Few guidelines exist on safe prescription of postoperative analgesia to obese patients undergoing ambulatory surgery. This study examines the preferences of providers in the standard treatment of postoperative pain in the ambulatory setting.Providers from five academic medical centers within a single US city were surveyed from May–September 2015. They were asked to provide their preferred postoperative analgesic routine based upon the predicted severity of pain for obese and non-obese patients. McNemar’s tests for paired observations were performed to compare prescribing preferences for obese vs. non-obese patients. Fisher’s exact tests were performed to compare preferences based on experience: > 15 years vs. ≤15 years in practice, and attending vs. resident physicians.p = 0.002); for moderate pain, 329 (72.7%) for obese patients vs. 348 (77.0%) for non-obese (p = 0.011); for severe pain, 398 (88.1%) for obese patients vs. 423 (93.6%) for non-obese (p < 0.001). Less experienced physicians are more likely to prefer an opioid for obese patients with moderate pain: 70 (62.0%) attending physicians with > 15 years in practice vs. 86 (74.5%) with ≤15 years (p = 0.047), and 177 (68.0%) attending physicians vs. 129 (83.0%) residents (p = 0.002).A total of 452 providers responded out of a possible 695. For mild pain, 119 (26.4%) respondents prefer an opioid for obese patients vs. 140 (31.1%) for non-obese (While there is a trend to prescribe less opioid analgesics to obese patients undergoing ambulatory surgery, these medications may still be over-prescribed. Less experienced physicians reported prescribing opioids to obese patients more frequently than more experienced physicians. There is growing concern regarding overprescription of narcotic pain medication following ambulatory surgery. The use of postoperative opioid medication increases the risk of opioid-related morbidity, particularly gastrointestinal, cardiorespiratory, and central nervous system depression –3. FurthThese risks are further magnified in obese patients undergoing surgery. Obese patients are at increased risk of opioid-induced respiratory complications –16. AddiThe past decade has seen an increase in the prevalence of obesity and the number of ambulatory surgeries performed , 26. HowAs such, there is a need to assess the attitudes and preferences of providers regarding their approach towards managing postoperative pain. This study surveys the preferences of providers in a large, urban network of academic health centers regarding their postoperative analgesic protocols of choice for their obese and non-obese patients following ambulatory surgery.Providers caring for ambulatory surgery patients within a consortium of five medical centers in New York, NY from May through September 2015 were surveyed. These hospitals have a strong community presence and treat a diverse socioeconomic population with a wide adult age range. Providers surveyed were all of these hospitals with an appointment in a surgical department who have medication prescribing priveleges. While all analgesic orders are generally reviewed by the attending surgeon, all providers in this study have the ability to independently propose and place orders for pain medication. At each participating hospital in this study, ambulatory surgery is defined as any surgery in which the patient is discharged on the same day as the operation. The participating hospitals are insured by the same medical liability company directed by a group of physicians focused on patient safety. This company regularly undertakes patient safety evaluations and quality initiatives aimed at identifying and mitigating patient risk.For this pilot study, there was interest in evaluating the providers’ baseline attitudes regarding use of opioid analgesia in patients with obesity, a population known to be at increased risk for respiratory complications. Threfore, a structured questionnaire was developed with the aim of eliciting current practice habits from these providers. Survey participants were asked to indicate their role , specialty, and years in practice . They were asked to indicate whether there is a BMI at which they will not perform ambulatory surgery on a patient, and if so, to indicate the BMI. They were then asked to provide their most frequently prescribed postoperative analgesic to obese and non-obese patients based upon the predicted severity of pain: mild, moderate, or severe. Survey participants either completed paper versions of the survey during departmental meetings or received an electronic version through e-mail. Responses were recorded into an encrypted database with uniquely generated, de-identified respondent IDs linked to further protect respondent identity as well as to prevent duplicate submissions.The primary objective was to examine whether providers indicated different prescribing preferences for their obese vs. non-obese patients given the predicted severity of pain. Therefore, for each analgesic protocol indicated in the survey, the percent of providers that preferred the analgesic was calculated for both obese and non-obese patients for each pain severity level . McNemar’s tests for paired observations were performed to compare the prescribing preferences of the providers for their obese vs. non-obese patients. For each pain severity level, the proportion of providers who indicated an opioid vs. a non-opioid protocol, as well as the proportion indicating each individual analgesic, were compared between obese and non-obese patients.p-values less than 0.05 were considered significant.The secondary objective was to examine the relationship between provider experience and prescribing preferences. First, attending physician respondents were categorized by years in practice, with more experienced attending physicians defined as those with greater than 15 years in practice, and less experienced defined as 15 years or fewer. This designation was a pragmatic decision based on surveys routinely distributed throughout the medical community that group providers similarly –33. The A total of 452 providers, out of a possible 695, responded to the survey for an overall response rate of 65%. Of these, 260 (57.5%) were surgical attending physicians, 155 (34.3%) were surgical residents, and 24 (5.3%) were physician assistants or nurse practitioners. Of the surgical attending physicians, 113 (43.5%) had been in practice for greater than 15 years, and 116 (44.6%) less than or equal to 15 years. Of the surgical residents, 34 (21.9%) were PGY-1, 35 (22.6%) PGY-2, 27 (17.4%) PGY-3, 30 (19.4%) PGY-4, 16 (10.3%) PGY-5, and 9 (5.8%) PGY-6 or greater. The most represented subspecialties were general surgery , obstetrics and gynecology , and orthopedic surgery  (Table Table p = 0.002). The most commonly listed analgesics for mild pain were acetaminophen, NSAIDs, and acetaminophen plus oxycodone. For moderate pain, 329 (72.7%) providers would prescribe an opioid to obese patients compared to 348 (77.0%) providers for non-obese patients (p = 0.011). For severe pain, 398 (88.1%) providers preferred an opioid for obese patients compared to 423 (93.6%) providers for non-obese patients (p < 0.001). For both moderate and severe pain, the most commonly preferred analgesics were acetaminophen plus oxycodone, acetaminophen plus codeine, and NSAIDs.For mild pain, 119 (26.4%) providers indicated an opioid as their analgesic of choice for obese patients compared to 141 (31.1%) providers for non-obese patients (p = 0.047). There were no significant differences between the proportions of more vs. less experienced attending physicians who indicated an opioid as their analgesic of choice for obese patients with either mild or severe pain.Table p = 0.023). Similarly to obese patients, there were no significant differences between the proportions of more vs. less experienced physicians who indicated an opioid as their analgesic of choice for non-obese patients with either mild or severe pain.For non-obese patients with moderate pain, 75 (66.7%) more experienced attending physicians indicated an opioid as their choice analgesic compared to 93 (80.2%) less experienced attending physicians (p = 0.002). There were no significant differences between the proportions of attending vs. resident physicians who indicated an opioid as their analgesic of choice for obese patients with either mild or severe pain.Table p < 0.001). Similar to obese patients, there were no significant differences between the proportions of attending vs. resident physicians who indicated an opioid as their analgesic of choice for non-obese patients with either mild or severe pain.For non-obese patients with moderate pain, 186 (71.7%) attending physicians indicated an opioid as their choice analgesic compared to 135 (87.1%) resident physicians (This study is one of the first to describe attitudes and preferences regarding opioid prescription to obese patients from the provider perspective. Most previous studies on this topic report data at the patient or the medical encounter level; i.e. how many patients received opioids, how many prescriptions for opioids were filled at pharmacies, or how many hospital visits included a prescription for opioids –37. The However, the results from this study appear to confirm and contribute data toward the fact that providers may be overprescribing opioid analgesics to patients. Indeed, even for mild pain, about 30% of providers in this study stated their preference for an opioid analgesic. A notable result from this study was the finding that less experienced physicians – i.e., residents and attending physicians who have been in practice for 15 years or less – were more likely to prefer opioid medication for both their obese and non-obese patients with moderate pain compared to their more experienced counterparts. The results from this study may be suggestive of a difference in treatment priorities between younger and older physicians. It is possible that younger physicians are more concerned about preventing and treating their patients’ postoperative pain, whereas older physicians are more worried about opioid-related complications. Several reports from the primary care literature have found that younger physicians are less confident in their understanding of opioids, less confident with managing pain, and more reluctant to prescribe opioids, seemingly in conflict with the results of this study , 41. HowGiven the heterogeneity in postoperative pain management approaches found amongst providers in this study, and the possible gaps in understanding regarding pain control and opioid prescription that it highlights, there remains a need for standardized postoperative analgesic protocols. Recommendations for postoperative analgesia that are focused on obese patients emphasize the need to limit opioid use and propose strategies such as preoperative doses of NSAIDs, opioid alternatives, and multimodal analgesia , 43–49. This study has several limitations that are necessary to mention. First, all of the providers are employees of the participating hospitals within the consortium insured by the single medial liability company. All of these hospitals serve the New York City community. While this is a socioeconomically diverse community, the providers themselves may share common practices by virtue of being within a common academic setting. The results may not be generalizable to providers working in different settings, such as more rural communities or those in private/independent practices. Additionally, the survey relied on providers’ subjective interpretations of mild, moderate, and severe pain. One way to address this would have been to design a study in which clinical vignettes are given to the providers, and they are asked to propose an analgesic protocol. However, the primary objective of this study was to assess providers’ baseline attitudes and perceptions regarding postoperative analgesia for obese patients. It was felt that the more straightforward approach – i.e., asking directly about management with respect to pain severity – would avoid confounders such as age, demographics, and other comorbidities that, while allowing for a more standardized assessment of analgesic management, would detract from the primary question of pain control in obese vs. non-obese patients. Additionally, this was not meant to be an educational intervention, and there was concern that exposure to such vignettes would inadvertently lead to changes in patient care before a proper evaluation of baseline provider habits was assessed. Furthermore, providers were asked to identify a BMI above which they would not perform surgery. There is a risk that this oversimplifies the complexities involved in determining whether a patient is a candidate for surgery, including the patient’s comorbidities and the type of procedure being done. However, this study focused specifically on ambulatory surgery, which is defined in this study as surgery in which the patient leaves the hospital on the same day. This was felt to be a sufficiently narrow clinical scope for the purposes of this survey. Lastly, it is possible that the design of the survey could contribute towards survey bias. Providers were asked to fill in their preferred analgesic protocol for obese and non-obese patients for different levels of severity side-by-side. It is possible that providers would reflexively assume that they should input different responses upon seeing this format, when in practice their analgesic management of obese vs. non-obese management is not different. However, the fact that there was such a heterogeneous set of responses, including a high rate of providers who preferred opioids for mild pain as mentioned previously, seems to underline the initial motivation behind this study – that there are very few guidelines to aid in the management of these patients.This study, which aimed to survey of the prescribing preferences of providers for the pain management in obese and non-obese patients after ambulatory surgery, found that while providers tend to favor opioid analgesics less for their obese patients, many providers still prefer opioid analgesics even in situations when they may not be necessary. Furthermore. less experienced physicians may be prescribing narcotics at higher rates to both obese and non-obese patients than more experienced physicians. These results emphasize the need to develop post-discharge analgesic protocols with specific consideration for patients with obesity in order to provide adequate pain control while minimizing the risk of opioid-related adverse events.


The aim of this study was to examine patients' and physicians' satisfaction, and concordance of patient-physician satisfaction with patients' pain control status.  This cross-sectional observational study involved 465 adults prescribed analgesics for cancer-related pain from 22 sites across Indonesia, Malaysia, Philippines, Singapore, Thailand, and Vietnam. Pain intensity, pain control satisfaction, and adequacy of analgesics for pain control were documented using questionnaires. P < 0.001 for all).  Most patients (84.4%) had stage III or IV cancer. On a scale of 0 (no pain) to 10 (worse pain), patients' mean worst pain intensity over 24 hours was 4.76 (SD 2.47). More physicians (19.0%) than patients (8.0%) reported dissatisfaction with patient's pain control. Concordance of patient-physician satisfaction was low . Most physicians (71.2%) found analgesics to be adequate for pain control. Patients' and physicians' satisfaction with pain control and physician-assessed analgesic adequacy were significantly different across countries (NCT02664987). Despite pain-related problems with sleep and quality of life, patients were generally satisfied with their pain control status. Interestingly, physicians were more likely to be dissatisfied with patients' pain control. Enhanced patient-physician communication, physicians' proactivity in managing opioid-induced adverse effects, and accessibility of analgesics have been identified to be crucial for successful cancer pain management. This study was registered at ClinicalTrials.gov (identifier  Pain associated with cancer is prevalent and negatively affects a patient's psychological and emotional states . ApproxiPatient satisfaction may be used as a key indicator of the effectiveness of cancer pain management in terms of analgesic treatment outcomes . PreviouDespite established cancer pain management guidelines and effective pain medications, a substantial number of patients with cancer pain in Southeast Asia (SEA) still remain inadequately treated for pain symptoms , 9. AlthThis was a multicenter, multinational, cross-sectional, observational study conducted between October 2015 and December 2015 at 22 sites in 6 SEA countries . Eligible patients were recruited based on these criteria: at least 18 years old; diagnosed with cancer pathologically; outpatients with cancer pain due to cancer itself or its treatment; and treated with any analgesics for more than one month for the management of cancer pain. Patients were excluded from the study if they met any of the following criteria: had an operation for any reason within 3 months; had an oncologic emergency; had any interventional therapy  related to cancer pain within the past 6 weeks; and current participation in any other interventional clinical trials for cancer treatment or supportive care. All patients provided written informed consent before study enrolment.Study protocol, case report forms, and documents used for obtaining patients' informed consent were reviewed and approved by the local ethics committee at each study site. All study procedures were conducted in accordance with the Declaration of Helsinki and in compliance with local regulatory requirements.Patient demographics, cancer characteristics, treatment histories, and current analgesic prescriptions were obtained from medical records. Questionnaires were administered to patients for self-assessment of worst pain intensity over the past 24 hours , from 0 (no pain) to 10 (worst pain imaginable) ), sleep P values < 0.05 were considered statistically significant. All statistical analyses were performed using R version 3.1.3 .Of 465 patients recruited into the study, 462 patients met eligibility requirements and were included in the analyses. Patient demographics, cancer characteristics, treatment histories, pain intensities, EQ-5D-3L responses, satisfaction with pain control, and total daily dose of analgesics prescribed were summarized using descriptive statistics. Quantitative variables were summarized as mean (SD) whereas qualitative variables were expressed as number (percentage). Concordance of satisfaction with pain control between patient and physician was evaluated by weighted kappa statistics and McNemar test. A total of 465 patients from 6 SEA countries  were recruited into the study. Three patients did not fulfil eligibility criteria and were excluded from the analysis , leaving 462 patients in the analysis population.The analysis population consisted of 46.3% males and 53.7% females, and the mean age of patients was 55.14 (13.39) years. The majority of patients (84.4%) were diagnosed with stage III or IV cancer, and 93.1% had received surgery, radiotherapy, or chemotherapy .n=248) were prescribed a combination of nonopioid and opioid analgesics to manage their cancer pain. On the other hand, 37.0% (n=171) received only opioid analgesics, while 9.3% (n=43) received only nonopioid analgesics. Of those who received opioid analgesics (n=419), more received at least one strong opioid (57.8%) than weak opioids alone (42.2%). Morphine  and tramadol  were the most frequently prescribed strong and weak opioids, respectively.More than half of all patients . Responses to the EQ-5D-3L questionnaire revealed that 82.3% of patients experienced problems with pain/discomfort, 65.8% with usual activities, 58.2% with mobility, 56.3% with anxiety/depression, and 39.2% with self-care . More thP < 0.001); satisfaction was the highest in the Philippines and the lowest in Malaysia (Supplementary P < 0.001); satisfaction was the highest in Singapore and the lowest in Indonesia  than those who were less satisfied with pain control ; adequacy was assessed to be the highest in Singapore and the lowest in Indonesia .Concordance of patient-physician satisfaction with patients' pain control status is depicted in Evaluating overall concordance of satisfaction with pain control between physicians and patients, a weighted kappa of 0.36  was obtained, suggesting low overall agreement on satisfaction with pain control. Concordance of patient-physician satisfaction based on weighted kappa appears to be highest in the Philippines and lowest in Indonesia  most patients were satisfied with pain control despite unrelieved moderate pain, (ii) low concordance between patient- and physician-reported satisfaction with patients' pain control status, and (iii) physicians tended to be less satisfied with the level of pain control than their patients.Interestingly, patient satisfaction with pain control was unexpectedly high (60.2%) in our cohort despite clear evidence of unrelieved moderate pain (mean worst pain intensity in the last 24 hours: 4.76 (SD 2.47)). This phenomenon was particularly perplexing given that the majority of patients also reported problems with pain/discomfort (82.3%) and sleep disturbance due to pain 54.8%). Notably, the coexistence of patient satisfaction with pain control and unrelieved moderate to high pain has been reported by others in the literature –18. Some4.8%. NotA recent study found a discrepancy in reported cancer pain intensity between patients and physicians, suggesting that clinical assessments by patients and physicians may not always be aligned . Indeed,The small proportion of patients who were less satisfied with their pain control compared to their physicians also contributed to the low patient-physician concordance in satisfaction observed in the present study. Patient-physician contact time is an underrated yet crucial determining factor for both patient satisfaction and physician satisfaction with cancer pain management . PatientAmongst the 6 SEA countries included in the present study, Indonesia scored the lowest for physician satisfaction, patient-physician concordance in satisfaction with pain control, and adequacy of analgesics. In addition, median daily doses of the weak opioid, tramadol, and the strong opioids, fentanyl and morphine, were also the lowest in Indonesia amongst all studied countries. Notably, the median daily dose of prescribed morphine was only 20.00 mg in Indonesia—one third of the dose reported to be effective for opioid-tolerant patients with moderate pain . These oIn the present study, study outcomes were primarily evaluated using self-reporting tools. Assessments depending solely on such tools are often one-dimensional and do not capture all aspects of the treatment experience . In addition, owing to the cross-sectional study design, data on all variables were collected only once, and the associations identified between variables were difficult to interpret. The relationship between the variables measured and prescribed analgesics may be better reflected if the questionnaire had been administered before and after analgesic treatment. It is also important to note that variations across countries in patient education levels, types of hospitals , number of recruited patients , and physicians' education regarding cancer pain management were not taken into account in the comparison of data across countries. More importantly, our findings may not be representative of the whole range of clinical settings for pain management in SEA. Cancer pain management in less-developed regions of SEA is, therefore, likely to be more challenging in reality as issues with healthcare systems and analgesic accessibility and availability still persist.The results of our study highlight the complexity of managing cancer pain in SEA. Despite relatively high patient-reported satisfaction with analgesic treatment for pain control, many patients still reported unrelieved pain, problems with quality of life, and sleep disturbance due to pain. In addition, there was low concordance between patients' and physicians' satisfaction with patients' pain control. Successful management of cancer pain will require action on a number of fronts—firstly, noting that patient-reported pain measures are often one-dimensional and do not capture all aspects of the patient's pain control status, an all-round assessment of patients' pain symptoms  would be crucial in assessing the effectiveness of prescribed analgesics. Additionally, one important finding of this study is the evidence of a gap in satisfaction with pain control between patients and their physicians, which suggests a need for further improvements in patient-physician communication about analgesic treatment expectations and pain control. To improve patients' analgesic compliance and quality of life, physicians are also encouraged to proactively assess and manage opioid-induced adverse effects. Finally, national health policies that support and improve the accessibility of analgesics are welcomed so that patients can access the best possible analgesic treatment for their cancer pain.


Chronic exertional compartment syndrome (CECS) is a condition of pain induced by exercise, and it is characterized by muscle swelling and impaired muscle function in the lower leg. Given the diversity in the diagnosis and treatment of CECS, it is desirable to determine variables pertaining to prognosis and recovery. The purpose of this study is to identify prognostic factors for conservative treatment outcomes in servicemen with CECS who were treated at a Military Rehabilitation Center.t-test or Mann-Whitney U test, according to the normality of the data distribution. Differences between the pre- and post-intervention outcomes were evaluated using the Wilcoxon signed rank test. To evaluate the magnitude of prognostic factors, a univariate logistic regression analysis was performed. The prognostic factors included age, body mass index, body fat percentage, self-efficacy beliefs, foot malalignment, intramuscular pressure, other comorbidities, protein and creatine use, smoking, alcohol use, complaint duration, physical demands, and duration of military service.Patients from all military services were referred from the special unit for lower leg pain at the Central Military Hospital, Utrecht, the Netherlands. Descriptive analysis was used to report the characteristics of the participants and their baseline measurements. Group differences were analyzed using a Student’s After the rehabilitation period, we observed 25 patients with a successful outcome, which was defined as a reduction in pain (≥ 2 points) during the capacity test measured using a verbal rating scale and 20 patients with an unsuccessful outcome. Factors demonstrating a limited increased odds ratio for an unsuccessful outcome included smoking, alcohol use, intramuscular pressure, a complaint duration of more than 6 months, and physical demands of service. However, these factors did not reach significance.This study did not identify any prognostic factors that predict the outcome of a rehabilitation program for CECS. A larger sample using an identical design might provide further evidence regarding prognostic factors, which would facilitate development of a model that predicts the outcomes of a rehabilitation program for CECS. Chronic exertional compartment syndrome (CECS) is an exercise-related condition of the lower leg that is common in athletes and servicemen. In a recent study performed in the United States, 4100 servicemen with CECS were identified over a 6-year period, with an incidence of approximately 0.49 per 1000 person-years [CECS is a condition of pain induced by exertion and is characterized by tightness, muscle swelling, and pain that is classically localized to the anterolateral area of the lower leg . The patIntramuscular pressure (IMP) measurements remain the gold standard for the diagnosis of CECS. However, IMP thresholds vary considerably between studies –11.Studies of CECS treatment have principally focused on the outcomes of surgical management of CECS . Better Given the rates of CECS in the military and the burden of both surgical management and the management of complications, CECS constitutes a significant liability for military healthcare.Only a few studies, which are mostly case series, have reported on the success rate of conservative treatment, e.g., massage, gait training, and chemodenervation, for CECS –20.Although prognostic factors for the outcomes of surgical treatment of CECS have been reported, these factors remain controversial in the literature , 21, 22.To this end, we merged previously examined conservative treatment methods into a multidisciplinary program that combined physical therapy, physical fitness, mental coaching, and application of insoles . Given tThis was a prospective study with the aim of identifying prognostic factors for the outcome of a rehabilitation program for CECS in servicemen treated at the rehabilitation center. All patients were referred from the special unit for lower leg pain at the Central Military Hospital, Utrecht, the Netherlands. The staff of this unit included a surgeon, a physiatrist, and a sports physician who were responsible for deciding whether patients met the inclusion criteria for this study.Patients from all military services of the Netherlands Armed Forces (NAF) between 17 and 45 years old were eligible for this study. Patients referred to the special unit for lower leg pain were screened using the following inclusion criteria: 1) positive IMP measurement (> 30 mmHg) in at least one of the compartments of the lower leg; 2) symptoms of CECS that persisted for >3 months; and 3) CECS as the primary complaint. Patients with other conditions hampering the treatment of CECS as well as patients who had been treated by fasciotomy in the past year or who were not willing to participate in the study were excluded .Ethical approval of this study was obtained by a waiver from the Central Committee for Human Research (CCMO) of the Netherlands and Defense Health Organization (DGO), the Netherlands. All patients provided informed consent.2  and ≥25 kg/m2 (overweight) [All baseline demographic values and prognostic factors were assessed by a trained independent observer at the start of the rehabilitation period at the Military Rehabilitation Centre in Aardenburg. During the initial evaluation, each patient completed a standardized questionnaire and underwent a standardized physical examination. The prognostic value of the following factors was evaluated: duration of military service, age, body mass index (BMI), body fat percentage, self-efficacy beliefs, foot malalignment, IMP measurements, comorbidities, alcohol use, supplement use, smoking status, complaint duration, and the demands of service. BMI was analyzed in a dichotomous manner with a cut-off set at <25 kg/mrweight) . Self-efrweight) . Foot marweight) . IMP meaThe primary outcome measurement at 6 weeks was ‘successful’ or ‘unsuccessful’ rehabilitation, with restoration of function and resolution of pain being the primary goals of rehabilitation. A functional capacity test, which consisted of a 12 min walk or run, was performed at baseline and at 6 weeks. The test was performed by the same observer, who was not involved in the treatment procedure, at the two time points. A ‘successful’ outcome of the rehabilitation program was defined as a reduction in pain (≥ 2 points) during the capacity test, which was measured using the verbal rating scale (VRS) . The VRSAll patients followed the rehabilitation protocol in group sessions 3 times a week for 6 weeks at the rehabilitation center. The rehabilitation protocol was divided into an observation stage of 1 week and a treatment stage of 5 weeks. The indication and treatment objectives were defined based on the observation period. Two physical therapists and a sports trainer were involved in all of the group sessions. The main goal of the treatment protocol is to reduce the complaints as much as possible and to balance the load-carrying capacity to increase the employability of the subject. The treatment protocol is divided into 4 modules. First, the “pre-conditions” module is characterized by normalization of joint mobility and restoration of normal muscle tone. Second, the “body awareness physical training” module consists of strength improvement and endurance of muscle power, especially the calf muscles, through walking instructions and stability training of the core and lower extremities. Third, the “posture and movement” module is focused on functional gait training, deviations when standing, adaptation of footwear and/or inlays and core stability training. Fourth, the “behavioral” module involves a graded activity approach. This protocol has previously been described in detail by Meulekamp et al. .When a successful outcome of the rehabilitation program was obtained, patients returned to their unit with tailored advice for further treatment and support to obtain complete recovery and full return to work. In cases of an unsuccessful outcome, the patient was referred for further evaluation to the lower leg pain unit of the Central Military Hospital, Utrecht, the Netherlands.t-test or Mann-Whitney U test according to the normality of data distribution. Continuous variables are presented as the mean ± SD, unless otherwise noted.All data analyses were performed with SPSS version 22 . Descriptive analysis was used to report the characteristics of the participants and baseline measurements, and the data were tested with the Chi-square test unless otherwise stated. Group differences were analyzed using the Student’s For evaluation of the supplementary patient-reported outcome measurements, we calculated group means with the standard deviation for the differences between baseline and follow-up measurements after 6 weeks. Differences between the pre- and post- intervention outcomes were evaluated using the Wilcoxon signed rank test. To evaluate the magnitude of prognostic factors, a univariate logistic regression analysis was performed, and estimated odds ratios and 95% confidence intervals (CI) were derived.A total of 45 patients participated in this study. The study flowchart is presented in Fig. Ultimately, there were 25 patients with a successful outcome after rehabilitation and 20 patients with an unsuccessful outcome. The baseline assessment and outcomes after 6 weeks of rehabilitation are presented in Table At baseline the successful group reported a lower VRS on the capacity test than the ‘unsuccessful’ group, however, the difference was not significant. Likewise, no significant differences between the successful and unsuccessful groups were observed at baseline for the items severity of leg pain on the NRS current moment and for past week. Only for disability in daily activities on the PSFS, the difference at baseline was significant.At 6 weeks, the successful group experienced a non-significant reduction compared with the unsuccessful group in severity of leg pain during the capacity test. For current pain and past week pain significance was also not observed. For the disability for activities on the PSFS there were significant difference between the successful and unsuccessful groups.In the successful group significant differences were observed for the severity of leg pain on the capacity test, the current pain and disability for activities between baseline and at 6 weeks. Only the severity of leg pain for the past week showed no significant decrease. Notably, in the unsuccessful group, only disability in daily activities, as measured by the PSFS, significantly lower at 6 weeks compared with that at baseline.A univariate logistic regression analysis was performed to evaluate the magnitude of the association between prognostic factors and an unsuccessful outcome Table . FactorsThis study aimed to identify prognostic factors for an unsuccessful treatment outcome in servicemen with CECS who were treated with a rehabilitation program at a military rehabilitation center. The primary outcome of the rehabilitation program for non-operative CECS demonstrated that, in the short term, a modest result could be obtained. Interpretation of these results is difficult given that the study population consists of patients who failed to be rehabilitated after monodisciplinary conservative therapy at their unit. These patients were initially referred to the special unit for lower leg pain at the Central Military Hospital to consider surgical treatment as the obvious option. However, these patients were offered an alternative option, via this study, to participate in a multidisciplinary conservative approach delivered at a military rehabilitation center.Recently, it has been argued that the use of secondary outcome measurements for ‘current NRS’ and ‘NRS in the past week’ is questionable in this context. CECS patients experience pain that develops specifically during exercise, which is an issue that is not addressed by ‘current NRS’ and is only partially addressed by ‘NRS in the past week’ . In the This is the first study exploring prognostic factors for CECS. In the literature, no previous studies have examined the relationship between prognostic factors and the outcomes of conservative treatment. Only one study has evaluated risk factors for CECS. Increasing age, female sex, Caucasian race, junior enlisted rank, and army service were identified as factors that significantly increased the risk of CECS. We considered adopting these risk factors as prognostic factors in our explorative study, yet the number of individuals meeting such criteria in our sample was insufficient .In a ‘nonmilitary’ cohort of conservatively treated patients, outcomes were poor (success rate 41.0%) compared to a cohort undergoing fasciotomy (success rate 81.0%) . HoweverMilitary populations appear to be associated with poorer outcomes after fasciotomy for CECS than civilian cohorts with a success rate between 47.0% and 73.0% . Return Several limitations within this study must be addressed. First, this study is limited by the relatively small sample size of 45 patients, due to the lack of eligible patients with CECS. Because of the limited cohort, a multivariate analysis and prediction model were not possible. However, the results of this study will inform calculations for sample size requirements in future studies that will include more patients undergoing conservative treatment. Second, outcome measurements were exclusively short-term in nature. Since many patients were not able to return to duty at the end of the rehabilitation program, they continued the program within their own unit. Long-term outcome measurements, such as return to duty, are required for a more rigorous assessment of conservative treatment. Furthermore, activity levels, such as aerobic fitness, marching, lifting heavy loads, and field exercises cannot be measured appropriately. These elements, which cannot be controlled for, reflect the limitations of investigating this specific patient population. The number of patients who receive surgical treatment after the rehabilitation program is also an important issue. Third, we did not repeat the IMP measurement after rehabilitation. We refrained from selecting IMP measurements as a predictive factor due to continuing broad debate regarding the relevance of IMP as an indicator for surgery and as an outcome measurement tool , 13. FinOur study confirms modest short-term results for conservative treatment of CECS, as demonstrated in previous studies. However, we were unable to identify significant prognostic factors predicting the outcome of a rehabilitation treatment program for CECS. Since this study is predominantly limited by the relatively small sample size, a larger cohort using the same design might lead to identification of prognostic factors that are significantly related to conservative treatment outcomes. Given that obtained large samples of eligible patients is unlikely, a multicenter study design would be preferable for further research in this domain.


Chemotherapy has been associated with hyperalgesia. This prospective study was designed to investigate the effect of intraperitoneal chemotherapy with lobaplatin on post-operative pain intensity and sufentanil requirements after laparoscopic transabdominal resection of rectal cancer.Eighty subjects  scheduled for laparoscopic transabdominal resection of rectal cancer were included in this study. All subjects received standardized anesthetic and patient-controlled analgesia using sufentanil for 72 h post-surgery, as the only analgesics. Pain intensity scores, cumulative sufentanil requirements and side effects were recorded until 72 h post-surgery.vs. 142 μg; P = 0.008), significantly higher verbal rating scale post-surgery pain intensity scores at rest and with coughing (P < 0.05), and a significantly worse functional activity score (P < 0.05) over 72 h, compared with those without intraperitoneal chemotherapy. There were no post-operative differences in the incidence of side-effects  between the two groups.Following intraperitoneal chemotherapy, patients had a significantly higher total post-operative sufentanil requirement (193 μg Intraperitoneal chemotherapy is associated with significantly increased post-operative sufentanil requirements and pain intensity, suggesting chemotherapy-associated hyperalgesia. It is estimated that 20% to 40% of patients with cancer who receive chemotherapy will develop painful chemotherapy-induced peripheral neuropathy (CIPN), which commonly occurs in patients using taxanes, platinums and vinca alkaloids –3. The schictr.org ( ChiCTR-IOR-17010915 ).Informed consent was obtained from 84 subjects after approval from the Institutional Review Board of Liaocheng People's Hospital. The subjects were recruited preoperatively after a decision to operate made by the Department of General Surgery, during the period January to March, 2017. All subjects presenting for elective laparoscopic transabdominal resection of rectal cancer were included in the data analysis. The inclusion criteria included an American Society of Anesthesiology physical status of I, II or III, age of 46-65 years, and a body mass index less than or equal to 30. The exclusion criteria included contraindications to post-operative patient-controlled analgesia (PCA), an allergy to sufentanil, an allergy to lobaplatin, history of sinus bradycardia or atrioventricular block, history of major psychiatric disorder, history of substance abuse, current opioid use and history of chronic pain. Before surgery, the subjects were instructed in the use of the PCA device, numerical rating scale  and the functional activity score (FAS) for pain assessments. The study was registered at After informed written consent was obtained, a computer-generated randomization table was used to assign the patients into Group L and Group C (n = 40 per group) by an independent anesthetist before the surgery. Before the end of the surgery, a nurse blinded to the study prepared the experimental drug in the preparing room (lobaplatin 100 mg diluted in 500 mL in Groups L or 5% glucose in 500 mL in Group C), and then transferred it to the operation room. After the abdomen was closed, a single i.p. injection of lobaplatin in Group L or 5% glucose in Group C was administered via a drainage tube, and then the drainage tube was clipped for 6 h by the surgeon. The surgeons, anesthetists, nurses and members involved in the acute pain services were blinded to the patient classification.2 concentration at 30-35 mmHg.None of the patients had received any medication before the induction of anesthesia. At the start of the anesthesia, a peripheral venous access was established in the right upper extremity, and a five-lead electrocardiogram, blood pressure, and oxygen saturation were continuously monitored using an automated system (Philips IntelliVue MP50). All subjects received a standardized general anesthetic using propofol (2.0 mg/kg), fentanyl (3 μg/kg) and nondepolarizing muscle relaxation using cisatracurium (0.15 mg/kg) on induction; then, tracheal intubation was performed 3 min later. During the period of anesthesia, general anesthesia was maintained using inspired sevoflurane at 1.5-2.5% and an i.v. infusion of remifentanil at 1 μg/kg/h to maintain hemodynamic limits (both mean blood pressure and heart rate) between 20% less and 20% more than preoperative levels. An additional 0.03 mg/kg of cisatracurium was administrated every hour from induction up to approximately 1 h prior to the end of operation and a bolus of fentanyl (50 μg) was administered after each additional 30 min of anesthesia. No other analgesics were administered during surgery. The subjects were ventilated at a tidal volume of 10 mL/kg, with the aim of maintaining the end-tidal COAfter surgery, all the patients were transferred to the post-anesthesia care unit. The time of recovery of consciousness was defined as time 0. For 72 h after time 0, all subjects were provided with an i.v. PCA pump  as the sole analgesic. The PCA pump was programmed to deliver a bolus dose of 1.6 μg of sufentanil (2 mL), with a lockout of 5 min, no background infusion and a 4 h limit of 24 μg of sufentanil (30 mL). The goal of PCA was to maintain the at rest ≤4 post-operatively. Any subject with inadequate analgesia during the 72-h assessment period had the PCA sufentanil bolus increased to 3.2 μg (4 mL). For patients with a poor response to sufentanil, a NRS score of >7 (or NRS with coughing [NRSc]), or the occurrence of an obvious sufentanil-associated adverse effect, supplemental rescue boluses of 1 g of intravenous paracetamol were administered. The patients were monitored for adverse effects. Hypotension or bradycardia was treated using ephedrine or atropine, respectively, while respiratory depression was treated using naloxone and oxygen. The total dose requirements (72 h) for PCA sufentanil were calculated.The trial was designed only to reach the endpoint of consumption of i.v. PCA sufentanil during the first 72 h after surgery. The secondary outcome measures were the postoperative pain intensity scores, both at rest and with coughing (NRSc), and FAS. Objective pain intensity was assessed using NRS from 0 to 10, where 0 = no pain, 10 = the worst pain imaginable, both at rest and with coughing, at 4, 24, 48 and 72 h after the operation. The FAS is a subjective pain intensity assessment performed by doctors using A, B and C, such that A = not limited: functional activity not limited because of pain, B = mild to moderate limitation: functional activity mildly to moderately limited because of pain, C = severely restricted: functional activity severely limited because of pain. The FAS was also recorded at 4, 24, 48 and 72 h after the operation. The potential side effects of sufentanil were also recorded: nausea, vomiting, pruritus, respiratory depression (defined as a ventilatory frequency of less than eight breaths per minute) and dizziness. Subjects experiencing severe pruritus were offered 0.04-0.1 mg of i.v. naloxone. Any subject who experienced vomiting more than three times a day was treated using i.v. tropisetron (4 mg).Sample size was based on a power calculation, which showed that 35 subjects per group were necessary to achieve 80% power to detect a 20% difference in sufentanil requirement, assuming a significance level of 0.05 , 19. AssThe Kolmogorov-Smirnov test was used to assess the distribution of variables. The homogeneity of variance was determined using Levene's tests. Quantitative data are expressed as mean and standard deviation or median and inter-quartile range. Inter-group comparisons were performed using repeated-measures analysis of variance. Categorical data are expressed as frequency and percentage and were analyzed using chi-squared tests or Fisher's exact tests when appropriate. Probability values of P < 0.05 were considered statistically significant. Statistical analysis was performed using SPSS for Windows version 16.0 .The patient flow chart is presented in Figure The current study is the first clinical study that describes increased post-operative opioid requirements and pain intensity in subjects following intraperitoneal chemotherapy with lobaplatin, with no significant difference in the incidence post-operative nausea and vomiting, pruritus, respiratory depression and dizziness.CIPN is a potentially dose-limiting side-effect, commonly observed after application of various chemotherapeutic drugs including taxanes, vinca alkaloids, platinum compounds, bortezomib and thalidomide ,3. It isThis is consistent with the findings of the current study, in which an increased requirement for postoperative opioids was observed among subjects following IPC. The exact underlying mechanisms of some anti-cancer drugs have only recently begun to be understood. Dorsal root ganglia are considered to be the primary target of Pt drugs, where they cause apoptosis of sensory neurons and DNA damage . The mecDespite the strong evidence for chemotherapy-induced mechanical hyperalgesia, clinical prospective studies to date have yielded varying analgesic requirement patterns. The main reason for this is that human studies rely on the subjective responses of patients to assess pain. Moreover, humans have more control in experimental pain studies, compared with experimental animals in animal studies, and can choose not to participate at all or withdraw at any point during the study. In consideration of the subjectivity of NRS, we used FAS, a three-level scoring method recommended by the Victorian Quality Council to assess pain intensity, as an objective pain intensity assessment method. The FAS is a reliable and valid method, and is suitable for assessing dynamic pain in postoperative patients. It was observed that there were significant differences in the FAS between Group L and Group C at 4 h and 24 h, but no significant difference between Group L and Group C at 48 h and 72 h, indicating that IPC using lobaplatin could induce hyperalgesia in cancer patients.Nausea and vomiting are common complaints after general anesthesia, with a multifactorial etiology. The risk factors for increased post-operative nausea and vomiting include younger age, female gender, prior history of dizziness, a higher requirement for perioperative opioids, a longer duration of anesthesia and specific types of surgery, such as laparoscopic surgery . The incThe current study has some limitations. Firstly, it is a clinical study which provides few clues about the mechanisms of chemotherapy-induced hyperalgesia and only describes an increased opioid requirement and pain severity. Secondly, pain is an objective sensory phenomenon, and its intensity is associated with age, gender, psychological status and life experiences. The current study does not consider those factors, which may have affected the results. Finally, the current study was performed at a single center. Investigations of more diverse populations from different centers and the use of different surgical techniques would furnish more conclusive results.In conclusion, IPC using lobaplatin was found to be associated with increased sufentanil requirements, an increased NRS and a worse FAS within the initial 72 hours after elective laparoscopic transabdominal resection of rectal cancer, compared with subjects who were not treated using lobaplatin. Future studies could explore the mechanisms underlying IPC-mediated lobaplatin-induced hyperalgesia in a clinical setting. A longer term follow-up of patients following IPC, to compare rates of chronic post-surgical pain, would also be potentially beneficial.


Children must often endure painful procedures as part of their treatment for various medical conditions. Those with chronic pain endure frequent or constant discomfort in their daily lives, sometimes severely limiting their physical capacities. With the advent of affordable consumer-grade equipment, clinicians have access to a promising and engaging intervention for pediatric pain, both acute and chronic. In addition to providing relief from acute and procedural pain, virtual reality (VR) may also help to provide a corrective psychological and physiological environment to facilitate rehabilitation for pediatric patients suffering from chronic pain. The special qualities of VR such as presence, interactivity, customization, social interaction, and embodiment allow it to be accepted by children and adolescents and incorporated successfully into their existing medical therapies. However, the powerful and transformative nature of many VR experiences may also pose some risks and should be utilized with caution. In this paper, we review recent literature in pediatric virtual reality for procedural pain and anxiety, acute and chronic pain, and some rehabilitation applications. We also discuss the practical considerations of using VR in pediatric care, and offer specific suggestions and information for clinicians wishing to adopt these engaging therapies into their daily clinical practice. Children have always enjoyed games of “pretend.” While immersed in a game, they often become deeply absorbed and able to ignore aversive stimuli. Immersive virtual reality (VR) is a promising and engaging intervention that may help to decrease pain and anxiety for children undergoing painful procedures and suffering from acute pain. In the context of their medical care, children may also endure chronic pain and discomfort. Because VR makes it possible to transform how patients perceive their bodies, it allows other, novel interventions that are possible in no other medium. Beyond providing distraction and enjoyment, virtual reality may provide a corrective psychological and physiological environment, and can facilitate rehabilitation for pediatric patients suffering from chronic pain, as well as neurorehabilitation for children suffering from stroke and cerebral palsy. With the advent of inexpensive consumer VR systems, the opportunities to research and deploy VR in the clinic have expanded. However, the powerful and transformative nature of many VR experiences may also pose some risks and should be utilized with caution in developing therapeutic VR interventions .In this paper, we will review recent literature in pediatric virtual reality for procedural pain and anxiety, acute and chronic pain, and some rehabilitation applications. We will also discuss clinically relevant characteristics of VR experiences, such as the aspects of presence, interactivity, customization, social interaction, and embodiment. We will review how each of these requires special consideration, and in some cases adaptation of the hardware or software, for a child population. Finally, we will discuss the practical considerations of some currently available consumer VR systems, and offer specific suggestions and information for clinicians wishing to adopt these engaging therapies.We conducted a review evaluating articles that describe the use of VR in pediatric procedural, acute and chronic pain. see  We incluAcute pain is pain directly related to a temporary injury and typically lasts a short period of time (<6 weeks). Procedural pain and anxiety refers to distress derived from medical procedures, including intravenous (IV) injections, vaccinations, anesthesia administration, and other needle-related procedures, as well as other procedures required as part of routine care, such as burn wound dressing changes.p = 0.029). In comparison to standard care, the VR group showed decreased pain as well, though the difference was not statistically significant. Of note, the VR group was the only one in which the patients’ pain during the actual dressing change procedure was reported to be less than the pre-procedure pain [Virtual reality was first used to manage acute pain during painful repetitive dressing changes in patients with burn wounds . Schmitture pain .p = 0.061), which was significantly faster when adjusted for mean burn depth  [p < 0.05) [Brown et al. performed a randomized controlled trial of an interactive VR intervention entitled “Ditto” and showed not only a decrease in self-reported pain and anxiety in pediatric patients undergoing dressing changes, but also an increased rate of epithelialization and faster wound healing in those patients undergoing VR intervention for their procedures , CI: −4.38 to 0.1,  < 0.05) . Additio < 0.05) .N = 42) using a screen-based three-dimensional (3D) program [Virtual reality has also proven successful at lessening procedural pain and distress related to IV placement and other needle-related procedures. In a 2006 study, Gold et al. performed a randomized control trial on 20 pediatric patients requiring IV placement . The VR  program . PediatrBeyond VR’s use in acute pain, it can potentially be used to make patients more familiar and comfortable with procedures. Most hospital procedures are accompanied by some stress or anxiety on the part of pediatric patients. He et al. looked at the effect of therapeutic play on perioperative anxiety, negative emotional manifestation, and postoperative pain . Ninety-Unlike procedural or acute pain, chronic pain is persistent for a period greater than six weeks, often for months or years. It may include chronic headache, abdominal, limb, joint or back pain, neuropathic or sympathetically maintained pain such as complex regional pain syndrome (CRPS), and pain related to other medical conditions. In addition to symptom control, interventions often strive to maintain or improve function and minimize disability. While there is little research on using VR for the treatment of chronic pain in children , promisiVirtual reality may have the potential to amplify the neuromodulatory effects of traditional mirror visual feedback (MVF), which can modify patients’ pathological cortical representations in the group of chronic pain syndromes that includes phantom limb pain, complex regional pain syndrome and fibromyalgia. Mirror visual feedback was first applied to adult patients suffering from phantom limb pain (PLP) by Ramachandran and Rogers-Ramachandran . This teBesides providing a new medium for mirror therapy, VR also allows other avatar configurations to be altered. For example, patients can also experience augmented motion such that a small motion in the physical world maps to a large motion in the virtual one, or vice versa. Thus, a small movement of the arm made in real life could be rewarded by a larger, more apparent arm movement in VR. Conversely, for patients prone to guarding, movements made by patients in real life could be depicted as more restrained in the virtual world , which mThe hypothesis supporting the efficacy of neuromodulatory chronic pain therapies is founded in the association between brain connectivity changes and improvement in chronic pain symptoms. A study conducted by Lebel and colleagues found significant changes in the somatosensory processing of symptomatic pediatric CRPS when compared to post-treatment CRPS patients and control patients . BecauseAs discussed above, VR offers an engaging opportunity for children to practice motions that would be impossible or unsafe in the real world . EspeciaIn addition to alterations in neuronal representation, patients with chronic pain often exhibit a debilitating fear of inducing more pain through movement. This fear not only seriously affects patients’ ability to function; it can also inhibit physical therapy efforts. Trost et al. discusses the use of VR interventions to provide graded exposure treatment for pain-related fear and disability in adults with chronic low back pain . ColladoAnother possible application is the use of a virtual pain coach. A VR experience could reinforce therapeutic movements and exercises in an out-of-clinic environment. This is especially useful for long-distance patients or patients who are unable to be physically present for other reasons . The varFinally, the effects of VR may potentially be augmented by other techniques such as biofeedback or hypnosis. Biofeedback is the process of providing the patient with information on his or her own neurological data such as heart rate variability, temperature, or muscle tension. In a recent pilot study, non-immersive VR mirror visual feedback was used successfully in combination with biofeedback to treat pediatric patients with chronic headaches . VirtualIn the next section, we will discuss five qualities of VR that are of interest in considering clinical applications for children: presence, interactivity, social interactions, customization, and embodiment. We will then summarize current research on how these qualities may be useful for treating children, and note some potential areas of caution see .Presence is the subjective feeling that the user is experiencing the environment and interactions in the virtual world are . It is oAge may influence how virtual environments are experienced. For example, during burn wound care treatment with VR, pediatric patients reported higher levels of presence compared to adults receiving the same treatment . ExperieGiven that children may be more vulnerable to believing virtual experiences as real, virtual environments may need to be carefully selected and contextualized so that children are able to interpret their memories of the experience as derived from media rather than real life. In addition, for some age groups, debriefing post-VR experience may be necessary.Virtual reality therapies incorporating tracked body movements allow for greater interactivity. In a study examining cold pressor-induced pain in 40 children of age 5–13, greater interactivity led to greater pain tolerance . ChildreHigh levels of interactivity, while effective in reducing pain, can be accompanied by a sense of nausea and increased potential for collisions with objects in the real world. Clinicians using VR as therapy should be aware of these minor risks and take appropriate precautions for pediatric patients. The more immersed users are in a virtual environment, the more the sensory input from the real world is occluded, and active users risk painful collisions.Even adults can be at risk of falling or colliding with objects; during set-up, consumer VR systems require users to define a safe “play space”, and displays are equipped with safety warnings and reminders to be careful when users approach the edge of this area. As children move around a virtual space, they may come dangerously close to objects in the real world. Even if children are seated, they should be monitored. Careful spotting is necessary to prevent them from injuring themselves or bystanders by accidentally colliding with real-world objects.In addition, although both children and adults can be prone to “cybersickness” or feeling nausea or dizziness, children may be less able to anticipate and articulate their discomfort. Caretakers and clinicians will need to be aware of the possible signs of sickness and develop ways to measure children’s discomfort in non-verbal and unobtrusive ways such as how children are moving their bodies. Another alternative is to set pre-determined timers to take short breaks.Many factors affect children’s and adolescents’ attraction to video games, one being their ability to share the experience with friends . The useChildren with chronic pain may have particular deficiencies in their abilities to develop and maintain peer relationships due to increased school absences, decreased physical ability to engage in sports or social activities, and decreased mood and motivation . VirtualHowever, as in real life, children need age-appropriate environments. Social virtual environments where children can interact with others such as High Fidelity (highfidelity.io) or AltspaceVR  may require additional permissions so that outsiders cannot interact with patients. In addition, the risks and benefits of social media are also applicable when social media platforms provide opportunities for patients to engage virtually. While Facebook’s current beta application, Spaces (oculus.com/experiences/rift/), and other environments linked with social media platforms may make it easy for children to engage with Facebook friends in immersive virtual reality, such interactions should not allow children to isolate themselves from face-to-face interactions.Clinicians or patients themselves can select different virtual scenarios, and as commercial VR experiences become more common, there will be more entertainment options from which to choose. Allowing children to contribute towards selecting their virtual experience allows them agency and the ability to tailor content to their interests, as in a study by Ni et al.  in whichAnother area in which customization can be advantageous is in avatar representation. Children can select and customize their own avatar, providing them with a sense of control in a clinical setting that can significantly reduce patient stress . When emWhen body trackers, such as hand trackers, are used in virtual reality, participants can move their tracked limbs in real life and see their movements represented by the movements of their avatars in virtual reality. Thus, when patients are embodied in an avatar, they gain the sense that their avatar body has replaced their real body. This allows interventions that are possible in no other medium.The tracking capabilities inherent in embodied VR experiences also offer clinicians the ability to monitor their patients’ physical movements and quantify rehabilitative effort without relying on self-report data. As wearable monitors for tracking physiological data such as gait and posture become increasingly used, clinicians may observe their patients on multiple levels and tailor their treatment accordingly. As with all patient data, movement data in children must be carefully protected.Movement is not the only aspect of patient activity that can be visualized. Biofeedback is one arena that would lend itself well to the flexibility of virtual reality, allowing the visualization of pain-linked physiological signals. This could be particularly useful for children who may not be as adept as adults at verbally describing sensory information, or translating verbal instruction into action. An example is described in a recent pilot study mentioned above, where non-immersive VR mirror visual feedback was used in combination with biofeedback to treat pediatric patients with chronic headaches .In VR, patients can also be embodied in novel avatars, or avatars that do not conform to the limitations of their physical bodies ,58. As dClinicians looking to integrate virtual reality into their practice may benefit from the following information about the strengths and limitations of current consumer VR set-ups.At a minimum, virtual reality requires a display in which the user sees the virtual environment. In the most common consumer systems, this is done through a head-mounted display (HMD). An HMD is a type of VR headset that displays digital images on two screens in front of the user’s eyes. In phone-based VR systems such as Gear VR, Google Cardboard or Google Daydream, the HMD consists of a smartphone wrapped in an inexpensive case with lenses, such that the phone provides both the computing power and display. In more powerful VR systems, such as the Oculus Rift or HTC Vive, the content displayed on the headset is generated by a desktop or laptop computer certified as “VR ready” by the manufacturer, or, in the case of PlayStation, by a video game console. In all of these systems, the user’s movements are tracked, and the system updates the content that is displayed to the user based on these tracked movements. Thus, as a child turns her head when looking around a virtual environment through an HMD, the content updates on the screens in front of her eyes, just as it would in the physical world if she turned her head to look at a different part of the room. Brief descriptions of some currently available consumer systems are found in Tracking users’ movements while they experience VR is a key factor in creating realistic and compelling scenarios . Two kinIn VR systems that only have orientation, users are unable to move through scenes using their own body movement . Instead, users might navigate through virtual environments using gaze, touchpad input or other less-embodied navigation techniques. Currently, smartphone-based devices tend to track only head orientation. While these systems are more limited in some respects, they are generally portable and self-contained, and require very little set-up time or space to use. They are also lighter, cheaper and potentially easier to clean and/or have disposable components, all of which may provide significant advantages when using them for pediatric patients.In addition to orientation tracking, systems can also have positional tracking . Position, shown in While they increase the level of interaction available, systems with sophisticated tracking capabilities that include hand trackers tend to be more expensive than those that only capture orientation. While still portable to an extent, more complex systems also require sufficient space for patients to safely move around, and the headsets may be heavier. They will also require more set-up time.Although consumer headsets are designed to be adjustable, they can be too heavy or too large to be easily used by smaller children, as Dahlquist, et al. speculate in their 2009 study . An addiThese issues and more can be easily addressed through modular additions and adaptations to the basic VR unit, which would allow the technology to be effective in a wide range of clinical situations. Some consumer systems have washable covers to protect the parts of the headset that come into contact with patients’ skin. Cleansing wipes can also be used on both trackers and sensors. In a 2014 study on a patient who had burn wounds on his head, a consumer HMD was mounted to an articulated arm so that the patient did not actually need to wear the device . Very yoResearchers seeking virtual content have three options. They may use existing free or inexpensive consumer content. They may develop their own content. Finally, they may work with industry partners focused on the clinical use of virtual reality. The following section lists some resources available at press time.Free or pre-existing games designed for virtual reality are becoming increasingly available and may be an appropriate option, particularly for procedural pain. Such games can be purchased and downloaded; for example, through the Steam and Oculus libraries. Another type of frequently free virtual content is 360° videos, which can be downloaded directly to the device. Some main content libraries are currently YouTube360, Within, Jaunt, NYTVR, Condition One, WSJ, and LifeVR . Most coVirtual content can be also created for specific clinical purposes using development platforms such as Unity3D (unity3d.com), Unreal  and Vizard (vizard.com). Researchers seeking to create customized content, which might include those investigating rehabilitation or neurorehabilitation, may require specialized tracking and rendering or customization. Such researchers might consider collaborating with university departments, for example computer science, information science, or communication departments, or work with existing software companies. Recording one’s own immersive video is also an option. Cameras ranging in complexity and price from the hundreds to thousands of dollars allow researchers to record their own video content and prepare it for viewing through a phone-based HMD.Finally, there is increasing commercial interest in supplying clinicians with virtual reality applications. While it is outside the scope of this paper to recommend specific companies, searching for “virtual reality therapy” online will provide a list of suppliers. In addition, it is possible to make some recommendations for clinicians to take into consideration when working with a supplier. If patient data is collected as part of treatment, it may raise confidentiality issues. Developers should have experience working in a clinical setting. Compatibility with hardware should also be considered, as some application developers use proprietary hardware, while others allow the use of consumer systems. A brief list of currently available free games can be found in While more research is necessary to determine the more complex aspects of VR in pediatric care, VR can be used immediately to improve the quality of life for pediatric patients. A clinician may order one of the above-mentioned devices to be kept in the clinic and made available to patients who require one of the procedures described earlier in this review. For example, a child might be given a headset and immersed in a relaxing forest scene while they are receiving an immunization or IV placement. Alternatively, a child requiring frequent dressing changes, or other painful procedures may choose to purchase a unit for home use to assist with pain management. A patient with chronic pain may find it beneficial to use VR interventions to temporarily alleviate symptoms, or to assist in performing challenging tasks while in physical or occupational therapy. The number of applications is unlimited, and can be adapted to the individual child’s interests and the clinical therapeutic need.In summary, VR is a promising new technology that offers unique opportunities to modulate the experience of pain. These opportunities include the management of acute and procedural pain and familiarizing children with future procedures via simulation. In addition, extrapolating from current evidence in adults, we propose that virtual reality may assist in the treatment of pediatric chronic pain via neuromodulation, as well as physical therapy.Given the reduction in cost and increased ease of access, we hope that clinicians will be encouraged to explore the potential of this new modality. While the immediate adoption of VR can already engage and entertain children in a clinical setting with potential therapeutic benefits, continued study of the applications and efficacy of virtual reality in the treatment of pediatric pain is needed to better understand the impact upon quality of life for pediatric patients.


Background. We need to understand more about how DNF performs in different contexts and whether it affects the pain threshold over myofascial trigger points (MTrPs). Purpose. The objectives were to investigate the effect of neck muscles training on disability and pain and on pain threshold over MTrPs in people with chronic neck pain. Methods. Patients with chronic neck pain were eligible for participation with a Neck Disability Index (NDI) score of over 5/50 and having at least one MTrP on either levator scapulae, upper trapezoid, or splenius capitis muscle. Patients were randomly assigned into either DNF training, superficial neck muscle exercise, or advice group. Generalized linear model (GLM) was used to detect differences in treatment groups over time. Results. Out of 67 participants, 60  completed the study. Neck disability and neck pain were improved over time between and within groups (p < 0.05). However, no differences were found within and between the therapeutic groups (p < 0.05) in the tested muscles' PPTs and in cervicothoracic angle over a 7-week period. Conclusion. All three groups improved over time. This infers that the pain pathways involved in the neck pain relief are not those involved in pain threshold. Pain in the cervical region is a pathological condition which is associated with increasing disability in the general population –3. The pMyofascial trigger points (MTrPs) are known factors that can be associated with neck pain . It has Although deep and superficial cervical flexors training have shown to reduce pain and disability, it is unknown whether deep or superficial cervical muscles are more effective in improving neck disability and pain. Also, it is not clear whether exercise training of these sets of muscles can have an effect on the MTrPs of patients with neck pain. Therefore, given the above, the first objective was to determine the effect of neck muscle training on patients' disability and pain in the cervical region. The second objective was to investigate the effect on pain pressure thresholds (PPTs) over MTrPs in chronic neck pain patients.ISRCTN13364486. The first group was the deep neck flexor group (Group A), the second was the superficial muscle (Group B), and the third was the advice group (control). Ethical approval was granted from the scientific committee of the Department of Physiotherapy of the Technological Educational Institute of Western Greece.This was a prospective single-blind randomized controlled trial with 3 therapeutic groups in Patras, Greece, with trial registration number Patients between 18 and 65 years old with idiopathic chronic neck pain were invited to participate in the study. The selection of the sample was done through notifications and advertisements in local hospitals, rehabilitation centres, and social meeting places across the greater area . Patients eligible for participation must have had neck pain for at least 3 months (chronic), disability score 5/50 in Greek version of the Neck Disability Index (NDI) , and at Subjects who met the eligibility criteria completed the patient reported outcomes (PROs) and an assessment form which included information about the study, consent form, personal information, a brief medical history, demographic features, and a pain body diagram. The measurements and the training programs were performed by 2 physiotherapists who were trained in the intervention protocol to improve consistency of treatment between providers. Prior to the start of the study pilot studies were used to improve the consistency of the clinical measurement. After that, patients were examined for the presence of MTrPs in the following muscles: upper trapezoid, levator scapulae, and splenius capitis and the pain pressure thresholds were measured. In the end of this phase, all patients were digitally photographed and they performed the craniocervical flexion test (CCFT). The training program of the DNF group (A) was based on the CCFT level that they achieved in their first assessment and it was their starting point. All participants received instruction guidelines through written leaflet and digital video disk (duration of 17 minutes recorded by the two physiotherapists) with ergonomic pieces of advice and exercise guidelines for neck for a fuller understanding of the execution of the therapeutic exercises. All therapeutic interventions (for the two exercise groups described below) were provided twice per week, for approximately 30–40 minutes per session for 7 consecutive weeks. The difficulty of exercises was gradually increased (intensity and repetitions) depending on the response demonstrated by each patient. All the measurements (self-reported outcomes and clinician based outcomes) were performed at the beginning and at the end of the therapeutic training programs. Also, patients were instructed not to participate in other therapeutic sessions and/or receive any medication during the study.All the individuals were provided with an exercise leaflet guide and a digital video disk on how to perform the reported exercises at home. The program was divided into 3 parts, the warm-up, the basic part, and the ergonomic guidelines with stretching part. In the warm-up patients were instructed to do the following: slow rotations of the head in all directions, movement of the shoulders in all directions, and rotation of the arms in all directions. Patients were instructed to breathe normally during the warm-up period. In the basic part patients were instructed to do posterior movement of the neck from sitting position, posterior movement of the neck with towel or elastic belt from sitting position, isometric contraction of neck muscles in all directions , and by adding resistance with their hand very slow rotary motion of the head. In the stretching part, patients were instructed to do neck extension-flexion stretching, neck side flexion, and rotation stretching. In the end all the groups performed streching exercises. The group A and B performed the stretching part with the assistance of physiotherapists. The group C had written instructional guidelines and a digital video disk on how to perform the stretching part alone in their house. Ergonomic directions were given and patients were repeatedly instructed in the optimal position of how to sleep, drive, and sit on a chair.The DNF group (A) performed the following exercises: the craniocervical flexion test (CCFT) with air pressure biofeedback , noddingThe superficial muscle group (B) performed posterior head movement from sitting position with elastic band, posterior head movement from supine position, movement in all directions from pronation position, and “cat-camel motion exercise” .The advice group (C) performed only the home exercise program described in the leaflet and the digital video disk.The patient reported outcome (PRO) measures were the Neck Disability Index (NDI) , which wThe PPTs over active or latent Myofascial Trigger points (MTrPs) of levator scapula, upper trapezoid, and splenius capitis muscles (both sides) were tested with Wagner pressure pain algometer (FDK-20 model). MTrPs were clinically palpated according to Travell and Simons diagnostic criteria in order to verify the reproducibility of the location . The PPTThe CCFT measured the DNF muscle endurance with Chattanooga pressure biofeedback unit. The application of the craniocervical flexion test followed the protocol that was described by Jull at al. . The exaThe measurement of cervicothoracic angle is a clinical measurement  that indParticipants were randomly assigned by the leader investigator into one of the three therapeutic groups without knowing their therapeutic group, utilising computer-based randomization software. Randomization took place on the day they signed the informed consent and each therapist from each group was informed.α = 0.05, 95% CI.For the data analysis descriptive statistics were used to establish the clinical and demographic features of our sample. The dependent variables analyzed were the NDI (primary outcome measure), the NPRS, SF-12, the cervicothoracic angle, the CCFT, and the PPTs of the MTrPs. A repeated measures' generalized linear model was used to determine time and treatment group effects controlling for age and gender as covariates. The Client Satisfaction Questionnaire-8 (CSQ-8) was analyzed by using a one-way analysis of variance following by a post hoc Tukey test. The significance level was set at d: 0.8, desired statistical power level: 0.8, and probability level: 0.05). The minimum sample size per group was 21 (one-tailed hypothesis). A power analysis was performed to calculate the power of the sample size (60 subjects) with power strength 0.80 and as primary outcome measure the Neck Disability Index [An a priori sample size calculation was performed with anticipated effect size for the primary outcome measure based on mean differences of change between groups   completed the study . The parThe one-way analysis of variance of the patients' satisfaction (CSQ-8) revealed that the superficial muscle group (B) had greater satisfaction compared to the third group (control) but overall all groups had very high satisfaction levels .The results of this study showed that specific progressive training programs that are targeting the deep and superficial muscles are capable of reducing the pain and disability. However, they are not capable of changing the sensitivity of the PPT over MTrPs on the specific extensor and upper back muscles and the head posture. The descriptive analysis of the age of the sample in each group showed that there was homogeneity in the patients' age. Furthermore, the high prevalence of women compared to men in each group in terms of neck pain condition is clearly reflected in this clinical study confirming the available international literature .Regarding neck pain intensity, the results of this study confirm the positive effects of the DNF exercise in reducing pain and disability levels. Previous randomized trials, wherein the therapeutic interventions aimed at improving the activation of DNFs, have shown that they are effective in patients with chronic neck pain, since by increasing the activation of those muscles the pain and disability were decreased , 26, 27.p < 0.001); however the control group was found with markedly smaller decrease compared with the other two groups. These results show that a progressive exercise program of the deep neck flexors and superficial muscles lasting 7 weeks is sufficient to reduce the disability and neck pain. In contrast, the reduction was inferior to the control group, which may be explained by the fact that the patients did not have the supervision and guidance of the clinician . This observation maybe highlights the importance of the presence of the physical therapist during treatment sessions.The neck disability levels for the treatment groups  were found statistically significant  .p > 0.05) after treatment in each group. The initial values of the PPT of MTrPs in the levator scapula and upper trapezius showed different values between groups and between the right and left side within the same group. Instead, the original values of PPT in splenius capitis did not differ among themselves or between groups or between the right and left side because the ranges of the values measured in this muscle were very small  of the deep neck flexors group reached the maximum level of CCFT which was obvious because it was the main exercise for the therapeutic group (A). However, the other two groups were capable of reducing disability and pain but in the end the CCFT was not statistically significant before and after treatment. This can be explained by the fact that their exercises were more focused on the superficial muscles compared to the deep neck flexors. In the current literature so far there are no other studies that compared the CCFT between the deep and superficial muscle flexors by controlling the pain and disability levels.The strengths of this study are the comparison between deep and superficial neck flexors on neck pain and disability levels as well as the measurement of 360 MTrPs and the measurement of head posture. To our knowledge our study may indicate the importance of differential diagnosis regarding the management of neck pain.p = 0.010), suggesting that the DNF group was more disabled. It can be seen that the DNF group had the highest disability among the other two and therefore it can be assumed that it had the greater reduction in disability. The 7 persons' “dropout” (following randomization) could have influenced the initial homogeneity values on NDI between groups. The absence of the blind effect of the examiners and the fact that the sample had a high prevalence of females (80%) are the limitations of our study. However, the fact that chronic neck ache incidence affects mostly women can partly justify this discrepancy across men and women. Therefore, males in our sample are underrepresented since all our dropouts were males. Also, a long term follow-up will probably have had a more significant outcome. Also, the fact that the therapy was performed from two different therapists indicates the possibility that maybe one therapist outperformed the other one.The randomization of the sample had some differences in terms of baseline levels of NDI and the NPRS category “pain at worst.” In particular, the disability indicator of NDI used as the primary evaluation tool indicated a heterogeneity between intervention group (A) and a control group (C)  for MTrPs relief. Moreover, the progressive training programs of the deep and superficial neck flexors muscles did not have any alteration on sample's cervicothoracic angle. Further research in this area would be of great value.


Nocturnal bruxism can be managed by botulinum toxin (Botox®) in patients who have not responded to conservative treatment. The aim of this study was to evaluate the efficacy of botulinum toxin A (BTXA) in the treatment of nocturnal bruxism. The retrospective study comprised 25 female patients, aged 23–55 years (mean 35.84 ± 8.41 years). All patients received a single injection of BTXA in the right and left masseters. Evaluation was made by Visual Analogue Scale (VAS) values, complaint duration, onset of effect, and duration of effectiveness. BTXA produced significant improvements in pain scores. Only 2 adverse events (8%) were recorded. BTX-A is effective in the treatment of nocturnal bruxism. Nocturnal bruxism (NB) is defined as abnormal maxillomandibular activity during sleep, characterized by grinding and clenching of the teeth , 2. NB c Clostridium botulinum, which blocks acetylcholine release from cholinergic nerve endings into the neuromuscular junction, thereby causing inactivity of muscles or glands [Botulinum toxin (Botox) is an exotoxin produced by the bacteriumr glands . BotulinBTXA has been used in the treatment of cosmetic and noncosmetic conditions such as tremor, hemifacial spasm, temporomandibular joint dysfunction, bruxism, masticatory myalgias, sialorrhea, hyperhidrosis, and headache .Botox injections are directly applied into the masseter and temporalis muscles to relax these muscles. The clinical effects are typically seen on the first to third days after the injection, followed by one to two weeks of maximum effect, and the typical duration of the effect is three to four months .In two comprehensive review studies, Tinastepe et al.  and ManfIn the period 2014-2015, a retrospective data analysis was made of the data of 25 female patients who underwent onabotulinum toxin A  injections into the masseter muscle for clinically diagnosed nocturnal bruxism. The patients enrolled in the study had all failed to respond to conservative treatment. Exclusion criteria were temporomandibular disorders, pregnancy, active drug use, and psychological therapy.For evaluation of postoperative pain, Visual Analogue Scale (VAS) forms were completed by the patients scoring the degree of pain between 0 (absence of pain) and 10 (maximum pain) before the injection and then at 2 weeks, 1 month, 3 months, 4 months, and 6 months after the injection.The following data were recorded for all patients: maximum mouth opening changes, duration of the complaint before the injection, muscle weakness before injection, the time the first effects were seen, the time when the effectiveness started to be lost, and difficulty experienced in speaking, swallowing, or chewing.This study was based on routine service documents of NB patients. However, permission to analyse the data was sought from the management of the Dentistry Hospital of Afyon Kocatepe University. All procedures followed were in accordance with the ethical standards of the committee responsible for human experimentation  and with the Helsinki Declaration of 1975, as revised in 2008. Written informed consent was obtained from all the study participants.For all patients, 100 mouse units (MU) of onabotulinum toxin A  were diluted in 2 ml of saline.In all patients, a dose of 20 MU of BTXA was injected into a single masseter muscle using a 0.5 mL insulin syringe at four points (5 MU/site). The patient was requested to clench the masseter muscle, and the injections were applied to the origin, insertion, anterior, and posterior parts of the muscle.p < 0.05 was considered statistically significant.Statistical analysis was performed with the Statistical Package for the Social Science Program . Differences in individual parameters were tested using the repeated measures test ANOVA and post hoc Friedman and Wilcoxon test for abnormally distributed variables (pain). A value of Evaluation was made of the data of 25 female patients with a mean age of 35.84 ± 8.41 years . All the study variables are shown in Tables One patient had pain in the injection points. No adverse effects or dry mouth (injection into parotid gland) was reported in any other patients.There were no significant changes in respect of the maximum mouth opening. Only 2 patients (8%) had no significant improvements in the pain scores after treatment.The mean duration of the complaint before injection was 8.84 ± 4.57 years, the time that the effects were first seen was 12.24 ± 2.02 days, and the time that the loss of effectiveness started was 4.76 ± 1.01 months .The differences between two-week–four-month and one-month–three-month postoperative pain values were not statistically significant. However, differences between all other times were statistically significant .In the present study, there were significant differences in reduction of pain and bruxism activity.Van Zandijcke and Marchau  used botTo date, only BTXA and BTXB serotypes have been approved by the US Food and Drug Administration (FDA) for clinical use including cervical dystonia, severe primary axillary hyperhidrosis, strabismus, blepharospasm, hemifacial spasm, and glabellar wrinkles for BTXA and cervical dystonia for BTXB.Lang  reportedAlthough the pathogenesis of bruxism remains unclear, it is generally accepted that the etiology is multifactorial in nature. The occurrence of nocturnal bruxism suggests that it may occur as a result of possible physical or psychological conditions  , 15.The treatment of myofascial pain can be difficult for both clinicians and patients because most of these disorders involve multiple components such as somatic, neurogenic, and psychogenic components. Moreover, it can be resistant to conventional medical or behavioral therapy. There is no consensus on how the effects of Botox reduce pain. Some hypotheses have suggested changes in levels of muscle nociceptor sensitizers, nonacetylcholine neurotransmitters, and acetylcholine at autonomic synapses –18 and dNocturnal bruxism may lead to pain in the head, neck, jaw, teeth, and temporomandibular joint (TMJ). However, conservative treatments may be limited in the resolution of this problem. In the past few years, the use of Botox therapy has become a promising source for the management of myofascial pain . The finIn a study by Lee et al. , it was Kesikburun et al.  reportedThe maximum mouth opening may be increased after injection of BTXA. Sidebottom et al.  and GuarThe limitations of the present study include the small sample size and that there was no information about temporal injection or difference between genders.In conclusion, Botox therapy seems promising and beneficial in the treatment of nocturnal bruxism, although several limiting factors such as high cost and the necessity for repeated injections prevent its widespread use. When there has been no response to conservative treatment methods, botulinum toxin may be an alternative and effective treatment for nocturnal bruxism and masticatory pain. Future studies with a larger number of patients are required to confirm the conclusions reached in the present study.