion, a total of 100 patients who underwent upper and low gastrointestinal tract oncologic open abdominal surgery in our institution were included in the study . The patDemographic data  are summarized in p from 0.03 to <0.001, see p < 0.001, see p < 0.001 and 0.01, p from 0.002 to <0.001, p=0.002 and < 0.001, respectively, Accordingly, patients in the ESP group required fewer postoperative opioids (morphine) at 60 minutes to 12 hours after surgery and required additional non-opioid analgesia management at 4, 8, and 12 hours after surgery  for postoperative VAS score (at 60 minutes after surgery). Male gender was found to have a positive regression coefficient only for Q10  for postoperative VAS score (at 60 minutes after surgery). In addition, admission diagnosis was found to have a positive regression coefficient for Q50, Q75, and Q90  for postoperative VAS score (at 60 minutes). None of the other parameters were found to have predictive value on postoperative VAS score (at 60 minutes).We also analyzed predicting factors of adequate postoperative analgesia level (defined as VAS score less than 5) on the VAS score at 60 minutes after admission to the PACU by multivariate statistical analysis. Since VAS scores within the study population were non-normally distributed outcomes, the data were analyzed using quantile regression at quantiles 0.1, 0.25, 0.5, 0.75, and 0.9. Based on the results of quantile regression analysis, patients in the ESP group were considered a significantly relevant predictor with negative regression coefficients for Q10, Q25, Q50, Q75, and Q90 , In this study, we performed ultrasound-guided bilateral preincision ESP blocks alongside the standard pain protocol for postoperative analgesia. Our results showed that study group patients who received the ESP block along with the standard protocol had better postoperative pain control, as indicated by lower VAS scores, less opioid usage, and lower incidence rates of postoperative nausea and vomiting compared to the control group, who only received the standard protocol. We did not observe any postoperative complications related to the ESP block, indicating that it is a safe and straightforward option for postoperative pain management. These findings are consistent with previously published literature.Our analysis showed a reduction in postoperative VAS scores and opioid usage in both univariate and multivariate analyses. We chose VAS at 60 minutes and postoperative morphine use for our multivariate analysis, as they are the most effective indicators of analgesia. We observed that VAS at 60 minutes was not normally distributed among the study population. Therefore, we performed quantile regression analysis to identify independent risk factors that influence pain across different quantiles. The analysis revealed that the ESP group was a significant predictor of negative regression coefficients for Q10, Q25, Q50, Q75, and Q90 quantiles of postoperative VAS score (at 60 minutes), indicating its effectiveness in reducing pain across different levels. Additionally, male sex was found to be a positive regression coefficient only for Q10 of postoperative VAS score.During the last decade, interest in using different types of nerve blocks for postoperative pain control after abdominal surgery has emerged , 19, 20.Only several years ago, the ESP block was introduced as an alternative successful method for chronic and acute pain management in a variety of surgical and non-surgical patient populations . This tySince these early studies, the ESP block has been used effectively in a variety of procedures including the Nuss procedure, thoracotomies, percutaneous nephrolithotomies, ventral hernia repairs, and lumbar fusion . Even moBilateral ESP blocks have also been indicated for primary use in many upper and lower abdominal laparoscopic procedures, including laparoscopic sleeve gastrectomy, laparoscopic cholecystectomy, and inguinal hernia, in addition to endoscopic retrograde cholangiopancreatography, laparoscopic varicocelectomy, laparoscopic hepatic cystectomy, laparoscopic nephrectomy, laparoscopic hysterectomy, laparoscopic Nissen fundoplication, laparoscopic hysterectomy, laparoscopic ovarian cystectomy, and laparoscopic hemicolectomy . For exaWith regard to gender, male sex had a positive regression coefficient for postoperative VAS score in this study, but with inconsistent findings of a correlation between gender and postoperative pain outcomes. In contrast to our findings, Cepeda and Carr  and TaenIn our study, the admission diagnosis of low GI pathologies was found to have a positive regression coefficient for Q50, Q75, and Q90 for postoperative (at 60 minutes) VAS score. This finding is correlated well with previously published data that determine that abdominal surgery, especially for cancer, is a well-known positive predictor for postoperative analgesic consumption .In the present study, the main analgesic effect of the ESP block lasted until 12 hours after surgery. At 24 hours after surgery, we demonstrated significantly increased opioid requirements in ESP group patients and found subsequently increased VAS scores in the same study group. The reasonable explanation of this result might be related to the phenomenon of “rebound pain” . ReboundMultimodal approaches could mitigate the presentation of rebound pain, such as preemptive analgesia (before the effects of the block stop), intra-articular or intravenous anti-inflammatory medications, and use of adjuvants in nerve block solutions . We suggThis study has several limitations, such as relying on data from only one medical center and its relatively small sample size. In addition, our data did not contain complete records of complications that may have taken place during or after intra-hospital transport of the patients following their discharge from the PACU. Also, there was some difference in the prevalence of comorbidities between the study groups that could have had an impact upon the outcomes observed. We anticipate that future larger scale prospective studies on this topic will correct these limitations.Here, we describe an ESP block for postoperative pain control after abdominal oncologic procedures. We found ESP blocks to be safe, technically simple, and effective for postoperative pain management after elective oncologic abdominal procedures. However, in light of relatively high VAS score rates and opioid requirements observed at 24 hours after surgery, likely as a result of a rebound pain mechanism after nerve block, we advise an appropriate postoperative pain protocol and patient education to improve clinical outcome. This study contributes to the ongoing research into the implementation of ESP blocks as a viable pain treatment protocol, suggesting its efficacy but advising it as part of a comprehensive postoperative pain protocol.