At follow-up, 5/11 patients were very satisfied, 5/11 satisfied and 1/11 neutral. One patient experienced cramping and very minimal pain in the biceps. Six patients had still moderate shoulder pain, 1/11 minimal pain, 2/11 very minimal pain, while 2/11 had no pain. No patients had weakness in elbow flexion nor limits of daily activities due to LHBT. One patient showed Popeye deformity. All patients would undergo ultrasound-guided tenotomy again. Conclusion: ultrasound-guided percutaneous LHBT tenotomy is technically feasible and effective.Background: We prospectively tested technical feasibility and clinical outcome of percutaneous ultrasound-guided tenotomy of long head of biceps tendon (LHBT). Methods: We included 11 patients  with symptomatic full-thickness rotator cuff tear and intact LHBT, in whom surgical repair was not possible/refused. After ultrasound-guided injection of local anesthetic, the LHBT was cut with a scalpel under continuous ultrasound monitoring until it became no longer visible. Pain was recorded before and at least six months after procedure. An eight-item questionnaire was administered to patients at follow-up. Results: A median of 4 tendon cuts were needed to ensure complete tenotomy. Mean procedure duration was 65 ± 5.7 s. Mean length of skin incision was 5.8 ± 0.6 mm. Pre-tenotomy VAS score was 8.2 ± 0.7, post-tenotomy VAS was 2.8 ± 0.6 ( Complete rotator cuff (RC) tears are a common cause of disability and shoulder pain . TreatmeOver the last years, ultrasound (US) has gained a crucial role both in the diagnosis and the treatment of musculoskeletal conditions , includiIn this setting, a novel mini-invasive approach has been postulated to guarantee at least pain relief for those patients who have RC tear and still inserted LHBT. Thus, our purpose was to prospectively test the technical feasibility and clinical outcome of percutaneous US-guided LHBT tenotomy in vivo in patients with complete rupture of the RC.Our Institutional Review Board approved this prospective study and all patients provided their written informed consent to participate.This study is concerned with the evaluation of patients subjected to US-guided percutaneous tenotomy of the LHBT at our Institution from March 2017 to September 2019. Sample size was calculated taking into account that previous literature on arthroscopic LHBT tenotomy yielded an improvement of shoulder pain of about 50%. Setting α = 0.05, this yielded a sample size of 11 patients. Sample size was calculated using G *power software  . PatientThe visual analog scale (VAS) was used for pretreatment clinical assessment. It consists of a 10-cm graduated scale from 0 (no pain) to 10 (unbearable pain). Patients mark the point they believe best corresponds to their pain .Two radiologists with 15 years’ (L.M.S.) and 5 years’ (D.A.) experience in diagnostic and interventional musculoskeletal US performed the procedure. An ultrasound system  equipped with a high resolution linear array probe  was used. Prior to the procedure, a shoulder ultrasound was performed to confirm the RC tears and the presence of a continuous LHBT. The procedure was performed in a dedicated interventional room under strict sterile conditions with sterile cover for the US transducer and accurate skin disinfection using iodine-based solution . The patWe recorded the number of tendon cuts, the elapsed time from skin incision and scalpel retraction and the length of skin incision. Immediate complications were recorded. Technical success was defined as the ability of completing the tenotomy as initially planned according to our protocol ,41, withp < 0.001. The SPSS software  was used for calculation.Technique efficacy was defined at a timepoint of at least six months as a pain reduction on the VAS scale of 5 points ,41,42. Ap < 0.001). Technique efficacy was 100%. At follow-up, 5/11 patients were very satisfied (45%), 5/11 were satisfied (45%) and 1/11 was neutral (9%). Only one patient experienced cramping (about once per week) and pain  in the biceps muscle. The remaining 10 patients (91%) did not complain of cramping or pain in the biceps. Six out of 11 patients (54%) had still moderate shoulder pain, 1/11 (9%) minimal pain, 2/11 (18%) very minimal pain, while 2/11 (18%) did no longer complain of shoulder pain after the procedure. None of the 11 patients had neither any weakness flexing their elbow nor limits of daily activities due to the biceps, while only one showed biceps muscle bulge (Popeye sign) although he did not mind it from a cosmetic standpoint. Further, 100% patients would undergo US-guided tenotomy again. Full patients’ clinical data and answers to the questions are reported in Eleven patients  were enrolled according to our inclusion criteria. All patients presented with complete RC tear and continuous LHBT at the US examination performed on the day of the procedure. The procedure was carried on as planned in all cases, with the US proof of tendon retraction distal to the biceps groove in all patients. Technical success was 100%. A median of 4 (interquartile range = 4–4) tendon cuts were needed to ensure a complete tenotomy. The mean duration of the procedure was 65 ± 6 s (range 52–75 s). The mean length of the skin incision was 5.8 ± 0.6 mm (range 5–7 mm). No immediate complications related to the procedure occurred. At five days, one patient reported to our Department for increased shoulder pain related to fluid effusion in the subacromial bursa, which was then treated with US-guided steroid injection. At five and eight days, one diabetic patient reported to our Department for a delayed wound healing, which then resolved spontaneously. No patients were lost at follow-up. The mean follow-up was 10 ± 2.6 months (range 6–14 months). The mean VAS score was 8.2 ± 0.7 before the tenotomy and 2.8 ± 0.6 at the follow-up evaluation (Our main findings are that US-guided percutaneous tenotomy of the LHBT is a procedure with 100% technical success and technique efficacy, high degree of patient’s satisfaction and no immediate complications.This prospective study is the first cases series in living patients. Looking at the technical side of the procedure, previous feasibility studies on cadavers tested different approaches to sever the LHBT. In the first series published by Levy et al. , the autOur procedure had very high overall patient satisfaction rate, with 91% of patients being satisfied or very satisfied at follow-up examination. Only one patient was neutral and was also the only one presenting Popeye deformity, cramping once per week and very minimal pain in the biceps muscle. Furthermore, all patients experienced pain relief and would have their percutaneous tenotomy again, with neither weakness in elbow flexion nor limitation in daily activities due to the biceps. These results are in line with those reported by Meeks et al. who administered the same questionnaire to 104 patients subjected to arthroscopic biceps tenotomy . Ninety-No major complications were encountered, and the procedures were no painful with no significant bleeding. Indeed, although lidocaine is generally used for local anesthesia prior to US-guided musculoskeletal procedures ,38, we pSome limitations should be taken into account. First, our sample size was relatively small, although it was enough according to sample size calculation and it was sufficient to reach statistically significant results. Nevertheless, larger studies will enable to better understand the real frequency of complications related to this procedure. Then, this is a prospective non-controlled study, thus we did not compare the results of our procedure with those of arthroscopic surgery that is considered the standard of care. However, US-guided LHBT tenotomy was never tested before on living patients, thus a feasibility study was needed. We acknowledge that the shorter procedural time and higher cost-effectiveness of US-guided tenotomy do not require any comparison with arthroscopy. Nevertheless, future prospective randomized trial should be aimed at comparing our novel procedure to standard arthroscopy to understand the relevance of possible iatrogenic injuries to joint cartilage and RC tendons, as well as to assess the risk of intra-articular impingement related to the proximal LHBT stump and the clinical impact of possible missed diagnosis normally reached during arthroscopy. Last, we used a not validated questionnaire for follow-up clinical evaluation based on what previously published . HoweverIn conclusion, US-guided percutaneous tenotomy of the LHBT has 100% technical success and technique efficacy, high degree of patient’s satisfaction and no immediate complications. Future prospective randomized studies comparing the outcome of this procedure with the standard of care are warranted.


To evaluate the impact of nephrostomy tube type on postoperative pain and blood loss following percutaneous nephrolithotomy (PCNL).This is a prospective non-randomized study performed at Aga Khan University Hospital from July 2017 to June 2018. In this study we prospectively studied adult patients (16 to 65 years) who underwent unilateral PCNL. Patients who had nephrostomy with balloon (12Fr Foley’s catheter) were compared with patients who had nephrostomy without balloon (12Fr Nelaton™ catheter). STONE Nephrolithometry score was used to assess the stone complexity. Mean pain score at six and 24 hours and mean hemoglobin drop at 24 hours was compared between two groups using independent sample t-test, p-value of <0.05 was considered significant.Over one year, 198 PCNL were performed out of which 119 were included for analysis. Sixty-six had nephrostomy tube with balloon and 53 had nephrostomy tube without balloon. Mean STONE score (9.66±1.4 vs. 9.64±1.24) and operative time (72.84±28.34 vs. 86.05±32.1 minutes) was comparable. Mean postoperative pain score at 6 hours and 24 hours postoperative was significantly lower in balloon group as compared to without balloon group. Mean Hemoglobin drop was similar in both groups (p=0.60).The use of nephrostomy tube with balloon after PCNL as this is associated with less pain and comparable hemoglobin drop as compare to nephrostomy tube without balloon. PCNL is the standard of care for patients with moderate to large upper tract urinary stones. Despite being minimally invasive it can cause significant pain and sometimes lead to life-threatening complications such as bleeding, sepsis and peri-renal visceral injury.3Nephrostomy tube type is a modifiable factor, which can potentially influence postoperative pain and haemoglobin drop. Su H et al. in 20153) were excluded.This is a prospective non-randomized study performed at Aga Khan University Hospital from July 2017 to June 2018. Adult patients 16 to 65 years of age undergoing unilateral PCNL with single tract using 26Fr Amplatz™ sheath for stones in kidney confirmed on non-contrast CT abdomen were included. Patients who previously had open renal surgery on the same side or had a percutaneous nephrostomy already in place or raised serum creatinine (>1.2mg/dL), raised INR (>1.3) or reduced platelet , all patients who fulfill the inclusion criteria were included in the study following an informed consent. Consultant surgeon with more than five years of experience performed PCNL. Procedure was done in prone position after placing ureteric catheter in the same general anesthesia using a flexible cystoscope in supine position. Tract was dilated using serial metallic dilators. Stone fragmented with ultrasonic probe using EMS™ lithoclast master. At the end of procedure a 12 Ch., nephrostomy tube, both with or without balloon, was placed and clamped overnight. Patients who had 12 Ch. Foley’s catheter, with balloon inflated (approx. 1-1.5 cc) placed as nephrostomy were included in Group-A. Patients with 12Ch. Nelaton catheter™ placed as nephrostomy were included in Group-B. Choice of nephrostomy was left on operating surgeon’s discretion. Nephrostomy was de-clamped on first post-operative day and subsequently removed on 2-5Data was analyzed through SPSS™ version 21. Mean and standard deviation was calculated for quantitative variables i.e. age, BMI, stone size, density (HU unit) and pain score on VAS. Frequency and percentages were calculated for qualitative variables, i.e. gender, hydronephrosis. Mean postoperative hemoglobin drop was calculated after subtracting 24hr post op hemoglobin from preoperative hemoglobin. of each patient. Mean pain score was calculated at 6 and 24 hrs. Mean postoperative pain and hemoglobin drop of 2 groups were compared using independent sample student t-test. Effect modifiers were controlled through stratification of age, sex, and stone size and STONE score.7A total of 198 cases had this procedure during the study period out of which 119 were included for final analysis, 66 were in Group-A and 53 in Group-B . Baseline parameters are detailed in There was no significant difference in postoperative Hemoglobin drop between two groups, however mean postoperative pain score at six hours and 24 hours was signifcanlty lower in Group-A Tables- and III.Percutaneous nephrolithotomy (PCNL) despite being minimally invasive can cause significant pain and blood loss.13Multiple studies have shown that tubeless PCNL is safe and feasible for select group of patients. However, keeping nephrostomy at end of procedure is desirable in some conditions e.g. residual stone, longer operative time, more than 1 percutaneous access, significant perforation of the collecting system and significant bleeding.Postoperative bleeding is another major concern following PCNL. This bleeding is either parenchymal or arterial. Significant delayed bleeding is almost always due to pseudoaneurysms or arteriovenous fistulae. Serious arterial injury requiring angioembolization is around 1% in different studies.This was an interventional study however randomization was not done. Nephrostomy tube with balloon was used by single surgeon whereas Nelaton catheter was used by others, this may have contributed to differences in postoperative pain and operative time. Whether to clamp nephrostomy before removal and when to remove ureteric and urethral catheter was left on discretion of operating surgeon.The present study supports the use of nephrostomy tube with balloon (Foley’s catheter) after PCNL as this is associated with less pain and comparable hemoglobin drop as compare to nephrostomy tube without balloon (Nelaton catheter). Further randomized controlled trails are needed to compare both the tubes.SJ and MHA: Protocol/project development, Data collection or management, Data analysis, Manuscript writing/editing, are responsible for integrity of research.


A dry socket also referred to as alveolar osteitis (AO) is a common postoperative complication following tooth extraction, due to the disruption of the clot within the wound. This study aimed to evaluate the efficacy of concentrated growth factor (CGF) in the healing of alveolar osteitis following tooth extraction.  The study was conducted at University Dental Hospital Sharjah, UAE. Patients undergoing tooth extraction at the oral surgery clinic were advised to return immediately if they suffer from pain. Over the following first week after tooth extraction, patients who reported pain symptoms were recalled and all dry sockets were identified. The patients were divided into two groups. Group I patients received conventional treatment with socket curettage and saline irrigation only, while in group II CGF was inserted into the socket. Both groups were observed for pain score and quantification of granulation tissue formation. p = 0.001). Granulation tissue formation appeared in the conventional group I on day 7 while the CGF group II showed earlier granulation tissue formation by day 4 (p = 0.001). The posttreatment pain score is inversely proportional to the amount and rate of granulation tissue formation in the socket.  A total of 40 dry socket patients, aged between 18 and 60 years, from a total of 1,250 patients, were included in the study. 30 patients were given conventional treatment while another 10 patients were given CGF. Patients who received CGF had a pain score of 7–10 at presentation, and the pain score dropped to 0–3 on day 4 and further improved to 0-1 on day 7 ( The study suggests that delivery of CGF into a dry socket helps relieve pain and expedite the wound healing process as shown by a statistically much lower pain score and earlier and more rapid formation of granulation tissue when compared to the conventional alveolar osteitis therapy. A dry socket also referred to as alveolar osteitis is a postoperative complication following tooth extraction. Both terms “dry socket” and “alveolar osteitis” have been used interchangeably in the dental literature. It can be defined as “postoperative pain within and around the extraction site, which rises in severity at any time between the first and fifth days after the tooth extraction, accompanied by a partial or complete disintegration blood clot within the alveolar socket and with or without halitosis” . It occuEven, in this era of cell and molecular biology, the specific etiology of the dry socket has not yet been defined. However, numerous local and systemic elements make contributions towards it , 5, 6. SClinical and experimental research studies have described an elevated fibrinolytic activity as a major factor for the etiology of the dry socket , 11–14. Being an old surgical puzzle, many different methods have been advocated to treat alveolar osteitis, such as the application of local turmeric , zinc oxAs the knowledge on the biology of wound healing advances, the role of cytokines and growth factors in the healing of alveolar osteitis becomes more significant . Understth October, 2017. The study population was patient treatment at the oral surgery clinic of University Dental Hospital Sharjah. The subjects included were patients who underwent routine tooth extractions performed under local anesthesia following the diagnosis of irreversible pulpitis, chronic and acute apical pathology, periapical abscesses, and advance periodontitis. Other reasons for tooth extractions and the presence of local odontogenic tumors or malignancies were excluded. Patients with well-controlled systemic medical conditions such as diabetes and hypertension were included in the study. Following tooth extraction, the socket was curetted in cases of periapical pathology and patients were asked to bite on a piece of sterile gauze for 30 minutes to achieve hemostasis. There were no additional dressings or medication inserted in the socket. The presence of a nice healthy clot as observed by the attending dentist was confirmed before the patients were discharged from the clinic. They were advised to return immediately to the University Dental Hospital if they suffer from postoperative pain. Complicated tooth extractions under local anesthesia that lead to minor oral surgical procedures were excluded. All patients included in the study were not prescribed antibiotics. Over the following five days following the tooth extraction, the patients who reported suffering from postoperative pain symptoms were reexamined in the clinic.This study was conducted from August till October 2019 at University Dental Hospital Sharjah (UDHS), United Arab Emirates. Human ethics approval was obtained from the Research Ethics Committee University of Sharjah REC-17-02-14-01-S dated 24Patients who were diagnosed with alveolar osteitis were referred to the oral surgery department. The selection of the subjects was done according to the previous inclusion and exclusion criteria. All patients aged between 18 and 60 years who were diagnosed with alveolar osteitis were included in the study. Those with good oral hygiene who had undergone nonsurgical tooth extraction under local anesthesia and who suffered postoperative pain between 1 and 5 postextraction days presenting with empty dry socket were selected. Patients aged below 18 and above 60 years and those who had tooth extraction performed outside UDHS or patients who underwent surgical extraction were excluded. The patient's pain level was recorded on a visual analogue scale of 1 to 10 , 31 Fig, and theThe selected patients were divided into two groups based on their choice to be treated with either conventional treatment (group I) or CGF treatment (group II).In group I the patients were treated with conventional treatment whereby the dry socket was curetted and irrigated with saline under local anesthesia. A new bleeding socket was created following curettage and gentle saline irrigations help debride the necrotic debris. The patient was instructed to bite on a piece of sterile gauge to achieve hemostasis.In group II, the socket was similarly curetted and irrigated under local anesthesia and CGF in gel form was inserted into it. Preparation of CGF was performed by obtaining about 9 ml of the patient's blood into a vacuum test tube. CGF was prepared using Medifuge centrifuge machine, Silfradent, Italy, following a cycle duration of 5 minutes at 1,000 revolutions. The processing time is about 12 minutes and finally a thick yellowish color gel layer was produced known as CGF. This CGF gel was directly delivered into the socket using a surgical tweezer –34.A periapical radiograph of the socket was done for both groups before initiating treatment to exclude the presence of retained apices, bony fragments, and fracture of the alveolus. No dressing such as alvogyl or topical antibiotic was placed in both groups and no systemic antibiotic was prescribed.The day of the patient's return to the clinic with a dry socket presentation was recorded as “Day 0.” Both groups were observed for pain score using a visual analogue pain scale from 1 to 10  and quanContinued follow-up of patients in both groups was done through phone calls on a weekly interval for up to 4 weeks after dry socket treatment.All the data was entered into SPSS software. We used Kruskal–Wallis test to determine the mean and standard deviation for age and scoring of pain and granulation tissue formation.p value of less than 0.05 is considered significant.A Over a three-month period, a total of 40 dry socket patients, 25 males and 15 females, were included in the study see  from a tIn the conventional group I, the pain score was 7–10 on the day of presentation (day 0) and the pain score dropped to 4–6 on day 4 and further decreased to 2–4 on day 7 see  followinQuantification of clinically evident granulation tissue formation within the socket was recorded see , from daThe CGF applied sockets among group II patients also showed much earlier granulation tissue GT by day 4. By the second week postoperatively, both groups showed similar pain score and GT formation and showed comparable wound healing stage after 14 days of post dry socket treatment. The results were tested statistically .We noted that all patients suffer severe pain with a VAS pain score of 7–10 on the day of presentation. The lysis of the blood clot in the socket leads to fibrin degradation products attributed to the formation of kinins in the compact socket. Plasmin is involved in the conversion of kallikrein into kinins and together with other inflammatory mediators causes intense pain. Following conventional treatment under local anesthesia, the pain score dropped to VAS 4–6 on day 4 and clinical findings showed some laying down of GT formation within the socket. In the sockets treated with CGF, a much more drastic improvement in pain symptom was shown with a VAS of 0–3 as early as day 4, and clinical evaluation showed a much richer pool of granulation tissue within the healing socket. This observation demonstrated that the amount and rate of granulation tissue (GT) formation in the socket are inversely proportional to the pain score and there is a significant effectiveness of CGF on the healing of dry socket and improvement in symptoms , transforming growth factor (TGF), platelet factor interleukin (IL), vascular endothelial growth factor (VEGF), epidermal growth factor (EGF), insulin-like growth factor IGF, and fibronectin . TogetheIn this study, patients were advised to come back immediately in case of any pain following the tooth extraction. Most patients reported having pain after 4–7 days. However, all patients started to have pain from the very next day after the tooth extraction but due to their job circumstances, no leave from work, family commitments, and other factors they tend to return to the clinic after few days. It was observed that acute pain develops almost immediately following lysis of the clot and exposure of the unprotected dry bony socket and nerve endings, with the production of kinins and inflammatory mediators. Almost all the patients had a pain score from 7 to 10 on the visual analogue pain scale associated with tenderness of the regional lymph nodes. The severe pain from the dry socket is often underestimated by the attending dentist.An interesting observation in this study is the absence of pus discharge from the socket and afebrile status of a patient's body temperature. Many dental practitioners may misinterpret the yellowish necrotic bone slough as pus discharge from the socket. The absence of a rise in body temperature also signifies a dry socket to be a local wound dehiscence event without systemic physiological upset. The conventional treatment approach for the dry socket helps alleviate the pain through the formation of granulation tissue but recovery was slow. This phenomenon suggests that reformation of the natural blood clot  in the treated dry socket is not as effective as the first natural clot formed immediately after tooth extraction. The addition of CGF will enhance the compromised weaker secondary clot. CGF gel is known to have closely interwoven fibers exhibiting a relatively stiffer texture than the traditional platelet rich fibrin (PRF) and able to promote cell adhesion and migration  during tRutkowski et al., in 2010, used PRP to promote bone formation following extraction . They obGranulation tissue is young connective tissue possessing microscopic blood vessels which is formed on the surface of a wound during the healing process, forming a protective layer, and resistant to microbial invasion. It is friable and may be easily damaged, but CGF seems to promote the formation and protection of granulation tissue in a compromised wound. This could be the main reason for the dry socket healing expedition and reduction of pain.Our study showed that conventional dry socket treatment does provide palliation but the addition of CGF expedites the healing process and alleviates the symptoms much earlier . It furtThis study suggests that the delivery of CGF into a dry socket helps to relieve pain and expedite the wound healing process as shown by a much lower pain score and earlier and more rapid formation of granulation tissue when compared to conventional therapy. Chairside CGF techniques in the dental office are simple, feasible, and economical with predictable results.Pain from the dry socket is excruciating and often underestimated by the attending dentistDry socket is a localized failure of tooth extraction wound healingIt causes neither a systemic upset nor a rise in body temperatureLow contraceptive consumption in the community tends to produce a lower prevalence of dry sockets among women in childbearing ageDry socket does not occur in childrenConcentrated growth factor supports dry socket healing by expediting granulation tissue formation and alleviating pain


The effect of low-level laser therapy (LLLT) on pain mitigation following the third molar surgery is still controversial. The absence of a standard method for using laser among the studies is related to the types of sample selection, sample size, control, and LLLT parameters, which make pain mitigation following surgery more controversial. Therefore, this study aimed to determine the effect of LLLT on reducing pain, swelling, and trismus following the mandibular impacted third molar surgery.This study was performed on 25 healthy subjects. After the surgery, amoxicillin 500 mg was prescribed every 8 h for a 7-day period besides oral Ibuprofen (Gelofen) 400 mg every 12 h for a 3-day period. The intraoral Laser diode 940 nm was applied immediately after suture on the tested side, while on the placebo side, a fiber tip was used with no laser radiation following surgery. Eventually, the pain score was evaluated by VAS index from the 1st to the 7th-day post-surgery and then analyzed by SPSS 24.The results indicate that the mean swelling and trismus before, during, 2 days after, and 7 days after the intervention did not differ significantly between the two studied groups. However, the results show that on the sixth and seventh days, the pain was significantly lower in the intervention group compared to the control group.p < 0.05).The results suggest that although the pain, swelling, and trismus following surgery were lower on the radiated side, only pain was found to be significant on the radiated side (https://www.irct.ir/trial/36321.The registration number of the clinical trial in a Primary Registry in the WHO Registry Network is IRCT20141209020258N110 and the date of retrospective registration is 04/05/2019. The related URL is  Surgical extraction of mandibular impacted third molars is a typical dental surgery –5. This 2 for 8 s for four consecutive daily sessions suggested a significant clinical effect on pain and swelling [Low-level laser therapy (LLLT) was discovered by chance in an attempt to kill cancer cells using a laser . It was swelling . In anotswelling .The absence of a standard method for using laser among studies is related to sample selection, sample size, control, and parameters of LLLT, which consequently cause controversy in postoperative pain mitigation. One of the used wavelengths in LLLT is 940 nm . HoweverThis study was performed as a double-blind randomized clinical trial. The registration code of the clinical trial in a Primary Registry in the WHO Registry Network is IRCT20141209020258N110. The present study was performed after obtaining approval from the University Ethics Committee (Code: IR.ARAK.REC.1397.158). Accordingly, all the procedures were accomplished in terms of the associated instructions.Written informed consent was taken from all the patients.1) = 2.77, Standard deviation in group 1(σ1) = 1.45; Mean in group 2(µ2) = 4.11, Standard deviation in group 2(σ2) = 1.41, r = 1) [The sample size was calculated based on the previous studies  .\documePatient recruitment was done over 3 months. Each patient had two follow-ups once on the second and once on the seventh day after surgery. Twenty-five healthy subjects aged between 18 and 40 years old with asymptomatic mandibular impacted third molars were included in this study. In terms of impaction, the teeth should be in Class A according to Pell and Gregory’s classification. The exclusion criteria were as follows: a systemic disease, chronic pain, neurological or psychiatric disorders, photosensitivity, and sensitivity to local anesthesia. Furthermore, the exclusion criteria were acute pericoronitis and periodontal disease, pregnancy, breastfeeding, smoking, and the consumption of analgesic or anti-inflammatory drugs 2 weeks prior to the study. Before the surgery, the gender and age of the patients were recorded.The side on which the surgery was done was randomly specified in the participants of the case and control groups using computer software (Random Allocation Software with blocked randomizations setting) .This study was a double-blind study, in which neither the patient nor the surgeon and the researcher who measured the outcomes after LLLT were aware of the side that had received treatment. Only the operator who had applied the laser was aware of this information. The noise of the device was cut off during the exposures, so the patients were blinded to the side allocations.The allocated groups were recorded on sealed and opaque envelopes. These cards were prepared by an independent person who was not involved in the study protocol. To explain, once the patient underwent tooth extraction and agreed to participate in this trial, the allocation assignment was revealed by opening the envelope by this independent person.An oral surgeon performed both operations of mandibular impacted wisdom teeth with a 3-week interval on both sides for the patients.The right and left mandibular third molar surgeries were done using the standard technique. The patients received anesthesia of alveolar, lingual, and buccal nerve blockades using two 1.8 ml carpools containing lidocaine 2% with epinephrine 1:8000 . An incision was made by the use of Bromed blade No. 15  whereby the complete mucoperiosteal flap was prepared which was then repositioned using the periosteal elevator Malt 9 . The buccal and distal bone was removed using carbide round bur 8 Dentsply  connected to a surgical low-speed hand piece NSK . Thereafter, the teeth were divided into several parts using a fissure bur Dentsply 703  connected to a low-speed handpiece using NaCl saline solution 0.95. Finally, the wound suture was done using nonabsorbable silk fiber 0.3 that was attached to the reversed cutting round needle 3/8 .2. Thereafter, the laser was used as a noncontact continuous wave  every 12 h  for a 3-day period. The patients were asked to record the number of ibuprofen consumed by them. A trained dental assistant applied the intraoral laser diode 940 nm (BIOLASE) immediately after the suture on the experimented side. On the placebo side, after surgery, only the fiber tip was used without radiation. The laser parameters are shown in Table In this study, the primary outcomes were swelling, trismus, and pain; and the secondary ones were the number of analgesics consumed after the surgery.The pain intensity was recorded using a visual analog scale based on its scores . The patients were given a data recording sheet. The pain scores were recorded every day in a data sheet by the patients from the first day until the seventh-day post-surgery. The extent of mouth opening and swelling was evaluated by an examiner before, immediately after that, and on the second and the seventh days post-surgery. The extent of mouth opening was evaluated by measuring the maximum distance between the central teeth of the mandible and maxilla using a caliper . The extThe obtained data were entered into SPSS 24. Descriptive statistics were reported based on central indicators, distribution, frequency, and percentage. Chi-square and independent t-test were used to compare sex and age distributions in the two groups respectively. An ANOVA with repeated measures was also used to perform intergroup and intragroup comparisons of the outcomes ofthis studyIn this study, 25 patients were included to examine the effect of intraoral LLLT with the wavelength of 940 nm on pain, swelling, and trismus following surgical extraction of mandibular impacted wisdom teeth. The mean age of the patients was 24.08 ± 3.26 years old. Out of them, 15 (60%) subjects were women and 10 (40%) subjects were men. The number of analgesics consumed until the third day had no significant difference between the two groups, which is shown in Table p > 0.05), as shown in Tables The results indicate that the mean swelling before, during the study, 2 days after, and 7 days after the surgery did not differ significantly between the two groups (p > 0.05). Accordingly, these results are shown in Tables The results indicate that the mean trismus before, during the study, 2 days after, and 7 days after the surgery did not differ significantly between the two groups p > 0.0. Accordip < 0.05)  was used, the same reduced pain outcome was obtained on the laser side which was statistically significant. In this study, although low-level laser radiation was done in one session, it had a positive effect on reducing trismus, which could be attributed to the minimum thermal effect occurring during laser radiation that consequently, diminishes trismus. Since the internal pterygoid muscle is exposed to the radiation field, relaxation of the muscle may occur due to the thermal effect. Furthermore, although during this study, the power density and radiation duration were relatively low, some temperature elevations occurred that are always expectable even to a little extent in low-level radiation [2 [2 [2 was applied for pain, swelling, and trismus alleviation. It is noteworthy that low-level laser radiation through the protein absorption by activating macrophages and regulating the intra-capillary pressure via reducing the permeability of vessels could lead to anti-inflammatory properties in this region [The present study showed the effect of intraoral low-level laser (500 mw) with a wavelength of 940 nm and an energy density of 10 J/cm opening , 28.Chro opening . Postope opening . In the  opening . Some st opening . However opening , 32. Fur opening . The resuce pain . Althougadiation . Also, sadiation , it can ation [2 , 33. It on [2 [2 , 36. Hens region . It has s region . It is ws region . Neverths region . In a stIn some studies, no information on age and gender were given . Many reDifferences in the antibiotic and NSAID regimen between the two groups were included in the factors affecting the results . To elim2 was tested in one session after the surgical operation of the mandibular impacted third molar. The results reveal that LLLT has an alleviative effect on post-surgical pain. However, further studies are needed to improve the understanding of the effectiveness of LLLT on trismus and mouth opening by extraoral laser exposure on the masticatory muscles.In this clinical trial, the effect of intraoral low-level laser (500 mw) with a wavelength of 940 nm and an energy density of 10 J/cm


Current clinical guidelines recommend to use both clinical and self-reported measurements for evaluation of chronic neck pain. Among the self-reported outcomes, Neck disability index and patient-specific functional scale are the most widely used and recommended instruments. The purpose of our study was to determine the test-retest reliability and validity of patient-specific functional scale which was not validated in Turkish language previously. Translation and adaptation process had conducted according to the Beaton et al. Sociodemographic data, Turkish version of patient-specific functional scale and neck disability index were recorded at the initial assessment. Retest assessment was produced for reliability analyses and intraclass correlation coefficient  was determined. The correlations between patient-specific functional scale and neck disability index and hypothesis testing were examined for the convergent and construct validity analysis. The final form was completed by 110 chronic neck pain patients . Test-retest reliability of patient-specific functional scale was found good level (ICC: 0.85). The relationship between patient-specific functional scale and neck disability index was found moderate level . The median score of PSFS-T in the low disability group was significantly higher than the high disability group in the hypothesis testing of construct validity (P < 0.001).The Turkish version of the patient-specific functional scale is a valid and reliable scale for evaluating functional status in patients with chronic neck pain. Neck pain is a widespread problem which affects between 30%–50% of general population in a certain period of their lives [1]. Female gender, older age, high job demands, smoking history, low social/work support and prior history of low back pain were reported as risk factors of chronic neck pain [2–4]. Neck pain patients suffer from recurrent pain and this process is commonly become chronic. The latest recommendations of the International Association for the Study of Pain about the management of chronic pain has been highlighted the importance of patient-specific self-reports during the evaluation [5]. Moreover, Turk et al. has been reviewed that biopsychosocial and behavioral factors are the key points for the assessment of the chronic pain. Therefore, rehabilitation assessments seem to be shifting from traditional evaluations to a more holistic approach. Determining the patient-specific goals and making the patient part of the treatment process is very essential for the management of chronic pain .There are several relevant questionnaires in current literature for evaluating the pain and the disability associated with the neck pain. The neck outcome score, the fremantle neck awareness questionnaire, the Copenhagen neck functional disability scale,u2929, and neck disability index were translated and validated before into Turkish language [7–11]. However, the current guidelines and systematic reviews have mostly recommended neck disability index (NDI) and the patient-specific functional scale (PSFS) in the assessment process . The patient specific functional scale (PSFS) has been developed by Stratford et al. for determined the functional ability of patients with musculoskeletal chronic pain . PSFS is a self-administered scale that the patient lists the activities of difficult to attend and score them in the goal setting process [14]. The examiner records the scores according to assessment date and in the rehabilitation process, patients have opportunities to observe the improvement oftheir limited activities in daily life. PSFS is short, time-consuming and easy to use scale and it has been reported in the literature as valid, reliable and responsive in terms of psychometric properties for different musculoskeletal conditions such as low back pain, carpometacarpal osteoarthritis and lateral epicondylitis [15]. All these properties of PSFS provide advantageous in clinical management. Besides, it has been used many randomized controlled trials as an outcome measure [16–21]. PSFS is also valid and reliable for chronic neck pain patients. The availability of the validation of a recommended questionnaire in another language and culture is commonly required to be used . While the NDI has been validated in the Turkish language before, as to our knowledge no attempt has been made for the validation of PSFS.PSFS has been validated in Finnish, Swedish, Portuguese, Japanese, Nepali, and Dutch [24–29]. The aim of this study is to conduct the test-retest reliability and convergent-construct validity of the Turkish version of PSFS in neck pain patients.This validation study was conducted in the School of Physical Therapy and Rehabilitation of Dokuz Eylül University between October 2016 and April 2017. The ethical approval was obtained from Noninvasive Research Ethics Committee of Dokuz Eylül University  prior to the study and all procedures were conducted according to the Declaration of Helsinki. The signed informed consents were obtained from all participants prior to the study. The required permission has been obtained from the original author of the scale (Paul Stratford) via e-mail.The sample of the study was the patients with chronic neck pain complaints. The inclusion criteria were determined as following: the ability to read and understand Turkish and having a chronic neck pain for at least three months. Exclusion criteria were patients with red flag medical conditions , cervical radiculopathy signs, having psychiatric disorders and those who having undergone spinal surgery, an ongoing physical therapy program and could not read in Turkish language. The physiotherapist informed the patients about the study and their informed consent forms were obtained.The Turkish version of the PSFS  was constructed by a repeated back and forward translation process. The process was managed by an independent translator team with following the translation and cultural adaptation processes as described by Beaton et al. (Table 1) [22].NDI is a widely used self-report questionnaire to assess the symptoms of neck pain patients and the limitations of their functional activities. The questionnaire had 10 sections; pain intensity, personal care, lifting, reading, headaches, concentration, work, driving, sleeping, and recreation. Each item scored between 0 (no disability) and 5 . NDI was reported as a valid and reliable tool for evaluating neck symptoms and functions according to the current literature and guidelines. The Turkish version of the NDI was used, and the validation was performed by Aslan et al. in 2008 [11]. PSFS was developed by Stratford et. al for evaluating patient-specific functional disability level and have a good reliability and validity [13]. Patients were asked to list three activities which cause the most difficulty related to their neck pain. Then, each activity was scored between 0 (unable to perform activity) and 10 (able to perform activity at the same level as before the onset of symptoms) [12]. Analyzes of data were performed by using “SPSS 20.0 for Windows” program. The cultural adaptation of the PSFS-T was evaluated at the beginning of the study (Table 1). Sample size was determined as 83 chronic neck pain patients by calculation in GPower 3.1 program using the data of PSFS Japanese version study convergent validity data [25]. And, the study was completed with 110 patients . Normal distribution was evaluated with Kolmogorov-Smirnov test. However, nonparametric analyses were used since there was no compatibility with normal distribution.In order to determine the test-retest reliability intraclass correlation coefficient (ICC) was calculated. PSFS-T was reapplied to the first 30 patients 4–14 days following the initial evaluation [30]. The  model was used. Level of ICC was interpreted using following criteria: <0.5 = weak, 0.5–0.75 = moderate, 0.75–0.90 = good, >0.9 = excellent [31].Convergent validity analysis was determined by performing the Spearman correlation analysis of PSFS-T and NDI due to nonparametric conditions. The level of correlation was interpreted as 0–0.25: no relationship, 0.25–0.50: fair relationship, 0.5–0.75: good relationship, >0.75: excellent relationship [32]. Therefore, there was a excellent relationship between NDI and PSFS-T in the hypothesis one as these instruments are based on a parallel construct. Construct validation by extreme groups  is a type of validation where the instrument is assessed on two extreme groups, which should score significantly different on the measurement instrument [33]. Extreme groups were defined on initial disability levels by NDI. We assumed that patients with high disability (>15) would have a higher level of perceived disability on PSFS. The Mann Whitney-U test was used to test the difference between known groups. For hypothesis 2, we expected a significant difference between the groups (high and low disability) according to PSFS.A total of 110 chronic neck pain patients included in this study. Descriptive characteristics of patients and disability scores related to NDI and PSFS-T scales were summarized in Table 2. While the ICC scores for the first (ICC = 0.73) and the second activities (ICC = 0.76) showed moderate reliability in PSFS-T, third activity (ICC = 0.85) and total scores (ICC = 0.85) showed good reliability. Test-retest results, ICC scores, confidence intervals (CI) were summarized in Table 3.A moderate and negative correlation was determined between PSFS-T and NDI . When the patients were examined according to the activities they reported in the first place, the correlation increased to an excellent level (r = –0.865) for reading, however, cleaning (r = –0.487) and lifting a thing over the head (r = –0.575) activities showed moderate correlations (Table 4). In this context, hypothesis one was not defined, as the relationship between PSFS-T and NDI was –0.578, indicating a good relationship instead of a excellent relationship (>0.75).Hypothesis 2 was confirmed as differences between “known groups” were statistically significant. The median score of PSFS-T in the low disability group was significantly higher than the high disability group (P < 0.001) (Table 5).As the PSFS is a personalized questionnaire, chronic neck pain patients reported difficulties in 27 different activities. The 3 most frequently reported activities were reading books (19.7%), cleaning (18.1%) and lifting a thing over the head (12.4%) (Table 6). The importance of evaluating functional activity limitations with reliable and valid tools is increasing day by day in physiotherapy [34]. These outcome measures help to determine the benefits of treatment and allow us to follow the changes in the patient’s conditions. However, mostly, other clinical methods such as muscle strength measurement, the range of motion evaluation and pain assessment are performed in musculoskeletal physiotherapy practice . Current clinical guidelines related to physiotherapy assessments in neck pain recommend including functional activity and participation assessments during the evaluation. In this manner, PSFS is a widely recommended tool . However, in the light of the current literature, the PSFS scale has not been found translated into Turkish before. Thus, PSFS was adapted in Turkish language and found valid and reliable in terms of evaluating functional activities of chronic neck pain patients in the present study. As to our knowledge, there are 6 studies focus on reliability and validity of PSFS in patients with neck pain up to date . A comparison of the previous studies and the recent study was provided in Table 7. The major part of these studies was conducted in English speaking countries except the Japanese and Dutch version studies . The studies were conducted in different neck pain conditions such as radiculopathy, neck dysfunction, and chronic neck pain. Most of the studies reported high test-retest values (ICCs: between 0.82–0.98) as we determined in the present study (ICC: 0.85). However, Young et al. reported very low test-retest value (ICC: 0.17) for the PSFS. These authors concluded that ICC scores may be affected by dynamic symptom distribution of cervical radiculopathy patients . The present the validity analysis of the PSFS-T were compatible with Japanese and Dutch version studies within the scope of convergent and construct validity . Nakamaru et al. found low relationship between NDI and PSFS in the convergent analysis (r: –0.35) (25). However, we determined moderate relationship between NDI and PSFS (rho: –0.57), similary with Dutch version study (rho: 0.54). We thought that the differences in the correlation results could be related with cultural factors since the sample sizes were similar of the compared studies. Besides, Thoomes-de Graaf et al. was indicated a significant difference between low pain and high pain groups for construct validity hypothesis of PSFS [29]. In this context, our result was similar with the Dutch version. We also found a significant difference between low and high disability groups in accordance to PSFS-T for the hypothesis of construct validity. Future studies can also be carried out on the sensitivity analysis of PSFS-T which recommended on assessing measurement properties in the current literature [33].Cleland et al. listed the most reported activities in PSFS as driving car (50%), sleeping (50%) and using the computer (40%) respectively [32]. In our study, reading (19.7%), cleaning (18.1%) and carrying heavy things (12.4%) were reported as the hardest activities related to neck pain, respectively [38]. The nature of PSFS is a self-administered and different cultures or living styles could change the affected activities reasonably. Additionally, if a patient’s activity selection on PSFS matched with NDI activities, correlation coefficient could vary. In our study, the correlation between the total PSFS and NDI scores was excellent in patients who listed “reading” activity in the first place (r: –0.865). In contrast, the correlation between the total PSFS and NDI scores was fair in patients who listed “cleaning” activity which is not covered by NDI (r: –0.487). Thus, we think that reported activities in PSFS scale might conduce different correlations with NDI total scores (Table 4). Neck pain does not only lead a decline in physical functioning but also causes additional negative emotional conditions such as depression and fear avoidance beliefs [41]. Therefore, assessing the restriction in the functional activities of the patients who experience chronic problems might lead the health professionals to offer more reliable outcome measures. In this direction, the use of self-reported outcome measures in physiotherapy is getting increase . However, a survey study among the physiotherapists showed that self-reported measurements are not preferably due to time constraints, the length of the scales and long duration of appropriate scale selection [35]. In this manner, PSFS is a very available scale for musculoskeletal evaluation, as it is short and does not contain too many questions. Therefore, PSFS might help to clinician cover the symptoms of the patient more in detail [37].It seems logical to use a tool which serves specifically to a population. However, tools that are specific to a disease or condition could not cover the needs of all populations with the same level of sensitivity. For instance, a tool which is specific to sedentary populations might not provide accurate results in the athletic population. However, PSFS is a person specific tool which allows collecting results unique to the patient. In the report of Fairbairn et al. 2911 different activity items which were collected via PSFS and were found 100% matched with the international classification of functioning disability and health (ICF) [42]. These results indicate that PSFS might be able to cover the ICF which aims to build a common language system for health. Moreover, PSFS was used in a variety of musculoskeletal conditions such as lateral epicondylitis, upper extremity injuries, osteoarthritis, low back pain [15]. Future studies could be conducted about its validity and reliability in the other musculoskeletal conditions. Besides all the patient specific features of the PSFS, the use of this tool for academic purposes might be a challenge. Wiitavaara et al. performed a systemic review on shoulder-neck pain related outcome tools and mentioned that a comprehensive assessment should include pain, physical condition, mental and cognitive situation assessments. They also stated that PSFS is a really sensitive scale for patient follow-up, but the analysis of the scale is so difficult especially comparing the patients’ conditions to each other[43]. Similarly, Pietrobon et al. reviewed all neck pain scales and recommended 5 outcome scales including PSFS and they concluded same as in Wiitavaara’s report [44]. According to both authors, PSFS is a very patient specific scale and useful in clinical settings, but it is also very hard to use the PSFS in research studies.The Turkish version of PSFS was found valid and reliable for Turkish-speaking neck pain patients in the present study. However, no follow-up periods were provided. Therefore, responsiveness analyses were not discussed. This is the limitation of our study. The authors would like to thank Paul Stratford for their permission to conduct this study, translators for their voluntariness and patients for their participation. Also, the authors have appreciated to Deniz Bayraktar on their help in language corrections. All authors declare that there is no conflicts of interest.The ethical approval was obtained from Noninvasive Research Ethics Committee of Dokuz Eylül University  prior to the study and all procedures were conducted according to the Declaration of Helsinki. The signed informed consents were obtained from all participants prior to the study.


Goal setting is linked to person-centred care and is a core component in physiotherapy, but the associations between goal classes, patient characteristics and outcome measures for musculoskeletal disorders has not been investigated. The study’s purpose was to examine 1) how goals used in clinical practice for patients with musculoskeletal disorders (MSD) are distributed in classes based on ICF, 2) if goal classes were associated with patient characteristics and 3) whether goal classes were associated with treatment outcome.N = 2591). Goals were classified in symptom, function/structure, activity/participation and non-classifiable. Associations between patient characteristics and goal classes were examined using x2 and one-way ANOVA. Association between goal classes and outcomes were examined using multiple logistic and linear regression models. Outcomes are reported at 3 months or end of treatment if prior to 3 months.Data analysis from a longitudinal observational study (p < .001). Activity/participation goals were associated with better outcomes on GPE . Non-classifiable goal was associated with poorer outcomes on pain intensity .There was a high variability in goals used for patients with MSD. 17% had symptom goals, 32.3% function/structure, 43.4% activity/participation and 7.4% non-classifiable goals. We found significant associations between goal classes and age, gender, severity, region of pain/diagnosis and emotional distress .  Musculoskeletal disorders (MSD) are a major social and economic burden and the leading cause of years lived with disability worldwide . A systePrevious research has shown that goals of physiotherapy interventions can be described using the The International Classification of Functioning, Disability and Health (ICF) . One stuDemographic, anthropometric, psychosocial and disease-specific factors are associated with outcomes for patients with MSD –19, and Previous studies have reported the association between goals, psychosocial factors –19 and tWe wanted to explore 1) how goals used in clinical practice for patients with MSD are distributed in classes based on domains of ICF, 2) if goal classes were associated with certain patient characteristics and 3) whether goal classes reflecting different domains of ICF were associated with treatment outcome.This cohort study is part of the Norwegian longitudinal observational project Physiotherapy in Primary Health Care (FYSIOPRIM). The project includes data from adult patients seeking physiotherapy in nine municipalities Norway. All patients seeking physiotherapy in the 36 participating clinics in the primary health care system were eligible for inclusion. Patients were invited to participate on their first encounter with a physiotherapist in primary health care and were given project information and consent forms. The patients were treated by 109 different physiotherapists. 74 were general physiotherapists, 21 specialised as manual therapists and 14 specialised as psychomotor physiotherapists. Baseline data was collected in two steps. First, data were registered by the physiotherapist and the patient in collaboration. They jointly agreed, and defined, the main treatment goal and scored the most important functional problems using the Patient-Specific Functional Scale (PSFS) . The phyFor this study we included the following variables: treatment goal, body region/diagnosis, and demographic, anthropometric, psychosocial and disease specific variables previously shown to be associated to outcomes for MSD –19. The The outcome measures were Global Perceived Effect 7-point scale (GPE)  , self-evBefore statistical analysis could be conducted, the treatment goals were coded based on definitions of the goal being symptom related, function or structure related, activity or participation related, combinations of these or being non-classifiable. Definitions were based on the main categories from ICF , as follDescriptive data are presented as frequencies and percentages or means and standard deviations as appropriate. Chi-square were used to examine univariable associations between categorical variables. One-way analysis of variance (ANOVA) with post hoc bonferroni test were used to examine associations between continuous variables.p < 0.20) were included in the multiple regression models. A backward manual elimination method was used to remove those variables with the highest p-value. The elimination was repeated until only variables statistically significant at the 5% level (p < 0.05) remained. To prevent elimination of a variable at one step in the analysis process being crucial, the variables removed on backward elimination were all re-entered in the models one by one and remained in the models if they were statistically significant at the 5% level. Goal class, age and gender were kept in the multiple regression models regardless of significance.To examine the associations between different goal classes and response on different treatment outcome measures, univariate logistic and linear regression analysis were used with 95% confidence intervals (CI). The assumptions of regression analysis were assessed. Multiple logistic and linear regression models were then used to control for demographic (age and gender), anthropometric (BMI), psychosocial  and disease-specific variables . All variables were examined in the univariate models. The variables that were statistically significant at the 20% level (N > 50 + 8 m (m = number of independent variables) for sample size calculations for multiple regressions. The lowest number of observations for one multiple regression analysis in our study was 975. This shows that the sample size was sufficient for the multiple regression analyses.To allow logistic regression, GPE and self-evaluated improvement on main goal were coded into a dichotomous scale. The GPE 7-point scale was divided into “improved” and “not improved”, where “improved” included the response of very much improved or much improved. “Not improved” included responses ranging from minimally improved to very much worse , 29. ForAll statistical analysis was performed with IBM SPSS Statistics 25.Figure p < .001) . This group also had more people scoring neither agree nor disagree to belief in effect of physiotherapy for their condition (39.5% higher than EC).The group with symptom only goals had patients with younger age , more females (10.3% more than EC), more patients with spinal pain (65.4% higher than EC) and more unspecific/multisite conditions (46.2% higher than EC). Fewer patients in this group totally agreed in that they believed in effect of physiotherapy for their condition (17.4% less than EC) and more patients neither agreed nor disagreed (52.6% higher than EC). The group including function/structure related goals had more patients with upper extremity pain (37.8% higher than EC). The group with activity/participation goals had more males (10.3% higher than EC), more patients with lower extremity pain (25.4% higher than EC) and less patients scoring neither agree nor disagree to belief in effect of physiotherapy for their condition (19.2% less than EC). The group with non-classifiable goals had more females (10.4% higher than EC), more patients with unspecific/multisite conditions (171.7% higher than EC) and higher emotional distress  in the multiple logistic regression analysis. In addition, lower age, more positive treatment beliefs and lower emotional distress was associated with improvement, while having unspecific/multisite pain were associated with less improvement.Compared to the goal class symptom, the goal class There were no association between goal classes and self-evaluated achievement of treatment goal in the univariate or multiple logistic regression analysis Table . Lower eSimilarly, there were no association between goal classes and PSFS used as outcome Table . In the non-classifiable goal was associated with less improvement with a B-value of .87  found that more than 70% of patients with spinal pain chose reduction of pain as one of their goals for physiotherapy treatment. In contrast to this finding, Gardner et al. (2015) showed that patients with chronic low back pain tend to set goals orientated around activity, participation and coping, and not symptoms alone. This contrast might be due to difference in recruitment setting as their study predominantly recruited non-care seeking participants from the community. It could also be due to the goal setting process, as their study included giving the patients preliminary information on the chronic pain model, self-management tips and goal setting before the patient filled in their goals.We found interesting differences in use of goal classes between different body regions/diagnosis. Patients with spinal pain chose symptom related goals more than other patients, while patients with unspecific/multisite conditions had more non-classifiable goals. Patients with upper- or lower extremity pain used more goals related to function/structure or activity/participation. Henry et al. (2017) found that patients with chronic musculoskeletal pain who were prescribed long-term opioids, prioritized symptom relief as the most important goal. Most patients in their study had several pain sites, with lower back being reported by 75% and a substantial proportion had comorbid mental health diagnoses. This is somewhat comparable to our findings as most patients in their study would correspond to our categories of spinal pain or unspecific/multisite conditions, although we do not have information about the patients use of pain medication. This supports our finding that patients with spinal pain or unspecific/multisite conditions more often define treatment goals related to symptom relief. Our findings show that patients with MSD related to the extremities uses more goals related to function/structure and activity/participation, less symptom related goals and have less non-classifiable goals. This might indicate that it is easier for patients to set goals related to specific functions and activities when they have MSD related to their extremities compared to having spinal pain or an unspecific/multisite condition.It has been indicated that goals related to the activity and participation domain in the ICF, are the most meaningful and person-centred goals . Still, We found an association between goal classes and GPE and pain intensity as outcome measures. Moreover, activity or participation related goals were associated with better outcomes on GPE and non-classifiable goals were associated with poorer outcomes for pain intensity. Previous studies on other patient groups have found comparable results, with improved outcomes for patients having goals comparable to activity or participation –34. TheyWe found that non-classifiable goals were associated to characteristics previously linked to poorer outcomes for MSD, such as being female, having high psychosocial distress and multisite or unspecific pain diagnosis –18. FurtInterestingly, there were no association between goals and outcomes on PSFS or self-evaluated improvement on main goal. It could be expected that having a symptom related goal would be associated to less improvement on PSFS, as previous research has indicated that the pursuit of pain-related goals might negatively influence non-pain related goals . HoweverOur results provide a broader understanding and more knowledge about patients’ personalized goals for treatment. We found associations between goals, patient characteristics and outcomes as well as large variations in types of goals being important to patients. This knowledge can be useful for therapists in making more person-centred treatment plans.One strength of this study is the use of a large database including more than 2500 patients with MSD seeking physiotherapy in primary health care. This indicates that our results reflect clinical practice in primary health care in Norway.There are also some limitations that should be considered. Firstly, there was a high number of dropouts that did not fill out outcomes at 3 months. 1207 patients did not fill out GPE at 3 months, 1560 patients for self-evaluated improvement on main goal, 1616 for PSFS and 1360 for pain intensity. Secondly, as the only instruction to the therapist was to set a main goal in collaboration with the patient, it is unknown whether there was an equal contribution in the goal setting process. Previous research has shown that there is a large variation in contribution between therapist and patient when setting treatment goals. Therapists with a biomedical treatment focus was associated with less patient involvement in goal setting compared with therapists with a biopsychosocial focus . We do nWe found large variability in goals used for patients with MSD seeking physiotherapy in primary health care in Norway. The content of goals were classified to the whole range of the domains of ICF, with only about one third restricted to either function or structure improvement or limitations in activity or participation. Most goals included a mix of domains. Less than 10% of the goals were not classifiable according to ICF. We found an association between goal classes and the patient characteristics; age, gender, severity, body region/diagnosis and emotional distress. Additionally, we found a weak association between goal classes and outcomes, where including activity and/or participation in the main goal was associated with better outcomes for GPE and having a non-classifiable goal was associated with poorer outcomes for pain intensity.


IntroductionClosed reduction is an effective method of treatment for distal end radius fractures. We present a case series of patients with distal end radius fractures who underwent closed manipulative reduction using the periosteal block. We describe the technique in detail and examine its efficacy in pain lowering effect during closed reduction.MethodsNineteen patients with distal end radial and ulnar fractures were included and grouped based on the Frykman classification. The reduction was performed using a periosteal block of 10 ml of 2% lignocaine injection. The severity of pain was recorded by utilizing the visual analog scale (VAS) in five phases: 1) before injection, 2) after 15 minutes of analgesia in a resting position, 3) during minimal motion, 4) during full manipulation and reduction, and 5) post-procedure. The VAS scoring was classified as painless (VAS score of 0), mild pain (VAS score between 1-3), and painful (VAS score of 4 and above).ResultsThe study included 19 patients [median age of 53 years (range: 18-88 years)]; there were 11 (58%) males and eight (42%) females. The mechanism of injury was a fall  or a motor vehicle accident . There was a statistically significant reduction of pain between phase one and all the other phases. Between the different fracture configurations, there was no significant difference in pain reduction. The most painful phase was expected to be phase four, ie, during full manipulation, in which four (21%) patients had a VAS score of 0, 12 (63%) patients had a VAS score between 1-3, and three (16%) patients had a VAS score of 4. Thus, 16 out of 19 patients (84%) had no or minimal pain during the most painful phase. There were no complications from the periosteal blocks.ConclusionsThe periosteal nerve block is an effective procedure providing satisfactory analgesia during the reduction of distal radial and ulnar fractures. It has no side effects and is free from complications associated with conventional sedation. One of the most common fractures seen in the emergency department is the distal radius and ulna fractures. It has a bimodal distribution with a higher incidence reported in children and the elderly ,2. In thIn many centers, sedation is the normal practice before the surgical procedure; however, it is associated with complications such as post-sedation nausea and vomiting and respiratory depression. Moreover, patients need to be monitored until they are fully conscious. As an alternative to sedation, the hematoma block is widely utilized due to its safety and simplicity ,5. HowevA new technique of periosteal block was devised by Tageldin et al. in 2015, where local anesthesia (lignocaine) was infiltrated around a greenstick fracture of the radius and ulna proximal to the fracture site . There wThere seems to be a wide variety of pain perception during fracture manipulation under hematoma block, with patients reporting highly varied mean visual analog scale (VAS) scores: 5.50 , 2.8 9]9], 2.08 A few studies have reported the use of WALANT in distal radius plating. A single patient in a case report by Ahmad et al.  reportedThe objective of this study was to evaluate the efficacy of using the periosteal block in the reduction of distal end radius fractures. Specifically, we wanted to assess pain scores at different phases of the fracture manipulation and in relation to fracture patterns.The study included patients aged 18 years and above with closed displaced distal radial fractures  that required a closed reduction either as a temporary or definitive treatment. The exclusion criteria were as follows: patients with multiple fractures, those with ipsilateral shaft fracture, patients requiring repeat CMR, unconscious patients, open fractures, undisplaced fractures not requiring CMR, patients who refused local anesthesia, and patients with clinical evidence of compartment syndrome and allergy to local anesthesia. This study was approved by our university's ethical committee .The case series consisted of 19 consecutive patients over a period of six months. Fractures were classified according to the Frykman classification . Pain scores were recorded in five different procedural phases: 1) before the periosteal injection, 2) after 15 minutes of analgesia infiltration in a resting position, 3) during minimal motion and manipulation, 4) during full manipulation and reduction of the fracture fragments, and 5) post-procedure. Patients were briefed about the procedure in advance and they understood the different phases where they would be asked about the VAS score. The VAS scoring was then classified as painless (VAS score of 0), mild pain (VAS score between 1-3), and painful (VAS score of 4 and above). If the patient experienced a painful procedure (VAS score of 4 or above), intravenous ketorolac 30 mg stat was given as a rescue dose. Ketorolac was selected as the drug of choice as it has no side effects of nausea and vomiting, which are possible side effects of lignocaine toxicity. All periosteal blocks were performed by a single operator with at least five years of experience in orthopaedics and trained to perform periosteal blocks. Vital signs and any side effects and toxicity symptoms of local anaesthesia were monitored, including cardiotoxicity, central nervous toxicity, and allergic reaction. The procedure was performed in the emergency department with cardiac monitoring and an emergency trolley with lipid emulsion available as an antidote .Periosteal block technique The patient was placed in a supine position with the injured hand and forearm resting on a dressing table. A precautionary intravenous cannula was inserted into the uninjured arm. Oxygen and intravenous fluids were available. Local anesthesia was infiltrated based on the universal standard aseptic technique with 2% lidocaine at a dosage of 2 mg/kg of body weight in a volume of 10 ml for a single bone ,7,14. ThWe then waited 15 minutes before minimally mobilizing the forearm, which was followed by close manipulation and reduction. After the reduction, casting or a splint was applied. The patient was observed in an observation room for two hours before being discharged. Any complications or side effects were recorded.All statistical analyses were performed with SPSS Statistics 23.0 for Windows  and Microsoft Excel 2003 . The Wilcoxon signed-rank test and the Kruskal-Wallis test were used to analyze data.A total of 19 patients were included in the study. The median age of the patients was 53 years (range: 18-88 years). Seven (37%) patients were below 50 years old and 12 (63%) patients were above 50 years old. There were 11 (58%) males and eight (42%) females. With regard to the mechanism of injury, 12 (63%) patients sustained the fractures following a fall and seven (37%) following motor vehicle accidents. The demographic data are presented in Table All patients were further subdivided into eight groups based on their fracture configuration (Frykman classification). Group II  had the highest number of patients . There were no patients in groups I, VII, and VIII Table .There was significant pain reduction seen in each of the phases Figure . A paireWith regard to pain experienced in all the five phases, the VAS score was grouped as painless (VAS score of 0), mild pain (VAS score between 1-3), and painful (VAS score of 4 and above)  procedural sedation (using a combination of opioids and benzodiazepine) and 2) neural blocks, which are further grouped into i) regional  and ii) local block (hematoma block). Hematoma blocks offer a better quality of reduction and similar effectiveness for pain relief compared to brachial plexus block with the advantage of having no motor paralysis ,16. HemaProcedural sedation remains the most popular method of analgesia . AlthougSimilar to the findings of Tageldin’s study, we too found that the proximal periosteal block is a very acceptable method of facilitating distal end radius fracture reduction. It provides an excellent mode of pain relief, resulting in high patient satisfaction levels. All patients do not require anxiolytic or sedation such as benzodiazepine during closed reduction. This will reduce complications related to drugs, especially opioids. It also facilitates post-reduction treatment as there is no need for post-sedation observation. In our center, administering sedation requires the patient to be transferred from the green zone to the yellow zone where the patient is then attached to a blood pressure cuff and pulse oximeter with an emergency trolley on standby. Therefore, apart from providing excellent pain reduction, the periosteal block also significantly shortens the total treatment duration in the emergency department.There seems to be a wide variety of pain perception during fracture manipulation under a hematoma block. A pilot study by Orbach et al. with a hematoma block reported a mean VAS score of 5.50 in one group (10 mL of 2% lidocaine) and 3.09 in another group (20 mL of 1% lidocaine) although the difference was not statistically significant . AnotherTageldin et al.’s periosteal block reported a VAS score of 0 in 36 patients and a VAS score between 1-3 in six patients . None haAdditionally, we observed that pain was associated with extensive soft tissue injury. In the three patients mentioned above, the fracture sites were extensively swollen with multiple bruises compared to other patients. This might indicate that the periosteal block may effectively block pain stimulus caused by bone fractures and joint capsule rather than the surrounding soft tissue. We did not record the degree of soft tissue injury in this study.Our study showed a statistically significant decrease in pain scores with the periosteal block in all the four points phases: 15 minutes post-analgesia, post-analgesia with minimal manipulation, during manipulation, and 15 minutes after manipulation. The results of our study are comparable with that of Tageldin et al., and we have taken a step further by performing a statistical analysis.In the study by Bajracharya et al., one out of 50 patients had an infection after a hematoma block, requiring drainage and external fixation [All of the blocks were performed by the main author. However, team members who observed the procedure felt confident of repeating the technique although this was not assessed. We did not assess anxiety levels, which would have been interesting as Celik et al. have reported higher anxiety levels in females and those with higher education . DavisonThe periosteal nerve block is an effective method for providing excellent pain relief during the phases of manual reduction of distal radial and ulnar fractures. It can be used in all types of fracture configurations in the Frykman classification and provides similar outcomes. However, we have not compared periosteal blocks with any other modality of treatment.The periosteal nerve block provides an alternative to the conventional sedation method and can avoid the complications associated with conventional sedation. Even though this study was performed by orthopaedic doctors, we believe that with proper training and education, the periosteal nerve block can be performed by any medical personnel in an emergency setting.


Background: Symptomatic lumbar spinal stenosis (SLSS) is a condition in which narrowing of the spinal canal results in entrapment and compression of neurovascular structures. Decompressive surgery, with or without spinal fusion, is recommended for those with severe symptoms for whom conservative management has failed. However, significant persistent pain, functional limitations, and narcotic use can affect up to one third of patients postsurgery.Aims: The aim of this study will be to identify predictors of outcomes 1-year post SLSS surgery with a focus on modifiable predictors.Methods: The Canadian Spine Outcomes Research Network (CSORN) is a large database of prospectively collected data on pre- and postsurgical outcomes among surgical patients. We include participants with a primary diagnosis of SLSS undergoing their first spine surgery. Outcomes are measured at 12 months after surgery and include back and leg pain, disability , walking capacity (ODI item 4), health-related quality of life, and an overall recovery composite outcome . Predictors include demographics , physical activity level, smoking status, previous conservative treatments, medication intake, depression, patient expectations, and other comorbidities. A multivariate partial least squares model is used to identify predictors of outcomes.Conclusion: Study results will inform targeted SLSS interventions, either for the selection of best candidates for surgery or the identification of targets for presurgical rehabilitation programs. Instrumented spinal fusion is usually reserved for patients with SLSS with associated deformity or instability, and these procedures have significant risk of complications.6 Unfortunately, significant persistent pain, functional limitations, diminished HRQoL, and narcotic use can affect up to one third of patients postsurgery.7–9 More specifically, there is evidence to suggest that approximately 30% of patients do not reach a minimal clinical important change in disability, pain, or quality of life 1 year postsurgery.10–12 Further, a recently published large population-based study identified that more than 40% of patients undergoing fusion for SLSS remain long-term opioid users.14The majority of patients with SLSS receive conservative interventions such as physiotherapy, steroid injections, and opioids.15 Poor surgical outcomes as related to disability, pain, walking capacity, or HRQoL may include an array of potential predictors, such as frailty, obesity, smoking, recovery expectations, depression, opioid use, better walking capacity, and lower pain at baseline as well as higher education level and socioeconomic status, age, sex, and comorbidities.15–18 A limitation of these studies is that they are unable to account for a large number of predictors because of the likelihood of multicollinearity and therefore generally only include a limited number of factors in their models.15–18 In addition, as with many studies in SLSS, outcomes used in prediction analysis are variable, which means that it is difficult to make generalized conclusions. A major advantage of the current protocol is that it allows for a stable and simultaneous analysis of multiple outcomes with a large number of predictors using core back pain outcomes.19A number of studies have evaluated predictors of postsurgical outcomes, including a systematic review published in 2006.As previously mentioned, the literature could be improved upon by utilizing sophisticated statistical modeling on very large, high-quality data sets to identify modifiable predictors. Personalized management strategies to identify best candidates for surgery and the development of a presurgical rehabilitation program may improve patient outcomes. Thus, our primary aim is to identify predictors of back and leg pain, disability, walking capacity, HRQoL, and clinically important change across all outcomes (recovery) 1-year post SLSS surgery.20–22 The STROBE  checklist is used for reporting of the study and was used to construct the protocol.23 This study received ethics approval from the Hamilton Integrated Research Ethics Board (HiREB #7285-C). The CSORN is a large database consisting of spine surgical data collected from patients of more than 50 neurosurgeons and orthopedic spine surgeons at 18 sites across Canada. It includes data pre- and postsurgery that were collected from patients diagnosed with a variety of different spinal pathologies, including SLSS. Data collection is conducted at baseline (pre-op), as well as at 3 and 12 months postoperatively. Standardized questionnaires are used to collect information on demographics and comorbidities and include lifestyle questions such as physical activity level and work status, past and current management strategies as related to the condition, self-reported expectations of outcomes, and pain, disability, and HRQoL as outcome measures. Surgeons also record surgical information such as specific procedure, complications, and length of hospital stay. All 18 sites that contributed to the registry obtained research ethics board approval prior to any data collection. Recently, the CSORN steering committee implemented improvements to their data collection procedures to improve data completeness; thus, only data from January 2015 to September 2019 will be utilized in this study.This is a historical cohort study using data from the Canadian Spine Outcomes Research Network (CSORN) registry.Patients must have a primary diagnosis of SLSS provided by the treating spinal surgeon. Diagnosis was provided based on the surgeon’s assessment and clinical judgment because there are no clearly established diagnostic criteria.Availability of 12-month postoperative CSORN outcome data .The inclusion criteria for this study include two factors:Exclusion criteria include previous history of spinal surgery (self-reported), as well as low levels of back and leg pain , low levels of disability (<20% on the Oswestry Disability Index [ODI]), and high quality of life  measured at baseline. There were no exclusions in relation to the length of symptoms or comorbidities. These are included in our analysis as potential predictors. We did not exclude participants based on the presence of additional imaging findings such as disc herniation or degenerative disc disease.19 The NRS is a scale ranging from 0 (no pain) to 10 (worst possible pain), with patients indicating their current pain intensity. Disability was measured using the ODI, a condition-specific outcome measure for spine- and back-related disorders that presents a subjective percentage score of a patient’s level of function (scored from 0 to 100).24 The ODI is also a core outcome measure in low back pain with significant evidence for validity, reliability, and responsiveness.19 Walking capacity is assessed using item 4 of the ODI. This self-reported question assesses a patient’s ability to walk various distances . This question is often used in SLSS literature, has been found to have good evidence for responsiveness,25 and is a recommended outcome from a recent systematic review of walking tests in SLSS.26 HRQoL was measured using the EQ-5D-5L, which is a questionnaire describing the patient’s health state using an index value system .27 This instrument utilizes a value set that weighs each health state description according to the preferences of the general population of a region.28 Overall recovery composite outcome is used as a surrogate measure of recovery and is assessed using a combination of clinically important change in pain, disability, and HRQoL.29 A patient is deemed fully recovered if he or she meets all four criteria outlined in 30Six different outcome measures are included in this study, including back pain, leg pain, disability, walking capacity, HRQoL, and clinically significant change. Back and leg pain were measured using a numeric rating scale (NRS). The NRS is one of the most frequently used instruments to measure low back pain and is currently a core outcome measure in the last low back pain outcome measures consensus.17 and lower levels of obesity (body mass index < 30).11 Shorter duration of symptoms prior to surgery is also positively correlated with reduced pain postsurgery.15 Factors that have been identified in the literature as being associated with improved walking capacity outcomes include younger age, male sex, higher reported walking capacity at baseline, lower levels of back and leg pain at baseline,16 and better self-rated health at baseline.16 Factors that have been identified to be associated with poor postsurgical outcomes include depression , high levels of back pain at baseline, higher expectations of pain relief expectations going into surgery,15 cardiovascular comorbidity,12 and smoking, living alone, and unemployment.17 The data available from the CSORN registry include many of these predictors. The predictors we have chosen to include in our models are listed in Predictors were chosen for the present study based on data available from the CSORN registry, previous literature, and clinical assumptions. Factors that have been identified to be associated with improved disability outcomes include higher education level, higher quality of life (EQ-5D) at baseline, lower disability (ODI) at baseline, shorter duration of back pain,31 that allows for the simultaneous analysis of multiple outcomes with a large number of predictors and is stable even when the input data have moderate levels of collinearity. PLS is a technique that combines principal component analysis with multiple linear regression. The mix of categorical and continuous predictor variables requires the use of a modified version of the PLS algorithm, partial least squares correspondence analysis.32 This technique has been used for neuroimaging and genetics data sets. The set of predictors are listed in The goal of this analysis is to identify the predictors that are most relevant to the six identified outcome measures. The outcomes  are likely correlated, and the large number of predictors would probably suffer from multicollinearity in a multiple regression model. Therefore, we use a multivariate approach, partial least squares (PLS),Prior to the analysis, the CSORN data were preprocessed using the table functions in MATLAB; for example, to compute total scores or identify rows with missing data. As part of our inclusion criteria, we excluded any patient who did not complete 12-month follow-up. When data were missing for predictors and covariates (at a maximum of 20%), we used multiple imputation and conducted a sensitivity analysis after removing rows with missing data. However, when data were missing for outcomes , the patient record was excluded from the analysis of multiple outcomes.33 This method identifies the least important variable, eliminates that variable, reruns the analysis, and repeats until the desired balance of parsimony and prediction is achieved.An objective criterion was used to eliminate predictors from the model to achieve a more parsimonious model. An example of such a criterion is iterative variable importance for projection.The PLS model was cross-validated by a hold-out procedure. This step prevents overfitting the model to extreme observations. The data are split into two sets, a training set and a test set, with set membership being random. The PLS model building step was repeated with the training set, and ability of the model to predict test set observations was evaluated. This was repeated 1000 times to ensure that every combination of observations was tested.34Concomitantly to the PLS, we also conducted traditional regression analysis for each independent outcome. We used multiple linear regression for the continuous outcomes of pain, disability, and HRQoL; logistic regression for the outcome of recovery; and ordinal regression for the outcome of walking capacity (ODI item 4). Assumptions and multicollinearity were assessed as appropriate. Regression was conducted in Stata 14.0 with a significance level of 0.05. Following Sex and Gender Equity in Research guidelines, we conducted sex-specific analyzes (sex as per collected in the CSORN) by including sex as a cofounder in the total model and performing a disaggregated analysis by sex.35 With a total of 16 predictors, we needed to include at least 160 fully recovered and 160 unrecovered patients in the model. Thus, based on the literature that 30% of patients do not recover from pain-related disability following surgery,18 our logistic regression model required a minimum sample size of 540 participants. However, we included at least 10 patients per predictor category as is customary for creating robust multivariable models.We conducted an a priori sample size calculation considering the baseline risk for our primary outcome of disability (assessed using the ODI). Although this outcome is continuous, we dichotomized the outcome as per the overall recovery composite outcome. As per Peduzzi et al., we included at least 20 patients  per predictor category.SLSS treatment outcomes, whether conservative or surgical, are variable, with a large number of patients continuing to have significant levels of pain, disability, and diminished HRQoL. To date, interventions are delivered based on health care professionals’ expertise without much guidance on what treatment may be best for different patient subgroups. Recognizing the impact that this disorder has on the lives of the patients, it is imperative to develop better treatment approaches, treatment pathways, and personalized care. Modifiable predictors such as smoking, physical activity level, medication intake, and patients’ expectations could all be addressed in a prehabilitation program and potentially lead to improved patient outcomes.15The strengths of this study are the large sample size and data collected within usual clinical practice that reflect the Canadian context. Additionally, the robust, multivariate statistical analysis using PLS allows for the inclusion of predictors that are collinear within the model and the identification of patients who fit and do not fit within the predicted outcomes. This analysis also allows for the inclusion of multiple outcomes within a single model, potentially identifying patient phenotypes and their predictors . This modeling approach provides important insight into the complex relationships between predictors and outcomes that will allow for more person-specific prehabilitation by identifying subgroups of patients with similar pathways. Additionally, a comprehensive use of the Sex and Gender Equity in Research guidelines for reporting sex differences allows for a better understanding of the role of sex given previous conflicting evidence reported in a systematic review of predictors of outcomes.The CSORN database is a valuable resource with a large number of participants, allowing for the inclusion of a large number of predictors and outcomes. However, there is always inherited bias when using registry data, such as the potential for large numbers of missing data, leading to high attrition bias and potential selection bias. Recent support from the Canadian Spine Society has resulted in improved data collection within the CSORN registry. Thus, we decided to exclude data collected prior to January 2015 in order to increase the quality and completeness of available data and thus reduce the risk of bias. Additionally, we attempted to reduce the risk of potential bias by using multiple imputation and a sensitivity analysis for missing predictor data in order to reduce the amount of data eliminated from the analysis. In addition, data analysis was limited to data available within the database as well as the format and measures used to collect the outcomes. Nonetheless, the knowledge gained through the proposed approach will better inform prospective and treatment trials to further our understanding of modifiable factors that predict poor postsurgical outcomes for SLSS.This protocol describes the first study of a Canadian surgical database to identify modifiable factors associated with pain, disability, HRQoL, and recovery in patients with SLSS. It is anticipated that the knowledge gained from the study described within this protocol will facilitate clinical decision making for managing patients with SLSS and inform the development of a prehabilitation program.