Acute pancreatitis (AP) during pregnancy is a rare presentation with an estimated incidence of 1 case per 1000 to 10,000 pregnancies. Severe epigastric and abdominal pain is the earliest and the most common symptom of AP, and adequate pain relief is an integral part of patient management. The aim of our study was to investigate the different pain relief modalities that are used in pregnant women with AP and the efficacy of each method used, in terms of better pain relief and maternal-fetal outcomes.  This was a retrospective observational study over a period of 6 years conducted at a tertiary care hospital. Pregnant women with clinical and biochemical diagnoses of acute pancreatitis were included in the study. Patient's history and clinical and biochemical data were collected from the medical records of the hospital. t intravenous (i/v) infusion of fentanyl or i/v boluses of injection tramadol, in whom VAS was never reduced below 3. With satisfactory results, labour analgesia and anesthesia for caesarean section was provided via the same catheter in 2 and 3 patients, respectively. Maternal and fetal outcomes were comparable in all the patients.  A total of 12 patients were included in the study, 5 out of 12 patients had gall stones associated with AP, 2 patients had hypertriglyceridemia, and 1 each had preeclampsia and eclampsia. Epidural analgesia at the level of L1-L2 spinal level showed a reduction of VAS scores from 8 or 9 to 1 or 2, indicating excellent pain as compared to  AP in pregnancy, when diagnosed early and managed accordingly, leads to better maternal and fetal outcomes. Epidural analgesia was better than intravenous analgesia in terms of pain management and better recovery of acute pancreatitis patients. In these patients, labour analgesia and anesthesia for caesarean section can be provided through the same catheter, making it a potential novel modality in the treatment of acute pancreatitis in pregnancy. Acute pancreatitis (AP) during pregnancy is a rare presentation with an estimated incidence of 1 case per 1000 to 10,000 pregnancies . The etiThe diagnosis of AP is more frequent in multiparous women 75%) , 4. AP i% , 4. APSevere epigastric and abdominal pain are the earliest and most common symptoms of AP, and adequate pain relief is an integral part of patient management [11]. Intravenous opioid analgesic is a commonly used modality for pain management in AP. Epidural analgesia causes excellent pain relief and is one of the most effective methods of perioperative pain management. However, the role of epidural analgesia in the management of AP is not very well defined, but many centers in the world have been using it for acute pain management in AP , 13. OneThis is a retrospective study, which includes 12 cases of acute pancreatitis in pregnancy, who were admitted to our hospital from January 2013 to December 2018. The aim of our study was to investigate the different pain relief modalities used in AP in pregnancy and the efficacy of each method used, in terms of better pain relief and maternal-fetal outcomes.This is a retrospective observational study over a period of 6 years conducted in Fernandez Hospital, which is a recognized tertiary center for high-risk pregnancies and perinatology. The study was conducted from January 2013 to December 2018. Pregnant women with clinical signs and symptoms suggestive of acute pancreatitis were included in the study. Patient consent was obtained to use the patient data for research purposes. The diagnosis was confirmed using the revised Atlanta classification as defined by the presence of two of the following: (i) typical upper abdominal pain, (ii) increase in serum amylase and or serum lipase levels higher than three times the upper limit of normal, and (iii) imaging suggestive of AP. Abdominal ultrasound was done to see the pancreatic appearance, pancreatic duct, peripancreatic collection, and CBD and to detect gall stones in cases of AP. Fetal well-being was ensured with complete clinical and radiological evaluation. The severity and prognosis of AP were assessed by Ranson's criteria .1-L2 interspace was given, with boluses of 10–15 ml of 0.1% ropivacaine at 2 to 3 hours of intervals. The same dose is used via the same catheter for labour analgesia. Four out of 5 patients underwent preterm caesarean section in the epidural analgesia group, 10–12 ml of 0.2% ropivacaine via the same epidural catheter. The women were followed up until discharge. The APGAR scores and birthweight of neonates were noted at the time of delivery. Maternal and fetal conditions at discharge were noted.Conservative medical management was the mainstay of the treatment. In 7 out of 12 patients, intravenous (IV) analgesics (fentanyl and tramadol) were used for pain management. I.V. fentanyl was given as an infusion at a rate of 1 mcg/kg/hr, and tramadol was given as 100 mg i.v. boluses for 8 hourly intervals. In 5 patients, high lumbar epidural analgesia at the level of LThe data were collected in a Microsoft Excel sheet. The data were reported as numbers and percentages to characterize the patients' demographic and obstetrical parameters, results, and outcomes.Twelve patients with clinical and biochemical diagnoses of acute pancreatitis were included in the study. The mean age of the patients was 25.5 years, and 6 patients (50%) were in the age group of 25 to 30 years. None of the patients were below 20 years old, and only one patient was more than 35 years old, i.e., elderly gravida. Three-fourth of the patients was in their third trimester of pregnancy. Six patients were second-gravida, 3 were primigravida, and 1 patient was multigravida (parity >3). One patient had a bad obstetric history with 4 previous abortions. Demographic and obstetric parameters are described in All the patients underwent transabdominal ultrasonography. Liver function tests, serum amylase, and serum lipase were done along with other baseline investigations, and the results are depicted in Eight out of 12 (66.7%) patients had preterm delivery (<37 weeks), and all patients underwent LSCS, with no other maternal complications. In the fentanyl group, out of 2, 1 baby required NICU care because of neonatal jaundice. In the tramadol group, out of 5 patients, 3 had preterm deliveries out of which 1 baby required NICU care because of respiratory distress. In the epidural analgesia group, out of 5 patients, 4 had preterm deliveries, and 1 baby required NICU care in view of neonatal jaundice, as shown in Acute pancreatitis (AP) in pregnancy is an uncommon presentation. Almost 80% of the cases are mild, and only 20% of the cases are moderate to severe. It is most often associated with gallstone disease or hypertriglyceridemia , 2. GallAcute pancreatitis in pregnancy is more difficult to diagnose in the first trimester as compared to the second and third trimesters because the signs and symptoms mimic hyperemesis gravidarum. The majority of our patients presented with epigastric pain, anorexia, nausea, and vomiting. Therefore, in pregnant women presenting with severe nausea and vomiting, we should always evaluate the serum amylase and lipase levels. None of our patients had associated pulmonary findings. Abdominal tenderness and guarding were found in 50% of the patients. Two patients presented with jaundice with increased total bilirubin and AST levels. Abdominal ultrasound was done in all the cases as it is more sensitive for the diagnosis of acute pancreatitis and is safer than CT in pregnancy.The management of AP in pregnancy does not vary from that in a nonpregnant state. It includes fluid restoration, oxygen supplementation, analgesics, and cessation of oral feeding to suppress the exocrine function of the pancreas . ConservOne of the most important symptoms of AP is epigastric and abdominal pain. Therefore, pain management in AP patients is of prime importance. The most common mode of providing analgesia in AP patients is via intravenous opioids. Epidural analgesia is primarily used by anesthesiologists to treat pain in the postoperative period and for obstetric analgesia . There hThe limitations of this study are its retrospective nature and very small sample size. Yet, the strength is that it focuses upon a cohort of patients in which analgesia is the mainstay of management.Epidural analgesia is better than conventional intravenous analgesia in pregnant women with acute pancreatitis, as it also aids in improving disease prognosis. In these patients, labour analgesia and anesthesia for caesarean section along with pain management of AP can be provided through the same catheter when required, which makes it a potential novel modality in the treatment of acute pancreatitis in pregnancy. Large-scale studies are necessary to validate these results.


Frailty and pain in hospitalised patients are associated with adverse clinical outcomes. However, there is limited data on the associations between frailty and pain in this group of patients. Understanding the prevalence, distribution and interaction of frailty and pain in hospitals will help to determine the magnitude of this association and assist health care professionals to target interventions and develop resources to improve patient outcomes. This study reports the point prevalence concurrence of frailty and pain in adult patients in an acute hospital. A point prevalence, observational study of frailty and pain was conducted. All adult inpatients (excluding high dependency units) at an acute, private, 860-bed metropolitan hospital were eligible to participate. Frailty was assessed using the self-report modified Reported Edmonton Frail Scale. Current pain and worst pain in the last 24 h were self-reported using the standard 0–10 numeric rating scale. Pain scores were categorised by severity . Demographic and clinical information including admitting services  were collected. The STROBE checklist was followed. Data were collected from 251 participants (54.9% of eligible). The prevalence of frailty was 26.7%, prevalence of current pain was 68.1% and prevalence of pain in the last 24 h was 81.3%. After adjusting for age, sex, admitting service and pain severity, admitting services medical (AOR: 13.5 95% CI 5.7–32.8), mental health  and rehabilitation  and moderate pain  were associated with increased frailty. The number of older patients identified in this study who were frail has implications for managing this group in a hospital setting. This indicates a need to focus on developing strategies including frailty assessment on admission, and the development of interventions to meet the care needs of these patients. The findings also highlight the need for increased pain assessment, particularly in those who are frail, for more effective pain management.Trial registration: The study was prospectively registered . Frailty is defined as ‘a medical syndrome with multiple causes and contributors that is characterised by diminished strength, endurance and reduced physiological function, that increases an individual’s vulnerability for increased dependency and/or death’ Increasing numbers of hospitalised older people present growing challenges for patient care, particularly given many of these patients are categorised as frail and have complex health care needs5. The impact of frailty extends beyond the patient to the health care system due to increased care needs and management of frail older patients and the related costs6. Frail people often have multiple co-morbidities which adds another level of complexity to the management of this population7. Growing evidence suggests frailty and pain are closely linked9 and poor pain assessment and management can contribute to the progression of frailty12. A greater understanding of the prevalence of frailty in hospitals, and other associated factors such as pain, may result in improved care for frail patients and allow for the implementation of initiatives to reduce the progression of frailty13.Frail patients in hospital are at increased risk of adverse events, including falls, clinical deterioration, delirium, post-operative complications, increased length of stay and higher levels of frailty, as well as death during hospitalisation15 or sub-groups of patients, for example surgical patients16, meaning that the prevalence and distribution of frailty across the entire hospital is not well understood. The paucity of studies in this area may be in part due to the challenges of administering many performance-based frailty assessment tools which often require lengthy assessments by specialists . The development of patient self-report frailty assessment tools, such as the Reported Edmonton Frail Scale (REFS)18 and the modified REFS (mod-REFS)19, which have been validated18, have enabled larger prevalence studies.Prevalence studies of frailty in hospitals have often focussed on older adults20 utilised the REFS to assess the point prevalence of frailty in a tertiary hospital in New Zealand. This study found the prevalence of frailty to be almost half of patients at 49%; frailty significantly increased with age and there were higher rates of frailty amongst patients admitted to a medical speciality. Similarly, Condon et al.21 found 52% of patients at an Irish tertiary hospital were frail. No previous studies have explored the point prevalence of both frailty and pain and their concurrence across an entire hospital.Richards et al.The aim of this study was to determine the point prevalence of frailty and pain for all adult inpatients, excluding those in high dependency units, in an acute care private metropolitan hospital.The study was conducted at the largest private, acute care, metropolitan hospital in Western Australia with 860 licensed beds at the time of the study, providing care across surgical, medical, rehabilitation, mental health, critical care, and day procedure areas, but the hospital did not have an emergency department. Adult inpatients (aged over 18 years) admitted prior to 0800 h on one day in November 2020 were eligible to participate. Patients in day procedures, high dependency units (including the intensive care unit [ICU] and cardiac care unit [CCU]), patients with severe hearing impairment, severe intellectual disability and those considered too unwell to participate (as determined by the ward manager) were deemed ineligible and excluded.Given the relationship between frailty and cognitive decline and, in order to fully capture frailty, it was important that cognitive decline was not an exclusion criterion. Processes were put in place to gain proxy consent from family members of patients with cognitive decline. Only two eligible patients were identified as requiring proxy consent due to cognitive decline but were unable to be recruited due to failure to contact the proxy.Data collectors worked in pairs with one pair assigned to each ward. They were either registered nurses, final-year nursing students, or allied health professionals. All data collectors received training on the data collection procedures and followed a data collection script. One member of each pair was a senior nurse from the assigned ward and was responsible for accessing patients’ medical records.22 data collection tool running in the Qualtrics Offline Surveys application on an iPad or iPad-mini by the data collector. One data collector then performed the pain assessment followed by the frailty assessment while the other collected demographic and clinical information from the patient’s medical record.Prior to approaching patients, data collectors obtained a list of current patients and consulted with the ward nurse manager to identify any patients meeting the exclusion criteria. Patients were provided with a participant information sheet and a verbal description of the study. Patients were asked for verbal consent and their response was entered into a Qualtrics19. This 13-item questionnaire evaluates multifunctional domains , and produces a score between 0 and 18 with scores of 8 and above classified as frail19. Scores were also coded according to severity of frailty: 0–5 not frail, 6–7 apparently vulnerable, 8–9 mild frailty, 10–11 moderate frailty and 12–18 severe frailty19. The data collector asked the patient the questions and recorded their responses in Qualtrics. To explore self-perceptions of frailty, participants were asked 1) Do you consider yourself to be frail? (yes/no);and 2) Based on your answer to the previous question, on a scale of 0–10 where 0 is ‘not at all frail’ and 10 is ‘extremely frail’, how frail do you think you are? Participants were instructed to respond to the questions based on their abilities prior to admission and their self-reported performance two weeks prior to admission19.Frailty was assessed using the self-report modified Reported Edmonton Frail Scale (mod-REFS)23. To enable pain assessment in patients with cognitive decline, pain was assessed using the PainChek® application25. PainChek® is an evidence-based pain management system that utilises automated facial recognition and analysis to recognise facial action units indicative of pain presence, combined with user completed checklists of pain behaviour to calculate a pain intensity score (https://www.painchek.com/). Pain scores were recorded within the application on either on an iPad or iPad-mini.The participants were asked to rate the intensity of their current pain verbally using the standard numeric rating scale where 0 is no pain and 10 is the worst possible pain. They were then asked to rate the intensity of their worst pain experienced in the last 24 h from 0 to 10 and whether that was whilst resting or on movement. Pain ratings were recorded by the data collector in Qualtrics. For the prevalence analysis of both current pain and worst pain in the last 24 h, pain ratings of 0 were coded as no pain and ratings of 1–10 as pain reported. For modelling, ratings were coded according to severity of pain: 0 = no pain, 1–3 = mild pain, 4–6 = moderate pain, and 7–10 = severe painDemographic and clinical information relevant to frailty and pain were collected from the patient’s medical record. This information included year of birth, sex, admission type (elective/acute), indigenous status and pre-admission residential status . Admitting diagnosis, active medical conditions, and prescribed analgesics (dosage and time of last dose) were also collected but are not reported here.These data were collected on paper forms and then, after data collection, entered into a Qualtrics form by two members of the research team. Any missing information identified at the data cleaning stage of analysis was requested from the ward nurse manager who then retrieved the missing information from the patient’s medical record. Classification of admitting service  was performed post hoc by the administrative health information coding staff.26. Chi-square tests were used to determine if there was a difference in categorical variables between patients categorised as frail versus not frail according to the mod-REFS. Univariate and multivariate binary logistic regression was performed to identify factors predictive of frailty. Regression coefficients were reported as odds ratios with 95% confidence intervals. The area under the receiver-operating characteristic (ROC) curve was used to determine the goodness-of-fit for the multivariate model. The variables included in the final adjusted model included age, sex, admitting service and current pain. Admission type was not included due to collinearity with admitting service, similarly for pain in the last 24 h and current pain and for self-report frailty and mod-REFS score. Current pain as a continuous variable was highly skewed, current pain severity was therefore included as a categorical variable.All recruited participants were able to provide informed consent and self-report pain, therefore only the numeric rating scale pain data are reported. Categorical variables were reported as whole numbers and percentages and continuous as mean (standard deviation) and median (Interquartile ranges). Chi-square test was conducted for categorical variables and Kruskal Wallis for continuous variables. Spearman rank-order correlation coefficient tests were conducted to determine if there was a correlation between the mod-REFS score and self-reported ‘how frail do you think you are?’, and between current pain and worst pain in the last 24 h. Cohen’s kappa was used to measure the interrater agreement between the mod-REFS (frail or not frail) and ‘do you consider yourself frail’ (yes/no)27. The reporting of this study complies with the Strengthening the Reporting of Observational Studies in Epidemiology Statement (STROBE) Checklist28 Appendix .Ethical approval was granted by the Human Research Ethics Committees of Ramsay Health Care (WA/SA) (ref: 2038) and Edith Cowan University (ref: 2020-02008-SAUNDERS). All methods were performed in accordance with the relevant guidelines and regulations of the HREC approving institutions. A verbal consent process was approved by as the research was considered low risk, the interaction with the patient was minor, and assessments of pain and frailty are part of standard care, verbal consent from patients was sought and their response recorded by the data collector in Qualtrics. If a patient was unable to provide informed verbal consent due to cognitive impairment or inability to verbally communicate, written proxy consent would have been sought from their guardian or next-of-kin following guidelines from the Western Australian Department of Health to adhere to the requirements of the Western Australian Guardianship and Administration Amendment  Act 2020. However, there were no patients in the study sample who were unable to provide informed consent.At 0800 h on the day of data collection, 457 of the 503 eligible beds were occupied. Consent was obtained from 253 patients (55.4% of occupied eligible beds) and full data was collected from 251 patients (54.9%). Frailty and numeric rating scale pain data were not collected for two patients due to data collector error. Of the 204 excluded patients, 87 (19.0%) refused, 23 (5.0%) were unavailable and 94 (20.6%) met exclusion criteria . The level of agreement between mod-REFS frailty status (frail/not frail) and self-reported ‘do you consider yourself to be frail?’ (yes/no) was 80.5%, however, Cohen’s kappa of 49.9% suggests this is a moderate strength of agreement between the two measures.Of the 251 participants with complete data, 67 (26.7%) were classified as frail according to the mod-REFS .Current pain was reported by 68.1% of participants and 81.3% of participants reported pain in the last 24 h  in the current study compared to a previous study (38.1%)20 is likely to have contributed to the overall prevalence of frailty in the current study. As in previous studies, surgical patients were less likely to be frail than medical patients. Given the majority (78%) were undergoing elective surgery, frailty prevalence might have been be influenced by the pre-operative assessment of potential patients for eligibility for surgery at a private hospital.Overall, the point prevalence of frailty in the hospital (26.7%) was lower than a previous hospital-wide study  which found 49% of patients were frail30. The mod-REFS self-report questionnaire used in this study may be useful for this purpose as it is a quick self-assessment taking approximately 5 min, can be administered by nurses and a version of this questionnaire (REFS18) has been validated for use in hospitals18. Alternatively, the development of comprehensive admission assessments such as those developed by InterRAI that automatically include frailty measures along with other standard risk assessments may prove valuable in the future to inform care interventions and reduce administration at admission31.Consistent with previous studies, this study found older patients were more likely to be frail, however age was not a significant predictor of frailty in the adjusted model. Frailty was not restricted to older adults with 34% of frail patients being under the age of 65. This finding combined with the high prevalence of frailty, particularly in medical (55%) and rehabilitation (43%) patients, highlights the potential value of assessing all patients to identify those who are frail and direct appropriate care and interventions during their inpatient stay and on discharge. Assessment of frailty is potentially not routinely completed in the acute care setting partially due the time and expertise required to administer some assessment tools32. Frailty in mental health patients is an important area for future research.The prevalence of frailty in the mental health wards (28.6%) was relatively high particularly given the relatively young age of these participants (median 35.5 years). The mod-REFS has not been validated with this population so these results may not reflect physical frailty and should be interpreted with caution. There is limited research in this area particularly with younger mental health patients. A previous study found the prevalence of frailty in older adults (mean age 74.6 years) in an acute psychiatric hospital was 37.9%33. Given the distress that pain can cause patients, effective pain assessment and pain management should be prioritised in hospitals and more education provided to staff. Our finding in this cohort study that higher levels of pain predicted frailty supports recent findings of an association between frailty and pain9.Overall, pain was highly prevalent across the participants both when reporting current pain (68.1%) and worst pain level in the last 24 h. Of those participants (81.3%) who reported pain in the last 24 h, 37.5% rated their worst pain as severe. Comparison with other studies is difficult due to variation in methodologies and patient cohorts, however, these results are similar to previous studies that have found the point prevalence of current pain in hospitals to be between 37.7% and 84.0% and worst pain in the last 24 h to be between 52 and 65%17  may have produced different estimates of prevalence. The lack of consensus on how best to assess and measure frailty is a barrier to comparison across studies34. Second, the results of this study may also be limited in their generalisability. Given that private hospitals account for approximately 40% of all hospital admissions in [redacted for blind review]35 it is important to understand the prevalence and distribution of frailty in that setting. While the patient population is likely comparable to other [redacted for blind review] private hospitals without emergency departments, those with emergency departments may have different prevalence and distribution of frailty. For example, there might be a higher number of frail surgical patients admitted acutely through emergency requiring surgical interventions following trauma. Thirdly neither the mod-REFS19 nor the REFS have been validated in the younger age group, but the REFS has been utilised in another hospital wide prevalence study20.There are some limitations to the current study. First, there are inherent issues with the use of self-report measures within a health setting due to either over or under reporting. Furthermore, the self-report measure of frailty may not have accurately assessed frailty, as it is possible that a physical performance-based measures of frailtyThis study adds to the growing evidence that frailty is prevalent in hospital patients, particularly older medical patients. Given that the majority of patients in this study, who were identified as being frail were aged over 65 years, managing this group of patients to improve health outcomes needs some attention. This finding highlights the importance of routine assessment of frailty on admission to direct appropriate care. The findings also argue for the development and implementation of interventions directed at this large population of vulnerable patients. The high prevalence of pain experienced by patients in this study, and the association with frailty, identifies the need for more consistent and routine pain assessment and management to improve patient outcomes. Therefore, assessment and management of both pain and frailty are vital to improve patient care and tailor discharge advice.Supplementary Information 1.Supplementary Information 2.


IntroductionPlatelet-rich plasma (PRP) intra-articular injections have gained popularity and are suggested to be more effective and longer lasting than corticosteroid or visco-supplementation therapy. There are few studies comparing PRP with corticosteroid injections and none comparing PRP in patients with bilateral knee osteoarthritis with the patient acting as their own control.MethodsWe performed a double-blind randomized controlled trial including 29 patients (58 knees) with radiologically confirmed mild-to-moderate bilateral knee osteoarthritis. They were randomized to receive an intra-articular PRP injection into one knee and a methylprednisolone injection with a local anesthetic into the contralateral knee. The primary outcome was measured using the Western Ontario and McMaster Universities Arthritis Index (WOMAC) before the treatment and at six weeks, three months, and six months. Secondary outcome was measured pain with the visual numerical pain rating scale (VNS).Results2,139=0.173, p=0.84). The secondary outcome also delivered the same result with improvement at all time points but no statistically significant difference .Corticosteroids and PRP were both effective in improving pain, stiffness, and function at all time points, with maximal improvements at six weeks and three months. PRP scored slightly better than steroid injections at six months; nevertheless, there was no statistically significant difference between corticosteroids and PRP injections (FConclusionsBoth corticosteroids and PRP interventions are effective in improving pain, stiffness, and function in patients with bilateral knee osteoarthritis up to six months with no statistically significant difference between the two. Osteoarthritis (OA) is the most common cause of arthritis, disability, and knee pain in elderly patients . FurtherCurrently, no disease-modifying agents are available for the treatment of OA; therefore, the only definitive treatment available is surgical management, which entails a total knee arthroplasty . Prior tIntra-articular injections would usually be reserved for patients who do not have adequate relief of symptoms on oral treatment regimens . HyaluroThis is a single-center, prospective, double-blind randomized controlled trial performed in the Orthopedic Department at Letterkenny University Hospital between August 2021 and April 2022. This study included 31 patients and therefore 62 knees  diagnosed with primary bilateral knee OA and classified according to the Kellgren-Lawrence classification scale . Of these 29 patients, each patient received a PRP injection into one knee and a corticosteroid injection into the contralateral knee. The knees receiving the PRP injection comprised the intervention group and the knees receiving the corticosteroid injection comprised the control group . A written informed consent was obtained from each patient prior to participation in the study.The interventions were randomized using simple randomization. This was performed with a coin toss to determine the intervention group (PRP injection). If it landed on heads, then PRP would be injected into the right knee and tails the left knee. The contralateral knee would then be injected with a corticosteroid.During the PRP preparation, 15 mL of blood was taken from the antecubital fossa of each patient under sterile conditions with an Arthrex ACP® double syringe system . This was then inserted into a Rotofix 32A centrifuge with a counterweight and centrifuged for 5 minutes at 6,000 rpm. Once removed, the autologous PRP was then drawn up from the inner syringe, which would usually be around 5 mL for each patient, which would then be injected into the knee joint.The corticosteroid injection used was 80 mg (2 mL) of methylprednisolone acetate injectable suspension (Depo-Medrol) with 40 mg of levobupivacaine (8 mL of 0.5% chirocaine). Patients were then positioned supine with both knees flexed up to 70° with a sheet divider blocking the patients’ view of the interventions given (blinding the patients). After randomization, the PRP and corticosteroid were injected in the appropriate knees with an inferolateral approach.The intensity of pain and knee function were evaluated based on the Western Ontario and McMaster Universities Arthritis Index (WOMAC) and the visual numerical pain rating scale (VNS) before the onset of treatment and at six weeks, three months, and six months after initial treatment. In the VNS, a score of 0 represents no pain at all and a score of 10 indicates highest intensity of pain ever experienced. The WOMAC score consists of three sections, which include pain, stiffness, and a function scale. The two experienced physicians who recorded the initial as well as follow-up scoring were blinded to the interventions given to each knee. The treatments were labelled as treatment A (PRP) and treatment B (corticosteroid). The statistician was also blinded to the treatment as she was only given the data to analyze for treatments A and B.To perform the statistical analysis, a linear mixed effects model with random patient effects was used. This method was employed as patients were given both corticosteroids and PRP into contralateral knees, and there were repeated measurements of the outcome over time. Adjustments were made for differences in the baseline value, of the outcome score, by including it as a covariate in the model. An interaction term between treatment and time was included  to assess evidence of a difference in treatment effects at different time points. Following this, 95% confidence intervals were measured by bootstrapping. F statistics were reported from the ANOVA tables for the linear mixed effects models. The statistical analyses were conducted using R Version 4.1.0  and the lme4 package .Corticosteroids and PRP were both effective in improving pain, stiffness, and function at all of the different timeframes, with maximal improvements at six weeks and three months Table .2,139=0.173, p=0.84)  effects at different times for the total WOMAC score . As mentioned before, there was a statistically significant improvement in WOMAC score over time for both treatments . PRP scored slightly better than steroid injections at six months, although no statistically significant difference was identified between corticosteroids and PRP intervention at six months’ follow-up. In both interventions, total WOMAC scores worsened from three months (PRP=48.24 and steroids=48.14) to six months (PRP=56.03 and steroids=56.9) but still scored better than baseline (PRP=60.93 and steroids=59.1)  . As we would expect, we found statistically significant improvement in pain score over time for both treatments .Our secondary outcome (VNS) delivered the same result with improvement of the pain score from baseline to six weeks, three months, and six months with the PRP injection  as well as the steroid injection  Table , althougThe patient with Kellgren and Lawrence grade II knees had the best response to both corticosteroid and PRP injection. This patient group had the most significant improvement in WOMAC total score from baseline (60.22) to six weeks (30.22), and the improvement lasted up to six months, with the total WOMAC score still below 45.Knee OA treatment begins with conservative therapies, which involve oral analgesic agents (NSAIDs), physical therapy, weight loss, patient counselling, and exercise. As the disease progresses, other therapeutic methods become important such as intra-articular injections, which include corticosteroids, hyaluronic acid, and PRP . There iA recent systematic review performed comparing intra-articular PRP and steroid injections for the management of symptomatic knee OA showed that PRP has an overall greater efficacy compared to corticosteroid injections over 12 months’ follow-up. Although it is important to note that seven of the eight studies assessed in this study followed up patients for only six months. This effect was statistically significant from three months onward and is most pronounced at six months’ follow-up. The benefits were greatest with patients with grade II to III OA. PRP showed greater efficacy in reducing pain scores while also improving stiffness and general physical function . In contIntra-articular corticosteroid injections are widely used to reduce pain and limitation of joint movement in knee OA, particularly in the presence of inflammation and joint effusion . But twoPRP injection has been shown to be a safe treatment option with no serious complications. Minor side effects have been reported with repeated intra-articular injections, which include symptoms of pain, swelling, and mild effusion that can last a few days . None ofIt is important to keep in mind that it has been suggested that PRP injections are more effective in patients with mild-to-moderate OA as well as patients of younger age . Kon et It has been suggested that multiple PRP injections likely have a better outcome than single PRP injections ,21. ThisThis study has several limitations. First, a small sample size was included in the study and the study had a short to midterm follow-up period. Another limitation is that injections were not administered under ultrasound guidance, although we used two experienced orthopedic doctors to administer all the injections with a standardized technique. One of this study’s greatest benefits could also be considered as a limitation, that is, using the patients’ own contralateral knees as their own control group. This removed the interpersonal variations between different patients with regard to patient demographics and comorbidities. But there is a possibility that there might be some carryover effect between the two knees as patients will inadvertently be comparing one knee to the other when reporting on pain, stiffness, and function in the WOMAC as well as VNS scoring systems.Both PRP and corticosteroid injections are effective in improving pain, stiffness, and function in patients with bilateral knee OA. The greatest effect is in patients with mild OA for both corticosteroid and PRP injections. The degree of pain and functional improvement reduces at six months postinjection. The PRP group scored slightly better at six months’ follow-up, but this was not statistically significant.This study adds to the continuing controversy regarding which injectable therapy is the most effective in treating patients with mild-to-moderate knee OA. There is still a need for more larger, well-constructed, multi-center randomized controlled trials comparing PRP and corticosteroid injections with long-term follow-up to attempt to provide more clarity on the matter.


Low back pain is a major and worldwide cause of global disability. It is not rare that an acute episode of low back pain evolves towards a chronic status without any specific cause. While many clinicians focus their treatment on low-value -care interventions , best clinical practice guidelines now recommend a mixed approach combining exercises and education. Furthermore, owing to the potential advantages that confer patient interactions with others , we decided to launch such an intervention program in a group setting (MyBack program) and aimed to evaluate its effectiveness through this study. Following this 8-week intervention program, approximately three-quarters of the patients reported a relevant reduction in pain intensity (78%), catastrophic thinking (78%), functional disability (74%), and fear of movement and work-related activities (74%). Only a quarter of the patients (26%) reported a relevant improvement in quality of life, probably because this outcome was already high before treatment. The MyBack program combining education with multimodal group exercises led to satisfactory clinical, functional, and psychosocial outcomes.p < 0.05) in the pVAS (5.3 ± 1.2 vs. 3.1 ± 1.6), RMDQ (8.8 ± 3.3 vs. 4.0 ± 3.7), PCS (24.5 ± 9.4 vs. 11.7 ± 7.9) and TSK (41.5 ± 9.2 vs. 32.7 ± 7.0). The EQ-5D-3L also statistically improved . The responder rates were 78% for the pVAS and PCS, 74% for the RMDQ and TSK, and only 26% for the EQ-5D-3L. The MyBack program combining education with multimodal group exercises led to satisfactory clinical, functional, and psychosocial outcomes.Currently, there is no consensus on the best rehabilitation program to perform for nonspecific chronic low back pain (NSCLBP). However, multimodal exercises, education, and group-based sessions seem to be beneficial. We, therefore, launched such a treatment program and aimed to evaluate its effectiveness in improving patient health status. We retrospectively analyzed the records of 23 NSCLB patients who followed the MyBack program at La Tour hospital from 2020 to 2022 . Patients were evaluated before and after intervention using pain on a visual analog scale (pVAS), Roland–Morris Disability Questionnaire (RMDQ), Pain Catastrophizing Scale (PCS), Tampa Scale of Kinesiophobia (TSK), and the EuroQol-5D-3L (EQ-5D-3L). Responder rates were calculated using minimal clinically important differences. Patients reported a significant reduction ( Low back pain (LBP) is one of the major causes of global disability in most developed countries ,2, with Before starting a pharmacological or surgical treatment, best clinical practice guidelines recommend a biopsychosocial approach using exercise and education to support the self-management of nonspecific chronic low back pain (NSCLBP) ,11. CompBased on current published recommendations, an NSCLBP treatment group-based program has been recently launched at our institution combining education with multimodal exercises such as Pilates, resistance training, and aquatic exercises. Since there is little or no published data on such a treatment program, the authors aimed to evaluate and report its effectiveness in reducing pain intensity and improving functional disability, kinesiophobia, pain catastrophizing, and health-related quality of life.The authors conducted a retrospective cohort study on 29 patients with NSCLB who followed the MyBack program at La Tour hospital  from November 2020 to June 2022. Participants were included if a physician diagnosed them with NSCLBP , were aged between 18 and 65 years old , with paAll patients completed a questionnaire comprising patient-reported outcome measures (PROMs) before the 8-week intervention program. Outcome measures included: (i) pain intensity, measured on a Visual Analog Scale (VAS); (ii) functional disability, measured with the Roland–Morris Disability Questionnaire (RMDQ); (iii) catastrophic thinking due to low back pain, measured with the Pain Catastrophizing Scale (PCS); (iv) kinesiophobia, measured with the Tampa Scale of Kinesiophobia (TSK); and (v) health-related quality of life, measured with the EuroQol-5D-3L (EQ-5D-3L). Following the end of the intervention, patients were asked to fill up the same questionnaires and to assess their perception of overall change through the Patient Global Impression of Change (PGIC).The pain on VAS is a simple and highly reproducible method of expressing the subjective degree of pain. The pain intensity score ranges from 0 to10, with 0 indicating no pain and 10 being the worst imaginable pain . Two poiThe RMDQ is a 24 items questionnaire that measures the level of functional disability related to normal activities of daily living. Each item represents 1 point, and the total score varies from 0 (no disability) to 24 (extreme disability) , with a The PCS evaluates inappropriate coping strategies and catastrophic thinking about pain and injury through 13 items, with a total score ranging from 0 to 52. Higher scores indicate higher levels of catastrophizing . The MCIThe TSK is a reliable and valid tool for measuring fear of work-related activities, fear of movement, and (re)injury in patients with chronic pain. It is a 17 items questionnaire rated through a 4-point Likert scale ranging from ‘strongly disagree’ to ‘strongly agree’. The total score of the scale range from 17 to 68, where 17 means no kinesiophobia, 68 means severe kinesiophobia, and a score of ≥37 indicates there is kinesiophobia ,26. The The EQ-5D-3L evaluates several important aspects of health-related quality of life, such as mobility, self-care, usual activities, pain/discomfort, and anxiety/depression, with three different levels: no problem, some problems, and severe problems. The health state is transformed into a single index score ranging from −0.59 to 1, where 1 is the best possible health state. In addition to the five dimensions, there is a VAS that assesses self-rated health on a vertical VAS, with endpoints labeled “best imaginable health state” (100) and “worst imaginable health state” (0). The EQ-5D is one of the most widely used PROMS to measure the quality of life in patients with LBP . The MCIThe PGIC assesses the patient’s perception of overall improvement through a 7-point scale, ranging from 1 (“no change” or “condition has got worse”) to 7 . Patients were asked to rate the question, “Since the beginning of the treatment, how would you describe the change (if any) in your symptoms?”. Scores ≥5 were considered indicative of moderate to considerable changes in the patient’s perceived status ,30.All participants performed a total of 25 sessions during an 8-week intervention program in a group (4 to 6 patients), 3 times per week, consisting of education and multimodal exercises such as Pilates, resistance training, and aquatic exercises. It is worth noting that group-based therapy has potential advantages owing to patient interactions with others . All the interventions were provided by a trained physiotherapist with ≥3 years of experience. An overview of program details can be found in The education program consisted of one individual session (30-min) at the beginning of the program, followed by four group sessions (90-min each) through the 8 weeks. The program content was based on general education recommendations for LBP , self-maThe Pilates-based mat exercises were carried out by a Pilates-certified physiotherapist and consisted of one session per week (60-min) from weeks 2 to 7, based on the protocol described by de Oliveira et al. (2019) . On averThe resistance training consisted of one session per week (60-min) from weeks 2 to 7, focusing on muscle strengthening, endurance, and stabilization of the core muscle, based on the protocol described by Cortell–Tormo et al. . Each seThe aquatic exercises consisted of one session per week (60-min) during all the interventions, carried out in a therapeutic pool at 32° ± 1°, as described by Abadi et al. . Each seAn a priori sample size calculation to ensure fulfillment of the principal goal of the study indicated that 10 patients would be needed to detect a difference in pain on VAS of 2.0 points (MCID) with a standard deviation of 1.2 points (based on pre-treatment pain on VAS of our enrolled cohort), an alpha error probability of 0.05, a statistical power of 0.90 and an anticipated drop-out rate of 30%.t-test (if Gaussian distribution) or the Wilcoxon signed-rank test (if non-Gaussian distribution). The improvements in the aforementioned outcomes were compared to their respective MCID to calculate the responder rates. The effect size of the treatment was calculated using Hedges’ g ]) for the different studied outcomes and interpreted as follows: small (0.2 ≤ Hedges’ g < 0.5), medium (0.5 ≤ Hedges g < 0.8), large (0.8 ≤ Hedges’ g < 1.2) and very large (1.2 ≤ Hedges’ g) [p-values < 0.05 were considered statistically significant.Descriptive statistics were used to summarize the data. Continuous variables were reported as mean ± standard deviation (min-max), and categorical data were reported as proportions. The normality of continuous variable distributions was assessed using the Shapiro–Wilk test. Differences between the pre-operative and post-operative values  were evaluated using either the paired student dges’ g) . StatistFrom the enrolled cohort of 29 patients, three (10%) refused to give their consent for the use of their data for research purposes, and three (10%) did not attend all treatment sessions. This left a final cohort of 23 patients with complete pre-and post-treatment data. This study cohort was aged 45.6 ± 11.6 years at the time of treatment and mainly comprised women (74%) and active workers (71%). Other patient characteristics can be found in p < 0.001) (p < 0.001), PCS  and TSK   , RMDQ (8< 0.001) .The net improvement was beyond the MCID for 78% of the patients for the pain on VAS and PCS, 74% for the RMDQ and TSK, 61% for the PGIC score but only 26% for the EQ-5D score .Low back pain represents a major public health issue. Therefore, we implemented a treatment program combining patient education and multimodal exercises in groups at our institution and aimed at evaluating its impact on patient pain intensity, functional disability, as well as pain catastrophizing, kinesiophobia, and quality of life. The findings of the present study revealed that this intervention program has a large and positive effect on most aforementioned outcomes, with more than three-quarters of the patients reporting a relevant improvement in their pain and functional disability.The reductions in pain intensity and functional disability observed in our patient series (2.3 and 4.9 points) compare well with those reported by Kim et al.  (1.9 andOur intervention program was effective at reducing kinesiophobia (8.9 points) and pain catastrophizing (13.2 points) with 74% and 78% of responders, respectively. Likewise, Bodez Pardo et al.  reportedOur results showed a large treatment effect on the EQ-5D score with an improvement that reached statistical significance. However, only 25% of the included patients were characterized as responders with a reported change above the MCID. This finding illustrates that effect sizes remain statistical results and emphasizes the importance of clinical relevance in the interpretation of PROM changes. The fact that only a quarter of our patients perceived a relevant improvement in this PROM could be explained by a relatively high health-related quality of life before treatment. Effectively, the pre-treatment quality of life reported by our patients was 20% higher  than that reported by Soer et al.  on a patExercise has proven its effectiveness at reducing pain and disability as well as improving quality of life in individuals with NSCLBP, but the neurophysiological mechanisms are still under debate. Although the traditional main goals of exercise are to improve muscular strength and endurance, the mechanisms to reduce pain in individuals with chronic pain may not solely be due to these aspects . InsteadMoreover, more literature sets the importance of nonspecific (or placebo) effects and the natural course of the condition as well as psychological factors such as self-efficacy, coping strategies, and fear-avoidance beliefs to explain the effects of exercise and education on CMSP interventions ,56,57. FThis study has, however, several limitations. First, the evaluation of our institutional program is retrospective, non-comparative, and based on a small number of patients. Thus, our results might not be generalizable to other institutions, and further studies involving a community and selfcare based program  would be needed. Second, even though the intervention protocol’s effects grant very satisfactory short-term results, medium and long-term follow-ups have not been performed. This might be of particular importance in individuals with NSCLBP since they must deal with persistent pain and other associated symptoms over time. Furthermore, the purpose of the study was not to evaluate the results of a novel therapeutic approach (since most of its components are currently widely used and accepted), but rather to provide indications of its level of performance. Such information could, for instance, help in the design of future prospective comparative clinical trials  to further evaluate the benefits of specific program components . Finally, a selection bias must be considered. It is generally accepted that patients who are attended at different healthcare levels present differences in symptom severity. The inclusion of patients who only reported pre-treatment pain equal to or above 4 points and the single medical referral are aspects that limit the external validity of these study results.The MyBack rehabilitation program combining education with multimodal exercises in a group led to satisfactory results with a relevant reduction of pain intensity and functional disability for more than 74% of our patients suffering from NSCLBP. Likewise, fear of movement and catastrophic thinking related to pain decreased to the same extent, illustrating the global benefits of such a rehabilitation program on clinical, functional, and psychosocial patient status.


P < .001, 3 days vs 5 days; P < .001, 19 mg vs 634 mg; P < .001). Cryoanalgesia appears to reduce postoperative hospital stay and opioid consumption compared with epidural analgesia. The outcomes of this study indicate that cryoanalgesia might be a safe and effective method for pain control following MIRPE.pain following minimally invasive repair of pectus excavatum (MIRPE) is a critical concern that leads to a prolonged hospital stay and high doses of opiates administered to the patients. This study aimed to evaluate the efficacy of intraoperative cryoanalgesia  during MIRPE. We retrospectively analyzed the data of 64 patients who underwent MIRPE and received cryoanalgesia or epidural analgesia between January 2019 and January 2021. The oral morphine milligram equivalent (MME) was used to calculate the dosage of opioid agents. The median age was 15 years . The median postoperative hospital stay was 4 days , with a median oral MME consumption of 45 mg (ranging from 0 to 1360 mg). Cryoanalgesia was performed in 38 patients, and epidural analgesia was administered to the remaining 26 patients. The cryoanalgesia group had a significantly lesser pain score, shorter postoperative hospital stay and lower oral MME consumption than the epidural analgesia group (5 vs 2;  The Nuss procedure using a substernal bar, a minimally invasive repair of the pectus excavatum (MIRPE), is the most commonly performed surgical procedure for correction.,3 Compared with the Ravitch procedure, MIRPE allows for smaller incisions, shorter duration of surgery, and less blood loss, with excellent postoperative outcomes.,5 Despite these benefits, postoperative pain is a major disadvantage of MIRPE.Pectus excavatum, an inward displacement of the sternum, is the most common congenital chest wall deformity, with a prevalence of approximately 1 in 400 to 1 in 1000 live births. However, these techniques are useful within the first 2 to 3 postoperative days and can cause severe problems, such as respiratory depression.,7 Hence, cryoanalgesia has recently been adopted and employed to overcome these drawbacks.Following MIRPE, pain management is an important factor in determining the postoperative course. Epidural analgesia and intravenous patient-controlled analgesia are widely used to manage postoperative pain.,9 However, we believe that cryoanalgesia in the previous studies was performed at more levels of the intercostal nerves than necessary. In these studies, cryoanalgesia was performed at 5 levels on each side: the level of bar insertion and 2 interspaces above and 2 below. In this study, we evaluated whether intraoperative cryoanalgesia could be applied at fewer levels of the intercostal nerves (the level of bar insertion and one interspace above and below) and still provide effective control of postoperative pain in patients with pectus excavatum.Cryoablation of the intercostal nerves, also known as cryoanalgesia during MIRPE, has been reported to effectively and to safely control postoperative pain.A retrospective chart review of the data of all patients who underwent MIRPE between January 2019 and January 2021 was performed. Patient data, such as demographics, symptoms, details of surgery, and type of analgesia , were collected for review. In addition, the patients’ medical records of the postoperative course, including daily pain score, postoperative hospital stay, and pain medication used, were also reviewed. The opioid usage during the hospital stay was converted to oral morphine milligram equivalent (MME) for each patient. The study was conducted in accordance with the Declaration of Helsinki (revised in 2013) and approved by the local institutional review board (No.: 3-2020-0333).Postoperative hospital stay was defined as the number of days from the day of surgery to the day of discharge. Haller index was calculated by dividing the maximal transverse diameter of the thoracic cavity by the maximal anteroposterior diameter of the thoracic cavity on computed tomography scan. Complications were defined as any adverse events during or after the surgery, such as infection, bleeding, pneumothorax, hemothorax, bar displacement, conversion to sternotomy or thoracotomy, cardiopulmonary injury, pneumonia, reoperation, prolonged pain, readmission, or death.-1 followed by rocuronium 0.6 mg kg-1 for muscle relaxation to facilitate tracheal intubation. Anesthesia was maintained by administration of sevoflurane 1.5 to 2.5% and remifentanil 0.05 to 0.2 μg kg-1 min-1. About 20 minutes before the end of surgery, ondansetron or ramosetron were administered. At the end of surgery, any residual neuromuscular blockade was reversed with sugammadex or neostigmine.Atropine or glycopyrrolate was administered intravenously as premedication. When patients arrived at the operating room, standardized monitoring was initiated. Anesthesia was then induced with propofol 2 mg kg After general anesthesia and intubation, minimal bilateral incisions were made in the mid-axillary line. Two bent bars (lower and upper bars) were prepared. The lower bar was inserted to elevate the sternum, and the upper bar was inserted into the subcutaneous tissue, just above the sternum, using the same incisions. Two bolts were used to fix the upper and lower bars on both the left and right sides. The skin edge was pulled over the end of the bars to place the bars under the subcutaneous layer.Sixty-four patients underwent MIRPE, which was performed by an experienced surgeon. MIRPE was performed using a double compression and complete fixation bar system.Before the introduction of the cryoablation machine in our department, postoperative pain after MIRPE used to be conventionally managed using epidural analgesia. Cryoanalgesia is being used to manage postoperative pain following MIRPE since the installation of the cryoablation machine. The patients in this study were selected sequentially.TM probe was inserted into the ipsilateral thoracic cavity under thoracoscopic visualization. This procedure required approximately 2 minutes of ablation, with a temperature of -70°C at each of the targeted intercostal nerves. The targeted intercostal nerves were at the level of bar insertion, as well as one interspace above and below. Thereafter, MIRPE was performed . However, these are somewhat subjective. Therefore, we planned to use additional objective values, such as postoperative hospital stay and opioid dose consumed.P < .05.Continuous variables are expressed as medians and ranges, and categorical variables are expressed as counts and percentages. Continuous variables were compared using the Mann–Whitney test, and categorical variables were compared using Fisher exact test. The Bonferroni correction and Brunner and Langer method were used to compare the daily opioid requirement in both groups. Statistical analyses were conducted using SPSS  and SAS . Statistical significance was set at Of the 64 patients, 51 (80%) were male, and the median age was 15 years . The median MME consumed was 45 mg , and the median postoperative hospital stay was 4 days . The median duration of surgery was 70 minutes , and the median Haller index was 4.02 . Thirty-eight patients underwent cryoanalgesia, and the remaining 26 patients received epidural analgesia.P value was not statistically significant (P = .052). As expected, the median duration of surgery was longer in the cryoanalgesia group than in the epidural analgesia group .The baseline characteristics, such as age, sex, weight, height, and body mass index did not differ between the 2 groups Table . Haller P < .001, 19 mg vs 634 mg, P < .001; 3 days vs 5 days, P < .001). No complications occurred intraoperatively or during the hospital stay. The daily NPIS and the requirement of opiates were significantly higher in the epidural analgesia group during the hospital stay  intact. Due to the frozen axons, the transfer of electrical signals is prevented, and an analgesic effect is obtained. Subsequently, Wallerian degeneration progresses from the point of injury to the nerve endings. Intact fibrous neural structures allow axonal regeneration at the rate of approximately 1 to 3 mm/day. The continuous flow of blood acts as a heat sink to the intercostal vessels that are intact during cryoablation. it has been used to manage pain in various surgeries, including craniofacial, chest wall, abdominal and pelvic, lower back, and lower extremity. In addition, cryosurgery is indispensable in dermatology.–19 Nelson et al introduced cryoablation to manage post-thoracotomy pain, and subsequently, recent studies reported that cryoablation could be used for pain management after pectus excavatum correction.,21–24 Cryoanalgesia has been reported to show promising results compared with other pain control modalities. Similar to our study, Keller et al and Graves et al also demonstrated that patients undergoing cryoablation of the intercostal nerves during MIRPE had a shorter length of hospital stay and lesser consumption of opioid agents than those treated with epidural analgesia.Since the first cryoprobe was developed by Cooper in 1961,Theoretically, 12 minutes was required to perform cryoablation in our protocol: 2 minutes per nerve for 3 nerves on each side. Our data showed that the duration of surgery was not statistically different between the 2 groups. Skin incisions were the same for the port and bar insertion; thus, it did not significantly increase the total duration of the procedure. Moreover, unlike in other studies, we performed cryoablation at 6 intercostal nerves, and not 10. In this study, we compared the daily narcotic requirements between the 2 groups. Compared with the cryoanalgesia group, MMEs from postoperative days 0 to 2 were significantly higher in the epidural analgesia group due to the infusion of opioids. However, daily MMEs were constantly low until discharge in the cryoanalgesia group. The differences between the groups decreased after the removal of the epidural infusion catheter. In our protocol, epidural catheters were removed when the epidural infusion was exhausted. We set the infusion for 48 to 72 hours. This led to a significant difference in MME consumption between the groups on postoperative days 0 to 2. reported that there was minimal risk of postcryoablation neuropathic pain in pediatric patients. In 25% of adult patients, the numbness did not resolve, and 3 patients had persistent neuropathic pain. In this study, we aimed to address these concerns. We hypothesized that the more the number of intercostal nerves blocked, higher would be the rate of complications. Therefore, we performed cryoablation at 6 intercostal levels instead of 10. Consequently, in the cryoanalgesia group in this study, 3 patients had no symptoms, whereas 7 had numbness. However, the degree of numbness improved over time in all 7 patients.Neuralgia and numbness of the chest wall are 2 common concerns related to cryoanalgesia. Zobel et alThis study had some limitations. First, the sample size was small. Second, the study design was retrospective in nature. Third, more information, such as longer follow-up duration, is necessary.Despite these limitations, our study had several strengths. Cryoablation in this study was performed for fewer intercostal nerves compared with that in the previous studies, and our patients showed good recovery. The consumption of narcotics was significantly reduced, and the duration of hospital stay was shorter in the cryoablation group.The results of this study showed that intraoperative cryoanalgesia could be easily performed to reduce the postoperative hospital stay and opioid dose. This illustrates that it could be an effective and safe modality for pain management following MIRPE.The authors thank Medical Illustration & Design, part of the Medical Research Support Services of Yonsei University College of Medicine, for all artistic support related to this work.


The primary outcome variable was pain severity, measured by a standardized visual analog scale (VAS). VAS values were collected at 1, 3, 7, and 14 days and 1 and 3 months after patients were treated with NB or PRF. Results: Compared with patients treated with NB (n = 40) and those treated with PRF (n = 48), no significant difference in pain reduction was observed in the short term ; however, in the medium and long term (1 to 3 months), there were statistically significant improvements in the PRF group over the NB group (p < 0.001). Moreover, it was noted that the average pain severity of primary PN and PN due to sacral perineurial cyst was significantly reduced with PRF therapy in the medium and long term when compared to other secondary PNs, including surgery, trauma, and diabetes. Discussion: The ultrasound-guided, improved, and innovative PRF/NB puncture path technique allows for gentler stimulation and faster identification of the pudendal nerve. The PRF technique may provide better treatments for primary PN and sacral perineurial cyst causing secondary PN in the medium and long term.Objectives: To investigate the efficacy and safety of an improved ultrasound-guided pulsed radiofrequency (PRF) and nerve block (NB) for patients with pudendal neuralgia (PN). Methods: This retrospective analysis included 88 adults with PN treated in the Pain Department of Southwest Hospital from November 2011 to June 2021, with treatment including NB ( Pudendal neuralgia (PN) is a well-known medical challenge involving the motor 20%), sensory 50%), and autonomic 30%) functions of the pudendal nerve, with a prevalence of approximately 6.6% in the population in general ,2. The e0%, senso0% functi0%, and aAccurate pulsed radiofrequency (PRF) therapy combined with nerve block is a novel method to improve the function of pudendal nerve and to relieve the pain of PN patients ,9. In reAt present, only a few cases and clinical trials involving nerve block or PRF techniques for refractory PN have been conducted due to insufficient study populations and follow-ups. The objectives of this retrospective study are as follows: (1) to find a novel, simpler, and faster puncture path for ultrasound-guided stimulation and confirmation of the pudendal nerve; (2) to compare the therapeutic efficacy and safety between PRF and NB therapies in the medium to long term; and (3) to further discuss and analyze the efficacy of ultrasound-guided PRF for the therapy of secondary and primary PN.This retrospective study was approved by the ethics committee of the First Affiliated Hospital of the Army Medical University, PLA . Hospitalized patients who visited the pain department at Southwest Hospital from November 2011 to June 2021  were eliWe included age, gender, VAS, and short-term  and med-/long-term (1 to 3 months post-treatment) results as variables for the patients treated with NB and/or PRF. Pain severity and pain reduction were reassessed and standardized from the patient’s initial VAS score level to the latest recent VAS score level to increase the objectivity of the data. Lower VAS scores indicated less severe pain, and higher VAS scores referred to more severe pain. Data on pain severity were collected by telephone or Wechat video call follow-up.For patients with PN in the lithotomy position, a previous study described the conventional pudendal NB approach taken . In brieAfter positioning the PN patient in a prone position , a low-fThe day before a patient with PN receives PRF treatment, physicians must determine the effectiveness of pudendal NB therapy under ultrasound guidance. We administer PRF therapy only when the pain severity in pudendal NB is reduced by more than 50% within 2 continuous hours by pudendal NB therapy. An RF needle  with a 5 mm active tip is placed laterally to the internal pudendal artery and is observed to generate a sensory abnormality by stimulation testing  at a frequency of 50 Hz and a voltage of 0.1–0.5 V. The parameters of PRF ablation are then delivered at a frequency of 2 Hz, a pulse width of 20 msec, and a voltage of 45 V and 42 °C for 240 s, with the procedure conducted in two cycles. A total of 5 mL of the compound liquid with 2% lidocaine 1.5 mL, 1% ropivacaine 2.5 mL, and triamcinolone 5 mg is administered after the PRF application. The same PRF procedure is repeated after 5–7 days, with 2 PRF treatments during hospitalization.In this study, the primary outcome was VAS, a standard measure of pain severity. The pain severity ratio was used as a VAS relative ratio, which measured the VAS score at a given time point (post treatment score) over the baseline (pretreatment score) for each patient. A chi-square test was used to demonstrate whether a significant relationship existed between treatment groups and the characteristic variables, including sex, side, and etiology. Thus, a significant result meant that there was a significant difference in pain severity in the characteristic variables. A t-test was applied to test for equality of the variables of age and pain severity within the NB/PRF group. Post treatment VAS values and pain severity at different post treatment time points  were compared with baseline (pretreatment), respectively, with paired t-tests to analyze whether there were significant changes in pain severity pre/post treatment. One-way ANOVA tests were conducted for 4 types of secondary PN comparison. Statistical software SPSS 19.0  was used to analyze the VAS values, and pain severity of the independent variable groups was defined as significantly different at the 0.05 level.p > 0.05, NB vs. PRF, Phone follow-up of the 88 subjects was conducted at 1, 3, 7, and 14 days, and 1 and 3 months after they completed NB or PRF treatment. The follow-up was terminated if there was no treatment effect. No significant side effects were observed in any treated patients. The clinical characteristics of the PN patients are listed in p > 0.05, conventional vs. improved, p < 0.001, BS vs. 1 and 3 days, p > 0.05, BS vs. 7, 14 days, 1 and 3 months, The NB group consisted of 40 patients, including 22 with conventional pudendal NB and 18 with ultrasound-guided improved pudendal NB puncture. There was no significant difference in pain severity from D1 to M3 after NB treatment  and primary (n = 20) PN, had an impact on the outcome of PRF treatment. As shown in p > 0.05, secondary vs. primary, p < 0.05, secondary PN vs. primary PN, p < 0.001, We further analyzed whether the etiology of PN, including secondary (n = 6), trauma , sacral perineurial cyst (n = 6), and diabetes (n = 4). As shown in n = 6) slowly and gradually increased from 21.7% to 43.3% compared to 22 other secondary PN cases in the medium and long term , p < 0.05). All of these results suggested that although some secondary PN is not significantly relieved in the medium and long term after PRF treatment, it could be possible that PRF treatment of secondary PN patents with sacral perineurial cyst results in improvements in the medium and long term.The etiology of secondary PN patients who had received PRF treatment in our Pain Medicine department included surgery  to post treatment , we set relief values > 50% as treated effectively ,17 Tabl. A standn = 40) or PRF (n = 48). Moreover, the new and improved puncture path under ultrasound guidance was evaluated for the first time. The therapeutic efficacy of PRF for the treatment of patients with secondary and primary PN was then further analyzed.In the present study, we explored a novel and improved puncture path technique to alleviate refractory pain in the medium and long term by observing the therapeutic outcomes of patients with PN who were treated with NB (The standardized pain severity measured by the VAS was significantly decreased by 70% or more in both the NB and PRF groups within 3 days (short term) after treatment. In patients with PN who were considered to be refractory to oral systemic lamotrigine and opioids, PRF treatment significantly relieved pain, especially in the medium and long term (1 month and 3 months). Furthermore, we observed that the pain reduction in the medium and long term (1 month and 3 months) was higher in patients with primary PN treated with PRF than in patients with secondary neuralgia. Another important finding was that PRF treatment of secondary PN with a sacral perineurial cyst could reduce the severity of pain compared to the other three etiologies of secondary PN in the medium and long term.The observation data are from 2011 to 2021, which is a long time span. However, we did follow up the treatment effect by telephone or Wechat video call, and from 2011 to 2015, our treatment for pudendal neuralgia was nonvisualized pudendal nerve block, and only five patients were lost to follow-up. We started using ultrasound-guided pudendal nerve block and pulsed radiofrequency therapy in 2016. Therefore, the long time span has little effect on our ultrasound-guided nerve block and pulsed radiofrequency results.At the ischial spine level, the average diameter of the pudendal nerve is only approximately 5 mm . DespiteIn the current study, under ultrasound guidance, the improved puncture approach is from the lateral side of the transducer. In a previous study, the puncture needle was considered an in-plane approach to the conventional pathway from the medial transducer ,20. HoweAll of the patients with PN in this analysis received a 5 mL liquid mixture of lidocaine, ropivacaine, and triamcinolone. In this retrospective study, patients in both the conventional and improved NB treatment had an onset of pain relief approximately 3 days after treatment. It was assumed that the effectiveness of local anesthesia is predominant in the short term, although the half-life of triamcinolone is close to 30 days, which is consistent with other studies ,26. DuriThe most common sequence is to perform PRF with the parameters of 2 Hz pulse frequency, 45 V, 20 msec pulse width, and 42 °C ,27. HoweFrom a long-term perspective, patients with primary PN receiving PRF treatment had better outcomes than those with secondary PN, from which it is speculated that secondary factors of surgery and trauma may lead to adhesions between the local muscle fascia and the pudendal nerve or branches. In PRF treatment, moreover, secondary PN with diabetes also had poor therapeutic results compared to primary PN in the medium and long term, so patients may need further strict control of their blood glucose fluctuations in the future. Another key finding is that PRF treatment had better efficacy for treating PN caused by sacral perineurial cysts than PN caused by the other three secondary factors, especially during the medium and long term. Sacral perineural cyst, also known as Tarlov cyst, is a cystic nerve root lesion that is common in the sacrum ,29. ElsaFinally, we used the VAS to measure pain intensity; a higher VAS score indicates greater pain intensity. Nevertheless, pain reporting may vary according to subjective factors; the same intensity of pain may be reported differently by different individuals. Thus, the pain severity ratio was used as a VAS relative ratio, which measured the VAS score at a given time point (post treatment score) over the baseline (pretreatment score) for each patient. Furthermore, the results indicated a high standard deviation in pain severity after PRF treatment in patients with PN, especially in those with secondary PN. These patients with secondary neuralgia, including surgery, trauma, sacral perineurial cyst, and diabetes, were administered PRF treatment, and only patients with a sacral perineurial cyst had a significant average reduction in pain severity during the medium and long term, which may be the reason for the large standard deviation.The study’s limitations included a single-center design and a small number of patients. Auxiliary technologies, such as virtual reality (VR) and 3D simulation would be required in the future to improve research precision and practicality.In this study, ultrasound-guided, improved, and innovative pudendal NB and PRF puncture path techniques were proven to be safe and effective for PN patients and were more easily implemented once we understood the pudendal nerve and its adjacent anatomical structure. In addition, the PRF technique showed significant improvement in the treatment of primary PN and PN caused by sacral perineurial cyst in the medium and long term. The results of the current study, as well as the ultrasound-guided improved path technique, are particularly important and meaningful for the treatment of PN and should be widely applied.


Two patients present to the sports medicine clinic with shoulder pain and limited range of motion. A 51-year-old healthy female rower presents 5 months after developing left shoulder pain. She had no specific inciting injury, although she increased overhead workouts with dumbbells prior to the onset of pain. She describes soreness that started in the left biceps and then shifted to the lateral shoulder. The other patient, a 61-year-old male golfer with a history of hyperlipidemia and hypertension, developed right shoulder pain also after increasing overhead exercises with weights 3 months prior to presentation. His pain is most significant with sleeping on the right side, abducting the right arm, and lifting heavy objects. Both patients have limited shoulder flexion, abduction, and internal rotation despite 8 weeks of physical therapy.3 It has been estimated to affect less than 1% to 5% of the general population but up to 20% of patients with diabetes.3 The condition is thought to be caused by an initial musculotendinous or tenosynovitis inflammatory process that then leads to capsular thickening and adhesion formation, although this historically accepted pathophysiology has started to be questioned.4 However, both patients in our case presented with a history of increased activities that led to an initial inflammatory process, followed by limited range of motion.Adhesive capsulitis, commonly referred to as frozen shoulder, is a relatively common condition that results in significant pain and limitation of active and passive range of motion of the glenohumeral joint.3 Although adhesive capsulitis is often described as a self-limiting condition that spontaneously resolves after 2 to 3 years, up to 40% of patients experience persistent symptoms, ranging from mild discomfort to permanent disability.3 Treatment options include anti-inflammatory oral medications, physical therapy, steroid injections, capsular or arthrographic distension, and operative management.3 Corticosteroid injections are a common treatment option to treat pain and dysfunction from adhesive capsulitis, and a 2020 meta-analysis showed superior outcomes in short-term pain control, range of motion, and function, as well as longer term functional outcomes with corticosteroid injections compared to no treatment or placebo.1 However, studies and clinical care remain heterogeneous regarding the optimal injection location. This review evaluates whether the site of the corticosteroid injection affects pain control and functional outcomes in patients with adhesive capsulitis.Adhesive capsulitis is characterized by three stages: pain with progressively decreasing range of motion of the glenohumeral joint , stiffness , and, finally, improvement in range of motion with resolution of symptoms .1 in 2020 compared pain, using visual analog scale (VAS) pain scores, and function, using validated scores , in patients receiving intra-articular vs subacromial injections for adhesive capsulitis. The outcomes showed that intra-articular steroid injections were superior to subacromial injections for early short-term (2 to 6 weeks) pain control (P=0.02) but had similar functional outcomes.1 Intra-articular injections had similar late short-term (8 to 12 weeks) pain control and superior late short-term functional outcomes compared to subacromial injections (P=0.03).1 Midterm (<12 months) results were similar in pain and function between the 2 injection sites. When compared to physical therapy alone, intra-articular steroid injections were superior for early short-term function and late short-term pain; however, no differences were seen in midterm results.1 Range of motion was not significantly affected by physical therapy, intra-articular corticosteroid injections, arthrographic distension, or acupuncture, except when intra-articular corticosteroid injection alone was compared to intra-articular injection plus physical therapy which showed that the latter had superior outcomes in the early short-term period only.1Multiple studies, including a number of randomized controlled trials, have evaluated the different sites of corticosteroid injections in the treatment of adhesive capsulitis. A systematic review and meta-analysis by Challoumas et alP=0.02).11 In this review, the corticosteroid selected in 5 studies was 1 mL 40 mg/mL triamcinolone, while 4 studies used 1 mL 40 mg/mL methylprednisolone acetate. In all but 1 study, lidocaine 1% to 2% was mixed with the corticosteroid, with a total volume of 1 to 10 mL injected. Subacromial injections showed greater improvement in internal rotation at 8 to 12 weeks (P=0.02), although this difference in improvement did not translate to a difference in function (the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score7 and the Constant-Murley Score9).11 On subgroup analysis, no further differences in pain or range of motion were seen at time points up to 24 weeks, and the pooled effect showed no overall differences between the 2 injection sites.11 These findings imply that while the 2 injection sites may differ in outcomes at specific time points, improvements do not last longer than the specified time frame.11Another meta-analysis and systematic review by Shang et al in 2019 also indicated better pain relief measured by VAS scores at 2 to 3 weeks following intra-articular injection compared to subacromial injection , and type and amount of steroid and anesthetic injected.12 The posterior approach was placed “2 cm below and lateral to angle of acromion directed towards coracoid,” subacromial was placed “directed towards acromioclavicular joint through supraspinatus muscle,” and subcoracoid was “obtained by running the needle on subscapularis surface 0.5-1 cm inferior and lateral to coracoid passing towards the lateral third of coracoid,” all of which were completed while the arm was externally rotated during the injection of the mixture.12 The Constant-Murley Score9 was used at baseline and follow-up at 3 weeks, 6 weeks, and 6 months postinjection. Pain scores significantly improved at each follow-up point in both groups, but pain improvement in the 3-site injection group was higher and occurred earlier (P<0.0005).12 The 3-site injection group also had more improvement in abduction and external rotation than the single-site injection group and reached near-normal scores in all 3 planes at 6-week follow-up.12Some data suggest that multisite corticosteroid injections may be more effective than an injection at a single site. Pushpasekaran et al conducted a prospective randomized study comparing a group that received a landmark-guided single posterior injection of 40 mg of methylprednisolone and 2 mL of 2% lidocaine (n=43) to another group that received a landmark-guided injection into 3 sites  with the same mixture diluted with 8 mL normal saline.13 The single injection group received 1 mL of triamcinolone acetonide (40 mg/mL) and 2 mL of bupivacaine (0.5%) in the glenohumeral joint. Both groups underwent ultrasound-guided injections. The multisite corticosteroid injections resulted in significantly lower VAS scores at 1 month (P<0.001), 3 months (P<0.001), 6 months (P<0.01), and 1 year (P=0.012) compared with the single-site injection group, as well as significantly better active and passive range of motion at all time points (P<0.05).13In the Koraman et al prospective randomized comparative study, the multisite injection group received 2 mL of triamcinolone acetonide (40 mg/mL), 4 mL of bupivacaine (0.5%), and 34 mL of saline solution divided between the glenohumeral joint, posteroinferior capsule, subacromial space, posterosuperior capsule, biceps long head, and coracohumeral ligament.3 The main side effects reported were pain after injection (29.8%), facial flushing (12.3%), and menstrual irregularities (10.1%), with a number needed to harm for steroid injection vs physical therapy of 11.4 for pain, 9.5 for menstrual irregularities, and 7.1 for facial flushing.3 No studies reported tendon rupture, a theoretical risk of corticosteroid injections.3Koh published a systematic review in 2016 examining the safety of corticosteroid injections.14 Habib and Miari investigated the effects of corticosteroid injections in patients with well-controlled diabetes and knee osteoarthritis.15 The small (n=30) prospective randomized short-term study found that intra-articular knee injections with 20 mg of triamcinolone hexacetonide or 40 mg of triamcinolone acetonide led to significant increases in blood glucose levels, with peak levels at 32.5 hours postinjection when using triamcinolone hexacetonide and 24.5 hours postinjection when using triamcinolone acetonide.15 Given this information, all patients should be counseled on the risk of post corticosteroid injection hyperglycemia.Corticosteroids increase blood glucose levels through increased insulin resistance, especially in patients with underlying diabetes or impaired glucose tolerance.13 Any injection is likely to be superior to physical therapy alone for short-term pain control.1 However, the heterogeneity among the studies should be considered when individualizing a patient's treatment plan.In the treatment of adhesive capsulitis, intra-articular injections appear superior to subacromial injections for short-term pain control, and multisite injections may be superior to single-site injections for pain control and range of motion.13Overall, corticosteroid injections are well tolerated with infrequent significant side effects. The multisite injection studies show promise but used different injection sites and injectate volumes than the studies in the meta-analyses. Also, a limitation of both multisite injection studies is the absence of a control group.P=0.025).16 In contrast, landmark-guided subacromial injections appear to have the same accuracy as image-guided injections .16 In situations when timely referral to a sports medicine or orthopedic specialist is not available for intra-articular or multisite injection, a landmark-guided subacromial injection may be a reasonable first step for pain control in patients with adhesive capsulitis.Some primary care physicians may not feel comfortable giving intra-articular injections, and data suggest that landmark-guided intra-articular injections are less accurate than image-guided injections (72.5% vs 92.5%, Both patients were found to be in the freezing stage of adhesive capsulitis and received a corticosteroid injection in conjunction with physical therapy. The 51-year-old female received a single-site landmark-guided subacromial injection of 1 mL of 40 mg/mL triamcinolone acetonide and 4 mL of 1% lidocaine without epinephrine, while the 61-year-old male received a landmark-guided glenohumeral intra-articular injection with 1 mL of betamethasone 6 mg/1 mL and 4 mL 1% lidocaine without epinephrine. Post intra-articular corticosteroid injection, the male patient had improved pain and function, measured using the Shoulder Pain and Disability Index, and restoration of uninterrupted sleep at 2 weeks and 10 weeks. At 11 weeks after the injection, his range of motion had improved by approximately 15° of forward flexion and 5° of both internal and external rotation. Post subacromial injection, the female patient had improvement in pain and function, also measured using the Shoulder Pain and Disability Index, at 4 weeks, although she reported that the relief decreased at 8 weeks postinjection. She did not have improvement in range of motion.


To assess the relationship between pre-operative psychological state, postoperative pain and function one year after total shoulder, hip or knee arthroplasty.Patients undergoing shoulder, hip or knee arthroplasty between March 2014 and November 2015 were included. Pain catastrophizing score (PCS) was determined preoperatively, at six months and at one year follow-up. Joint pain at rest was quantified using a Visual Analogue Scale (0‒100). Depressive symptoms were measured using the Beck Depression Inventory or Geriatric Depression Score, situational anxiety and dispositional anxiety were measured using the State-Trait Inventory and joint function was assessed using the Western Ontario and McMaster Universities Osteoarthritis Index for the hip and knee and Oxford Shoulder Score for the shoulder.2). Pre-operative PCS was significantly correlated with pain > 30/100 at one year and with functional scores, for all joints. Multivariate analysis identified the following variables as risk factors for pain intensity > 30/100 at one year: pre-operative PCS > 20/52 , trait-anxiety score ≥ 46 , pre-operative pain ≥ 60/100  and pain for at least 3 years .A total of 266 patients were included  age: 71.8 ± 10.3 years; mean body mass index: 27.5 ± 5.0 kg/mPre-operative pain catastrophizing and trait-anxiety are risk factors for post-operative pain after shoulder, hip and knee arthroplasty.www.clinicaltrials.gov NCT02361359. Total knee arthroplasty (TKA), total hip arthroplasty (THA) and total shoulder arthroplasty (TSA) relieve pain and improve physical performance in patients with osteoarthritis. However, 7‒23% of patients after THA and 10‒34% after TKA continue to report pain 12 months after surgery .One important risk factor for poor pain and functional results is pre-operative mental health, especially anxiety, affecting patients undergoing TKA , 7 or THThe aim of this study was to analyse the correlation between pre-operative psychological state and pain and function 1 year after TSA, THA or TKA. The secondary aim was to quantify the relationship between psychological factors and chronic joint pain at one year follow-up. Our hypothesis was that there would be a less favourable clinical outcome in patients with pre-operative psychological distress, mainly pain catastrophizing, irrespective of the joint.This prospective, single-centre study was conducted between March 2014 and November 2015. All patients undergoing TSA, THA or TKA because of primary degenerative arthrosis, > 18 years of age, autonomous and living at home were included. Exclusion criteria included the following: previous surgery on the same joint, absence of consent or patient unable to understand the questionnaires.https://clinicaltrials.gov/ .The study was performed in accordance with the Declaration of Helsinki and was approved by the local institutional review board (CPP). All individuals involved in the study gave their informed consent. The study was registered with The main evaluation criterion was pain catastrophizing score (PCS)  determinThe secondary evaluation criteria were joint pain at rest quantified using a Visual Analogue Scale (VAS) from 0 (none) to 100 (worst imaginable pain), the Beck Depression Inventory (BDI)  or the Gr) of 0.8, with a confidence interval (CI) of 0.20 and a risk of error (α) of 0.05. The CI was 0.204 (0.676‒0.880). The sample should be at least 56 per group. Assuming a 5% rate of incomplete questionnaires, the number of patients included in each of the three groups  must be at least 60, resulting in a minimum of 180 patients recruited.The number of patients necessary was calculated to obtain a Pearson’s correlation coefficient  using the paired Student’s t test and between several independent groups by analysis of variance. For qualitative variables, the chi-square test was used following a trend test in the case of a comparison of several independent groups and the McNemar test for paired groups (before/after). Correlations were investigated using Pearson’s correlation coefficient. The correlation was considered strong (r > 0.5), moderate (0.5 < r < 0.3) or weak (0.3 < r < 0.1). The optimal cut-off value of pre-operative PCS for pain with an intensity of > 30/100 at 1-year follow-up (yes/no) was determined by constructing receiver operating characteristic (ROC) curves, with sensitivity (Se) as the abscissa and specificity (Sp) as the ordinate. This cut-off value was chosen to obtain the highest Se and Sp possible with the best proportion of subjects well classified. The positive likelihood ratio (LR +) and negative likelihood ratio (LR −) were calculated. The diagnostic interest of preoperative PCS was evaluated from the area under the ROC curve (AUC) as follows: nil (AUC = 0.5), poorly informative (0.5 < AUC < 0.7), fairly informative (0.7 ≤ AUC < 0.9), highly informative (0.9 ≤ AUC < 1) and perfect (AUC = 1). The risk factors for pain intensity > 30/100 after 1 year were investigated by multivariate logistic regression analysis including all variables with a p value < 0.20 in univariate tests. A p value < 0.05 was considered statistically significant. All statistical analyses were carried out using Stata 10.For quantitative variables, differences between two independent groups were determined using Student’s p = 0.03) and had a lower BMI (p = 0.004) and joint pain appeared later (p = 0.0002) than in the other two groups . However, at one year follow-up, significantly less patients undergoing TSA had neuropathic pain compared to the TKA and THA groups . No significant differences were found in the proportion of patients with pain intensity > 30/100 at 1 year . Total mean (± SD) pre-operative PCS (/52) was 13.9 ± 9.9 for TKA patients, 14.3 ± 9.1 for THA and 13.8 ± 9.5 for TSA  pain intensity (/100) between the three groups . The optimal pre-operative PCS cut-off whatever the prosthetic joint was 20/52 .In the TKA group, pre-operative PCS was fairly informative of pain intensity > 30/100 at 1 year (AUC = 0.83 ± 0.04 [95% CI: 0.75‒0.91]). The optimal pre-operative PCS cut-off was 18/52 .In the THA group, pre-operative PCS was fairly informative of pain intensity > 30/100 at 1 year (AUC = 0.81 ± 0.04 [95% CI: 0.72‒0.89]). The optimal pre-operative PCS cut-off was 19/52 .In the TSA subgroup of patients, pre-operative PCS was poorly informative of pain intensity > 30/100 at 1-year (AUC = 0.67 ± 0.07 [95% CI: 0.53‒0.81]). The optimal pre-operative PCS cut-off was 23/52 .p < 0.00001), had suffered from pain for longer before surgery , had a significantly worse QoL mentally (SF12 MS (/100): 39.3 ± 10.2 vs. 47.2 ± 10.4; p < 0.00001), had significantly greater pre-operative catastrophism ((/52): 20.1 ± 8.6 vs. 11.3 ± 8.5; p < 0.00001), were significantly more anxious (STAI trait (/80): 39.6 ± 9.5 vs. 34.2 ± 9.4; p < 0.00001; STAI state (/80): 39.3 ± 11.8 vs. 34.1 ± 10.7; p < 0.0005), were more likely to have moderate to severe depression  and were more likely to experience neuropathic pain .In univariate analysis, patients with pain intensity > 30/100 at 1 year had significantly more pre-operative pain (VAS (/100): 64.8 ± 14.4 vs. 53.3 ± 18.1 (≤ 30/100); p = 0.0001), trait-anxiety score ≥ 46 , pre-operative pain ≥ 60/100  and pain for at least 3 years . After adjustment, the variable ‘type of prosthesis’ was eliminated from the final model.Multivariate analysis included the following variables: sex, BMI ≥ 30), type of prosthesis  and pre-operative pain intensity (≥ 60/100), pain duration (≥ 3 years), SF12 mental dimension (< 50%), PCS (> 20), STAI trait (≥ 46) and state (≥ 46) and existence of moderate‒severe neuropathic pain. The following were identified as risk factors for pain intensity > 30/100 at 1 year , 83 patients (31.2%) had pain intensity > 30/100 vs. 242 (91%) pre-operatively (p < 10−5) and 56 (21.1%) patients suffered from neuropathic pain vs. 90 (35%) pre-operatively (p = 0.0003). Function was significantly improved for all types of joint at one year .At one year follow-up, patients expressed significantly less catastrophism and were less anxious compared to their preoperative state. However, no improvement was noted in the existence of moderate‒severe depression. A significant improvement was observed in joint pain, neuropathic pain and QoL. Mean intensity of joint pain at one year (/100) was 23.7 ± 20.2 vs. 56.9 ± 17.8 pre-operatively , 14.3 for THA  and 13.8 for TSA .This study has several strengths. It is the first to compare the influence of psychological factors, particularly pain catastrophizing and anxiety, on knee, hip and shoulder arthroplasty outcomes. In previous studies, pain catastrophizing was related to anxiety and depression and had an influence on TKA and THA outcomes. Our study is the first to include shoulder arthroplasty in this correlation. However, our study is limited by the number of patients, which was too small to determine the influence of depression on arthroplasty results. Depression is considered to be partly responsible for poor pain and functional results.According to our results, catastrophizing is strongly related to CPOP after THA and TKA, but less so after TSA. This could be because the hip and knee are joints of the lower limbs and are therefore more handicapping than those of the upper limbs.A recent publication  showed tIn conclusion, high pre-operative catastrophizing and trait-anxiety are risk factors for CPOP after shoulder, hip and knee arthroplasty.