To analyse various corneal nerve parameters using confocal microscopy along with systemic and orthoptic parameters in patients presenting with ocular surface pain using a random forest artificial intelligence (AI) model.Observational, cross-sectional.Two hundred forty eyes of 120 patients with primary symptom of ocular surface pain or discomfort and control group of 60 eyes of 31 patients with no symptoms of ocular pain were analysed. A detailed ocular examination included visual acuity, refraction, slit-lamp and fundus. All eyes underwent laser scanning confocal microscopy  and their nerve parameters were evaluated. The presence or absence of orthoptic issues and connective tissue disorders were included in the AI. The eyes were grouped as those (Group 1) with symptom grade higher than signs, (Group 2) with similar grades of symptoms and signs, (Group3) without symptoms but with signs, (Group 4) without symptoms and signs. The area under curve (AUC), accuracy, recall, precision and F1-score were evaluated.Over all, the AI achieved an AUC of 0.736, accuracy of 86%, F1-score of 85.9%, precision of 85.6% and recall of 86.3%. The accuracy was the highest for Group 2 and least for Group 3 eyes. The top 6 parameters used for classification by the AI were microneuromas, immature and mature dendritic cells, presence of orthoptic issues and nerve fractal dimension parameter.This study demonstrated that various corneal nerve parameters, presence or absence of systemic and orthoptic issues coupled with AI can be a useful technique to understand and correlate the various clinical and imaging parameters of ocular surface pain. Ocular pain and chronic discomfort are generally reported by patients presenting to the ophthalmology outpatient clinic nowadays . SuccessDry eye is one of the most common causes for ocular surface pain presenting to the clinic. However, there can be many other causes as well. These symptoms are described in TFOS DEWS II and can affect patients’ quality of life . A signiin vivo confocal microscopy (IVCM) has identified several changes in the sub-basal corneal nerves and linked it to changes in various corneal inflammatory mediators in patients with ocular surface pain [The successful and comprehensive management of such pain and discomfort requires a thorough understanding of the role played by each of these contributing factors. Research on ace pain . While tace pain , 10. TheThis was a retrospective analysis of patients presenting with ocular surface pain who visited the outpatient department of the Narayana Nethralaya eye hospital. The study was approved by the Narayana Nethralaya ethics committee (Reference number: C/2021/07/02). The study followed the tenets of the Declaration of Helsinki. A total of 300 eyes of 151 patients were evaluated. These included 240 eyes of 120 patients with the primary symptoms of ocular surface pain or discomfort and a control group of 60 eyes of 31 patients with no symptoms of ocular surface pain or discomfort and no clinically visible ocular signs on examination. Detailed clinical and systemic history were acquired. Ocular examination included visual acuity, refraction, slit-lamp and fundus imaging. In addition, non-strabismic binocular vision abnormalities and accommodation related problems which can lead to ocular surface pain or discomfort were also evaluated [The discomfort was assessed using the ocular surface disease index (OSDI) , 12. An A detailed orthoptic evaluation was done to assess abnormalities of the eye muscles that prevent normal binocular vision and may lead to ocular surface pain . It inclAs corneal nerve related alterations are known to be associated with ocular surface pain, IVCM was done for all patients. They underwent laser scanning IVCM using the Rostock Corneal Module/Heidelberg Retina Tomograph II . The section mode was used to scan the central cornea and two-dimensional digital images with an image size of 400×400 μm, a lateral digital resolution of 1 μm/pixel and a depth resolution of 2 μm/pixel were obtained. The various corneal nerve parameters studied using confocal microscopy were related to the sub-basal nerve plexus of the cornea and three high-quality sub-basal nerve plexus images were selected from each eye based on a previously defined standardised image selection protocol , 17. The2) of frame assessed [The dendritic cell (DC) density was quantified from the same image frames used to quantify the sub-basal nerve plexus. The number of highly reflective cells with (mature) and without (immature) dendriform structures  were couassessed , 19. Theassessed , 24. Theassessed , 26. Theassessed .As dry eye is one of the most common causes of ocular surface pain , systemi+/-D++) included 76 eyes in whom the discomfort/symptom grade was higher than the grade/severity of signs. Group 2 (S+D+) included 131 eyes with similar grades of discomfort/symptoms and signs. Group 3 (S+D-) included 33 eyes without discomfort / symptoms (OSDI score: <12) but presented with signs (TBUT: <10 secs and/or Schirmer’s test 1: <10 mm / 5 mins). Group 4 (S-D-) included 60 eyes without discomfort / symptoms (OSDI score: <12) and no clinical signs . Hence, Group 4 subjects were presumed as normal or control eyes.All the eyes were classified into groups based on their ocular surface pain or discomfort symptoms (D) and signs (S). Group 1  classifier. RF classifier is fundamentally an ensemble of many decision trees put together, to classify or predict a particular target with the given set of features/parameters . Each trThe performance of the AI model was evaluated using area under the curve (AUC), classification accuracy (CA), precision (Pr), recall (Rec) and F1-score. The Orange version 3.25.0 data mining package was used for analyses and MedCalc v19  was used for further statistical analyses.A total of 300 eyes of 151 patients were analysed, which included 79 males and 72 females with an average age of 29 ± 4.6 years. Thirteen parameters  were ana+D+ achieved the highest accuracy while S+D- achieved the lowest accuracy. The performance was also evaluated. Over all, the AI achieved an area under the curve of 0.736, accuracy of 86%, F1-score of 85.9%, precision of 85.6% and recall of 86.3%.Hence, microneuromas were an important feature to classify subjects with discomfort greater than signs. The RF model had high accuracy while classifying patients with ocular surface pain. +/-D++) in whom the discomfort/symptoms grade were greater than the grade/severity of signs.Our understanding of ocular surface pain is constantly evolving and possible pathophysiological mechanisms related to ocular surface inflammation, altered nociception or neuropathy were explored , 31. To The parameter with next highest importance in the RF model  was DC dIVCM provided objective parameters to assess corneal sub basal nerve plexus including the CNFL, CNBD, CNBW and CNFrD. The CNFrD is a measure of tissue structural complexity. It has applications in resonance imaging scans where it has been used to identify distinct tissue geometric patterns in different neurodegenerative diseases , 37. CNFMany patients present with non-specific eye pain symptoms and this does pose a major challenge. Interestingly, orthoptic related problems were picked up among the top five parameters . StudiesCorneal nerve beading was also detected by the RF model though not as one of the top six parameters. Beading is neither a specific nor sensitive marker for corneal pain. Beading reflects increased metabolic activity and was seen in normal subjects as well . AnotherA limitation of the present study was that it was done entirely on Asian-Indian population. Another limitation was that the study did not include any measures of change in parameters but looked at a single time point. The purpose of this study was to provide a simple RF framework to combine various IVCM and demographic parameters, which can help us better manage patients presenting with non-specific complaints of ocular surface pain. This is the first study which demonstrates the importance of use of AI in stratification of various parameters in patients presenting with ocular surface pain. However, orthoptic related issues and systemic associations in patients presenting with ocular surface pain should also be considered. The assessment of ocular pain on the basis of questionnaires and correlating it to clinical metrics and confocal features such as corneal dendritic cell density and microneuroma-like structures can help clinicians better understand the condition and aid in customized treatment planning. Treatment which is targeted at improving the nociceptive balance could help improve patient symptoms and long-term comfort. We therefore have proposed an easy-to-use and understand, classification of patients with ocular surface pain using AI, which can help evaluate and stratify patients for customized management. For instance, patients suffering from ocular surface pain (discordant symptoms and signs) with increased corneal dendritic cell density, with or without presence of microneuroma-like structures can be managed with topical anti-inflammatory medications, and may help break the vicious cycle of chronic inflammation driven pain. However, in patients suffering from ocular surface pain (discordant symptoms and signs) with normal corneal dendritic cell density but with presence of microneuroma-like structures can be referred to neurology consult and possibly systemic pharmacotherapy as first line of management strategy. However, it is important that multicentric studies across different ethnicities and larger cohort should be conducted to validate our findings to provide a clinically actionable algorithm that uses these patient specific corneal features for stratifying patients with ocular surface pain.S1 File(XLSX)Click here for additional data file.


Reducing postoperative pain immediately after surgery is crucial because severe postoperative pain reduces quality of life and increases the likelihood that patients develop chronic pain. Even though postoperative pain has been widely studied and there are national guidelines for pain management, the postoperative course is differently from one patient to the next. Different postoperative courses could be explained by factors related to the treatment context and the patients. Preoperative emotional states and treatment expectations are significant predictors of postoperative pain. However, the interaction between emotional states and preoperative treatment expectations and their effect on postoperative pain have not yet been studied. The aim of our study was to identify the interaction between emotional states, treatment expectation and early postsurgical acute pain.In this prospective clinical trial, we enrolled patients who had received a TKR at a German hospital between October 2015 and March 2019. Patients rated their preoperative pain on a numeric rating scale (NRS) 0–10 (0 = no pain and 10 = worst pain imaginable), their emotional states preoperatively on the Pain and State of Health Inventory (PHI), their preoperative treatment expectations on the Stanford Expectation of Treatment Scale (SETS), and their postoperative level of pain on a NRS 0–10.F = 8.32, p < 0.001, with an excellent goodness-of-fit, R2 = 0.31. Furthermore, a mediator analysis revealed that the indirect effects and therefore relationship between the emotional states sad , anxious , and irritable  and postoperative pain is fully mediated by negative treatment expectations. Whereas the emotional states tired , dizzy/numb , weak . Emotional states predict negative treatment expectation The relationship between emotional states and postoperative pain is mediated by negative treatment expectations. Therefore, innovative treatment strategies to reduce postoperative pain should focus on eliminating negative treatment expectation through establishing a differentiated preoperative expectation management program that also focuses on emotional states. Postoperative pain is often still treated inadequately –4. Many The total knee replacement (TKR) is a surgical procedure that is associated with severe postoperative pain . SpecifiIn the long term, 20% of patients who received a TKR experience pain for 1 year after the surgery , 17. HowTo reduce early postoperative pain, potential predictors must be identified and treated. Significant predictors for postoperative pain are preoperative emotional states  and preoperative treatment expectations. Hence, not only postoperative pain processing mechanisms are relevant for the control of postoperative pain, but it can also be predicted and, potentially, influenced preoperatively. Higher pre-operative anxiety ratings lead to increased pain during the time in the ward and at home , 21, andTo our knowledge, this is the first time that the relationship and interaction between preoperative emotional states and treatment expectations relating to early postoperative pain in patients receiving a TKR has been analyzed. Therefore, the aim of this paper is to investigate the relationship between preoperative emotional states and treatment expectations related to early postoperative pain. Specifically, we aimed to investigate whether preoperative emotional states have a direct influence on early postoperative pain or whether postoperative pain is influenced by treatment expectations. We expected that treatment expectations play a mediating role between emotional states and postoperative pain.Patients were eligible if they were at least 18 years old and received a TKR due to knee osteoarthritis and excluded if they were cognitively impaired, had an insufficient command of the German language, suffered from mental disorders , consumed any mind-altering substances , or suffered from pain requiring special causative medical treatment . Patients were only included if they received a primary TKR. Patients who received a replacement for an existing protheses were excluded. All participation was voluntary, the patients were informed about the study and provided informed written consent.In this prospective clinical trial, we enrolled patients who received a total knee replacement (TKR) due to osteoarthritis at a German hospital between October 2015 and March 2019. All patients who met the inclusion criteria and had none of the exclusion criteria were invited to participate in the study. The relevant instruments are scales to measure emotional states, treatment expectations, and postoperative pain.Patients rated their emotional states with the Pain and State of Health Inventory . The insinter alia, include general treatment expectations  or specific expectations related to the treatment or a symptom . However, the majority of generally utilized expectation measures used in clinical studies, if expectations are included in the study design, are not validated single scales that depend on the research question. The only treatment expectation scales validated thus far in the perioperative setting is the Stanford Expectation Treatment Scale (SETS)  . The SETTo measure preoperative pain, patients were asked 1 day prior the surgery to rate their pain on a NRS 0–10 .To measure postoperative pain, patients were asked to rate their pain on an NRS 0–10. Patients rated their pain every 2 h on the first day after the surgery, from 6 am until midnight, in a pain diary. Subsequently, the mean pain rate for the day was calculated from the pain ratings.In this prospective clinical trial, we investigated the relationship between preoperative emotional states and treatment expectations and their effect on postoperative pain for patients receiving a TKR. All patients who received a TKR at the German hospital center, Schön Klinik Hamburg Eilbek, were screened on paper by a study physician. If the patients met the inclusion criteria on paper, they were screened in person by the study physician 1 day prior to the surgery. If the patients met the inclusion and none of the exclusion criteria, they were informed one day prior to their surgery and asked to participate. All patients participated voluntarily and provided written consent. To assess their emotional states and preoperative treatment expectations on the relevant scales, patients completed the PHI  and the p < 0.05 were considered statistically significant. In the path model, the independent variables were the individual emotional states, the dependent variable was postoperative pain, the mediators were treatment expectations of medical treatment, and the confounder was preoperative pain. To calculate the path model (model 4) of the SPSS Hayes’ macro, PROCESS . The tests with  PROCESS , which u PROCESS , in whicp < 0.05 to assess the required sample size for mediation effects. PROCESS is based on the bootstrapping method to analyze mediation effects. Hence, the percentile bootstrapping row in the table is relevant for our sample size calculations. Former research found a medium association between emotional states and treatment expectation (α-path) and a large relationship between treatment expectation and postoperative pain (β-path) (The sample size was estimated by using Table 3 of Fritz and Mackinnon . The tab(β-path) , 36. TheA total of 122 patients participated in the study . Of the A total of 119 patients completed all items related to emotional states. The internal consistency of emotional states in this sample was Cronbach’s α = 0.83. Preoperatively, the mean rating of being sad on an NRS 0–10  was 2.05 . The mean rating of being anxious was on an NRS 0–10  was 2.31 . The mean rating of being tired on an NRS 0–10  was 2.45  was 0.94 . The mean rating of being weak on an NRS 0–10  was 1.97 . The mean rating of being irritated on an NRS 0–10  was 1.61 .A total of 118 patients completed all items related to positive and negative treatment expectations. The mean negative treatment expectation was 4.77 (SD = 1.43), which implies that, on average, patients neither agreed nor disagreed or slightly disagree that they expected a negative treatment outcome. The internal consistency of this sample for negative treatment expectation was Cronbach’s α = 0.78. The mean rating for positive treatment expectation was 2.29 (SD = 0.85) which implies that, on average, patients agree slightly to moderately on expecting positive effects from their treatment.All patients rated their preoperative pain. The mean preoperative pain score on the NRS 0–10 1 day prior the surgery was 6.5 . The internal consistency for repeated measured level of pain of this sample was Cronbach’s α = 0.84.F = 8.32, p < 0.001, with excellent goodness-of-fit R2 = 0.31. The results reveal that preoperative pain does not confound the regression. Moreover, negative treatment expectation predicts worse postoperative pain F = 7.65, p = 0.007, with a weak goodness-of-fit R2 = 0.06. Being anxious (ß = −0.54), dizzy/numb (ß = −0.13), and irritated (ß = −0.13) are the strongest factors influencing negative treatment expectations, while being tired (ß = 0.05) and feeling weak (ß = −0.02) are the least influential predictors. A feeling of anxiety , being dizzy/numb , and irritated  had a statistical significantly influence on negative treatment expectations.The results show that emotional states predict negative treatment expectation F = 1.94, p = 0.08) with a mediate goodness-of-fit adjusted R2 = 0.10. Furthermore, positive treatment expectation does not predict postoperative pain F = 1.09, p = 0.30) with no goodness-of-fit adjusted R2 = 0.001.The results show that emotional states do not predict positive treatment expectation a = −0.20, p = 0.004), anxiety , tired , dizzy/numb , weak , and irritated  predicted the mediator significantly, which, in turn, predicted postoperative pain significantly , anxious , tired , numb/dizzy , weak , and irritated , while the indirect effects for emotional states were sad , anxious , tired , feeling numb/dizzy , weak , and irritated . This implies that the interaction between emotional states  and postoperative pain are fully mediated and the emotional states  are partially mediated by negative treatment expectation.After the mediator (negative treatment expectation) and the confounder (preoperative pain) were entered into the model, the emotional states sad (ntly see . We founIn the present study, we provide evidence that negative expectations are an important mediator for postoperative pain. Negative treatment expectations correlates with the emotional states of feeling sad, anxious, tired, numb/dizzy, weak, and irritated. This aligns with previous research that also found evidence that preoperative mental states influence postoperative pain . FurtherOur results align with the bio-psycho-social pain model that holds that pain experience is shaped by somatic, psychological, and social factors . In our Our findings suggest that emotional states predict treatment expectations and, therefore, play a critical role in the treatment outcome for postoperative pain. According to the literature concerning placebo mechanisms, positive treatment expectations are crucial to enhance surgical treatment outcomes , 45. HowInterestingly, we found that emotional states influence negative treatment expectations but not positive treatment expectations. One reason could be that the placebo and nocebo systems do not share the same network . Nocebo This is the first study to report on the interaction between emotional states, expectations and postoperative pain in a clinical sample of patients expected to experience early acute postoperative pain. Previous studies have investigated healthy participants rather than a clinical sample. However, pain pathways, experiences, and treatment expectations may differ between healthy and clinical participants. With this study, we detected that emotional states, such as being sad, anxious, feeling dizzy/numb, weak or irritated, individually or in combination, can influence negative treatment expectations, which, in turn, influenced postoperative pain experiences in a clinical sample. We further detected that the relationship between emotional states and postoperative pain is fully mediated by negative treatment expectations. Therefore, we detected the mediator between emotional states to postoperative pain in the underlying mechanisms of the placebo and nocebo effects. We further found that negative interaction between emotional states and postoperative pain is fully mediated by negative treatment expectations. In consequence, our results provide the foundation for future innovative treatment options that are required for optimal postoperative pain management.via a self-report. Second, only patients who received a TKR were included in the study, and TKRs are often associated with severe postoperative pain. In addition, patients have usually experienced pain for a long period prior to the TKR and have often been treated conservatively. Hence, the results cannot be generalized to other surgeries per se, but they are a good indicator for patients undergoing TKR surgery. Patients were included, when they received a TKR due to osteoarthritis. Osteoarthritis can be classified based on the Kellgren and Lawrence system of classification (Several limitations in this study warrant comment. First, the data used were based on self-reporting, and there might be altered response behavior. However, because pain is subjective and there are no objective measurement tools to assess it, postoperative pain can only be assessed fication . In thisAs already noted, this study provides a foundation for future research. Resulting from our findings, there are several aspects that should be investigated. First, modulators should be investigated to discover the underlying mechanisms and the interaction between emotional states and treatment expectations. In this context, the underlying biochemical and neural mechanisms should be examined to establish their effect on perioperative procedures. Second, further studies should investigate how emotional states can be positively influenced and whether this will decrease negative treatment expectations, which should, in turn, decrease postoperative pain. Therefore, it should be investigated how negative expectations can be mitigated or changed into positive expectations. In this regard, it is necessary to further investigate the different modulators of positive and negative treatment expectations. This could be a precursor for innovative pre- and postoperative treatment strategies that can be developed to enhance treatment outcomes and the associated placebo effect. Therefore, future interventions could focus on reducing negative treatment expectations by considering the influential mechanisms of impaired emotional states. By focusing on the influential factors of negative treatment expectations, postoperative pain can be reduced directly after the surgery. Hence, developing a preoperative differentiated and specialized expectation management program will be highly relevant. In the light of the current opioid crisis , 57, it This study investigated a sample of patients who received a TKR at a German hospital. The results reveal that the relationship between impaired emotional states and postoperative pain is fully mediated by negative treatment expectations. Therefore, novel and innovative treatment strategies to reduce postoperative pain should focus on negative treatment expectations through a differentiated and specialized preoperative expectation management program that should also aim to reduce the emotional states of being sad, anxious, numb/dizzy, tired, weak, and irritated. A specialized treatment expectation management program developed with consideration of our findings might mitigate and change negative expectations to influence postoperative pain positively.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.JS and RK contributed to conception, design of the study, and wrote the first draft of the manuscript. JS performed the statistical analysis. Both authors contributed to manuscript revision, read, and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Dear Editor:We have recently read an article published by Carvalho et al., in volume 52 of the present journal, in which they showed the effects of an exercise program on pain perception and quality of life in patients with tropical spastic paraparesis. The three study groups showed slightly improved pain perception even though one did not receive intervention and two groups showed reduced functional loss in the program,Depression is presented as a disorder of emotional and somatic scope, where up to 75% of patients feel pain. Chronic pain and quality of life are personal perceptions; hence, they can be influenced. Some factors previously identified are hope, acceptance of pain, and optimism, which have also been observed to affect functionality. However, it has been identified that there is bi-directionality in the interaction between depression and pain, with an increase in its perception in those who are depressed; this would be even more pronounced in patients with a prolonged early-onset disease, which is not rareTropical spastic paraparesis is a chronic disease in which pain is frequent, and it has been previously demonstrated that patients suffering from it generally have depressive and anxiety symptoms associated with chronic painIn conclusion, participation in the psychiatric field should be considered when studying chronic diseases that generate pain and alter the quality of life since they predispose the research to generate inaccurate data due to the alteration in perception.


All except one study reported on patients experiencing back pain on average for 19.6 ± 11.6 months. The VAS-pain score was presented in all studies without significance between the interventional and control group (p = 0.399 before and p = 0.277 after intervention). Only one research group found significantly higher improvement in PROMs for the application group, whereas the remaining showed similar results compared to the control group. Using application-based rehabilitation programs provides an easily accessible alternative or substitute to traditional physiotherapy for patients with back pain. Given that smartphones are so prevalent in activities in our daily lives, this will enhance and improve rehabilitation if patients are self-dedicated and compliant.Smartphones and their associated applications are used frequently by patients and clinicians alike. Despite the technology being widely accessible, their use to aid in rehabilitation is yet to be adopted. The SARS CoV-2 pandemic has presented an opportunity to expedite their integration given the difficulty patients currently have in accessing healthcare. The aim of this study was to perform a systematic literature review on the use of smartphone rehabilitation applications compared to standard physiotherapy for back pain. We conducted a search of Medline/Pubmed and google databases using the search terms [APP] AND [[Orthopaedic] OR [Neurosurgery]], following the PRISMA guidelines. All prospective studies investigating rehabilitation applications for back pain or following spine surgery were included. A total of nine studies met the inclusion criteria which investigated 7636 patients, of which 92.4% were allocated to the interventional group ( Rehabilitation is a common feature in patients in the post-operative phase after spinal surgery as well as patients with chronic back pain . TraditiSmartphone ownership worldwide surpassed 6 billion in July 2022 . In 2021Apps are increasingly used in healthcare, streamlining communication, recording patient outcome data and in some cases measuring outcome data. A survey of 146 patients in a neurosurgical waiting room found that 81% of patients (whom had not had previous surgery) expressed interest in using a postoperative communication and monitoring app . A 2015 There is evidence supporting telerehabilitation in general orthopaedics ; howeverA systematic review was performed on the 30 July 2022. The Pubmed/MEDLINE, Cochrane and Google Scholar databases were searched following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines . The seaApplying the PICO scheme, our objective included the comparison of control versus interventional group  in patients with low back pain . Hereby, we assumed that the app-based rehabilitation is at least as efficient as general physiotherapy .The quality of publications as well as the risk of bias was assessed . Data onp-values < 0.05.SPSS  and Microsoft Excel  were applied for statistical analyses. Data are presented as absolute numbers and percentages and significances are set to Using our search terms, a total of 1122 articles were found and screened for inclusion criteria. Overall, 91 articles were duplicates and a total of 105 articles were screened. One article needed to be exluded as it analyzed postoperative recovery without specifying the surgery , as we believed that this would return articles relating to unspecific back pain or nutritional apps. The quality of the individual studies was low (range of bias scores 1–3/5), and therefore a meta-analysis was not completed due to the heterogeneity of the data. However, these studies represent the most important examples in this field. The consistent factor within the studies was the visual analogue scale of pain. Additionally, the time to follow up ranged from only 4 weeks to 6 months. Furthermore, different patient reported outcome measures were used, including SF-36, Likert, the Oswestry Disability Index, current symptoms, PHQ-9, and the Korff score. Finally, it has to be mentioned that chronic back pain may resolve itself over time regardless of the rehabilitation activities performed. However, we would expect a significant difference between the two groups, as rehabilitation activities may hasten the rehabilitation.Application-based rehabilitation for back pain and following spine surgery is as good as standard physiotherapy. Although no significant differences can be found between the two cohorts, application-based rehabilitation’s integration into healthcare seems promising, especially in motivated patients who regularly engage in independent rehabilitation. Furthermore, in patients who are unable to visit physiotherapists, such as during pandemics or due to living in rural locations, this is an excellent approach which may further lower healthcare costs.


Aims: The authors evaluated the impact of the first coronavirus disease 2019 pandemic wave on French chronic pain structures (CPSs). Methods: An online survey assessed CPS resource allocation, workflow and perceived impact on patient care. Results: All CPS workflow was severely impacted by the reallocation of 42% of specialists. In-person appointments were cancelled by 72% of participants. Follow-up was maintained in 91% of participants (telemedicine). Skills in end-of-life decision-making/counseling were rarely solicited. The perceived impact of the crisis on the experience of patients was high (eight out of ten), with a significant increase in access-to-care delay. Conclusion: CPSs maintained patient follow-up. Special features of CPS specialists were rarely solicited by coronavirus disease 2019 teams experiencing a high workload. Recommendations on optimal CPS resource reallocations have to be standardized in crisis conditions. The ongoing coronavirus disease 2019 (COVID-19) pandemic declared by the WHO in March 2020 has profoundly affected the healthcare system. Strict country-specific measures have been taken all over the world to fight the crisis and to manage the surge of COVID-19 patients. In March 2020, the French government declared stage 3 of the Organisation de la Réponse du Système de Santé en Situation Sanitaire Exceptionnelle emergency preparedness plan to set up a specific organization for healthcare structures (‘Plan Blanc’) . This haThe reported prevalence of chronic pain in the French population is about 30% (approximately 22 million people), and 5% of the adult population present moderate to severe chronic pain with neuropathic characteristics . Such coad hoc care. Most French CPS centers did not use telemedicine before the pandemic crisis, but a telephone follow-up was used frequently.French chronic pain structures (CPSs), created in the early 2000s, offers multidisciplinary pain care. More than 240 French CPSs (including 38 pediatric structures) were functional before the COVID-19 outbreak, with an annual estimated volume of 400,000 patients . The typFollowing the implementation of ‘Plan Blanc', a large proportion of pain physicians and paramedical staff were allocated to different hospital units. National directives encouraged physical distancing and online medical consultations. As such, French CPSs have had to adapt their workflow, mostly by limiting in-person consultations, suspending or delaying pain management procedures and using telemedicine ,23,24.The objective of this study was to assess CPS human resource allocation, changes in CPS workflow organization and the perceived impact on patient care in the context of the COVID-19 pandemic sanitary crisis. The data obtained will allow us to discuss the workload of French pain specialists, initiate strategies to prevent psychological impact on caregivers and develop possible strategies to maintain patient access to care during similar crises and beyond.A semistructured mixed qualitative/quantitative survey research design was used with nonprobability sampling (convenience sample). For the purpose of the study, an anonymous French language online survey, including multiple choice and open questions, was developed by the board of the Société Française d'Etude et de Traitement de la Douleur (French Society of Pain Management). The Société Française d'Etude et de Traitement de la Douleur is the French chapter of the International Association for the Study of Pain and a member of the European Pain Federation. The computer-administered survey aimed to identify the new missions given to CPS human resources, assess the strategies to maintain follow-up of chronic pain patients, evaluate the overall impact on the functioning of CPSs, evaluate the perceived impact on patient care and assess whether there were any supply/medication issues or shortages during the period of ‘Plan Blanc' in the region of the participant's practice.Supplementary data.A Delphi method was used to design the survey. After identification of the participant's role and affiliation , the survey comprised of 57 items divided into three categories: current professional appointment  and functions, resources and solutions to maintain chronic pain patient follow-up and information on difficulties with the supply of medications and medical devices. Response options were binary (yes/no), categorical (preselected lists of items), 11-item scales , continuous (mostly for time-related questions) and open text. The translated questionnaire is provided in the The survey invitation was distributed by email to all members of the Société Française d'Etude et de Traitement de la Douleur working in French CPSs 1 month after the ‘Plan Blanc' termination beginning in June 2020 and made available up to August 2020, with three reminders. Participants were not limited to physicians; all members of CPSs were welcome to participate. Survey participation was voluntary, and no compensation was offered. A secure web application was used for building, collecting and managing the survey data. This study has been declared to the Commission Nationale de L'informatique et des Libertés (French Data Protection Agency).Most data were analyzed descriptively and presented as frequency and percentage or as median and interquartile range (IQR) accordingly. Some participants did not answer all questions or provided answers that could not be analyzed. Percentages were calculated based on the number of responses to each question. Open questions were manually reviewed to identify keywords, and were ‘pile-sorted’ and reported as frequency and percentage whenever possible. Data comparison was made using the Wilcoxon matched-pairs signed rank test or chi-square test. A p < 0.05 was considered statistically significant.In total, 224 responses were collected. Most participants were physicians , followed by nurses , psychologists , secretaries  and others . Most participants were from the mainland.Of the 224 respondents, 93 (42%) were reallocated to different medical services and were not able to maintain their primary activity at the CPS. Among all respondents, 143 (64%) were volunteers to be reallocated. Half (72 of 143) were indeed reallocated, and 28% (23 of 81) of the participants who were not volunteers were nevertheless reallocated, responding to institutional and sanitary needs. More than a third of participants were assigned to COVID-19 patient care units, including medicine and intensive care units (ICUs) .Almost half  of the physicians participated in on-call or at-hospital 24-h shift care. 76 (58%) of the 130 participants who could stay at their initial position also worked in a COVID or non-COVID ICU, operating room, nursing home, palliative care, non-COVID medical or surgical unit, sanitary reserve, emergency medical services or on-call or 24-h shift care. A heterogeneous proportion of respondents participated in psychological support offers (listening groups). There were 29 (13%) different specialists in listening groups for patients and families - including psychologists , physicians , and nurses . 49 (22%) specialists were offering psychological support for clinicians. The following CPS specialists were involved – psychologists ; physicians ; nurses . Reallocated respondents often combined different activities. 89 respondents detailed their functions in newly created structures. Physicians (n = 59) mainly joined chronic pain telemedicine consultations, COVID crisis cells (management and ethics), COVID units or consultations, ICU or emergency room night shifts, non-COVID units or on-call chronic pain and palliative care. Pain nurses (n = 17) mainly performed biological samplings for COVID patients. Psychologists (n = 6) were mainly involved in the creation of a family/patient psychological hotline as well as psychological or medical support for clinicians. A total of 28% (55 of 197) of respondents maintained in-person appointments, mostly for urgent reasons, including patients with severe pain, acute-on-chronic pain, acute neuropathic or facial pain , cancer or palliative care  or interventional pain treatment procedures , and for new patients . One respondent maintained in-person appointments for clinicians/colleagues. 11 (20%) participants did not specify their criteria for in-person appointments.Telemedicine solutions, including telephone calls and video consultations, were used by 91% (180 of 197) of respondents. Telephone calls were used by 92% (n = 165) of telemedicine users, and 49% (n = 89) used video consultation through online software. Video calls were used in more than half  of cases involving existing patients but also for new patients , patients who specifically asked for them  and patients with specific criteria . These criteria included unsatisfactory pain management/re-evaluation of treatment , anxiety or emotional troubles , transcutaneous electrical nerve stimulation (TENS) follow-up , cancer or chemotherapy , acute pain or reactivation of symptoms  and risk of severe COVID . 15 (23%) participants did not specify their criteria.Among respondents who were not familiar with telemedicine consultations before the COVID-19 crisis, 57% (85 of 150) recognized telephone consultations as useful and 40% (n = 60) considered them a precious tool. Video-assisted consultations were ranked as useful by 49% (42 of 85) of respondents and as a precious tool by 42% (n = 36). Overall, participants positively rated both methods, with a median score of 7 (IQR: 5–8) for both telephone and videoconferences on a scale of 0 (no interest) to 10 (major interest).A quarter (49 of 197) of participants maintained hospital day care for the following reasons: capsaicin patch application ; intrathecal pump management ; ketamine infusion ; patients with complex pain, cancer or neuropathy ; patients with intravenous morphine pump ; and patients without any risk factors who needed treatment . In one CPS, hospital day care was maintained for all patients. 12 (25%) participants did not specify their reasons for maintaining hospital day care.At the time of the survey, the respondents' CPS teams were restored completely in 62% (116 of 188) of cases and partially in 35% (66 of 188) and not restored at all in 3% (six of 188). Partial return to the fully equipped CPS team was because of absence of psychologists (95%), physicians (92%), nurses (86%), secretaries and others (71%). Almost half  of the participants indicated that the pandemic will deeply change the way they perform their daily work. A large majority will continue to use teleconsultation when possible, in particular for at-risk patients or patients living far from the pain structure . Moreover, a majority of participants indicated that following the crisis the organization of consultation will be adapted, with an impact on the welcoming of patients and an increase in barrier measures and time between patients as a result of disinfection of the room and equipment . A few participants indicated that they had accumulated a significant backlog that would be difficult to catch up with  and that they will update the way they deal with new patients by making them fill in an auto-evaluation form before the first appointment , develop therapeutic education for patients  and have a decreased amount of time to dedicate to pain structures . Other answers included the use of computer-based files for patients instead of paper documents; increased use of hypnosis; more listening skills for caretakers in response to the high anxiety level of patients following the crisis; more reactivity, anticipation and synergy; and a change in hospitalization mode. 18 (21%) participants did not specify their treatment adaptation.According to the opinions of respondents (n = 197), disruption in the established workflow of CPSs due to the SARS-CoV-2 outbreak will have a strong impact on patients, with a median score of 8 (IQR: 7–9) on a scale of 0 (no impact) to 10 (major impact). This is related to the estimated delay in appointments before and since the crisis, which was reported to be increased from a median of 3 (IQR: 1–5) to 3.5 (IQR: 1–6) months (p < 0.001).The altered supply was noticed for medications  and medical devices/materials . Participants mostly listed midazolam , propofol , ketamine , opioids  and dronabinol . Provision issues for materials and medical devices were associated with lack of protective equipment   and TENS units . Five (11%) respondents did not specify any provision problems.A third  of respondents reported that they had to change the treatment of their patients during the crisis. The majority of treatment adaptations  were associated with a decrease in or complete withdrawal of NSAID treatment. Other adaptations were associated with procedures usually administered in hospital day care  . Respondents reported an increase in anxiolytic/antidepressant prescriptions  and replacement of midazolam with other sedatives in palliative care . Other changes included the use of pharmacological treatment to replace nonpharmacological techniques unavailable during the crisis , opioid rotation , treatment adaptations linked to antiemetic supply issues  and treatment for migraine crisis . 13 (27%) participants did not specify any treatment adaptation.During the COVID-19 sanitary crisis, 42% of human resources (mostly physicians and nurses) across France were detached from CPSs following the ‘Plan Blanc' deployment. A total of 47% of reallocated respondents were involved in the psychological support of caregivers, patients and families or palliative care. Such reallocation led to a more than two-thirds reduction in in-person appointments, although an effort was made to maintain physical consultations for urgent chronic pain care, cancer and palliative patients and for interventional procedures. Only a quarter of day care hospitalizations were maintained, favoring patients with the need for interventional pain treatment. As a response to this situation, telemedicine solutions were developed, with telephone calls being the most widely used method (92%). Half of respondents used videoconferences – in one-third of cases for new patients. Telemedicine solutions were ranked as important tools, with more than 40% of respondents rating them as precious. Caregivers perceived the impact of the crisis on the experience of patients to be high (eight out of ten), with an expected significant increase in access-to-care delays. One-third of responding physicians have modified patient treatment, mostly due to temporary NSAID withdrawal. A shortage in supply was reported by a quarter of respondents, mostly with regard to midazolam, anesthesia-related drugs, protective equipment and TENS units.This clearly demonstrates that French CPSs were strongly affected by the COVID-19 crisis. Despite this serious impact, many efforts were made to maintain follow-up and new patient management. This included the preservation of in-person consultations and day care hospitalizations as well as communication with patients via the widespread use of telemedicine. No shortage of critically important medications  was reported. After the termination of ‘Plan Blanc,' all CPSs regained their staff quickly.A few reports have begun to be published in the literature and are in line with what the authors observed in French CPSs. This includes Europe, where headache management and chronic pain centers reported huge limitations in in-person consultations, cancelled or postponed treatments and increased use of telemedicine, making access to medical treatment and patient education more difficult . The samFirst, pain physicians and nurses were mostly reallocated to COVID units, with a concomitant increase in workload and night shifts. Of the 46% who were not volunteered for reallocation, almost one-third (28%) had to join different structures, including COVID units. Such mandatory reallocation, which is associated with stress, lack of equipment and high workload, may be a source of exhaustion  and burnSecond, many efforts were made to maintain follow-up and new patient management. This included the preservation of in-person consultations and day care hospitalizations as well as communication with patients via the successful use of telemedicine. There was no difference in rankings for telephone calls or video consultations for chronic pain patients, but half of the respondents reported using video consultations. However, this might be limited by material aspects, as patients need appropriate equipment to have access to video consultations.Telehealth technology is promising for pain care, and interest has already been demonstrated, not only for patient follow-up but also for communication-based and behavioral interventions . SwitzerSeveral participants acknowledged the importance of telemedicine, indicating a willingness to use teleconsultations in the future. This could be more convenient for some patients and may provide an effective and simple follow-up tool. Again, in the case of a sanitary crisis, a predefined telehealth strategy for maintaining follow-up as well as triage procedures to determine the necessity of an in-person appointment would be necessary.Le Figaro , was taken seriously by many physicians [Third, a lot of ‘fake news' circulated on social networks and in the media during the beginning of the pandemic . For insysicians . AlthougFinally, chronic pain specialists have specific knowledge related to managing care-associated pain  and guiding discussions regarding limiting or withdrawing care in end-of-life situations. According to the authors' survey, only 12% of respondents were involved in the palliative care process during the sanitary crisis. Reported international initiatives may include the use of pain physicians and nurses as palliative care specialists, not only for cancer and end-of-life patients but also in severe COVID-19 patients with ineffective critical life support  or in whThe main limitation of this study is the response rate, which was difficult to evaluate because of the database structure of professional emails. However, analyzed responses came from clinicians, who were motivated to share their experience during the pandemic wave. The authors' survey reflects the staff perception of the crisis and its organizational impact but not the perception and view of the patient. Increased access-to-care delays were noted. Although statistically significant, this difference should be interpreted with caution, as it corresponds only to an estimation done by the participants and collected immediately after the end of ‘Plan Blanc'.Recently, strategies to minimize the impact of the crisis on CPS management have been created. These include criteria for postponing interventional procedures, reducing in-person consultations (except for urgent procedures), encouraging the use of telemedicine for pre- and post-procedure evaluations, encouraging multidisciplinary therapy for the psychosocial aspects of chronic pain and avoiding new implantable devices in the context of a sanitary crisis .During the March–April 2020 COVID-19 crisis, all French CPSs were severely impacted, with a 42% reduction in human resources. Despite a two-thirds reduction in in-person appointments, the follow-up of chronic pain patients was maintained, and access to physical appointments was reserved for urgent reasons such as severe pain as well as cancer and palliative care patients. Few cases reported a disruption of pain treatment due to altered provision of drugs. Chronic pain specialists' specific knowledge of palliative/end-of-life care, neurocognitive interventions, alternative medicine and acute pain management was underutilized, and in almost 30% of specialists, who were reallocated against their wishes, burnout may be expected.National recommendations and an action plan are necessary for efficient management of CPS centers and the use of specific knowledge of CPS human resources in a sanitary crisis. This should take into account the possible decrease in human resources and detail recommendations on the use of teleconsultations, triage procedures and criteria to maintain in-person consultations and interventional treatments as well as treatment replacement strategies for all chronic pain patients.The first coronavirus disease 2019 wave severely impacted all specialized care structures, including chronic pain structures.In France, this has led to >40% reduction in human resources and two-thirds reduction in in-person appointments for patients.Pain specialists perceive the impact of such disruption on patient care as major.Of reallocated pain specialists, 30% had their occupation changed against their wishes, which is a source of potential burnout.The crisis promoted telemedicine consultations.Pain specialists' specific knowledge of palliative care, end-of-life decisions and counseling was underutilized.Recommendations and an action plan are necessary for more efficient management of chronic pain structure human resources.


Knee osteoarthritis (KOA) can cause chronic pain and seriously affect the quality of patient lives. The continued emergence of high-quality RCTS requires us to update the quality of evidence. This study aims to evaluate the efficacy of acupuncture for KOA patients and calculate the required information size (RIS) to determine whether further clinical studies are required.  We searched PubMed, Embase, WOS, CBM, CNKI, VIP, WHO ICTRP, ChiCTR, and Grey literature to collect randomized controlled trials (RCTs) of acupuncture for KOA from inception to December 2021. A meta-analysis was performed according to the Cochrane systematic review method by using Review Manager 5.4 and TSA 0.9.5.10 beta, and GRADE was used to evaluate the quality of the evidence. Trial sequential analysis was used to control random errors and calculate the required information size. n = 2387; SMD = −0.12, 95% CI ; I2 = 0%] and improved patients function activities , but true acupuncture showed no significant effect in relieve patient's stiffness . We pooled the studies which found no significant difference in improving the quality life of mental  and patients physical health (SF-36 or SF-12)  compared with sham acupuncture. The pain and function TSA graphs indicated that cumulative Z-curves intersected with the traditional level of statistical favoring acupuncture, and more RCTs will required in the future studies.  Eleven RCTs with 2484 patients were included in our meta-analysis, meeting the inclusion criteria for the meta-analysis. The meta-analysis indicated that acupuncture had beneficial effect on knee osteoarthritis in reducing pain [ Acupuncture has beneficial effect on pain relief and improves function activities, and this treatment can be recommended as a beneficial alternative therapy in patients with KOA, particularly for chronic patients and those currently undergoing long-term pain and help them increasing quality of life. But it should be further verified through more RCTs in function. Available studies suggested that acupuncture was superior to sham acupuncture in reduce pain and function as verified by TSA. Knee osteoarthritis (KOA) is a chronically degenerative joint disease which manifests as pain, swelling, stiffness, and dysfunction . The incAcupuncture, as a treatment with fewer side effects which has been practiced for over 2500 years in China, is widely used to manage chronic pain. At the 1997 National Institutes of Health Consensus Conference on acupuncture , 7. AlthTrial sequential analysis (TSA) can help to provide more appropriate interpretation of meta-analysis results; it can reduce early false-positive results due to inaccurate meta-analysis and repeated significance tests . The effCRD42021226983).This meta-analysis was reported according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement and recommendations  n = 2387; SMD = −0.15, 95% CI ; I2 = 73%].p = 0.05) before we added the study of Hanns  WOMAC Stiffness. The meta-analysis of WOMAC stiffness change scores in the 5 RCTs indicated that acupuncture was not significant effect compared with sham acupuncture  in relieving stiffness of the KOA ( the KOA .(3)Health Mental Survey. The meta-analysis of health mental survey changes scores in the 5 RCTs indicated that acupuncture have showed no statistically significant differences in health mental survey  (2 = 78%] .(4)Health Physical Survey. The meta-analysis of health physical survey changes scores in the 8 RCTs indicated that acupuncture have showed no statistically significant effect in improve health physical compared with sham acupuncture  (I2 = 0%] .(1)Duration of Illness. The meta-analyses of the 3 trials have a duration of illness less than 8 years (mean)  and 3 trials with patients have the duration of the disease more than 8 years (mean) . Studies have shown that acupuncture is superior over sham acupuncture compared with sham acupuncture for disease less than 8 years (mean) (s (mean) ..(2)BMI. Patient with BMI<25 acupuncture has a no effect compared with sham acupuncture . Patient with BMI 25~29.9 indicates that true acupuncture was more effective than sham on pain scores changes ; however, it showed no difference in pain changes compared with sham acupuncture at the BMI>29.9 .(3)Program Length. The study showed that patients treated with acupuncture less than six weeks (including six weeks)  have no difference compared with sham acupuncture; however, it showed beneficial effect on pain changes compared with sham acupuncture at 6~13 weeks  and program length at 26 weeks . Due to differences in statistical methods and combined with medicine, we use descriptive investigation for Jorge study .Previously, some meta-analyses have also mentioned the superiority of acupuncture treatments over no-acupuncture, but they have not confirmed whether the sample size was already enough, and our study have some advantages in this regard. We have similar findings to the above studies. When acupuncture was compared to sham acupuncture in reducing pain, the effect was different (SMD = −0.12). The TSA graph of this result, in which the Z-curve have been intersected the trial sequential monitoring boundaries, may confirm significant efficacy of acupuncture. The mechanism of acupuncture in alleviating pain and promoting functional recovery in KOA patients involved (1) inhibiting the overexpression of inflammatory factors such as IL-1 pathway –39; (3)  pathway , 41 (4)  pathway . Sham ac pathway . For exa pathway , 42. Ama pathway  indicate pathway .But in rThe TSA graphs proved that both cumulative Z-curves crossed the traditional level of statistical in terms of pain and function scores, and the efficacy of acupuncture was prominent, but the samples were not sufficient Figures ..n = 1745; SMD = 1.01, 95% CI ; I2 = 0%] and mental health . We think it is because acupuncture pays attention to the adjustment of spirit and the recognition, expectation, attention, preference, and doctor-patient communication of patients. And those are all important factors to improve the therapeutic physical health.According research we found that acupuncture shown no effect in physical health  on reducing pain for the duration of diseases for<8 years (mean). How to choose the best treatment time for improving the treatment are also important for improving the treatment. The length of treatment sessions difference can also affect the treatment. The study found that taking acupuncture for 6~13 weeks  had beneficial effect compared with sham acupuncture, but when the treatment sessions were less than 6 weeks  or on 26 weeks , there were no statistical difference between true acupuncture and sham acupuncture. In CHEN . So, we think it is very important to determine the reasonable course of disease treatment to improve the curative effect of acupuncture.The results of one study  use desc In CHEN . Therefo In CHEN . There wn = 1206, SMD = −0.18, 95% CI ; I2 = 45%], but when patients with BMI>29.9 (mean) obese patients, it showed no difference in pain changes compared with sham acupuncture. For women with symptomatic knee osteoarthritis, a loss of 5 kg of body mass was associated with a 50% reduction in the risk of progression. In obese patients, heavy knee loading accelerated the wear and tear of the knee cartilage, triggering the disease [The study indicates that physical function of overweight patients with knee OA improves even after a moderate weight reduction regimen . AccordiIn our study, we consider acupuncture as an effective treatment in relieving pain and improving function for people who are troubled by KOA, especially those refusing conventional drug therapy because of unbearable side effects , 52.We found that significant effects were demonstrated with respect to pain intensity, function when compared with sham, or placebo acupuncture. This finding could be used to guide doctors. Additionally, in the standardization of the outcome measures and the duration of acupuncture sessions, patient status such as weight and duration of illness used in trials should be focused in future studies.


Although laparoscopic total extraperitoneal (TEP) inguinal hernia repair has the advantages of less bleeding, less trauma, less pain, and fast recovery, there are several issues that need to be addressed. This study aims to evaluate the effectiveness of preperitoneal closed‑suction drainage on reducing postoperative complications in TEP inguinal hernia repair.A retrospective analysis of 122 patients who underwent TEP inguinal hernia repair between June 2018 and June 2021 was performed. The patients were divided into the drainage group and the non-drainage group according to whether the drainage tube was placed or not. Clinical data, surgical procedures and outcome of these patients were collected and analyzed to assess the effectiveness of drainage.p = 0.03). The rate of complications such as scrotal edema, seroma and urinary retention in the drainage group was significantly lower than that in the non-drainage group (p < 0.05). Multivariate regression analysis showed that drainage was beneficial to reduce postoperative complications . In addition, it was worth noting that in subgroup analysis, patients with hernia sac volume > 10 cm3 might receive more clinical benefits by placing drainage tube.A total of 122 patients undergoing TEP surgery were screened, of which 22 were excluded. Most of the patients were male with right indirect inguinal hernia. There was no difference in the mean length of hospital stay between the two groups. Postoperative pain was alleviated by preperitoneal closed‑suction drainage 24 h after operation (In TEP inguinal hernia repair, placing drainage tube is a simple and feasible traditional surgical treatment, which can promote postoperative recovery without increasing the risk of infection, especially in patients with large hernia sac volume.The online version contains supplementary material available at 10.1186/s12893-022-01900-9. Inguinal hernia is a common surgical condition, affecting approximately 220 million people worldwide . More thNumerous previous studies have reported the complications such as hematoma or seroma, scrotal edema, groin pain and urinary retention after TEP inguinal hernia repair , 6–10. UIn addition, many efforts have been made by surgeons to reduce postoperative complications, but there are still some disputes in these methods –15. In 1A retrospective study was performed from June 2018 to June 2021 in the General Surgery Department of Shanghai Ninth People’s Hospital. A total of 122 patients undergoing TEP inguinal hernia repair with complete reduction of hernia sac were included in this study. All relevant data were collected by the surgeon from the medical record system. All patients were followed up for 3 months after operation. The participants were categorized based on a review of their surgical history and divided into two groups according to whether a drainage tube was placed after an operation.Inclusion criteria: Patients were age older than 18 years, with a unilateral inguinal hernia, no additional surgical procedures at the time of the inguinal hernia repair, no surgical procedures in preceding 30 days; no other analgesic medication was administered during the postoperative period.Exclusion criteria: Patients were excluded if they had bilateral or recurrent inguinal hernia, irreducible hernia, incarcerated hernia, or severe co-morbidities.TEP inguinal hernia repair was performed in a standard surgical procedure as previously described . A prostAll patients underwent preoperative abdominal computerized tomography . According to previous studies, hernia sac volume (HSV) can be approximately regarded as an ellipsoidal structure . In ordeAll demographic and clinical data were collected from our hospital’s medical records, including surgical data , postoperative drainage fluid and postoperative complications .The gravimetric method is a simple, accurate, and clinically practical measurement, which is used to evaluate the blood loss in TEP surgery . AccordiThe visual analog scale (VAS) for pain was used to evaluate the perception of pain, on a scale of 0 to 10 with 0 indicating “no pain” and 10 meaning “worst pain”. VAS was performed in both groups at 6 h and 24 h after the operation. Pain score is: 0 = no pain, 1–3 = mild pain, 4–6 = moderate pain, and 7–10 = severe pain.SPSS 22.0 software  was used for statistical analyses. Quantitative variables were presented as mean ± Standard deviation (SD). Student’s t-test and nonparametric test were used for statistical analysis. Categorical variables including absolute and relative frequencies were tested by Pearson’s Chi-squared or Fisher’s exact. Univariate and multivariate analysis was performed using binary logistic regression. The multivariable regression models were constructed by stepwise addition of covariates shown via simple regression to be significantly associated with the outcome. The level of significance was set to α = 0.05 with 95% confidence interval (CI).A total of 122 patients undergoing TEP inguinal hernia repair with complete reduction of hernia sac were screen in this study. Twenty-two patients with other types of hernia repair surgery, incomplete medical records or severe co-morbidities were excluded, as shown in the consort diagram below (Fig. The TEP inguinal hernia repair was performed as described above. The hernia sac volume in the drainage group tended to be larger than that in the non-drainage group. However, we did not observe the differences of mean operative time or blood loss between the two groups. As shown in Table The VAS scores were collected at 6 h and 24 h after operation in both groups. At 6 h postoperatively, most of the patients reported moderate pain. The percentages of mild and severe pain in the drainage group were 15% and 12.5%, respectively, while those in the non-drainage group were 11.7% and 8.3%, respectively (Fig. The postoperative complications of the two groups are shown in Table In order to further assess the effectiveness of preperitoneal closed‑suction drainage, a regrouping analysis was performed based on the 24-h VAS pain score and complications. There was no difference in the proportion of patients with mild pain between the two groups. However, the proportion of patients with moderate pain in the non-drainage group was higher than that in the drainage group (Fig. 3 and > 10 cm3. As shown in Fig. 3. It was worth noting that patients with hernia sac volume > 10 cm3 received more clinical benefits by placing drainage, which could significantly relieve postoperative pain and reduce complications.Considering that hernia sac volume may also be related to complications, a subgroup analysis was used to investigate the relationship between hernia sac volume and clinical benefits of placing drainage. Based on the mean volume of hernia sac, patients were divided into two subgroups: hernia sac volume ≤ 10 cm3 might receive more clinical benefits by placing drainage tubes, which significantly reduced pain and complications. To our knowledge, this is the first study to investigate the effectiveness s of preperitoneal closed‑suction drainage and hernia sac volume on complications in TEP inguinal hernia repair.Compared with traditional laparotomy, laparoscopic inguinal hernia repair has the advantages of less trauma, faster recovery and lower recurrence rate . TEP ingThe formation of seroma is defined as the exudation and accumulation of fluid in the operation area. In previous studies, numerous interventions have been attempted to minimize its formation, including closure of the dead space with braided sutures, administration of fibrin glue, compression and cauterization of the operation area –27. HoweAlthough most seroma do not cause serious harm to patients, it is still a risk factor leading to other postoperative complications. In our study, the closed-suction drainage tube in the preperitoneal space was used to drain the accumulated fluid, which significantly relieved postoperative pain and reduced scrotal edema, urinary retention and other complications. Our findings are consistent with previous studies , 30, 31.In TEP inguinal hernia repair, the risk of infection is the main concern for surgeons, who are reluctant to place a drainage tube in the preperitoneal space. In the guideline on TEP treatment of inguinal hernia by the International Endohernia Society in 2015, there was level 3 evidence that the use of drainage tubes increased the risk of infection or recurrence. Only grade C evidence showed that a closed-suction drainage tube could reduce the risk of seroma formation without increasing the risk of infection . Our stu3 obtained more benefits by placing drainage, which remarkably relieved pain and reduced complications. Based on these findings, our study confirmed that there are greater clinical benefits from placing a drainage tube in patients with larger hernia sac volume. Indeed, the volume of hernia sac may be an important criterion for drainage in patients undergoing TEP inguinal hernia repair.Postoperative complications, such as seroma, inguinal pain and urinary retention, are associated with surgical trauma and exudation in the operation area. Although large incisions and surgical trauma are avoided by laparoscopic surgery, more severe swellings and exudation in the inguinal region may be caused by larger hernia sac , 33. AccIn TEP inguinal hernia repair, preperitoneal closed‑suction drainage is associated with the reduction of postoperative pain and complications. The placement of drainage tube is a simple and feasible traditional surgical treatment, which can promote postoperative recovery without increasing the risk of infection, especially in patients with large hernia sac volume.Additional file 1: Table S1 Comparison of postoperative complications. Fig. S1 Ellipsoid and the diameters A, B and C.


The World Health Organization (WHO) estimates that by 2025 about 2.3 billion adults will be overweight, with more than 700 million obese. Obese patients with joint pain and reduced physical function represent a challenging group to treat effectively. To evaluate patients undergoing bariatric surgery and the implications of this surgery on knee joint pain and to conduct anamnesis and apply specific questionnaires to deepen the discussion and elucidate the knee joint symptoms related to obesity. Observational cross-sectional study with tabulation and analysis of collected data. We obtained a significant result when comparing knee pain pre and post-surgery, in which pain increased by 15.8%.Level of Evidence IV, Case Series. Although worsening or maintenance of pain may occur, this fact is associated to factors such as the increase of functional activities of a joint that was previously in disuse and the loss of muscle mass as a sustainer. We concluded that the improvement of joint pain complaints were mainly due to the reduction of joint overload. The World Health Organization (WHO) estimates that by 2025 about 2.3 billion adults will be overweight, with more than 700 million obese.Obesity affects several systems of the body, including the musculoskeletal system, representing risks that affect the quality of life of affected individuals.Obese patients with joint pain and reduced physical function represent a challenging group to treat effectively. Joint pain is associated with osteoarthritis, and obesity is a risk factor for its increased incidence and progression. Other key factors that contribute to joint alterations associated with obesity are advanced age, female gender, smoking, diabetes, and physical workload, especially in the knee.Bariatric surgery has contributed not only to weight reduction but also to the management of comorbidities associated to obesity.This study is justified by the need to deepen, discuss, and elucidate the articular symptoms of the knee, as well as the support of bariatric surgery as a key factor for weight loss and reduction of joint overload. Still by the need to promote new studies related to the casuistry to help in the reflection of such a relevant theme for public health.To evaluate patients undergoing bariatric surgery and the implications of this surgery on knee joint pain.To perform anamnesis, apply specific questionnaires to deepen the discussion and elucidation of knee joint symptoms that are related to obesity.The method defined for the study is cross-sectional, observational with tabulation and analysis of data collected throughout the study.For data collection in the study, a questionnaire was used to evaluate the profile of the patients regarding gender, comorbidities, body mass index (BMI), consultation in the orthopedic clinic, physical activity, and use of medications or complementary therapies for pain control.), was used to evaluate knee pain. The instrument consists of multiple or binary choices as to the occurrence of symptoms in the various anatomical regions in which they are most common. The respondent should report the occurrence of symptoms considering the 12 months and seven routine days in the year preceding the interview, as well as report the occurrence of absence from activities.The osteoarthrosis-specific quality of life questionnaire (WOMAC) was also used. This questionnaire has been widely used in research and was validated in 2002 for use in the Brazilian population, maintaining its original parameters. It assesses three domains: pain, stiffness, and function, considered central to the evaluation of patient outcomes and the gold standard of measurement in knee osteoarthritis. After the answers, they are transformed into a score based on a Likert-type scale ranging from 0 to 4 points. The highest score reached by the sum of the points shows greater impairment in the domains cited.2 or BMI of 35 kg/m2 to 40 kg/m2 with comorbidities, BMI of 30 kg/m2 to 35 kg/m2 in Diabetes Mellitus II refractory to clinical treatment.We evaluated patients seen at the Orthopedics and Traumatology Department of the Hospital do Servidor Público Municipal of São Paulo who underwent bariatric surgery. They met the criteria of BMI of 40 kg/mAll patients signed an informed consent form. The protocol was approved by the Ethics Committee of Hospital do Servidor Público Municipal of São Paulo under opinion number 4.589.682.Inclusion criteria:Patients under outpatient follow-up;Clinical diagnosis of obesity subjected to bariatric surgery.Exclusion criteria:Cognitive alterations that prevent the application of the questionnaire;Loss of outpatient follow-up;Bariatric patients under 18 years.In the analyzed period, 38 people who underwent bariatric surgery answered the questionnaires. According to the analyses, 32 (84.2%) of the 38 research participants (84.2%) were female and six (15.8) were male.When analyzing the BMI, we observed a higher prevalence of overweight people (BMI 25 to 29.9) and grade I obesity (BMI 30-34.9); characterized by 12 (32%) and 15 (39%) respectively.When we asked the participants if they had ever been to an orthopedic consultation, 20 people (52.6%) answered that they had never been to the specialty, seven people (18.4%) had been before and after bariatric surgery, four people (10.5%) went after bariatric surgery, and seven people (18.4%) went only before bariatric surgery.Of the people who visited the orthopedic specialist, nine people (23.7%) reported pain or discomfort in the knee .All patients (100%) underwent surgery using the Roux-en-Y gastroplasty technique (gastric bypass).Of the 38 respondents, 33 (86.8%) did not perform physical exercises before bariatric surgery. Of the five people who reported doing some type of physical activity, two people (94%) walked, one person (2%) danced, one person (2%) did water aerobics, and one person (2%) did weight-training and dance classes. Regarding the weekly frequency, three people (7.9%) did their activities three times per week.When comparing the performance of physical activities before and after bariatric surgery, we observed a considerable increase of people who started to perform physical activities after the surgery. The number of respondents who started performing physical activities after surgery increased from five (13.2%) to 27 (71.1%). Walking  and water aerobics  were the most adhered activities. Some also associated two activities, such as hydrogymnastics and weight-training . Others performed only weight-training .Regarding the number of times per week, we noticed a significant increase. Most individuals  started doing physical activity three to five times per week. Two people (5.3%) started doing activity six times per week, and one person (2.6%) every day of the week.In the postoperative evaluation with the QNSO, 22 patients (57.9%) reported knee pain that limited their daily activities . On the The patients were analyzed in relation to knee pain by the WOMAC. On average, 50% of the interviewees reported feeling no pain during the activities to evaluate knee pain after bariatric surgery. Regarding knee pain after light walking on flat ground, 20 people (52.6%) reported feeling no pain and mild pain in 36.8% of the cases. Only one person (2.6%) reported a great difficulty when walking on flat ground.About pain when climbing or descending stairs, the patients reported no pain , mild pain , and moderate pain . Analyzing the difficulty when going downstairs, 14 people (36.8%) reported mild difficulty or no difficulty (36.8%). We found no difference regarding climbing stairs, as 14 people (36.8%) reported slight difficulty or no difficulty (34.2%).Regarding pain when lying down at night, 19 people (50%) reported feeling no pain and 16 (42.1%) reported mild pain. A total of 42.1% reported feeling no pain sitting or standing up and 39.5% reported feeling mild pain. Only three people reported feeling moderate (15.8%) or severe (7.9%) pain when standing up. Regarding stiffness when waking, lying down, sitting and/or resting, nine people (23.7%) had moderate or strong stiffness (5.3%).Only three people (7.9%) reported strong difficulty when getting up from a chair and eight people (21.1%) reported moderate difficulty. Most patients had no (44.7%) or mild (42.1%) difficulty in standing up after 72 h from surgery.Most patients  had no difficulty getting out of bed, lying in bed , putting on the stocking , and taking off the stocking .Regarding daily activities, more than half (55.3%) had no difficulty getting in or out of the shower; 15 people (39.5%) had mild or no difficulty (39.5%) in sitting down or getting up from the toilet.When questioned about heavy household tasks, the number of people who reported no difficulty or moderate difficulty was the same, 12 people, representing 31.6% for each level. For light household tasks, one person (2.6%) reported strong difficulty.Comparing the data compiled in the initial questionnaire that outlined the profile of the research participants and the QNSO, we had a significant result regarding the knee pain pre and post surgery. There was a 15.8% increase in pain .With the rising levels of obesity in Brazil, the risk of osteoarthritis increases. Obesity is one of the risk factors for osteoarthritis that can be modified, thus maintaining adequate body weight at all ages is recommended to avoid complications.In the United States of America (USA), the overall prevalence of knee pain in the adult population is 20%, with more than 61 million people affected. By 2025, it is projected to increase to 25% of the affected population.Studies show that for every kilogram lost, the load on the knee from excess weight is reduced twice. With this comorbidity increasingly present in young patients, the demand for “faster” weight loss has increased dramatically, and thus bariatric surgery is widespread.Vicent et al.According to Abu-Abeid et al.Patients subjected to weight loss present gait alterations, such as increased flexion and extension range of motion, external and internal rotation, and better distribution of joint stress. Improvements in gait kinematics, stride length, and cadence are also observed. This contributed to the results found, such as an increase in physical activity after bariatric surgery, considering the facilitation of patient mobility.),,,,11, or mild (47.4%) if evaluated after bariatric surgery.),, or mild stiffness (23.7%). Patients complained of no (42.1%) or mild (34.2%) degree of difficulty in function, which may be correlated with the significant increase in patients who started exercises after bariatric surgery. The performance of constant exercises as an aid in improving functional capacity and reducing joint stiffness is cited in several studies.),17,(Regarding the data collected with the QNSO, we verify that 57.9% complained of knee pain after bariatric surgery. However, when we compared the knee pain reported in the pre-surgery questionnaire, we observed an increase in pain of 15.8%.Bariatric surgery with the Roux-en-Y gastric bypass technique triggers considerable loss of lean body mass, a reflection of the inadequate energetic-protein supply, which may cause a disorder in metabolism, increased proteolysis due to major restrictions to provide substrate to gluconeogenesis. This tends to worsen joint pain, corroborating the results found of increased joint pain in 15.8% of patients in the postoperative period.Hamdi et al.This research assumed that weight loss and the reduction of joint overload would contribute to the reduction of joint pain complaints. During the study, we found that female subjects constituted the largest number of participants in the research. After the surgery, more people started to perform physical activities and the frequency of regular physical exercises increased.There was also considerable or total improvement in pain complaints, stiffness, and functionality when the WOMAC questionnaire was analyzed. When the QNSO and the patient profile questionnaire were analyzed, we observed the maintenance or non-expressive but significant increase in the pain complaint of the knee.We concluded that the improvement of joint pain complaints were mainly due to the reduction of joint overload. Even though worsening or maintenance of pain may occur, this fact is associated to factors such as the increase of functional activities of a joint that was previously in disuse and the loss of muscle mass as a sustainer.