Despite substantial progress, pathogenesis and therapy of chronic pain are still the focus of many investigations. The ATP-gated P2X7 receptor (P2X7R) has previously been shown to play a central role in animal models of nociceptive inflammatory and neuropathic pain. Recently, we found that the adaptive immune system is involved in the pathophysiology of chronic nociceptive and neuropathic pain in humans. So far, data regarding P2X7R expression patterns on cells of the adaptive immune system of pain patients are scarce. We therefore analyzed the P2X7R expression on peripheral blood lymphocytes and monocytes, as well as serum levels of IL-1β in patients suffering from chronic nociceptive and neuropathic pain in comparison to healthy volunteers in order to identify individuals who might benefit from a P2X7R modulating therapy.P2X7R messenger RNA (mRNA) and protein expression were determined in patients with either chronic nociceptive low back pain (CLBP) or neuropathic pain (NeP), and in healthy volunteers by quantitative real-time PCR (qPCR) and by fluorescence-assisted cell-sorting (FACS), respectively. IL-1β serum levels were measured with a multiplex cytokine assay.p = 0.038) and protein levels were significantly increased on monocytes  and lymphocytes  of patients with NeP, but not in patients with CLBP. Similarly, IL-1β serum concentrations were significantly elevated only in NeP patients .Compared to healthy volunteers, P2X7R mRNA : Registration Trial DRKS00005954. Purinergic P2X receptors (P2XRs) are ATP-gated cation channels, divided into seven subtypes P2XR1-P2XR7). They are predominantly expressed on cells of the hematopoietic lineage including macrophages, microglia, and lymphocyte subtypes [-P2XR7. TThe subtype receptor P2X7R has been found to play a major role in central nervous system (CNS) processes, including neurodegeneration, traumatic brain injuries, psychiatric disorders, and pain. The exceptional role of P2X7R in pain syndromes has been shown in various animal models of nociceptive inflammatory and neuropathic pain . In humaThe study followed the principles of the Declaration of Helsinki, was approved by the Ethics Committee of the LMU Munich, and has been registered by the German Clinical Trial Register .Subject recruitment was estimated for 2 years. Patients presenting to our Department of Pain Medicine with chronic pain who met the inclusion criteria, as well as healthy volunteers, were enrolled after written informed consent.Patients suffering from chronic non-specific low back pain (CLBP) without any signs of neuropathic pain components and patients suffering from neuropathic pain (NeP) were included. CLBP was defined as persistent low back pain not attributable to a detectable pathology . NeP was diagnosed according to its international definition (“pain caused by a lesion or disease of the somatosensory nervous system”). All patients were assessed by detailed pain history, physical examination, and the PainDETECT-questionnaire. This questionnaire consists of several items related to neuropathic pain symptoms  with excellent sensitivity (85 %) and specificity (80 %) . HealthyExclusion criteria were autoimmune, chronic systemic, inflammatory, neoplastic, or psychiatric diseases, drug abuse, and pregnancy. Patients on irregular medication with opioids, non-opioids, or co-analgesics were excluded. None of the patients had been treated with corticosteroids or had received immunomodulatory agents before or during the study. Any acute inflammatory process was ruled out by laboratory testing including serum concentration of C-reactive protein (CRP) and total and differential leukocyte count as well as measurement of the body temperature. Patients with mixed pain (nociceptive and neuropathic components), e.g., low back pain with radiculopathy, were excluded.Patients rated their recalled average pain intensity both at rest and while moving using an 11-point numerical rating scale (NRS): 0 meaning “no pain” and 10 meaning “worst pain imaginable.” Self-perceived stress was evaluated using the German version of the Questionnaire for Actual Demands (“KAB”: “Kurzfragebogen zur aktuellen Beanspruchung”) in patients and in healthy volunteers. The KAB was designed to repeatedly quantify the individual’s level of acute or chronic stress. It is highly sensitive to short-term or situational changes during a stressful experience . The ratg for 10 min to obtain cell-free serum. After centrifugation, supernatants were harvested and frozen at −80 °C until further use. IL-1β serum concentrations were determined using a human cytokine immunoassay . The microbead assay is based on a Luminex technology and quantifies protein in a similar manner to standard sandwich ELISA techniques, with comparable sensitivity and range [Peripheral blood was collected from patients and healthy volunteers between 9:00 and 9:30 AM. Samples were assessed for differential leukocyte count by routine laboratory testing. For cytokine assessment, blood was centrifuged at 2000×3) to eliminate any remaining DMSO. For extracellular staining, cells were co-incubated with PerCP-labeled antihuman CD4 antibody  and FITC-labeled antihuman P2X7R antibody  at room temperature for 1 hour. Again, cells were washed twice with FACS buffer  to remove excessive antibodies. P2X7R expression was then analyzed with an Attune Acoustic Focusing Cytometer  as described by Gudipaty et al. [+/CD4− cells and for analyses of mean fluorescence intensity (MFI) are shown in Fig. Peripheral blood mononuclear cells (PBMCs) from heparinized venous blood samples were separated by Ficoll density gradient centrifugation . PBMCs were then cryopreserved in RPMI freezing media containing 10 % FCS and 10 % DMSO, frozen at −30 °C for 24 h, and then stored at −196 °C . For FACy et al. . Represe+ cells were isolated from PBMCs by magnetic bead separation with the Whole Blood CD4 MicroBeads kit  according to the manufacturer’s recommendations. Subsequently, total RNA was isolated with the mirVana miRNA Isolation Kit, followed by a DNase digest with the Turbo DNA-free kit (Ambion). Quantity and purity of the isolated RNA were measured with a NanoDrop ND-1000 spectrophotometer (Peqlab). After the amplification of total RNA using the TargetAmp 1-Round aRNA Amplification Kit  and purification using an RNeasy Mini Kit (Qiagen), cDNA synthesis was performed with the SuperScript III First Strand Synthesis System (Invitrogen) and oligo-dT and random hexamer primers (Qiagen). Quantitative RT-PCR was performed in duplicates with a LightCycler 480 instrument  using LightCycler 480 Probes Master and RealTime Ready Single Assays (Roche Diagnostics). Cycling conditions were as follows: 95 °C for 10 min, 45 cycles at 95 °C for 10 s, 60 °C for 30 s, and 72 °C for 15 s. Relative mRNA expression of P2RX7 was calculated by the Relative Quantification Software (Roche Diagnostics) using an efficiency-corrected algorithm with standard curves and reference gene normalization against the reference genes succinate dehydrogenase complex subunit A (SDHA) and TATA box binding protein (TBP) as described previously [CD4eviously . Primer t test for results with normal distribution and the nonparametric Mann-Whitney Rank Sum Test for all data without normal distribution. Discrete variables were compared with the Fisher’s exact test. In order to determine significant differences between pain syndromes, we used a one-way ANOVA tests and multiple comparisons versus a control group (Holm-Sidak method). p values <0.05 were considered statistically significant. All results are expressed as mean ± standard deviation (SD).Statistical analyses were performed with SigmaStat 12.0 . Every statistical analysis was started with testing for normal distribution using the Shapiro Wilk Test. Differences between groups were tested with the Within 2 years of recruitment, 19 patients suffering from CLBP and 19 patients suffering from NeP who met the inclusion criteria as well as 19 pain-free volunteers were enrolled. As shown in Table + T cells as key players of the adaptive immune response. As shown in Fig. + T cells  did not differ between patients suffering from CLBP, NeP, or healthy volunteers.We quantified the number of neutrophil granulocytes, representing an essential part of the innate immune system, as well as total lymphocytes and CD4p < 0.05; Fig. The relative expression of P2RX7 mRNA was determined by qPCR. Compared to healthy volunteers, significantly elevated mRNA levels (1.6-fold) were detected in patients with NeP  revealed that compared to healthy volunteers, P2X7R protein expression levels on lymphocytes , as well as checking P2X7R levels in age-matched subgroups that yielded similar results as the main analysis. Moreover, no correlation was found regarding gender and receptor expression. Subgroup analysis of neuropathic pain syndromes revealed no differences in P2X7R expression between peripheral polyneuropathy/mononeuropathy, postherpetic neuralgia or orofacial pain.Since P2X7R expression has been associated with various diseases, we tested a set of potentially confounding variables for significant differences in distribution between healthy volunteers and patients , 25. As In this study, we found a significantly increased expression of P2X7R mRNA and protein in lymphocytes and monocytes as well as higher IL-1β serum levels in patients suffering from NeP, but not in those with nociceptive CLBP. These results might point to an important role of P2X7R and IL-1β in the pathogenesis and maintenance of NeP.Chronic pain is a global health problem, affecting up to 60 % of the population . Over thThese findings are consistent with our results demonstrating an increased expression of lymphocyte and monocyte P2X7R and IL-1β in patients suffering from NeP. It is not surprising, that only slight elevations of P2X7R protein, P2RX7 mRNA expression and of IL-1β levels were found in patients with CLBP, as CLBP is usually not associated with significant immune activation. These findings might point to a minor role of the P2X7R/IL-1β interplay in the pathophysiology of CLBP. This assumption is supported by recent research, showing a communication link between the immune system and the CNS . Lesion Since elevated P2X7R expression has also been associated with mood disorders such as depression and anxiety, we tested the CES-D depression scores and KAB values as potentially confounding variables. Healthy volunteers had significantly lower depression and stress scores than both patient subgroups, but no differences were found between patients suffering from CLBP or NeP. In order to exclude further factors being responsible for the different expression of P2X7R/IL-1β in pain syndromes, we performed confounder-analyses. Although age differed between patients and healthy volunteers, a potential confounding effect could be excluded. Furthermore, we found that gender did not correlate with the expression of P2X7R or IL-1β either. Regarding subgroups of NeP, no differences with respect to the P2X7R expression were found between patients suffering from peripheral polyneuropathy/mononeuropathy, postherpetic neuralgia or orofacial pain. One limitation of our study is that the analysis of P2X7R protein and mRNA expression was performed on lymphocytes, whereas IL-1β levels were determined in the peripheral blood. Since P2X7R is also expressed on the surface of other immune cells such as macrophages, which are also a major source of IL-1β production, further studies are needed to clearly define the source of elevated IL1β levels. Furthermore, it would be interesting to take the monocytes followed by LPS priming and ATP challenge to demonstrate different IL-1β release between groups.In conclusion, we here report that, in patients with NeP, P2X7R expression is significantly elevated. Activation of P2X7 has been shown to result in IL-1β release. Thus, based on our data, we propose the hypothesis that increased P2X7R expression leads to increased IL-1β blood levels, which may either predispose or maintain neuropathic pain. This P2X7R-driven inflammatory component seems to be absent in patients with CLBP. Our results suggest a major role of the purinergic-receptor/cytokine-interplay in NeP and may help identify patients who might benefit from P2X7R modulating treatment approaches.


Radiofrequency thermocoagulation (RFT) is widely used to treat trigeminal neuralgia (TN); however, the optimal temperature at which RFT is most efficacious remains under much debate. Thus, the aim of the present study was to determine the lowest temperature at which morbidity could be minimized and patient outcomes maximized.A multivariate analysis was used to study 1354 patients who underwent computed tomography (CT)-guided RFT for V2/V3 idiopathic trigeminal neuralgia (ITN) during from June 2006 to May 2015. RFT was carried out at 62, 65, and 68°C, while keeping all other RF parameters the same. This was a prospective cohort study, in which we assessed intra- and postoperative complications, pain relief, and long-term health-related quality of life (HRQoL).The intraoperative and in-hospital complications of patients were mainly facial hematoma, mouth and external auditory meatus penetration, nausea, vomiting, dizziness, and headache, which were all treated symptomatically. In long-term follow-up, patients with pain relief (defined as no pain and no required drug intervention) at 62, 65, and 68°C accounted for 94.2%, 98.3%, and 98.8% (at discharge); 83.8%, 90.1%, and 91.4% (at 1 year); 66.7%, 80.5%, and 88.2% (at 3 years); 59.0%, 64.3%, and 77.2% (at 5 years); 48.7%, 57.8%, and 72.3% (at 7 years); 40.6%, 53.7%, and 60.3% (at 9 years), respectively. The number of patients with facial numbness, masticatory atonia, or corneal hypoesthesia was increased with the elevation of temperature, but these complications were all mild. No blindness, deafness, intracranial hemorrhage, or death as a result of the surgical intervention occurred in any patients. SF-36 scores showed highest HRQoL in the group treated at 68°C, followed by the 65 and 62°C groups, respectively.Our results demonstrate that 68°C is a good choice for RFT of V2/V3 ITN. The alternative option is 65 or 62°C for RFT to minimize the occurrence of complications including facial numbness, yet which often yields a higher recurrence rate. The sequelae of the condition can influence activities of daily living such as speaking, eating, and tooth brushing. Although initial treatment for TN is generally pharmacological, when treatment fails, minimally invasive surgery is the major therapy for TN. Such surgical interventions include microvascular decompression, gamma knife radiosurgery, percutaneous balloon compression, radiofrequency thermocoagulation (RFT),,8 pulsed radiofrequency (PRF),,10 and intragasserian injection of substances such as Botox, phenol glycerite,,12 and anhydrous alcohol.Trigeminal neuralgia (TN) is the most common facial neuralgia, with a high morbidity and an incidence of 12.6 to 28.9/100,000 every year.–21 although the specific factors which produce the most successful outcomes are difficult to identify. For example, in review of these prior works, temperatures differed widely from study to study (60–95°C). Moreover, in some instances there was no mention of temperature differences for treatment of V1  versus V2/V3 (maxillary division/mandibular division) TN, or alternatively no mention of temperature and RF parameters at all. It is well known that complications may result from RFT, and that serious complications such as facial palsy, blindness, deafness, and even death may result with high temperatures. RFT parameters in these studies differed greatly; an abnormal sensation of pain was reproduced with 50 Hz current stimulation at 0.1 to0.5 V/millisecond, but 100 Hz, 500 microseconds, and 1.0 mA were also used. Across the board, the diagnostic criteria for TN patients vary, and in 1 study idiopathic trigeminal neuralgia (ITN) was not distinguished from secondary trigeminal neuralgia (STN). Other studies have small sample sizes (as few as 5) and only a subset of these studies investigated short-term postoperative complications. Therefore, it is difficult to determine the efficacy of a single technique for treatment of TN, as the outcomes are highly variable and the clinical significance of the reported results is unknown.Of the aforementioned surgical interventions, many favor RFT due to the ability to perform this in a minimally invasive, highly efficient manner, with little mortality and morbidity, while at the same time achieve satisfactory functional outcomes. Short-term pain relief rates for patients treated with RFT was reported to be 90% to 100% in some studies,,24 Although there is a high recurrence rate, secondary surgery is feasible after RFT, a technically matured mini-invasive surgery which can be completed within 30 to 40 minutes, is performed at a low temperature. Therefore, low-temperature RFT is necessary and feasible. The goals of the present study were to identify the optimal temperature for achieving efficacious treatment of ITN that would both optimize functional outcome and minimize complications.Following the principle of “safety first” is very important, especially in China where the doctor–patient relationship is tense. Some studies report that RFT at 60 to 70°C and RFT at a higher temperature consistently resulted in pain relief, while causing fewer complications in 60 to 70°C.22.1This was a randomized, controlled, double-blinded, prospective cohort study in V2/V3 ITN patients. These patients underwent RFT at 62, 65, or 68°C, with a unified set of RFT parameters and were then observed for intraoperative and in-hospital adverse reactions, pain relief, TN recurrence, postoperative complications, and long-term health-related quality of life (HRQoL). This study was designed to provide clinical guidance.All patients diagnosed with TN in the Department of Pain Management of Shengjing Hospital of China Medical University and the Department of Pain Management of Siping Hospital of China Medical University  and planned to undergo subsequent treatment with RFT from June 2006 to May 2015 were evaluated and followed long term. This study was approved by the Ethics Committee of Shengjing Hospital of China Medical University. All patients provided informed consent. All patients were 28 years of age or older, had a preoperative pain score greater than 6 (VAS), suffered no facial numbness and received drug treatment for TN. RFT was recommended for patients whose pain was not controlled after the standard analgesic treatment of high-dose carbamazepine, gabapentin, or pregabalin continuously for over 3 months, and/or who experienced intolerable adverse effects, such as nausea, vomiting, dizziness, blurred vision, drowsiness, limb edema, and impaired liver function.The diagnoses of all patients were established following the diagnostic criteria for ITN or STN in the International Classification of Headache Disorders: 2nd edition (HIS-II) (2004).The following patients were excluded: patients with STN, including postherpetic TN, intracranial occupying lesions  and multiple sclerosis; patients who previously underwent surgical treatment, including microvascular decompression, RFT, gamma knife radiosurgery, balloon compression, or other invasive interventions; patients with oromaxillofacial diseases including tumors; patients with concomitant hemorrhagic diseases; patients with severe cardiopulmonary insufficiency; patients with severe mental dysfunction; patients with V1 TN or complicated TN of V1, V2 and/or V3 were also excluded because primary therapy for V1 TN involves low temperature, peripheral RFT, or PRF.A total of 1354 patients routinely underwent preoperative trigeminal and cranial magnetic resonance imaging (MRI) to exclude intracranial occupying lesions  and multiple sclerosis that might induce STN. Patients with vascular compression adjacent to the root and gasserian ganglion of trigeminal nerve were also included into the study.At 30 minutes prior to surgery, reptilase 1 KU was injected intramuscularly, and ceftriaxone sodium 1 g  was infused intravenously. Immediately before operation, Innovar 2 mL was slowly injected intravenously, and 2 mL was added during operation as necessary.2.2Gasserian ganglion RFT was performed by puncturing the foramen ovale using the Hartel anterior approach, followed by infiltration anesthesia with 0.5% lidocaine. Thereafter, a 22G RFT cannula  was introduced gently and slowly along the puncturing pathway to reach the periphery of the foramen ovale, and then the puncturing direction was adjusted by computed tomography (CT) scan to enter the foramen ovale. After no blood and cerebrospinal fluid (CSF) return was observed, the RF instrument was connected to induce division paresthesia correspondingly at 50 Hz, 1 millisecond, and 0.1 to 0.2 V. Local anesthesia was achieved with the injection of 0.2 mL of 1.5% lidocaine and RFT was performed 2 minutes later.The patients were randomized to undergo RFT at different temperatures according to the random number table. RFT temperature was increased gradually from 50°C to the preset temperature  and a lesion was then made for a total of 180 seconds. During RFT, the presence of eyelash reflex and facial numbness were repeatedly assessed. At the end of RFT, if pain was still present in the innervation zone of the trigeminal nerve, the location of the needle tip was further adjusted (2–5 mm puncturing or withdrawing), and then RFT at the corresponding temperature was performed after retesting. After surgery, patients were ordered to take 24 hours absolute bed rest (including 6 hours prostrated bed rest without pillow), with vital signs monitored for 6 hours; reptilase and antibiotics were administrated routinely 1 to 2 times. All patients were observed for 3 days postoperatively, and those with pain relief and no serious adverse reactions were discharged. Any patient who experienced complications and/or pain remained in the hospital for continuous observation and treatment.2.3Pain relief, in-hospital complications , and treatment measures were recorded for each patient. In addition, those patients requiring propofol anesthesia due to surgical pain intolerance were noted. The BNI scoring is as follows: I (excellent), the pain disappeared completely, requiring no drugs; II, the pain was mild, requiring no drugs; III, the pain was moderate, requiring drugs for complete control; IV, the pain was moderate, requiring drugs but not completely controlled; V, the pain was severe or not relieved. BNI scores I–III indicated satisfactory pain relief, while BNI scores IV–V indicated poor pain relief. All patients were followed up once per month in the first 6 months and once every 3 months thereafter and BNI was obtained at these follow-up visits.At the time of hospital discharge, the patients’ level of pain relief was evaluated with the Barrow Neurological Institute (BNI) pain score, which incorporates both patient-rated pain as well as the degree of dependence on medication for pain control.Postoperative facial numbness was evaluated with the BNI facial numbness score, which incorporates the presence and degree of residual numbness as well as an indicator of the degree of bother to the patient. There were 4 levels of BIN facial numbness score: I, no numbness; II, mild numbness, causing no impact; III, moderate numbness, somewhat bothersome; IV, severe numbness, very bothersome.The numbers of patients enrolled, lost to follow-up, and completing follow-up were recorded. The follow-up investigator was blinded to the patients’ surgical grouping. Follow-up was performed outpatient or by telephone, some patients could not pay a visit to the outpatient or communicate by telephone because of poor physical condition or hearing problems, performed family visit.We assessed for postoperative complications including corneal hypoesthesia , masticatory atonia, and decreased hearing (hearing test). All complications were recorded in detail.2.4 The physical evaluation included 4 parts: bodily pain (BP), role/physical (RP), physical functioning (PF), and general health (GH). The mental evaluation also included 4 parts: social functioning (SF), vitality/energy (VT), mental health (MH), and role/emotional (RE). The Physical Component Summary (PCS) and Mental Component Summary (MCS), which are the subtotals for physical and mental evaluations, were determined.,29 The scores for single items in each part were summed to give a final score (a full score of 100). The greater scores indicated better patient status.Postoperative physical and mental status were assessed with the Short Form-36 (SF-36).2.5P < 0.05  suggested that a difference was statistically significant.The quantitative data of normal distribution were analyzed with variance analysis of complete random design and then Baetlett test, and those of nonnormal distribution were analyzed with Kruskal–Wallis test. The categorical data were analyzed with chi-square test. The postoperative follow-up data of patients were analyzed with Kaplan–Meier survival curves and then log rank test, Breslow test, and Tarone–Ware test. The censored point was defined as loss of follow-up, TN recurrence, death, and the last visit. The patients who underwent RFT and injection treatment again were not included into the study repeatedly, and their follow-up was closed. The relations between age, sex, pre-RFT drug dosage, division of TN or intraoperative complications and postoperative pain relief were analyzed by Cox regression. All data were analyzed using IBM-SPSS 19.0 statistical software . 3P > 0.05). Any 1 patient with bilateral TN was regarded as 2 cases and underwent RFT at the same temperature for bilateral TN.A total of 1354 patients meeting the inclusion criteria were included into the study. The general patient characteristics for each group are shown in Table 3.1P > 0.05). For those individuals the RFT cannula was replaced and the puncture was performed again. A total of 426 (31.6%) patients experienced facial hematoma during local anesthesia or intraoperative puncture (P > 0.05). In these instances, the surgical procedures were continued and a cold compress was applied postoperatively. A total of 310 (22.9%) patients experienced blood return after the puncture needle was delivered into foramen ovale, including 89, 114, and 107 patients in Groups A, B, and C, respectively (P > 0.05). The treatment in these instances consisted of puncture or withdrawal 3 to 5 mm after no blood return was observed, and even if the tested parameters were satisfactory, RFT was not performed at the initial position to prevent vascular wall injury and the resultant risk of postoperative intracranial hemorrhage. A total of 118 (8.72%) patients experienced CSF return, including 45, 38, and 35 patients in Groups A, B, and C, respectively (P > 0.05). When this occurred, RFT at the current position or the proper withdrawal of the puncture needle was performed based on the position of the needle tip with CT. No additional local anesthetic was injected. The temperature was slowly increased to the target temperature and the real-time eyelash reflex and forehead tests were conducted. If the patients could not tolerate the surgical pain, intravenous propofol 2 mg/kg was given as an anesthetic. In all, a total of 88 (6.50%) patients experienced a radiating pain of the external auditory meatus during intraoperative puncture. The puncture pathway was adjusted to prevent serious injury caused by a violent, rapid puncture, or RFT at a wrong position. When eyelash hypoesthesia, forehead numbness, or corneal hypoesthesia occurred during operation, RFT was aborted and the patients were asked and inspected about the pain area. If pain was still present or the patients could not locate the pain, the puncture needle was withdrawn 2 to 3 mm, the patients were reassessed with the previously described special tests, and then RFT was performed again. In Group C, 59 (12.55%) patients experienced eyelash hypoesthesia, 45 (9.57%) patients experienced forehead numbness and 37 (7.87%) patients experienced corneal hypoesthesia (P < 0.05) when compared with Group A. A total of 73 (5.39%) patients experienced bradycardia (heart rate (HR) < 60 bpm) or tachycardia (HR > 100 bpm) and 12 patients were treated symptomatically during operation; there were no differences among various groups. During the operation, 2, 2, and 3 patients in the 3 groups, respectively, experienced conscious ear discomfort, decreased hearing, or a blowing sensation. Of the number of patients requiring propofol anesthesia, there were no statistically significant differences between groups.CT-guided RFT was successfully completed in all patients. The RFT time was ≤30 minutes in all cases. The intraoperative data and complications are shown in Table 3.2P > 0.05). These individuals were treated with 1500 mL/d of fluid replacement and bed rest. These symptoms were resolved after a period of 7 days. External auditory meatus bleeding was observed in 4, 5, and 3 patients within each of the 3 groups, respectively. Tympanic membrane perforation and decreased hearing as determined by the otologist occurred in four patients; all recovered at 1 month after symptomatic treatment. All other patients with decreased hearing recovered by the time of hospital discharge. After RFT, 15 patients in Group A, 13 patients in Group B, and 15 patients in Group C reported no pain relief with BNI scores IV–V and these individuals directly underwent secondary RFT during hospitalization. Facial numbness occurred in 8, 43, and 102 patients within 3 groups, respectively (P < 0.05). At discharge, facial numbness disappeared in 6 patients within Group A. In Groups B and C, facial numbness persisted to different degrees in 22 and 43 patients, masticatory atonia was found in 3 and 12 patients, and corneal hypoesthesia was noted in 2 and 14 patients, respectively. These complications were continuously assessed in subsequent follow-up. None of the patients developed fever. Despite the fact that some patients experienced complications, all were satisfied with RFT surgery.As shown in Table 3.3P > 0.05, among 3 groups); these patients were regarded as censored cases. The survival time was defined as the time from discharge to the last visit. The remaining patients (Group A: 404 (90.58%), Group B: 384 (87.7%), Group C: 428 (91.6%) all completed follow-up). TN recurrence (BNI scores IV–V) was observed in 122 (27.35%), 91 (20.78%), and 59 (12.55%) patients within the 3 groups, respectively. A total of 95 patients underwent secondary RFT or blockage or other treatments, including 45 patients in Group A, 27 patients in Group B, and 23 patients in Group C. The follow-up deadline was the last visit before retreatment. The follow-up duration was 51.13 ± 25.24 (7–102) months in Group A, 53.62 ± 26.43 (7–105) months in Group B, and 57.73 ± 25.91 (7–107) months in Group C, respectively.During follow-up, 63 patients died (non-RFT causes) and 75 patients were lost to follow-up . In all groups, PCS and MCS gradually decreased over time, and patient satisfaction also declined. At 3 to 9 years after RFT, the comparisons among 3 groups showed statistically significant differences (P < 0.05).As shown in Table 4–22,30,31 Postoperatively, we observed the efficacy and safety of RFT at 62 to 68°C in achieving pain relief during long-term follow-up to determine the most appropriate temperature at which RFT can be delivered in clinical practice. Our study results demonstrated that RFT at 65 to 68°C may be reasonable treatment temperatures for ITN, as treatment at these temperatures achieved satisfactory pain relief and had a lower incidence rate of complications. Although complications such as facial numbness and masticatory atonia were present in these 2 treatment groups, such complications were mild and resolved in a short time. No serious complications occurred as a result of RFT .This study was aimed to treat ITN by RFT at a lower temperature (62–68°C) which was relative to 70 to 95°C selected for RFT in some previous study reports.,20,30–32 Meanwhile, RFT at <70°C achieved acceptable pain relief but had fewer complications,,24 which is confirmed by our study results. A study reported that in trans-foramen ovale RFT, the failure rate of surgical puncture was 4% while no failure of CT-guided surgical procedures happened in this study.We selected temperatures of 62, 65, and 68°C for RFT based on several considerations: First, in our previous clinical practice, several patients experienced complications such as severe facial numbness, masticatory atonia, and salivation after RFT at 70 to 75°C, which seriously affected their HRQoL and even led to medical lawsuits. In searching the available literature, we found that a significant number of patients experienced serious complications (some of which were irreversible) after RFT at ≥70°C.–18 Postoperatively, the general trend noted was that more patients experienced TN recurrence or the severity of pain was increased over time. For example, patients with initial scores of BNI I eventually had scores of BNI II–III or TN recurrence. There were fewer patients with BNI I in the 62°C group when compared with those in the 65 or 68°C groups. The number of patients with BNI I in the 65 and 68°C groups is higher than that in the studies of Haridas et al–36 and consistent with that in the studies of Hart et al.–40In the present study, satisfactory outcomes were observed after RFT at 62, 65, and 68°C, and the patient satisfaction with respect to pain relief (BNI I–III) was 100% at discharge, suggesting that short-term efficacy is determined by intraoperative technique. The percentage of patients absolutely without pain and requiring no analgesics (BNI I) was 94.2%, 98.3%, and 98.8% in 3 groups, which is consistent with the immediate pain relief rate obtained at a high temperature in the previous studies.In the present study, 15, 13, and 15 patients in 3 groups achieved no pain relief having BNI scores of IV–V in the immediate postoperative period. These patients were underwent secondary RFT and were then followed-up as per our protocol. Their inclusion into the study was reasonable and met the clinical treatment principles, as no pain relief was caused by the failure of assessment in the first RFT but not due to RFT technique itself.,20,24,41 ITN was not strictly distinguished from STN, including STN caused by herpes zoster, multiple sclerosis, intracranial occupying lesions, postoperative recurrence, and other factors. Some study results also revealed that RFT had a poor pain relief effect for STN.,34 There was a variation among RFT parameters selected. RFT parameters were not uniform in various reports,,30,31 and some intraoperative parameters were not defined in many studies. The smaller stimulation parameters indicated that the tip of the RFT puncture needle was closer to the target position. In this study, 0.1 to 0.2 V parameters were selected for confirmation, and RFT was successfully completed under the precise location by CT guidance in all patients, though the surgically technical requirements were increased. V1 of TN was excluded in this study. The specificity of V1 requires treatment with RFT at a low temperature, or peripheral RFT or PRF to prevent V1 injury and subsequent serious complications such as corneal hypoesthesia, keratitis, and even blindness. As a result, RFT for V1 could not be performed at the same temperature as that for V2 and V3. We therefore, only investigated V2/V3 TN in the present study. However, there is a possibility that V1 TN might be explored in other study. It is also important to note that patients with V1 TN were included for RFT in the previous studies, which might influence the observation results. There was a small sample size in 1 study, which might cause a bias of statistical results and the failure to objectively evaluate the surgical technique.A satisfactory analgesic effect was obtained at a low temperature, perhaps associated with the following aspects: Strict inclusion criteria were formulated, and HIS-II diagnostic criteria were referenced to include ITN and exclude STN. In some previous study reports,Our study results demonstrated that long-term efficacy of pain relief was better in the 65 and 68°C groups than in the 62°C group, though there was a statistical difference between 65°C group and 68°C group. Fewer patients noted excellent pain relief in the 65°C group when compared with the 68°C group; however, pain relief was still maintained at a level commensurate with that mentioned in some previous reports. The long-term pain relief rate in the 62°C group was slightly lower than that in the previous follow-up reports of RFT, indicating that 62°C is too low to guarantee the long-term efficacy of pain relief. However, this temperature is suitable for those young patients who wish to experience no complications. From the perspective of achieving efficacy in pain relief, RFT at 65 to 68°C is preferable for treating ITN.,30,38,41 Our study demonstrated that no patients experienced severe facial numbness, and those that did experience some degree of numbness recovered completely in a short time  months). There were 3 (0.68%) patients in 65°C group and 12 (2.55%) patients in 68°C group who suffered from mild masticatory atonia; none of the patients in 62°C group experienced masticatory atonia. The incidence rates of masticatory atonia in various groups are all lower than the figures in the previous reports (8% and 46.7%), and the recovery time of patients with masticatory atonia was 9.3 ± 4.6 (6–16) months. The patients with corneal hypoesthesia accounted for 2.97% in the 65°C group and 5.74% in the 68°C group, which indicates that the probability of corneal hypoesthesia is increased at a higher temperature. Corneal hypoesthesia might be a complication caused by the short distance between the RFT needle tip and V1 or by a high treatment temperature during RFT. Although strict intraoperative monitoring was performed, corneal hypoesthesia still occurred in some elderly patients who had a slow response and difficulties in communication. All patients with corneal hypoesthesia recovered within half a year  months), which is consistent with prior reports in the literature.,32,42 However, in the present study, the incidence of corneal hypoesthesia  is lower than that reported in prior studies (18% and 19.4%–31.4%).Long-term follow-up showed that the facial numbness and masticatory atonia were the major complications. In the present study, 2 (0.45%), 21 (4.79%), and 28 (5.96%) patients in the 62, 65, and 68°C groups, respectively, experienced mild facial numbness (BNI II). Moderate facial numbness (BNI III) was noted in 1 (0.23%) and 15 (3.19%) patients in the 65 and 68°C groups, respectively. Despite no statistical difference, as temperature was increased, more patients developed facial numbness and the severity of facial numbness was higher, which suggests that the temperature shall be carefully controlled for RFT. The percentage of patients with facial numbness in this study is far lower than the figures in some previous study reports, which ranged from 34.8% to 100%.Complications of RFT may include facial hematoma, headache, dizziness, or nausea and vomiting induced by intracranial hypotension and meningeal irritation. Moreover, postoperative pain at the puncture site and other complications can influence the postoperative evaluation of patients, though most patients recover rapidly within several days after operation. Meanwhile, the drugs  used by the patients would be gradually decreased and discontinued over several days. Therefore, in order to isolate the treatment effect of RFT and remove the potential confounding effect of postoperative complications and/or pharmacologic therapy, follow-up of patients was initiated at the time of discharge. During RFT, 52 (3.84%) patients experienced mouth penetration, 12 patients experienced external auditory meatus penetration with bleeding, and 4 patients experienced tympanic membrane perforation with transient decreased hearing or blowing-like tinnitus . These findings suggested that decreased hearing was caused by tympanic membrane perforation, as opposed to auditory nerve injury. The 2 aforementioned intraoperative complications were caused by intraoperative maloperation, which is a defect of real-time observation in CT-guided surgical procedures. Therefore, the principle of gentleness and slowness must be followed throughout the puncture process, so that adjustments are made in a timely manner according to the actual situation when the patients have relevant reactions. Violent, rapid puncture, or RFT at a wrong position must be avoided to prevent serious injuries.–29,44 Lam et al carefully observed the HRQoL of Chinese patients. The follow-up results in this study showed that the post-RFT HRQoL of ITN patients was well evaluated with SF-36. Before RFT, the patients suffered a fierce pain and had low PCS and MCS; after RFT, the pain was relieved and SF-36 scores were markedly increased in the postoperative window in all groups. The SF-36 scores in the 65 and 68°C groups were significantly greater than those in 62°C group, and overall patient satisfaction was improved in all groups.Patient HRQoL was evaluated with the SF-36 in this study. Many studies have proven that the SF-36 is a generally recognized good choice for the evaluation of patients HRQoL.–13,38,45 In review of literature in the field, a recent study by Lin et al reported patient outcomes when RFT was carried out under local anesthesia. So, the choice of local anesthesia was reasonable and feasible. But there are some shortcomings and deficiencies in terms of evaluation of pain relief scores. During RFT under local anesthesia, some patients experience severe pain, which influences the postoperative patient satisfaction evaluations. Following the use of local anesthesia, any or all 3 divisions of TN are numb, influencing the effect evaluation during RFT. In the present study, no pain relief (BNI IV–V) was observed in 43 patients after initial RFT, and the pain was noted to disappear in all these patients after repeat RFT. These results are related to poor position in order to avoid blood vessels and the reevaluation failure after local anesthesia during RFT. In addition to meningeal irritation signs in RFT, the incidence of postoperative nausea and vomiting is probably associated with the use of local anesthetic. At the same time, eyelash hypoesthesia, forehead numbness, or corneal hypoesthesia occurred during operation perhaps associated with a difference in temperature or due to the use of local anesthetic drugs, yet which was uncertain during RFT.In this study, the patients were conscious during RFT  to readily facilitate communication, exchange, and evaluation of their status in real-time in an effort to prevent serious complications. An economic burden was also one consideration, about RMB 1500 yuan was saved for each patient by the use of local anesthesia. The feasibility of such a technique has been proven by some studies on the intragasserian injection of phenol glycerite, anhydrous alcohol, Adriamycin or local anesthetic drugs combined with steroids.However, general anesthesia also has its own disadvantages. In this instance, while recovering consciousness and being able to communicate, patients are still under superficial anesthesia state and experience residual analgesic and sedative effects, which will affect the intermediate intraoperative evaluation and thus greatly prolong the operation time. rather than the thorough destruction of these nerve fibers by increasing the temperature. It is also important to note, however, that RFT position is known to play a role in reducing TN recurrence. Additionally, Luo et al pointed out that satisfactory pain relief of TN could be achieved by PRF at 42°C by increasing RF field intensity and output voltage.,48 Taken together, the aforementioned studies suggest that increasing temperature is only one way in which postoperative TN recurrence may be reduced. During follow-up in the present study, TN recurrence was observed in 122 (27.35%), 91 (20.78%), and 59 (12.55%) patients within the 62, 65, and 68°C groups, respectively. These present findings are consistent with previous study results, which reports that the recurrence occurred in 14.5% to 51.5% of the patients but this variability was due to differences in temperature (≥70°C), parameter settings, etc.,30,49–51 Prior studies reported that a temperature ≤80°C could selectively block action potentials of Aδ and C nerve fibers, and that at higher temperatures Aα and Aβ nerve fibers action potentials are blocked.,38,52 These considerations are often accounted for in temperature selection for clinical RFT and some observational studies. However, there is a need to further evaluate clinical RFT at such temperatures. Yang et al achieved satisfactory pain relief of TN by RFT at 60°C, proving the utility of RFT at a low temperature, which is supported by the results of the present study. Given that the trigeminal nerve is a mixed motor nerve, high temperature RFT may destroy neurons or axons, thereby reducing overall nerve function.Recurrence after treatment is an important consideration in the treatment of TN. Reportedly, the efficacy of RFT for TN is mainly dependent on the reduction of demyelinated nerve fiber synaptic transmission,,54; however, these parameters such as experimental design, case selection, temperature, anesthetic, voltage, current should be standardized to the maximal extent. Our study excluded V1 TN, it is known that our study outcomes do not completely represent those for all cases of treating ITN with RFT. Additionally, the same RFT parameters rather than several different RFT parameters were used, thus making it difficult to perform related comparisons between temperature with different parameters. Lastly, we did not compare the effects of general anesthesia vs local anesthesia on RFT, nor did we conduct a comparative observation by selecting higher temperatures. Each of the aforementioned limitations are areas that may be further explored in subsequent studies.Our study has some limitations. First, there are no uniform specifications in the previous study reports of TN treatment5RFT is effective and safe for ITN treatment; however, appropriate temperature selection is an issue worthy of wide concerns, because it is directly related to postoperative pain relief outcomes, as well as intra- and postoperative complications. RFT at a high temperature may improve pain relief and decrease recurrence, but this is at the risk of serious complications including facial numbness, masticatory atonia, blindness, deafness, and even death. In addition to temperature, RFT efficacy is closely associated with the surgical procedures, RFT parameters, and electrode position. Our study results demonstrate that RFT at low temperatures can achieve satisfactory pain relief with fewer and milder postoperative complications than when carried out at higher temperatures. Therefore, RFT at 68°C is recommended for treating V2/V3 ITN, and RFT at 62 to 65°C is optional for patients who wish to minimize the complications such as facial numbness.


A shorter duration of disease was strongly correlated with improvement in the 10m timed walk (p=0.05) but not with the reduction in pain. Although baseline cytokine concentrations did not correlate to baseline pain or gait impairment a decrease in tumour necrosis factor-alpha (TNF-α) concentration after pulsed methylprednisolone was associated with improvements in both. Pulsed IV methylprednisolone significantly reduced pain in patients with HAM/TSP and was associated with a transient improvement in gait that may be related to a reduction in TNF-α concentration.The efficacy of treatments used for patients with HTLV-1 associated myelopathy/tropical spastic paraperesis (HAM/TSP) is uncertain although corticosteroids are widely prescribed. The effect of pulsed IV methylprednisolone was retrospectively analysed in an open cohort of 26 patients. 1g IV methylprednisolone was infused on three consecutive days. The outcomes were pain, gait, urinary frequency and nocturia, a range of inflammatory markers and HTLV-1 proviral load. A plasma cytokine profile was conducted in nine patients and correlated to gait and pain. Significant improvements in pain and 10m timed walk were observed immediately after the 3


Osteoarthritis (OA) is the most common form of arthritis worldwide, affecting a growing number of people in the ageing populations. Currently, it affects about 50 % of all people over 65 years of age. There are no disease-modifying treatments for OA; hence preference-sensitive treatment options include symptom reduction, self-management and surgical joint replacement for suitable individuals. People have both ethical and legal rights to be informed about treatment choices and to actively participate in decision-making. Individuals have different needs; they differ in their ability to understand and make use of the provided information and to sustain behaviour change-dependent treatments over time.As a part of a larger research project that aims to develop and test a web-based support tool for patients with hip OA, this paper is a qualitative in-depth study to investigate patients’ need for information and their personal emotional needs. We invited 13 patients to participate in individual interviews, which were audiotaped. The audio-tapes were transcribed verbatim and analysed using an inductive thematic analysis approach.The thematic analysis revealed a pattern of patients’ information and emotional needs, captured in several key questions relevant to the different stages of the disease experience. Based on these results and research literature, we developed a model illustrating the patients' disease experience and treatment continuum. Six phases with accompanying key questions were identified, displaying how patients information and emotional needs arise and change in line with the progression of the disease experience, the clinical encounters and the decision-making process. We also identified and included in the model an alternative route that bypasses the surgical treatment option.Patients with hip OA are in great need of information both at the time of diagnosis and further throughout the disease development and care continuum. Lack of information may result in unnecessary and dysfunctional misconceptions, underuse of potentially helpful treatment options and uninformed decisions. Patients need continuous support from health professionals and their families in order to find and consider effective treatment strategies. Osteoarthritis (OA) is the most common form of arthritis and a leading cause of disability among older adults . While OOA is characterized by pain and stiffness, causing subsequent loss of functional capability and independence, with limitations in daily living activities and impaired quality of life , 6. As aPatients’ with hip OA experience their condition as painful, chronic, and incurable but susceptible to control through one or more of the aspects of treatment recommended by their health care provider. The more serious and symptomatic the patients experience the condition, the less positive they feel about the management strategies used to control it . ExercisTurner and colleagues explored the beliefs about the causes of OA among primary care patients . PatientThe optimal timing for surgery is not known , 27, butProper treatment – at the right place and right time  I have to admit that now, as a 65 year old – my father was 63 when he died – I think that I am so lucky to still being able to work and be active, and you see so many others that are incapable of that… you know? They suffer from far more serous conditions – everything is worse than this… It’s not serious in a way – nothing really to talk about …Some participants had a tendency to trivialize their experiences or play down their concerns by referring to possible natural causes, like getting older, pain conditions running in the family, or by comparing their problems with others.It’s like…… almost a bit embarrassing to talk about…… it’s something that you kind of need to expect when you are so lucky to get old… […] I believe there is a hierarchy – a status related to different diseases among.... in the health care system, yeah? When I got cancer, I was sort of at the top of the pyramid .Some also indicated a feeling of shame attached with talking about their emergent hip pain or OA diagnosis, and felt that their hip disease was lower in the hierarchy than other diagnoses, such as cancer and diabetes type 2.I have diabetes and I have typically discussed my hip problems when I have been to my doctor to check my blood glucose .Some participants clearly stated that they did not exclusively visit their GP to discuss their hip problems, but that it was brought up as an implicit concern at the end of the consultation.GPs aren’t specialists in osteoarthritis, so they.... they do what they can to refer me within the health care system, so I can’t say that I have anything to complain about in that respect… I get help for things I ask about, but I don’t really expect to receive any particular kind of information .A common finding across the data was that the participants had not received general information about OA and pain management from their GP. Most of the participants did not actively seek information during consultations. This was explained partly by the fact that they did not know what to ask specifically and because the GP was not perceived to have the necessary expertise about OA.I decided to replace this GP immediately, because I thought… I was a bit mad at him - I had lived and struggled with this for so many years without anything being done. They must dedicate more time to each patient, right? .One participant explained that she had chosen to replace her GP.I can tell you that I have the world’s best GP! She is 67 years old and dreads that she must retire at 70. She is so strict! She gives me all the information I need and instructs me what to do. - You should do this kind of exercises and you’ll have an X-ray and you should do this – she arranges the whole show. Everything comes into my mailbox and I check it regularly .One participant expressed great satisfaction with her GP, however, demonstrating the value of having an attentive GP.You know, when you visit the doctor you do it because of the pain… but .you don’t know what causes it.... it’s therefore a bit difficult to know what to ask about .Some found it difficult to appropriately disclose their concerns to their GP.The GP is just keen to get you out in order to let the next patient in… He listens to what you say, but haven’t taken it seriously enough .Many discussed available time as a barrier.The common experience patients have at this initial stage may be summarized in the question: “Something is wrong, what is this hip pain?” The patients’ experiences an unfamiliar hip-related pain sensation that may require a visit to the GP. The GP acquires the medical history, performs relevant examinations (e.g. Harris hip score) and refers the patient to X-ray examination to set the diagnosis OA of the hip. The patient receives basic and variable information about OA and available treatment options depending on the severity of the symptoms and the GP’s and other health professional’s competence and communication skills.When I have taken a shower, I have troubles drying my feet. I can’t reach down, and I can hardly manage to put my socks on. I can’t care for my toenails - cutting them for example - that is really difficult on this leg. Then I have to wear long trousers - grab the trouser leg and force the left leg on top of the right one. When I do that I get a lot of pain.... I somehow manage to complete the task, but it’s no solution to continuously cross the pain threshold – I have done that increasingly often lately …As the hip problems evolved, the participants experienced increased pain, causing difficulties in performing regular and self-care activities.When results of the X-ray came, the radiologist had told the doctor that nothing was wrong with me – they didn’t find anything.... Ok, it thought, then there was nothing I could do about it… But with time it became worse, and I was....... I managed to visit the doctor a few times, and eventually they advised me to try those needles (acupuncture)....... .Most of the participants had several x-rays, hoping that it would provide some answers.It’s not ok to carry on like that....... But they....... they just prescribe pills- and I’m not a pill person....... I said to them that pills only relieve the pain, it doesn’t....... you’re hip will only get worse, and it doesn’t cure you....... You know, when you have taken pills over a period of time you’ll eventually need even stronger ones .Most participants had clear objections about taking pain killers on a daily basis, although the doctor had prescribed it. They felt there were too many pills to consume with potential troublesome side effects. A recurrent description was not being comfortable with taking pills in general, with statements such as “I’m not a pill-person”.No, I don’t believe in that. I think that if you take pain killers, it will eventually lead to even more pain and worsening of the joints....... you won’t feel the pain and then the situation gets worse - I believe so anyway....... I would rather choose to rest – when you have had some rest, the pain isn’t so bad .One participant explained that he did not take painkillers because he believed that it might make the situation worse in the long run.The point is to try to manage it as long as possible. I have taken....... what have helped me so far is that I have taken a slow release tablet- one Ketoprofen every morning for breakfast....... By doing that I actually have managed to live with the pain. That is in fact the reason why I have been able to cope for so long .Despite the general picture of non-adherence to pain medication, some felt that taking painkillers on a regular basis helped them when they tried to cope with the situation.I try to concentrate on other things than sickness and pain....... Yeah- simply re-focus. That my focus should be on other things, and I also try to stay positive! .Some participants described alternative strategies to cope with the pain.I don’t think there is any point in attending physiotherapy ....... I don’t think they make a difference. The one I had didn’t anyway, and I felt kind of cheated. The only thing I did was ride a bike, that’s all .Most of the participants in this study did not attend physiotherapy on a regular basis. Some explained that they felt it was unnecessary because they had other ways of staying physically active.My hip really bothers me, what can I do? The patients experience that the hip problems continue to evolve, causing decreased physical function due to increased and more persistent pain levels throughout the day. They have various ways of adapting and coping, and some try alternative treatment options. Most continue to live as before, but using activity modification as a strategy to cope with pain and avoid pain exacerbation. Patients become more dependent on help from others for physically challenging household chores. Most have tried physiotherapy, but with various results. Some take pain medication in order to stay active, but most do not because of misconceptions or fears of possible side effects.Experiences attributed to the moderate hip OA stage can be summarized in the question: It is very unpleasant. I’m pretty active these days - have a lot to do and I want to make the most out of my days. So, it bothers me a lot....... that is why I went to the doctor and said that we need to fix my hip. I can’t live with this – its impossible .When the symptoms significantly restricted abilities to do desired activities in daily living, some participants expressed that they had explicitly requested referral to an orthopaedic surgeon.When I hear and see that people get a significantly improved life after surgery....... then, yes....... that makes me think about it as well. I have independently come to the conclusion that if it can help me to live a better life, I’m opting for surgery .......A decision for surgery may be driven by the hope for a better life.I had plans to do this last year, but I received a job offer that......... I have to do this kind of work during the winter season, so that I don’t make things worse for myself, huh? So, it’s about planning… And then, yet another year has passed. If so much time elapses, then another year goes by. That is how I have thought about it for many years really .Work responsibilities can influence a decision or desire to undergo hip replacement.What has annoyed me the most is that they won’t do a joint replacement… If only for the knee, so that I might perform better at work– during the time I have left… They say that as long as I manage as it is now, it’s not worth doing surgery, due to the fact that they can’t give any guarantees that it will turn out for the best .One participant wanted surgery in order to be able to work, but was advised to wait.I have a pretty wide social network, and many of them have in fact undergone hip replacement. That makes us talk about these things. It becomes a topic for discussion, and we give each other advice .Most participants explained that their social network of friends, neighbours and family was an important source for information and advice relating to decision-making about total hip replacement.When you have suffered long enough you’ll try almost anything… learning from the experiences of others I have talked to, who have had a successful hip replacement– it makes me see possibilities for myself as well .Learning from others’ experiences provided hope for a better future.You know, everyone has heard about someone who has replaced hips, and with such good outcomes– the surgeons now have such effective techniques with excellent outcomes .Undergoing hip replacement was perceived as a common procedure with excellent outcomes.He said (the orthopaedic surgeon) that you never know how it turns out… But I’m ready to take that chance– no one have absolute guarantees for anything in life, yeah? .Topics concerning possible risks for pre- and postoperative complications seemed to be of little importance in deliberation about undergoing THR. One stated that there are no guarantees in life.I consider the probability of that occurring very small, because I have always had confidence in specialists, and I trust them to deal with it… I won’t enter the operating theatre being scared! Others relied heavily on the experience and competence of the orthopaedic surgeon.Of course there is a chance, but with the two other operations that I’ve had, the gall bladder in 1999 and this (other hip) last year– it went just fine! I didn’t experience any problems with those… One participant brought up personal experiences with surgery performed earlier as grounds for deliberation about possible risks.“I can’t stand the pain, is it time for surgery?”. As the disease progresses and interferes with the patient’s physical function and well-being, the GP prescribes pain medication, refers the patients to a physiotherapist and gives some advice on how the patient should adapt and self-manage. While some patients find satisfactory ways to cope at this stage, some do not respond effectively and experience that the disease continues to progress, leading to significantly decreased physical function and quality of life. The pain levels increase and the sleep quality decreases as a consequence of frequent pain incidents during the night. These patients may be considered for a specialist evaluation to decide whether hip replacement is appropriate.The common experience patients have at the advanced stage may lead up to the question: The reason was to get help and pain relief. It is… it’s just that. Yes, I don’t exactly know why I asked to be referred, but I have had such terrible pain and currently have terrible pain. I kind of consider my future prospects as dark if I have to live like this the rest of my time! If anything can be done… but I don’t know, maybe I can do more– exercise more, or?… .Participants stated that pain was the main reason for considering hip replacement surgery.It’s something you really need to embrace… it’s a mental… you kind of surrender one part of the body… voluntarily, you know? I therefore found it helpful to listen to their story about the time before and after surgery. I found it very important to learn from their experiences… .A common finding was that it seemed important for the participants to discuss experiences with others who had undergone hip replacement.The X-ray showed very little radiographic changes, and they kind of laughed at me and… I asked them if any help is available for this… No! Come and see us in three years they said – that was it… .Participants who were denied hip replacement were told by their GP or orthopaedic surgeon that the features of the X-ray did not show significant changes that would allow for a hip replacement, or they were categorized as too young and therefore advised to postpone the procedure as long as possible.This phase represents the process of surgical decision-making and can be summarized by the question: “Will a hip replacement help me with my problems?”. This illustrates a complex process that is regarded as “the point of no return”, as one participant explained. After having updated hip x-rays, the orthopaedic surgeon and the patient review the current situation together. Many participants said that reaching this phase was a relief - something they knew existed as a final option and that might help the situation significantly. Decision-making for THR seems to start before the actual meeting with the orthopaedic surgeon, either as a result of advice from health professionals or after observing others’ experiences from undergoing THR. The patients know that this is a final and effective option, but the issue of timing depends on several factors. The question “The doctor tells me that the timing is not right for me, what now?” illustrates rejection as a possible outcome of surgical decision-making. In Norway, these patients have a legal right to a renewed evaluation and may opt for this if they disagree with the decision. Otherwise, these patients continue at their best with conservative treatment, but may be referred for a second orthopaedic evaluation at a later point in time. The question “I am waiting for surgery, what should I do?” reflects the outcome where patients are accepted for hip replacement and placed on the waiting list.I was told that it is smart to strengthen the muscles… I therefore started intensive training, but it was far too late… I started 14 days prior to surgery with intensive training, but I realize that I should have started much earlier. Clearly! .Most participants who were due for THR had been advised to do joint muscle-strengthening exercises prior to hospital admission.We were told that there was no use in doing that… It was no benefits doing surgery on hard muscles… The soft muscles however, the ones that were little trained was better –– they healed more quickly and you would have a shorter recovery period .However, one participant had been informed that muscle strengthening was contraindicated in the pre-operative period.I think that the information I received here at the hospital – the letters about where to meet, when and what tests to take – generally, the whole course of the operation. I think it was fantastic! .Elective patients receive standardized information prior to admission that explains what to expect and what they should do to prepare for the recovery period.The health providers here are very informative and good at telling what to do and what to expect. It makes you gain confidence in the staff… Yeah, I think it has been very satisfying! .Most of the participants in this study expressed satisfaction about the information provided by the hospital staff.After hospital admission, patients follow a standardized treatment and rehabilitation program. Most patients are discharged during the first or second postoperative day, but with an expectancy of a 6–12 month recovery period to regain full physical strength and energy. This phase is reflected by the question: “What will happen at the hospital?”. It represents a range of possible concerns and expectations that the patients might have during this period of the continuum. They are in need of professional guidance on how to adapt to a life with a prosthesis, and they learn ways to optimize its function and minimize the likelihood of complications.I spent four weeks, that is the maximum time allowed… there you can get all the training you need. Cycling, gymnastics of all kinds, training with weights on your feet, and climbing up and down the steps on a ladder… yes– overall, to get into shape… I don’t question that this is what has helped me improve this much .Patients are normally not offered in-house rehabilitation following THR in Norway. Most of the participants in Group One who had surgery the next day expected to return to their homes after discharge from the hospital. However, one of participants in Group Two who had previously undergone THR explained the value of admission to a rehabilitation unit.The question; “what can I expect after having surgery?” reflects the needs of patients who have undergone hip replacement. They are pre-informed before surgery and have completed preparations for this period, but are in need of support and information about ways to prevent postoperative complications. All patients are expected to stay physically active in order to optimize stability and function in the hip joint.I honestly don’t know… you hear what I’m saying – I have come to a point to wonder whether surgery is a wise thing to do. I’m not so happy about that either, you know .Patients who are not considered medically appropriate for surgery, or for some reason do not prefer the procedure, seem to have a need to accept the situation, while optimizing the available non-surgical treatment options in order to live a meaningful life despite pain and its accompanying limitations. One of the participants had ambivalent thoughts regarding surgery.I do feel that I accept it, I really do… I have to! I must accept it, but I am still thinking about whether there might be something that can help. I always do .One participant said that it was essential to accept the situation, but this did not mean one should let go of the hope that help could be obtained.What are my options if I'm not receiving surgery?”. This route is included as a possible outcome from surgical decision-making, as some patients may be ineligible for THR and others are cautioned because they have a greater than average risk of post-surgical complications . Some patients may also choose not to receive surgery due to personal reasons .This alternative route is reflected through the question: “The qualitative approach used in this study revealed findings that capture several aspects of the complex nature of how hip OA patients experience the development of their illness, including the encounters with the health care system and the clinical decision-making processes. The model presented with the accompanying key questions give an overview of the OA hip-journey, based on the participants’ experiences and research literature. We believe that it provides a simplified, but realistic map of how patients with hip OA navigate and interact with health professionals throughout the continuum. The identified questions are condensed representations of a range of related questions that patients have across the continuum. These questions need to be appropriately addressed in order to increase the patients’ possibilities for effective self-management and informed decision-making.The majority of the participants did not seem to receive information relevant to self-management and surgical decision-making, but at the same time they didn’t expect to be given this kind of information from their GP. Most of the participants did not adhere to a prescribed pain medication plan. Furthermore, most did not experience benefits from individual training with a physiotherapist. As a result, they struggle to find effective pain-management strategies in daily living, often including avoidance of activity resulting in increased pain and decline in physical function. Similar and other barriers to utilization of recommended treatments have been reported in several studies , 39, 40.These barriers may partly be explained by a gap in essential knowledge about OA and available treatment alternatives , 42, 43.The general picture in this study is that patients are not appropriately informed about possible complications associated with THR. This is problematic. Although THR have low complication rates, patients should be realistically informed about possible pre- and postoperative complications. Only a few of the participants expressed explicit concerns about undergoing surgery, and none stated that they had discussed the associated risks with an orthopaedic surgeon or GP. It seemed that they generally put their trust in the orthopaedic surgeons’ professional skills and that risks, according to them, hadn’t been appropriately addressed when they decided to undergo THR. When asked about the type of information that was perceived as important during orthopaedic consultations, most male participants explained a need to understand how the prosthesis is designed, and that the orthopaedist had drawn pictures and used models to demonstrate how it is fitted into the hip joint. Other aspects were related to an expectation of pain relief and restored physical function, and the abilities to return to work. These expectations have been reported as the most important pre-operative expectations that influence a decision for undergoing surgery . AlthougThe process of decision-making for THR should ideally be initiated by the GP during the early phases of the continuum in order to provide time and opportunities for careful deliberation and to identify the optimal timing for referral to an orthopaedic surgeon. The patients need to establish their goals and expectations, examine their values and preferences and how they relate to their ability to cope with their condition, their need for pain relief, quality of life restoration, and the goals and expectations of having THR or not. They might need to acknowledge fears surrounding the procedure and any previous experiences. Physician opinion, the social impact of others, and knowledge and concerns about recovery are also factors that may impact patients’ decisions regarding surgery . Shared We were able to recruit a relatively broad sample of participants in terms of age, gender and distribution within the hip OA continuum. By conducting in-depth interviews, we produced a rich source of qualitative data which contributes to the understanding of how patients might experience living and coping with hip OA within the Norwegian health care system. It is one of few studies that focuses on the whole hip OA continuum of care, as seen from a person-centred perspective. The proposed model and questions can act as a guide to help patients and their families to visualise the complexity of the disease, what to expect and their role as active participants in communication and decision-making.In this study we have made an effort to illustrate a typical hip OA continuum and further describe accounts that represent patients’ informational and emotional needs expressed explicitly or implicitly by the participants. It is clear that all patients entering this OA continuum are heterogeneous human beings with individual needs that are impossible to fully account for through methods used in this study. A relatively small sample of patients were included, thus we expect that other important aspects related to patients’ information and emotional needs are missing from this presentation. A majority of the patients included in the study had developed severe hip OA, and were due for or contemplated surgery. It is therefore likely that patients at early stages of hip OA are underrepresented in the sample and their experiences and questions less clearly explored. A future study could use the hip OA model as basis to recruit and allocate participants to each phase, and to assess specific needs expressed by both patients and their care providers.This study reveals that patients with hip OA are in great need of information and emotional support throughout the whole hip OA continuum. Patients’ needs, concerns and expectations must be appropriately understood and met by health providers caring for hip OA patients. The knowledge and model developed through this study will be used as a basis in the development of a web-based tool for hip OA patients, their families and involved health providers designed to increase patients’ knowledge and support communication during the process of preparing individualized care plans in clinical settings.


Incidence of postoperative pain has been reported to be between 47–100%. Ineffective postoperative pain management results in tangible and intangible costs. The purpose of this study was to assess the processes and outcomes of pain management in the surgical wards of Jimma University Specialized Hospital, Ethiopia.prn), solo analgesic, null analgesic, and intramuscular orders were noted for 31.3%, 89.29%, 9.7% and 20.1% of the prescription orders respectively. Though under dose, diclofenac and tramadol were the top prescribed medications, and only 57% of their dose was administered. Linear regression model showed that the predictors of satisfaction were sex of an individual and pain interference with functional status.A prospective cross sectional study was conducted among 252 postoperative patients during February 13 to April 30, 2012. A contextually modified and validated (Cronbach’s α coefficient of 0.78) American Pain Society Patient Outcome Questionnaire was used to assess pain experience of patients. Patients’ charts were reviewed to assess the pattern of analgesic use. Incidence of postoperative pain was 91.4%, and remained high over 3 measurements , and 80.1% of the patients were undertreated. The mean pain intensity, and pain interference on functional status were 6.72±1.44 and 5.61±1.13 on a 10 point Numerical rating scale respectively; both being strongly correlated(r = 0.86: p<0.001). Pain intensity was varied by ethnicity, education and preoperative information . Only 50% of the patients were adequately satisfied with their pain management. As needed (Despite patients’ paradoxical high satisfaction with pain management, the majority of patients were inadequately and inappropriately treated. Thus, further research is needed to determine how best to break down current barriers to effective pain management. It has been repeatedly confirmed by studies in the past 3 to 4 decades that 20 to 80% of patients undergoing surgery suffer from inadequately treated pain In Africa, the issue of pain has been explored largely in relation to HIV/AIDS and cancer In Ethiopia, a study conducted by the Ethiopian Public Health Association in 2005 showed that health care providers believes that pain was undertreated due to unstandardized practice, absence of medications and poor knowledge and attitude among professionals. The output of the survey was a step forward for the development of the 2007 National Pain Management Guideline The present study was conducted to assess the quality of postoperative pain management in the surgical wards of Jimma University Specialized Hospital (JUSH) by examining the incidence, intensity and interference of pain. Satisfaction and attitude of patients plus the patterns of pharmacologic and non-pharmacologic interventions with regard to pain management were also examined. After the conduct of this research, the department of Anesthesia of the University in conjunction with anesthesiologists from UK has taken a step to prepare a pain assessment tool and treatment guide for use by the surgical ward’s health care professionals.This study was conducted in the 3 surgical wards of JUSH during February 13 to April 30, 2012. The surgery department has 126 beds with a perceived 100% occupancy rate. Formal documentation of pain and preemptive analgesia are not common practices in this set up. Besides, anesthetists do not participate in the pain management of postoperative patients.Prospective cross sectional study design was used to determine the quality of postoperative pain management. Consecutive, hospitalized patients aged over 18 years and within 24 and 72 h of surgery were invited to participate in the study. Of the 280 approached patients over the study period, 252 were recruited for analysis . PatientBased on the 1995 and 2010 versions of the American Pain Society Patient Outcome Questionnaire (APSPOQ), a contextually modified tool was prepared to collect data on patient satisfaction level, beliefs about pain and pain treatment, pain intensity, and effect of pain on function through face-to-face interview. These two tools are dependable and has been used extensively to survey pain in various contexts by multiple studies We predominantly used the 1995 version since it is extensively used and validated in both developed and developing countries. Initially three items, related to the use of non-pharmacological intervention and what perceived side effects patients come across, were picked from the 2010 version. After the pretest 2 items related to satisfaction with nurses’ and doctors’ were deleted since patients were not able to differentiate between a physician and a nurse. Similarly, the item that questioned patient’s request for medication change was removed, since it resulted in unanimously similar response of ‘No’. The item from the revised 2010 version of APSPOQ-R that assess the side effects of drugs was also erased because the side effects indicated were mainly related with strong opioids, which were not available in the study setting during the study period.The final tool used in the current study had 13 items. The first item determines whether the patient experienced pain in the previous 24 hrs. The subsequent 3 items assess patients’ pain intensity level on the 0–10 Numerical Rating Scale (NRS). Item 5 relates to the degree to which pain interferes with six activities of daily living  on the same scale as previous. The next 2 items measures patients’ satisfaction with their overall pain management.th item enquire patients’ alleged waiting time for analgesics when they ask for pain relief from 10 minutes or less to more than 60 minutes. If patients have pain at the time of interview, they would be asked whether they like something stronger for pain relief in item 9. In the next item patients were asked about their agreement (attitude and belief) levels to statements (patient barrier statements) related to pain and pain management on a 6 point scale of 0  to 6 (agree very much); higher score to these statements indicates higher levels of patients barriers to pain management.Then, 8th item relates to whether nurses or doctors inform patients about the importance of treating pain and reporting pain. The last two items assess patients experience with non-pharmacological management, and encouragement received from the health care professionals. Moreover, a structured data abstraction checklist was utilized to collect data on the pattern of pharmacological/non-pharmacological interventions and demographic characteristics of patients from the patient chart.The 11st 24 hrs. Items on attitude and belief towards pain were collected for the 2nd 24 hrs. While wait time, need for stronger dose, non-pharmacologic intervention were assessed for the 3rd 24 hrs. The items on medication profiles, pain presence, pain severity and pain interference were interviewed for all of the 3 assessment episodes.Those who were in a state to participate in the study were asked the first item. Patients with an experience of pain in the previous 24 hrs were interviewed with the APSPOQ in full, while patients with no experience in the previous 24 hrs were not asked the questions about pain intensity or the effect of pain on activities of daily living. Analgesics prescription and administration information for the previous 24 hrs were recorded for all participants by reviewing their medical records or interview of the patient and ward nurses. Satisfaction items were collected for the 1Institutional Review Board, Jimma University. The data collectors  first assessed patients’ ability to both comprehend the plain language information about the study and to participate in the study, by asking patients to repeat back the information provided. Patient’s written informed consent to participate in the study was obtained after comprehensive explanation of the purpose and procedure of the study. Patients were informed about their rights to refuse or withdraw, and about confidentiality of the individual information obtained. Additionally, any personal information was de-identified before the final analysis. During data collection process, data of patients who were at any risk of complication due to pain were shared with their medical and nursing team for intervention.Permission to conduct this study was obtained from the Data were coded, cleaned and entered into and analyzed using the Statistical Package for the Social Sciences  version 19.0. Descriptive statistics were computed to summarize the participants’ socio-demographic and clinical characteristics, patient satisfaction, and pain management processes . The amount of analgesic patients received (mean dose ratio) was calculated as a proportion of dose administered to that of the total amount prescribed over the three episodes of measurements. The overall patients’ agreement levels to barrier statements related to pain and pain management were calculated as mean scores for each sub items. ANOVA, McNemar’s test, Pearson product moment were conducted to determine difference between groups, timed measurements, proportions, and link between variables accordingly.The reliability of the APSPOQ used in this study was estimated by using the Cronbach’s α coefficient. Reliability estimates for the various subscales were 0.93 for pain intensity (3 items), 0.88 for pain interference (6 items), and 0.79 for beliefs about pain (7 items). The overall reliably for all items was 0.78.Principal component analysis was used to reduce the 3 items of pain intensity, 6 items of level of pain interference on patients’ routines, and 7 items of barrier statements. The former two were measured over three days while the latter only at a point in time. The analysis was run independently for each the three factors. For the first two, the raw data matrix recoded so that the average of the three data point was taken during data reduction. However, the raw data matrix of the barrier statement was taken as it is since it was measured only once. Then, the appropriateness of the data was assessed using KMO’s and Bartllet’s test. The assessment of the Scree plot showed that only one component was enough for each category of measurement. Finally, the analysis for each was run again by setting the number of components to be one and the type of extraction Varimax. The generated scores were then used for subsequent analysis using ANOVA, correlations and linear regression.To determine the adequacy of postoperative pain management Pain Management Index (PMI) was used. The PMI is based on a patient’s level of worst pain intensity and is categorized into 0 (no pain), 1 (1–3: mild pain), 2 (4–6: moderate pain), and 3 (7–10: severe pain) Of the approached 280 patients 252 (90%) were included in the final analysis ; 162 (64.3%) were males. Patients were between 19 and 81 (40.4±15.5) years. Majority of the participants (71.4%) were Muslim by religion; and Oromo (72.6%) by ethnicity. Approximately 49% of the patients had no any formal education. Only 9.5% of the patients demonstrated previous surgical history of any type. The patients stayed in the wards for 0 to 28 days (5.2±5.1) prior to their surgery. Surgical interventions were categorized according to approach, with the largest being abdominal 90 (35.7%). The majority, 228 (90.5%), received general anesthesia, while the remaining subjects received spinal anesthesia. A large proportion of subjects, 198 (78.6%), had scheduled surgical interventions. The mean duration of all the surgical procedures was 82.9±43.7 minute .The principal component analysis generated one component for each group of items. The variations explained by the generated scores were 77%, 75% and 66% for pain intensity, interference and belief items respectively. The pain intensity component has the strongest correlation with the average pain item (r = 0.91), the interference one with mood (r = 0.87), while the barrier (belief) component with the addiction statement (r = 0.82).st, 2nd, and 3rd previous 24 hrs respectively. The pain incidence of the first assessment was significantly higher than that of the second day . The mean pain intensity for the three consecutive episodes were: (5.56±1.76), (6.46±1.33) and (8.16±1.23) for pain now, pain average, and pain worst pain respectively. A consistent and significant (P<.001) decrease in pain intensity was observed over time .When interviewed 240 (95.2%), 231 (91.7%), 210 (87.5%) of the patients had experienced pain in the 1Barrier to pain management (r = −0.17: p<0.05), age (r = −0.20: p<0.001) and duration of surgery (r = −0.16: p<0.05) were negatively and mildly correlated with pain intensity. Even though, it was not statistically significant, the ratio of drug administered and longer ward stay showed an inverse relation with pain intensity. In as much as the previous, patients who rated higher pain intensity were from the southern region of the country (P<0.05), more educated (P<0.05), and more pre-informed (p<0.05).Mean of pain interference over the 3 days in decreasing order were: walking ability (6.77±1.44), general activity (6.57±0.98), mood (5.83±0.97), sleep (5.59±1.22), coughing and deep breathing (4.89±1.19), and relation with others (4.01±1.02). The overall mean over the 3 days was 5.61±1.13, and it decreased significantly over time (p<0.001). Higher interferences were reported by individuals who; rated higher pain (r = 0.86: p<0.001), spent shorter duration in surgical procedures, were younger, exhibited less hindering attitude, and were more educated (p<0.05).Patients were asked to rate on a 0 to 5 scale  how much they agree with seven statements focused on common pain management misconceptions. The higher the rate on the likert scale, the greater the barrier (hindering attitude) to adequate pain management. Patients reported relatively higher levels of agreement with all 7 statements, with the highest level of agreement for the statement on addiction (3.8±1.22) .Only few patients (2.5%) reported that they received pain medication within 15 minutes of complain of pain. However, a large number of patients (70.8%) never asked for pain medication during hospitalization. Despite the fact that only few patients requested for pain medication, 42.2% of the patients responded “Yes” when they were asked whether they want stronger medication for pain relief. Moreover, 14.2% of the patients reported that they never received the analgesics they requested . Most paprn) orders for analgesics were noted in 31.1% of the orders. Analgesics that were prescribed with a fixed interval were administered 54% of the time; however, prn orders, irrespective of analgesic category, were only administered 5% of the time. The majority of patients were prescribed solo analgesics (89.29%). The remaining (10.71%) were prescribed dual analgesic: namely Diclofenac and Tramadol. It was also observed that forty five patients (10.1%) did not have prescription for any kind of specific analgesic. On average, the dose administered for Diclofenac was only 56.2% of the prescribed while for Tramadol it was 57.9% ; as needed . Change of prescription of pain medication was reported only in 3% of the cases. The most frequent non-pharmacological ways of managing pain were tolerating pain (84.4%), changing position (83.7%), and having family support (81.9%). Approximately, 83% of the participants did not receive support from the health care providers in this regard.The mean total daily dose (in mg) administered over the three measurements episodes were: 122.5±21.3, 88.8±14.2, 81.6±12.7 for Tramadol, and 101.4±19.3, 81.1±11.8, 64.9±9.5 for Diclofenac. The dose of the drugs administered decreased consistently and significantly over time  received ineffective pain medication. The remaining 48 patients (19.9%) received adequate to good pain medication.In response to questions about overall satisfaction with management of pain, 117 (50%) patients were satisfied or very satisfied. With a range of 1–6, the mean overall satisfaction with pain relief management was 4.22±1.51 for all patients. Though it was weak the only variable correlated with satisfaction level was pain interference . Significant differences were between male and female (P = 0.04); female being less satisfied.2 = 0.16) were sex of an individual and interference of pain with functional status. It was found that a unit increase in pain interference on functional status results in a 0.167 unit decrease in satisfaction level with pain management . Similarly, females’ satisfaction with pain management is lower than that of male by 0.137   = 5.311, p = 0.006, adjusted R −0.057) .This study is the first to evaluate the quality of postoperative pain management in JUSH using the quality improvement standards recommended by APS Findings from this study should be interpreted and understood within the context of barriers of pain management in Africa, and postoperative pain management in Ethiopia, where, at the time of data collection, there was one national general guideline prepared by the Federal Ministry of Health (MOH) In hospitals of most developing countries  pain management is derived from the medical staff’s experience, and is not always consistent with recommendations from organizations such as the APS The incidence and level of severity of pain reported in this study is higher than those from most Western and developing countries Age, attitude, information status and education are often considered indicators of the patient’s perception of power The role of ethnic background (ethnic origin) to affect pain perception and satisfaction was mentioned in studies done in Singapore and Nigeria The interference scores reported by the patients in this study were higher than those reported in other studies with more heterogeneous samples of hospitalized patients China, USA, and South America The majority of patients never requested pain medication or changes in pain medication. In comparison to patients from other countries Regarding adequacy of pain management, 80.1% of the population was poorly managed in the current study site. For comparison, 60.2% were inadequately treated for pain in Chinese population The principal means the study participants used to cope with pain were tolerating pain, self-prayer, family help, and changing positions. This finding is consistent with findings from Chinese and Mexican population A paradoxical high satisfaction despite high pain intensity was observed in our study samples. But, the overall satisfaction of patients was lower than reported by most studies in developed and developing countries The correlates of satisfaction in our study were gender and interference of pain. Female’s higher intensity of pain and dissatisfaction were also demonstrated by studies in Western countries Although this study is the first to use the APSPOQ, in Ethiopia, to evaluate the quality of postoperative pain management in this setup, limitations that can affect generalizability need to be noted. First, collection of data in a single site and from patients operated by a limited number of surgeons presents a limitation to the external generalizability of this study. Second, the majority of patients were male which might decrease pain intensity and interference ratings, because women are more likely to report higher pain and interference scores than men. Thirdly, the majority of the patients had similar socio-demographic characteristics which also affect variability of responses. Furthermore, there are known multifactorial influences related to setting of facility, patient’s expectations, professionals’ attitude and knowledge on pain experience that have not been explored in this study.In conclusion, postoperative pain management was suboptimal among postoperative patients of the surgical wards in JUSH. This was evidenced by the high incidence of postoperative pain and its consequences. Unstandardized treatment use, poor patient attitude, shortage of pain clinicians, lack of strong opioids, and lack of knowledge might be background causes. Thus, further research is needed to determine how best to break down current barriers to effective pain management.