Working memory (WM) is a critical process for cognitive functioning in which fibromyalgia (FM) patients could show cognitive disturbances. Dyscognition in FM has been explained by interference from pain processing, which shares the neural substrates involved in cognition and may capture neural resources required to perform cognitive tasks. However, there is not yet data about how pain is related to WM performance, neither the role that other clinical variables could have. The objectives of this study were (1) to clarify the WM status of patients with FM and its relationship with nociception, and (2) to determine the clinical variables associated to FM that best predict WM performance. To this end, 132 women with FM undertook a neuropsychological assessment of WM functioning  and a complete clinical assessment , including determination of pain thresholds and tolerance by pressure algometry. Patients with FM seem to preserve their WM span and ability to maintain and manipulate information online for both visuospatial and verbal domains. However, up to one-third of patients showed impairment in tasks requiring more short-term memory load, divided attention, and information processing ability (measured by the ACT task). Cognitive performance was spuriously related to the level of pain experienced, finding only that pain measures are related to the ACT task. The results of the linear regression analyses suggest that sleep problems and fatigue were the variables that best predicted WM performance in FM patients. Future research should take these variables into account when evaluating dyscognition in FM and should include dynamic measures of pain modulation. Fibromyalgia (FM) is a chronic pain syndrome without a fully known organic etiology, characterized by widespread musculoskeletal pain, stiffness, fatigue, non-restorative sleep, and cognitive dysfunction . Recent Although the presence of cognitive complaints is clearly noted in patients with FM, their specific objective cognitive symptoms are less well established . WorkingDyscognition in FM has been explained as interference from pain processing in cognition, as both share neural resources, e.g., the cingulate cortex and supplementary motor area , but datLikewise, the relationship between WM performance and other clinical symptoms apart from pain in FM patients is not clear. It has been suggested that depressed mood , anxietyThe objectives of our study were (1) to clarify the WM status of patients diagnosed with FM and its relationship with nociception, and (2) to determine the clinical variables associated to FM that best predict WM performance. For this purpose, we assessed FM patients with a variety of tests selected to cover the main components of WM, and we also examined their level of pain experienced . Relationship between these variables were assessed, and performance on working memory tasks of high and low pain threshold groups was compared. Finally, we analyzed which of a series of clinical variables self-reported by patients  are the best predictors of WM performance. In line with the evidence reported above, we hypothesized that FM patients with lower pain thresholds (greater pain sensitivity) would perform less well in WM tasks. Furthermore, in relation to the clinical variables, we expected that greater severity of FM symptoms and cognitive complaints would be associated with objective poorer performance in WM tasks.http://www.encepp.eu/(Register number: 24294) and approved by the Research Ethics Committee of Galicia (code: 2014/488).The study participants were 132 women  who were already taking part in a clinical trial to assess the effect of transcranial electrical stimulation on fibromyalgia. This clinical trial was conducted in Galicia (Spain) in the period from May 2017 to November 2018. It followed the Declaration of Helsinki, was preregistered at The first contact with participants was by phone; those who agreed to participate were scheduled for a first evaluation session, where we obtained the informed consent and confirmed the fulfillment of the selection criteria.The following inclusion criteria were applied: age between 25 and 65 years, diagnosis of fibromyalgia  and compliance with American College of Rheumatology (ACR) criteria for fibromyalgia , 2010. TMeasures section). For ethical reasons, withdrawal of their analgesic treatments was not requested during the study. The evaluations were conducted in the Brain and Pain Laboratory of the University of Santiago de Compostela and in health centers/hospitals in Galicia (NW Spain).The data analyzed were obtained in the pre-treatment evaluation session of the clinical trial. This session consisted of a complete clinical assessment that included a semi-structured interview and a series of self-report questionnaires to assess the health status relative to the core symptoms of FM, pressure algometry at tender points to measure pain threshold and tolerance, and a WM neuropsychological assessment (see description in 2) that induced pain. A point was defined as positive when the participant felt pain at pressure lower than 4 kg/cm2, as it has been established that in healthy women pain begins to be perceived at pressure greater than this level (2) was defined as the maximum pain-pressure value that was born at each point.A trained researcher evaluated the pain threshold and tolerance of the patients by using a pressure algometer  at the 18 tender points proposed by the ACR . Pain this level . For eacad hoc to assess the clinical status of the participants. The scales consist of a set of 10 cm long horizontal lines, scored from 0 to 10 (left end represented the best condition and the right the worst). The participants were asked to indicate their status in relation to the following variables: pain, functional state, morning stiffness, fatigue, mood, health status and non-restorative sleep.Visual Analogical Scales (VAS) were created The Revised Fibromyalgia Impact Questionnaire FIQ-R;  was admiThe Fibromyalgia Survey Questionnaire FSQ;  was usedThe Beck Depression Inventory BDI-1A;  was usedThe Hospital Anxiety and Depression Scale HADS;  was usedPittsburgh Sleep Quality Index PSQI;  was usedEveryday Memory Failures Questionnaire-30 MFE-30;  was admiA visual 2-back task was designed using the PsychoPy software , to evalForward task and in reverse order in the Backward task. The number of correct items repeated and span scores (the maximum number of digits correctly produced) were obtained for the Forward and Backward tasks.The Digit Span Subtest of the Wechsler Memory Scale  was compared using Student enmakers .Linear regression analyses were applied to each of the WM scores of FM patients, using nociceptive (pain threshold and tolerance) and the self-reported clinical measures  as possible predictors.Data were analyzed using the SPSS statistical package .n varied in each task, due to missing data).The descriptive statistics corresponding to participants’ data relative to the demographic, clinical and self-reported measures to assess FM symptoms are summarized in 2 (SD = 1.01), which is below the 4 kg/cm2 limit set by the ACR criteria, and their average tolerance was 2.66 kg/cm2. The scores on the VAS (range 0–10) showed that means of all measures were over the midpoint of the range (5 out of 10), and the symptom that manifested itself most intensely was fatigue .The mean number of years from patients’ diagnosis of FM was 9.96 (SD = 7.99). Their average pain threshold was 1.98 kg/cmRegards measures of impact and severity of FM, the average total score on the FIQ-R showed a severe impact of 67.43 (out of 100), and an average score of 19.24 (out of 31) was obtained for the fibromyalgia symptomatology measured with the FSQ.For the BDI-1A the average score was 21.82 points, which according to the normative data  correspoThe average score obtained by the participants on the PSQI was 13.09, which is higher than the score of 5 established as the cut-off point between good and poor-quality sleep . In factFinally, cognitive complaints were frequently reported in the MFE-30 by patients, with more than 70% of patients showing total scores between mild impairment and moderate impairment. Moreover, the average score was higher than 50 points, which according to available data  indicateZ ≤ −1.5) in the different WM measures.The descriptive statistics corresponding to the measures from the different tasks used in the study to assess WM in FM patients are summarized in The ACT task had the highest percentage of patients with scores 1.5 SD below the normative mean: 36.43% at 36 s, 15.5% at 18 s, 9.3% at 6 s and 10.08% at 0 s. On the other hand, Digit and Spatial Span produced the smaller percentages of patients with scores 1.5 SD below the normative mean (2.27%).r = −0.205; p = 0.031). Using the Bayesian approach, correlation analyses indicated anecdotal evidence of no correlation with pain threshold for ACT at 9 s (BF10 = 1.187). It was also found anecdotal/moderate evidence of no correlation with pain threshold for all other WM variables.Pearson correlation analysis to assess the relationship between pain threshold and WM scores were carried out. Only the correlation between pain threshold and ACT at 9 s was found to be significant (2) and Low Pain Threshold (≤1.89 kg/cm2) using t-test for independent samples are presented in 10 values obtained using the Bayesian approach. No significant differences between the subgroups were found for any of the WM performance scores using frequent statistics. In addition, we found anecdotal/moderate evidence in favor of an absence of difference in WM performance between the high and low pain threshold groups, based on Bayesian analyses.Moreover, the results of the comparison of WM performance of FM patients’ subgroups of High Pain Threshold  and the self-reported clinical measures as possible predictors of WM status of FM patients are summarized in R2 = 0.373; β = 0.273; t = 2.020; p = 0.047) and span  scores. In addition, the PSQI was able to predict performance on the Spatial Span Backward span score .Linear regression analysis indicated that sleep problems predict patient performance on some of the WM scores. The non-restorative sleep VAS yielded significant coefficients for the Digit Span Forward task, both for its direct , and for both Spatial Span Backward direct  and span scores .The results also showed the predictive capacity of the VAS-fatigue for several WM scores, specifically for the 2-Back correct score  and span  scores, and on the 0 s ACT score .In addition, the Health Status VAS showed predictive capacity on the Spatial Span Backward task, both for the direct  and Pain Tolerance  yielded significant coefficients for the 9 s ACT score (R2 = 0.312).Regards to pain measures, both Pain Threshold , and the Symptoms domain yielded significant coefficients for the 18 s ACT score .Finally, the Function domain of FIQ-R yielded significant coefficients for the Spatial Span Forward span score  are involved in both nociceptive processing and cognitive functioning. Previous studies reported that the detection and processing of nociceptive information can influence WM ability . We testFinally, we attempted to examine which of the clinical self-reported variables were the best predictors of WM performance. The results of the linear regression analyses suggest that sleep problems and fatigue were the variables that best predicted WM performance in FM patients, as found in previous research . In addiIn the case of sleep problems, unrefreshing sleep assessed by VAS was a significant predictor of direct and span scores in the verbal WM forward task, and the score obtained in the Pittsburgh Sleep Quality Index was significantly related to the span in the visuospatial WM backward task. These findings are consistent with those of previous studies supporting the idea that insomnia can negatively impact the WM of participants, even if they have not a diagnosis of FM . HoweverOn the other hand, VAS-fatigue proved to be a significant predictor of performance in the 2-Back task and of direct and span scores of the Spatial Span Backward task. This is consistent with previous findings , which iIn this study, we did not find any relationship between cognitive performance in FM patients and the clinical and self-reported scales used to assess anxiety and depression , and therefore we cannot corroborate results obtained in other studies on chronic pain syndromes .The study findings also failed to confirm any relationship between subjective cognitive complaints and objective WM performance in the FM patients. This is consistent with the results of previous studies suggesting a disconnection between neuropsychological performance and subjective complaints in FM patients . It is aRegarding the limitations of this study, several factors could affect the generalizability of the results obtained. On the one hand, the sample used was composed exclusively of women with FM because the prevalence of FM in the Spanish population is much higher in women (4.2%) than in men (0.2%) . In addiFinally, the pain threshold measurement used is static in nature. As one of our objectives was to investigate the relationship between WM performance and pain experience, it might have been more appropriate to use dynamic indices, such as those obtained in the Conditioned Pain Modulation protocol CPM; . The CPMPatients with fibromyalgia seem to preserve their ability to process and manipulate information in working memory but show impairment in tasks requiring more short-term memory load, divided attention, and information processing ability. Contrary to the expected results, pain threshold was only related to performance in the more demanding WM tasks (ACT task). Among the clinical variables associated with FM, sleep problems and fatigue seem to be the most closely related to cognitive functioning.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Research Ethics Committee of Galicia (code: 2014/488). The patients/participants provided their written informed consent to participate in this study.MP-M, DR-S, NS-V, and MC designed the study. MP-M and NS-V recruited the participants and made the assessments. AG-U, DR-S, MF-P, and MC analyzed and interpreted the data. AG-U wrote the first draft of the manuscript. AG-U, DR-S, and MC reviewed and wrote the last version of the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


We compared post-thoracotomy pain syndrome (PTPS) incidence in patients who underwentuniportal or multiportal video-assisted thoracoscopic surgery (VATS).n=19, multiportal: n=133; wedgelung resections—uniportal: n=16, multiportal: n=55). Weretrospectively studied incidences of PTPS in all subgroups.We included 223 patients who underwent either uniportal or multiportal VATSbetween January 2017 and October 2018  and the wedge lungresection group (P=0.0315) than for multiportal procedures.Incidences of PTPS were significantly less for uniportal procedures for both thepulmonary lobectomy/segmentectomy group (Patients who underwent uniportal VATS procedures had lower incidences of PTPS thanthe multiportal VATS group. The uniportal VATS approach is therefore beneficial forpatients. Compared with conventionalmultiportal thoracoscopic pneumonectomy, uniportal VATS reportedly shortens surgery time,reduces intraoperative bleeding, shortens the thoracostomy tube indwelling period andhospitalization period, reduces complication incidence, alleviates postoperative pain, andimproves esthetic outcomes.5Uniportal thoracoscopic lung resection was first reported by Rocco et al. in2004 for a wedge resection of the lung.6 and defined by the International Association for theStudy of Pain as refractory pain along a surgical wound, which persists for least 2 months aftersurgery or relapses at least 2 months after surgery.7 The reported incidence of PTPS is 11–80%.8 However, few studies have evaluated chronic pain following uniportalVATS.9 In this study, we compared PTPSincidence among patients who underwent uniportal or multiportal VATS.Post-thoracotomy pain syndrome (PTPS) has been previously reported,This retrospective study was approved by the Ethics Committee of Fujita HealthUniversity. At Fujita Health University Hospital, 516 patients underwent thoracoscopic surgerybetween January 2017 and October 2018. Among the 382 patients who remained after excludingthose who underwent either robot-assisted surgery or thoracotomy, 225 patients underwentpulmonary lobectomy and pulmonary segmentectomy (PLPS) and 157 patients underwent wedge lungresection. To compare chronic pain caused by uniportal and multiportal approaches, we excluded(a) patients who received bilateral thoracoscopic surgery in 1 or 2 stages; (b) patients whosemedical follow-up ended less than 2 months after surgery; (c) patients aged <10 years; (d)patients with suspected bone metastasis; and (e) patients who could not be evaluated withnumerical rating scale (NRS) pain scores. However, among patients who underwent bilateralthoracoscopic surgery in 1 or 2 stages, the first surgery was included in this study if theinterval between the first and second surgeries of a two-stage surgery was more than 2 months.After excluding the abovementioned patients, we included 152 patients who underwent PLPS and 71patients who underwent wedge lung resections.st assistant wasa surgeon skilled in uniportal surgery. Multiportal VATS was performed when the operator or1st assistant was not a surgeon skilled in uniportal surgery, when an undiagnosedtumor needed to be located by palpation, or when CT-guided needle marking could not beperformed. Among the 152 patients who underwent PLPS, 19 had uniportal VATS and 133 hadmultiportal VATS. Of the 71 patients who underwent wedge resections, 16 had uniportal VATS and55 had multiportal VATS . LigaSureTM Maryland  orHARMONIC® HD1000i  was used in lymphadenectomy;Powered ECHELON FLEX® GST System  or EndoGIATM Tri-StapleTM  was used for pulmonaryand bronchial cutting; and Powered ECHELON FLEX® 7 was used for pulmonary artery and pulmonary vein dissection. A drainage tube was insertedthrough the surgical incision.Uniportal VATS for PLPS was performed with only a 3–4-cm incision at themid-axillary line in the 6th intercostal space, a 1.5-cm incision at the anterior axillary line in the6th intercostal space, and a 1.5-cm at the posterior axillary line in the7th intercostal space. An Alexis® Wound Retractor XS  was inserted into the 3–4-cm incision, while ports were inserted into the otherincisions. The thoracoscopic port site was the anterior axillary line in the 6thintercostal space on the right side, and the posterior axillary line in the 7thintercostal space on the left side. The thoracoscope used was a 10-mm rigid device . The drainage tube was inserted through the incision at the 6thintercostal space.Multiportal VATS was performed with a 3–4-cm incision at the mid-axillary line inthe 4th intercostal space. The thoracoscope and equipmentused for lung resection were identical to those used in uniportal VATS for PLPS. The drainagetube was inserted through the surgical incision.Uniportal VATS for wedge lung resection was performed only with a 2-cm incision atthe mid-axillary line in the 6th intercostal space, a 0.5-cm incision at the anterioraxillary line in the 6th intercostal space, and a 1.5-cm incision at the posterioraxillary line in the 7th intercostal space on the right side. On the left side, thesurgery was performed with a 1.5-cm incision at the anterior axillary line in the6th intercostal space and a 0.5-cm incision at the posterior axillary line in the7th intercostal space. The thoracoscope used was a 0.5-cm rigid device , and the equipment used was same as that used in multiportal VATS for PLPS. Thedrainage tube was inserted through the incision at the 6th intercostal space.Multiportal wedge-resection VATS was performed with a 0.5–1.5-cm incision at themid-axillary line in the 4The drainage tube was removed after postoperative day (POD) 2 in patients whounderwent pulmonary lobectomy, and after POD 1 in those who underwent wedge lung resection. Inour department, the criteria for removal of the tube are (a) absence of lung collapse orpleural effusion in chest X-ray, (b) less than 200 ml of pleural fluid drainage volume on theprevious day, and (c) absence of any air leak. After drainage tube removal, patient progresswas observed in accordance with the clinical protocol followed in our department; if nocomplications were noted, patients were discharged on POD 7 after PLPS or on POD 2 after wedgelung resection.A catheter for a paravertebral nerve block was intraoperatively inserted into allpatients who underwent either surgery. The analgesic used was 200 ml of 0.2% ropivacainehydrochloride hydrate, which was continuously administered at 5 ml/hour after the surgery;analgesic administration was discontinued on POD 2. If the patient had no swallowingdifficulties, loxoprofen 60 mg was initiated at three tablets per day, beginning on POD 1. Ifpain was not alleviated, acetaminophen, celecoxib, tramadol hydrochloride, and/or pregabalinwere added. Oral analgesic dose and administration period were determined by the attendingphysician. We evaluated postoperative pain in outpatient follow-up visits for 2–3 months aftersurgery. Pain was evaluated by the attending physician using the NRS pain score.1), pathologic examination findings, pathologic stage, and number of lymphnodes subjected to lymphadenectomy , and otherdiseases  for allstatistical analyses. Continuous data were summarized as means±standard deviations, andcategorical data as percentages. Continuous data were compared using Student’st-test, non-continuous data were compared using the Mann–Whitney U test, andcategorical data were compared using the chi-squared test. P<0.05 wasconsidered significant.We used JMPP=0.0041). The incidence of PTPS was significantly lower in theuniportal VATS group  than in the multiportal VATS group . The uniportal and multiportal groups did notsignificantly differ in NRS pain scores at 2–3 months after surgery (P=0.1973)or in postoperative oral analgesic administration periods (P=0.0917).Pain evaluation results are summarized in P=0.0315). However, the uniportal and multiportal groups did notsignificantly differ in NRS pain scores at 2–3 months after surgery (P=0.0864),postoperative oral analgesic administration period (P=0.2043), andpostoperative oral analgesic dose (P=0.898).For the wedge lung resection patients, PTPS incidence was significantly lower in theuniportal VATS group  than in the multiportal VATS group  adversely affects multiple intercostal nerves, whereas uniportal VATS adversely affectsonly one intercostal nerve site. The observed effects of uniportal VATS are less severe thanthose of multiportal VATS. As such, compared with the use of multiportal VATS, the use ofuniportal VATS is thought to result in a lower observed PTPS incidence. Here, PTPS incidence inthe uniportal VATS group for patients who underwent PLPS was similar to that reported inprevious studies,14 Because of these diverse assessment methods, diagnostic criteria for PTPS arealso diverse, and no fixed criteria have been established. In the present study, patients werediagnosed with PTPS if their NRS pain scores were >1 at 2–3 months after surgery, or if theirpostoperative oral analgesic administration periods were more than 60 days. We includedpostoperative oral analgesic administration period >60 days in the evaluation of PTPS becausecontinuing analgesics is thought to indicate continuous pain. According to Louis et al.,because VAS data are extremely subjective, its use may reflect considerable bias from bothpatients and clinicians. Therefore, they advocated that analgesic intake should be used as amore objective method to evaluate postoperative pain.15 Accordingly, we included postoperative oral analgesic doses andadministration periods in assessing postoperative pain. For patients who underwent PLPS, thetotal dose of oral analgesics was significantly lower, and the postoperative oral analgesicadministration period tended to be shorter, in the uniportal VATS group than in the multiportalVATS group. After wedge lung resection, the total dose tended to be lower and the administrationperiod of oral analgesics tended to be shorter in the uniportal VATS group than in themultiportal VATS group. Based on these results, uniportal VATS may be better than multiportalVATS with respect to postoperative pain.Pain may be evaluated through various methods, such as the NRS, visual analoguescale (VAS), 5-point verbal rating scale, and McGill questionnaire.16 Therefore, pain evaluation in the present study could have beenbiased. In the future, to confirm the usefulness of uniportal VATS in preventing PTPS, clearcriteria for pain evaluation should be established. Randomized controlled trials, and studiesthat generate higher quality evidence, should also be conducted.This study has several limitations. First, it was a retrospective study, withrelatively few patients in the VATS group. Moreover, specific, standardized evaluators for painare not yet established; nor did we have clear criteria regarding the types and doses ofpostoperative analgesics or for dose reduction and discontinuation.This study investigated PTPS incidence in patients who underwent uniportal ormultiportal VATS for PLPS, or wedge lung resection. The incidence of PTPS in patients whounderwent uniportal VATS was lower than that in patients who underwent multiportal VATS.Uniportal VATS procedures are therefore beneficial for patients.


Heart diseases are the main reasons of death in the developed countries. This study was conducted with the aim of investigating the patterns of pain intensity and psychosomatic symptoms among cardiac patients.This is a descriptive study and the statistical population included all the cardiac patients who were admitted to an Iranian Hospital  during 2018 (From July to November) 250 people were selected out of the population using convenience sampling and 180 patients answered pain intensity assessment tools, the patient health questionnaire (PHQ-15) and the patient demographic information form.p> 0.05), however, significant relationship was found between psychosomatic symptoms and gender (p< 0.001). Moreover, there was no significant relationship between pain intensity and age, gender, marital status and drug abuse at the level of (p>0.05).The results of this study indicated moderate (52.2%), low (36.1%) and high (11.7%) levels of pain intensity plus mild (4.4%), moderate (28.3%) and severe (67.2%) psychosomatic symptoms with the most common psychosomatic symptoms being chest pain (52.8%), fatigue (52.8%), shortness of breath (49.4%), heart palpitation (47.8%).The results of chi-square test showed a no significant relationship between psychosomatic symptoms and variables of age, marital status, drug abuse and pain intensity (Psychosomatic symptoms and pain intensity are associated with certain functional disorders and health care, therefore, identifying psychosomatic symptoms and pain intensity is very useful in assessing the effectiveness of clinical approaches on cardiac patients. Heart diseases are the main reasons of death in the developed countries. Although death rate from heart diseases has reduced in recent decades, it still accounts for about one third of all the death over the age of 35, which causes 17 million people death each year; it is predicted if no prevented actions are taken till 2020, the death rate will reach 24.8 million  in 2018 (From July to November). Sampling was done through the available sampling -250 people were selected among the hospitalized patients in the hospital. The number of 180 patients answered the questions. The criteria for entering the study included the ability to answer the questions,the willingness to cooperate in the study; and the patients undergoing angiography and waiting for angiography while the criteria for withdrawing from the study included psychiatric illnesses and patients undergoing surgery and unwillingness to answer the questions. Ethical principles of being a volunteer for research; observance of individual rights and freedom of participants for non-willingness to fill out questionnaires. And it was also assured that the participants’ information is reported in groups.Study instruments: Following tools have been used for gathering data in this study.-Visual analogue scale (VAS) for pain measurement is presented as a 10 cm line with the left end (0) indicating no pain and the right end  indicati-The Patient Health Questionnaire (PHQ-15): it is a self-related instrument which contains 15 items which are based on the prevalence of various somatic symptoms seen in patients presenting to the outpatient setting. Ratings are done by considering the last 4 weeks into account, and each item is rated as 0 , 1 (bothered a little), or 2 (bothered a lot) with the total score ranging from 0 to 30. On the basis of the total score, the severity of somatic symptoms is classified as mild (0-4), moderate (5-9), and severe (>10) . The fulData Analysis: In addition to descriptive statistics, inferential statistics such as chi-square test was used to analyze the data. The software used to analyze the data was SPSS Version 20Patient characteristics: The current study has been conducted in 3 months, from April to June 2018. Among all 250 hospitalized patients, 180 individuals completed the questionnaire. The average age of these patients was 59.98±12.51 and 48.9 percent of them were females and 51.1 percent were males. The majority of the participants were married (75%), 43.9% of them were housewives and 36.7% worked as freelancer. 87.8 % reported no drug abuse  while 10.6 % resigned and 1.7% abused drugs. Regarding the measurement of pain intensity, 52.2% reported moderate pain. 36.1% had mild pain and 11.7% suffered severe pain. The results also indicated that 4.4% of the cardiac patients reported mild psychosomatic symptoms, 28.3 moderate symptoms and 67.2% severe symptoms. The most frequent psychosomatic symptoms were chest pain (52.8%), fatigue (52.8%) shortness of breath (49.4%), heart palpitation (47.8%), arm and leg pains (42.8%), back pain (25%), sleep disorder (21.7%), headache (19.4%), stomach pain (18.9%), dizziness (15%), nausea (13.9%), constipation and diarrhea (12.8%), debility (9.4%), painful intercourse (6.7%) and stomach cramp in women (2.8%). As shown in P>0.05) indicated that psychosomatic symptoms are not significantly associated with age (X2=1.917), marital status (X2=3.733) and drug abuse (X2= 1.350). But the results indicated a significant relationship between psychosomatic symptoms and gender (P<0.001 and X2= 18.736). The results of Cramer’s V test (0.323) also support the significant relationship between these two variables. The results of chi-square test (P>0.05) shown in 2= 2.466), gender (X2= 4.108), marital status (X2= 0.035) and drug abuse (X2= 4.98).The aim of this study was to investigate patterns of pain intensity and psychosomatic symptoms among cardiac patients and according to the results 67.2 % of the patients reported severe psychosomatic symptoms and chest pain, fatigue, shortness of breath, rapid heartbeat, arm and leg pain and back pain were respectively the most common symptoms observed among the patients. Our results are supported by researches of Lambert &Dawood  and by KBecause of the nature of their illness, and their constant concerns and worries about the occurrence of symptoms such as rapid heartbeat, short breath etc. cardiac patients seem to be more vulnerable to psychosomatic conditions. Furthermore, because of their constant experience of stress and vulnerability of a particular part of their body, these patients are more likely to experience psychosomatic symptoms. These patients’ understanding and perception about their environment are influenced by their physical condition and this eventually makes them more likely to report psychosomatic symptoms. The constant stress and anxiety experienced by the patients would lead them to passivity and despair thus makes them more likely to physicalize their symptoms.Maharaj et al.


Recurrent or persistent neck pain affects a vast number of people globally, leading to reduced quality of life and high societal costs. Clinically, it is a difficult condition to manage, and treatment effect sizes are often moderate at best. Activity and manual therapy are first-line treatment options in current guidelines. We aimed to investigate the combination of home stretching exercises and spinal manipulative therapy in a multicentre randomized controlled clinical trial, carried out in multidiscipline ary primary care clinics.The treatment modalities utilized were spinal manipulative therapy and home stretching exercises compared to home stretching exercises alone. Both groups received 4 treatments for 2 weeks. The primary outcome was pain, where the subjective pain experience was investigated by assessing pain intensity (NRS − 11) and the quality of pain (McGill Pain Questionnaire). Neck disability and health status were secondary outcomes, measured using the Neck Disability Indexthe EQ-5D, respectively. One hundred thirty-one adult subjects were randomized to one of the two treatment groups. All subjects had experienced persistent or recurrent neck pain the previous 6 months and were blinded to the other group intervention. The clinicians provided treatment for subjects in both group and could not be blinded. The researchers collecting data were blinded to treatment allocation, as was the statistician performing data analyses. An intention-to-treat analysis was used.p-value of 0,305. There were no statistically significant differences between groups for any of the outcome measures.Sixty-six subjects were randomized to the intervention group, and sixty-five to the control group. For NRS − 11, a B-coefficient of − 0,01 was seen, indication a 0,01 improvement for the intervention group in relation to the control group at each time point with a Based on the current findings, there is no additional treatment effect from adding spinal manipulative therapy to neck stretching exercises over 2 weeks for patients with persistent or recurrent neck pain.ClinicalTrials.gov, registration number: NCT03576846.The trial was registered 03/07/2018 at The online version contains supplementary material available at 10.1186/s12891-021-04772-x. Musculoskeletal pain is responsible for the third-largest number of years lived with disability worldwide . Its prePersistent or recurrent  pain is a prevalent condition, affecting 20% of the population globally , 5. Necknon-specific when no direct underlying cause is found, such as myelopathy or malignancy ..‘No reacDigital outcome questionnaires were administered on the day of the third (1 week after the first treatment) and fifth treatment (2–4 days after the fourth treatment), using a system managed by Survey & Report by Artologic  through Repeated measures of pain intensity (NRS-11) were recorded daily during the 2 week study period using SMS-Track® .This study investigated patients seeking care for their pain. A pure placebo trial was, therefore, not indicated . As all All study participants were assigned a unique number by a research assistant when included in the study. A code key connecting the participant’s ID and the unique number was stored according to the Swedish National Board of Health and Welfare’s requirements for the storage of journal documents.All collected data will be stored for at least ten years, and individuals can only be identified with the code key. Only researchers directly affiliated with the project have access to the material.The study was conducted in accordance with the Helsinki declaration . Data waContinuous variables were reported with means and standard deviations, categorical variables were reported as counts and percentages.Intention to treat analysis was used.Several subjects reported the McGill Questionnaire to be challenging to complete due to the numerous alternatives for quality of pain. Due to time constraints at the baseline visit, the subjects were instructed to skip the questions that did not relate to their pain instead of discussing them with the research assistant. Therefore, if a question was not answered, the subject did not experience the particular pain sensation.The NRS-11 data was incomplete with seven non-responses, of which four concurrent (same date) pain scores could be obtained from the McGill questionnaire. For the final 3 missing observations, the Last Observation Carried Forward (LOCF) was used. A method of multiple imputations with fully conditional specification and twenty imputation rounds was used for NDI and EQ-5D to produce unbiased estimates with appropriate coverage .Repeated measurements using all available time points were analyzed using a linear mixed effects model with person specific random intercept. A quadratic model was also estimated but the quadratic term did not improve model fit, judged by AIC (Akaike Information Criteria) and BIC (Bayesian Information Criteria). The parameter of interest was the interaction between group allocation and time, which can be interpreted as the difference in speed of change between the groups. Two additional analyses were performed; one adjusted for baseline values, the other also included age and gender.The graphical representations were done using a quadratic model to allow for more flexibility and easier visual interpretation of the time effect interaction.The change over the 2 weeks was calculated for all four outcomes; pain intensity, effective quality of pain, disability and quality of life. A minimal clinically important difference (MCID) was based on previous studies –53 and cFor linear and logistic regression analysis, both an unadjusted model, and models adjusted for baseline differences, as well as for age and gender, were estimated. The reported side effects are reported as proportions. A per-protocol analysis was performed as a sensitivity analysis, following the same method as the primary analysis for repeated measures.P-values smaller than .05 were considered significant. The analysis was performed using SPSS 27 [ SPSS 27  and StatA total of 131 patients were included in the study. See attached flow chart .The adherence to the stretching protocol was good, as shown in Table Four intense adverse events were reported in the study, defined by ≥8 (NRS-11) , three iThe current study was undertaken to investigate whether four sessions of SMT combined with 2 weeks of stretching exercises was superior to stretching exercises alone, in a group of chronic NP patients. Both groups improved with treatment, but we found no statistical differences for any of our outcome measures between the two groups.Previous studies have found a combination of home exercises and SMT superior to home exercises alone , 34, andThe stretching exercises used in this study were developed by Ylinen et al.  in a stuA population with persistent or recurrent pain will typically have periodic changes in pain intensity , and theThe number of people reaching MCID did not differ statistically between groups. Just below 40% reached this threshold in pain intensity (NRS-11), but only around 20% for the impact of pain quality (McGill questionnaire). This is an interesting observation as they are both measuring the subject’s pain experience. It appears that pain intensity is more readily affected by the intervention than the sensory and affective pain experience, measured using the McGill Questionnaire. However, an absolute consensus on MCID values does not exist, so care should be taken when comparing these values. It was not expected that a large part of the study population would reach MCID, considering the chronicity of their pain and the limitations of a two-week study period.It was observed that the SMT and stretching group experienced more adverse reactions than the group receiving stretching only. The difference was not statistically significant, but is not surprising considering previous research. It is estimated that about 50% of patients experience minor to moderate adverse events after any manual treatment, particularlyafter the first visit . Since tAdherence to the home stretching exercises was good in both groups . In the original stretching study, the investigator asked the subjects to perform the stretching exercises five times a week . We chosFor pain intensity (NRS-11), there was a difference between the treatment groups at baseline. This happened by chance in the randomization process and did not significantly affect the estimates when adjusted for.It was impossible to blind the therapists performing the treatments. This could possibly lead to bias favouring the intervention group. However, the therapists received written and verbal instructions on how to interact in a similar fashion with both groups to minimize this risk. As there was no significant advantage of the intervention group, this potential bias was considered to be low.Most of the participants had already been to the clinic at a previous time point. A possible selection bias may have occurred as many of the subjects already had a good experience with a previous chiropractic treatment. This is an unknown effect, not directly related to a specific treatment or clinician. If the subject had seen a therapist for their neck pain previously and experienced a good effect, this could have had a substantial impact on the expectations of a treatment effect. However, it can be argued that if a therapist was already managing a patient with neck pain successfully, i.e. they have a good relationship, and the patient is experiencing that the treatment regime helps them manage their life with pain, then participation in this study would not be needed. The improvement in pain and disability in the intervention and control groups was similar in this study. The first and obvious conclusion, is that the two treatments have equal clinical benefit to patients, which is not in line with previous publications , 34. TheWe had no minimum inclusion value for baseline measurements, and generally speaking, the study population had low levels of pain and disability. This was not done to include all aspects of persistent or recurrent NP patients, as it is a diverse group. For NRS-11 i.e., a level of 1 or 2 out of 10 at baseline will have limited the improvement to 1 or 2 points, respectively. This could possibly have limited the difference between groups.The inclusion criteria explicitly stated recurrent or persistent NP, where pain fluctuations are the norm . As the Four treatments were chosen as it has been seen from a previous study  that a dThese weaknesses may explain why the observed effect in the study population differs from previous studies, exemplified by the study by Maiers et al.  that hadBlinding seems to have been successful, and the research assistant and statistician were blinded to the group allocation. The study population was blinded to the other group intervention.Both groups received the same amount of time and attention from the chiropractors. The control group underwent a standard palpation examination as if the chiropractor intended to give manual treatment. Advise and reassurance were given in both groups.Measuring pain levels and the affective quality of pain is essential for capturing the chronic pain experience. Using multiple questionnaires, such as NRS-11, McGill questionnaire, and EQ-5D together covers the main aspects of chronic pain.The response rate was excellent, with a small number of dropouts and an exercise diary to investigate compliance. This showed a strong dedication to the stretching regime.This was a pragmatic study, applicable for all clinicians working with persistent or recurrent NP patients. The study was perfomerd in a normal clinical setting, reflected in the heterogenic demographics among the study population. It mirrored standard treatment strategies to allow for conclusions on effect.Daily stretching exercises with and without added spinal manipulation were associated with some clinical improvement over a two-week period, but no significant difference in improvement was observed between groups.Additional file 1. Graph NRS11. Daily development of mean pain intensity (NRS-11) with Confidence Intervals for both groups from baseline to the end of the intervention period (2 weeks). The graph is presented using a quadratic model.Additional file 2.. Graph McGill. McGill scores with Confidence Intervals for both groups measured at baseline, 1 week, and 2 weeks. The graph is presented using a quadratic model.Additional file 3. Graph NDI. Neck Disability Index scores with Confidence Intervals for both groups measured at baseline, 1 week and 2 weeks. The graph is presented using a quadratic model.Additional file 4. Graph EQ5D. EQ5D scores with Confidence Intervals for both groups measured at baseline, 1 week, and 2 weeks. The graph is presented using a quadratic model.Additional file 5. Stretch exercises to perform daily for 14 days.


To date, it is still unclear how fresh osteoporotic vertebral fractures (OVFs) affect the patient’s quality of life and low back pain during a follow-up period of more than 1 year. In the previous trial, women with fresh OVF were randomized to rigid or soft brace for 12 weeks, then both groups were followed for the subsequent 48 weeks. In women completing this trial at our affiliated hospitals, we conducted a follow-up study to investigate the long-term course of an acute vertebral fracture in terms of pain and quality of life. When comparing visual analog scale scores for low back pain and European Quality of Life-5 Dimensions Questionnaire scores between consecutive time points, a significant difference was found between 0 and 12 weeks, but not between 12 and 48 weeks or between 48 weeks and final follow-up. A total 25% had residual low back pain at the final follow-up. A stepwise logistic regression analysis identified age and previous vertebral fracture as predictors of residual low back pain at the final follow-up. Therefore, the degree of low back pain and impairment of the quality of life improved by 12 weeks after injury and did not change thereafter until a mean follow-up of 5.3 years. Vertebral fractures are the most common osteoporotic fracture . When osThis study was a follow-up study of women involved in the previous prospective randomized study UMIN000014876) that compared the effectiveness of rigid and soft braces for acute thoracolumbar OVFs [876 that Among the patients who completed the previous brace trial, patients from hospitals that agreed to participate in this study were included in this study. Accordingly, a total of 73 patients were enrolled. Of the 73, 3 died, 2 refused to cooperate, and 28 could not be contacted. Finally, 40 patients with mean 5.3 years of follow-up were included in this study. With regard to the use of anti-osteoporosis treatments during the 48-week brace treatment prospective randomized study, the patients were allowed to use only the medications that were used prior to the injury or newly prescribed active vitamin D [This study was approved by each hospital’s institutional review board, and informed consent was obtained from all the participants included in the study.Regarding the patient-reported outcome measures (PROMs), scores on the European Quality of Life-5 Dimensions   were useLateral radiography was performed at 0, 12, and 48 weeks. MRI was performed at enrollment. In the radiographic analysis, the anterior vertebral body compression percentage . To inveAll data were collected by a clinical research assistant. An analysis of variance with repeated measures was used to analyze the data over time. When there was a significant main effect of time, Tukey’s HSD analysis was performed to identify the differences among time points.p < 0.1 for entry). We then calculated the odds ratios (ORs) and their approximate 95% confidence intervals (CIs) for residual low back pain. For continuous variables, the OR reflects the incremental risk associated with a one-unit change in that variable. JMP version 12  was used for all statistical analyses. All tests were two-sided, and p-values < 0.05 were considered significant.In this study, “residual low back pain” was defined as VAS for low back pain ≥3.5 at the final follow-up; VAS score <3.5 is used to describe mild pain, and VAS score ≥ 3.5 is used to describe moderate or severe pain . We perfp < 0.001 and p < 0.001, respectively). Comparison of VAS scores for low back pain between consecutive time points showed a significant difference between 0 and 12 weeks (p < 0.001), but not between 12 and 48 weeks (p = 0.97), or between 48 weeks and final follow-up (p = 0.99) (p < 0.001), but not between 12 and 48 weeks (p = 0.82), or between 48 weeks and final follow-up (p = 0.99)  . Compari = 0.99) .We then divided the patients into two groups according to their VAS score at the last follow-up: the residual low back pain group and the no low back pain group. Of the 40 patients analyzed in this study, 10 (25.0%) reported residual low back pain at a mean 5.3 years after OVFs. The baseline characteristics of the patients are shown in p < 0.001 and <0.001, respectively). The EQ-5D score was not significantly different between the two groups at 0 and 12 weeks, but was significantly worse in the residual low back pain group at 48 weeks and final follow-up . We then examined the trends in the VAS score for low back pain in the residual low back pain group and no low back pain group. In the no low back pain group, a significant difference was found between VAS scores at 0 and 12 weeks (p < 0.001), but no significant difference was noted in the VAS scores between 12 and 48 weeks or between 12 weeks and final follow-up . In the residual low back pain group, no significant difference was found in the VAS scores between 12 and 48 weeks (p = 0.08), but a significant difference was noted in the VAS scores between 0 and 12 weeks and between 12 weeks and final follow-up .p = 0.17, 0.11, and 0.09, respectively).p = 0.04) and previous vertebral fracture .Lastly, the predictors at 12 weeks after OVFs for residual low back pain at the final follow-up were evaluated using a stepwise multiple logistic regression analysis . Based oThis study investigated the course of acute vertebral fracture in terms of pain and QOL. When comparing VAS for low back pain and EQ-5D scores between consecutive time points, a significant difference was observed between 0 and 12 weeks, but not between 12 and 48 weeks or between 48 weeks and final follow-up. Twenty-five percent of patients had residual low back pain at the final follow-up. The patients with residual low back pain after OVF had a higher percentage of pre-existing vertebral fractures and were older than those who did not have residual low back pain. A stepwise logistic regression analysis identified age and previous vertebral fracture as predictors of residual low back pain at the final follow-up.This study showed that when comparing VAS scores for low back pain and EQ-5D scores between consecutive time points, a significant difference was found between 0 and 12 weeks, but not between 12 and 48 weeks or between 48 weeks and final follow-up. This result is consistent with previous reports that pain improved by 3 months after the fracture and did not change significantly until 12 months thereafter [Among patients with acute vertebral fractures, 25% had mild or severe low back pain for an average of 5.3 years after injury based on VAS for low back pain. Patients with mild or severe low back pain were older and had a higher percentage of patients with pre-existing vertebral fractures than those with moderate or no pain. The results were partially consistent with a previous report stating that chronic pain after acute spine fractures was only maintained in patients with multiple compression fractures, reduced height, and low bone density .In this study, the VAS score for low back pain was not significantly different between the residual low back pain group and no low back pain group at 0 and 12 weeks, but was significantly worse in the residual low back pain group at 48 weeks and final follow-up. Regarding the transition of pain within the group, although not significant, the low back pain tended to improve after 12 weeks in the no low back pain group. By contrast, back pain deteriorated after 12 weeks in the residual low back pain group. In a randomized controlled trial comparing vertebroplasty and conservative treatment for patients with vertebral fractures who reported severe pain for more than 3 months, vertebroplasty was associated with better pain relief and improved functional outcomes at 1 year compared with conservative treatment . TherefoSince OVF-induced pain significantly improves by 12 weeks, we decided to investigate predictors for residual low back pain at 12 weeks after OVF. A stepwise logistic regression analysis identified age and previous vertebral fracture as predictors for residual low back pain at a mean of 5.3 years after OVFs. Therefore, when a new vertebral fracture occurs in an older patient with a pre-existing vertebral fracture, the patient is likely to have residual low back pain in the future. Furthermore, risk factors for OVFs include older age, low bone mineral density, and pre-existing vertebral fractures . TherefoThis study had some limitations. First, several patients were excluded after enrollment which might have led to a slight decrease in the sample size. Accordingly, attrition bias may limit the internal validity of this study. Second, we did not investigate the bone mineral density in this study. Although it is undeniable that the severity of osteoporosis may affect back pain, a decrease in bone mineral density does not necessarily lead to an increase in low back pain. In fact, the authors of several studies concluded that there is no evidence supporting a relationship between low back pain and bone mineral density ,18. ThirThis study demonstrated that the degree of pain and impairment of QOL after OVF improved by 12 weeks after injury and did not change thereafter, until a mean follow-up period of 5.3 years. In addition, patients with residual low back pain after OVF had a higher percentage of pre-existing vertebral fractures and were older than those who did not have residual low back pain.


Shoulder pain is a prevalent and often long-lasting musculoskeletal disorder. The overall prognosis of shoulder pain is highly variable with 40–50% of patients reporting persistent pain 6–12 months after consulting a clinician. The evidence for psychological prognostic factors for patients with shoulder pain is inconsistent. Therefore, the objective of this study was to investigate the association between fear of movement and emotional distress at presentation and self-reported disability over one year of follow-up.This is a prospective cohort study of consecutive patients referred to secondary outpatient care due to shoulder pain. Consenting patients underwent a physical examination and completed a comprehensive questionnaire at baseline, three months-, and one-year follow-up. Associations between baseline fear of movement (0–10) or emotional distress (1–4), respectively, and patient reported disability measured using Quick Disability of the Arm and Shoulder  over one year were analyzed with linear mixed-effects models (LMM) for repeated measures , adjusting for established prognostic factors.n = 117) and 79.7% (n = 100) at three months and one year, respectively. Adjusted associations revealed that for every point increase in baseline fear of movement, the QuickDASH score increased (worsened) by 1.10 points (95% CI 0.2–2.0) over the follow-up year. For every point increase in baseline emotional distress, the QuickDASH score increased by 19.9 points (95% CI 13.9–25.9) from baseline over the follow-up year.A total of 138 patients were recruited between March 2015 and January 2018, with response rates of 84.7% (Higher fear of movement and emotional distress scores at baseline were significantly associated with higher disability over one year in patients with shoulder pain referred to secondary care. Our study indicates that these psychological factors affect prognosis and should be considered by clinicians and researchers working with patients with shoulder pain. Shoulder pain is a prevalent and often long-lasting musculoskeletal disorder , 2. The Findings from previous prospective cohort studies suggest there is strong evidence that long-term disability in patients with shoulder pain is influenced by duration of symptoms , 10–12, The fear-avoidance model conveys how a person’s interpretation of their pain may lead to two different pathways . When acAlthough there is some support for the suggestion that fear of movement and emotional distress might be barriers to recovery, the authors of the above-mentioned systematic reviews concluded that more prospective cohort studies investigating fear of movement and emotional distress as prognostic factors are needed. The overall quality of the evidence was very low , 22 and This study is a prospective cohort study of consecutive patients referred to a secondary outpatient clinic at Aalesund Hospital (secondary care) in Norway due to shoulder pain, between March 2015 to January 2018. This study was reported according to the Strobe Statement for cohort studies  and the Patients were eligible for inclusion if they presented with a painful shoulder condition, were age 18 years or older, and had a sufficient command of the Norwegian language. Patients were excluded if they had shoulder pain due to other disease (such as systematic disease or cardiac disease), generalized pain, symptoms of cervical spine disease, serious psychiatric disorder, or had had surgery on the affected shoulder within the last 6 months.The diagnostic assessment was conducted by a specialist in physical medicine and a physical therapist. The assessment was based on a standardized questionnaire, case history, a clinical examination, and sometimes supplementary examinations as well . The patient case was discussed in an interdisciplinary team consisting of the physical medicine specialist, physical therapist, and an occupational consultant, and, if necessary, the patient was referred to an orthopedic or other specialist.The included patients underwent individualized management which reflected usual practice at the outpatient clinic at Aalesund Hospital. After the assessment, patients were given advice from the interdisciplinary team, based on a biopsychosocial approach. Some patients were offered individual and/or group treatment provided by the team at the outpatient clinic, and some were referred back to primary care clinicians. The main content of the hospital treatment was a cognitive-oriented physical therapy consisting of patient education and supervised shoulder strengthening and mobility exercises, and, in some cases, consultation with the occupational consultant. All patients were invited to a 3-month re-assessment at the hospital.The primary outcome of the study was the Quick Disability of the Arm, Shoulder and Hand Questionnaire (QuickDASH) . The QuiFear of movement was assessed using one question at baseline : “How muThe Hopkins Symptom Checklist-25 (HSCL-25)  was usedAs recommended in the PROGRESS framework , 27, we All participants providing baseline data on potential prognostic factors and the outcome (QuickDASH) at baseline and at 3-months or 1-year follow-up were included in the analysis.Descriptive data were presented as counts and percentages for categorical data, and means and standard deviations or medians and interquartile ranges for continuous normally distributed data and data with skewed distribution, respectively Table .Table 1Bn = 89). The normality assumptions for residuals were assessed by visual inspection (histogram and QQ plots). We used scatter plots to investigate whether the associations between potential prognostic factors and the outcome were linear.To estimate the strength of associations between the two potential prognostic factors  and the outcome , linear mixed-effects models (LMM) for repeated measures were fitted using an unstructured covariance matrix. The models for the outcome consisted of 3 fixed effects: measurement occasion (time), fear of movement or emotional distress, and the interaction term of time and fear of movement or distress. All measured time points of the outcome variables were considered and the LMM approach therefore adjusts for baseline differences. To test whether potential confounders influenced the results, LMM were adjusted for age, sex, BMI, educational level, duration of symptoms, and disability. Effect sizes of the adjusted associations were also calculated using the formula: d = mean change per point/SD. We also conducted a sensitivity analysis including only the patients with subacromial pain  and STATA  was used to perform all analyses.Statistical significance was inferred when the n = 117) and 80% (n = 110), respectively. The baseline characteristics of the included participants are provided in Table A total of 138 patients referred to secondary care at the outpatient clinic between March 2015 and January 2018 consented to participate in this study. The flow of participants is depicted in Fig. n = 117) was 10.2 QuickDASH points (95% CI 7.9–12.6), and at 1-year follow-up (n = 110) it was 13.3 QuickDASH points (95% CI 10.3–16.4). The proportion of participants reporting an improvement corresponding to a minimal important change of ≥ 10.8 QuickDASH points at 3-month and 1-year follow-up was 43.2% and 57%, respectively.The included patients underwent a median of 8 (range 1–36) treatment sessions with a physical therapist during the 1-year follow-up period. The patients reported that the main components of the physical therapy management were supervised exercise (74.2%), information/advice (68.2%), group-based exercise (12.1%), stretching (14.4%), and massage/manual therapy (6.1%). Eleven patients (9.1%) reported that they received analgesic medicines during the 1-year follow-up. The mean change from baseline to 3-month follow-up (p = 0.059). The calculated effect size for the adjusted association between fear of movement and QuickDASH score over the follow-up year was 0.24. Adjusted associations from the linear mixed effects models revealed that for every point increase in emotional distress at baseline the QuickDASH score increased (worsened) by 19.9 points (95% CI 13.9–25.9) over the 1-year follow-up. The interaction between time and emotional distress was not statistically significant (p = 0.601). The calculated effect size for the adjusted association between emotional distress and QuickDASH score over the follow-up year was 0.65.As displayed in Table n = 89), results were similar to those in the main analyses: the adjusted associations from the linear mixed-effects models revealed that for every point increase in fear of movement, the QuickDASH score increased (worsened) by 0.64 points (95% CI -0.77 to 2.05) over the year of follow-up. Adjusted associations from the linear mixed effects models revealed that for every point increase in emotional distress at baseline the QuickDASH score increased (worsened) by 22.5 points (95% CI 18.3–26.7) over the 1-year follow-up among the patients with subacromial pain. The interaction between time and the prognostic factors under investigation was not statistically significant for any of the sensitivity analyses.In a sensitivity analysis including the patients with subacromial pain only , moderate positive correlation (Spearman’s r = 0.42) between baseline disability and baseline emotional distress.Emotional distress is increasingly recognized as an important prognostic factor among patients with shoulder pain . Our stur = 0.81) [Although the QuickDASH does include domains such as sleep and confidence in being able to perform activities, these items only overlap to a small degree with those included in the HCSL-25. The QuickDASH focuses specifically on the impact of shoulder-upper limb problems on activities and pain, whereas the HCSL-25 measures generic symptoms of anxiety, depression, and somatization. The QuickDASH has been validated against SPADI, showing a strong correlation ( = 0.81) . The croSimilarly, the hypothesis that there was a significant positive association between fear of movement and disability was confirmed. This finding is in line with two other studies suggesting that fear-avoidance beliefs are associated with poor shoulder function in patients with subacromial pain , 44. A sKey psychosocial obstacles to recovery are becoming clearer, which puts us in a better position to advocate which factors should be the focus for assessment and treatment . BecauseA strength of this prospective cohort study was that we conducted a sound statistical analysis based on recommendations from the PROGRESS framework , 27 and In patients with shoulder pain referred to secondary care we found that both higher fear of movement and emotional distress scores at baseline were associated with higher self-reported disability over the follow-up year, when adjusted for established prognostic factors. Our study indicates that fear of movement and emotional distress affect the prognosis in patients with shoulder pain and should be considered by clinicians and researchers working with patients with shoulder pain.


Furthermore, patients over 60 years, without PCA use (both p < 0.001), and with more surgical blood loss (p = 0.001) tended to have slower pain resolution. The final predictive model fit the collected data acceptably . Conclusion: Latent curve analysis identified influential factors of acute pain trajectories after RCC surgery. This study may also help elucidate the complex relationships between the variations in pain intensity over time and their determinants, and guide personalized pain management after surgery for RCC.Background: Renal cell carcinoma (RCC) is the most common neoplasm in kidneys, and surgical resection remains the mainstay treatment. Few studies have investigated how the postoperative pain changes over time and what has affected its trajectory. This study aimed to characterize the variations in postoperative pain over time and investigate associated factors after RCC surgery. Methods: This retrospective study was conducted in a single medical center in Taiwan, where maximal pain scores in a numeric rating scale were recorded daily in the first five postoperative days (PODs) after RCC surgery. Latent curve models were developed, using two latent variables, intercept and slope, which represented the baseline pain and rate of pain resolution. These models explain the variations in postoperative pain scores over time. A predictive model for postoperative pain trajectories was also constructed. Results: There were 861 patients with 3850 pain observations included in the analysis. Latent curve analysis identified that female patients and those with advanced cancer (stage III and IV) tended to have increased baseline pain scores ( Renal cell carcinoma (RCC) accounts for more than 90% of cancers in the kidney . SurgicaMany factors are involved in the etiology of postoperative pain, from biological, psychosocial, to functional elements ,12. In aIn our previous studies, latent curve models were used to identify the influential factors of postoperative pain trajectory in patients receiving intravenous and epidural patient-controlled analgesia (PCA) ,26. HoweWe conducted this retrospective cohort study in Taipei Veterans General Hospital after the approval of our Institutional Review Board (IRB-TPEVGH No. 2019-07-004BC), and written informed consent was waived. We reviewed the electronic medical records and collected data from patients undergoing curative surgery for RCC at this center from 2011 to 2018. Patients were excluded from the analysis if they had to receive postoperative ventilator support or intensive care beyond 24 h, were unable to report pain intensity, or had fewer than 2 postoperative pain assessments within 5 days after surgery.−1 and fentanyl 1–2 μg·kg−1 for induction. Rocuronium or cis-atracurium was used to facilitate endotracheal intubation and keep muscles relaxed during surgery. Anesthesia was maintained using sevoflurane 2–3 vol% or desflurane 6–8 vol% in a mixture of oxygen and air. For those receiving PCEA, combined epidural anesthesia was also employed intraoperatively with a combination of bupivacaine 0.25% and 5 μg·mL−1 fentanyl. An infusion pump  was used to deliver morphine 1 mg·mL−1 in normal saline, or a solution of bupivacaine 0.1% with 5 μg·mL−1 fentanyl for the IVPCA or PCEA users after surgery, respectively. PCA was typically used for 48 to 72 h after surgery, and patients were switched to oral acetaminophen or non-steroidal anti-inflammatory drugs thereafter. For the patients without IVPCA and PCEA, intravenous or intramuscular morphine or ketorolac was administered for postoperative pain control as necessary, and oral acetaminophen, non-steroidal anti-inflammatory drugs, and tramadol were used for pain relief whenever oral feeding was possible.All patients received general anesthesia with propofol 1–2 mg·kgPostoperative pain was assessed at least once daily by a nurse in charge, with a self-report numeric rating scale (NRS) using an 11-point scale. Response options were arranged on a scale from “no pain” to “the worst pain”. The maximal daily NRS pain scores were retrieved during the first five postoperative days (POD) from the electronic medical databank, and served as the endpoints of the following latent curve analysis. All the patients were divided into three classes based on their analgesic choices . The other collected covariates included age, sex, body weight and height, body mass index, American Society of Anesthesiologists (ASA) class, stage of cancer, diabetes, anesthesia time, perioperative transfusion, and surgical blood loss. All the medical records were extracted by a specialist anesthesiologist not involved in data analysis. Random samples of the collected data were thoroughly checked by the authors to ensure data quality.p values greater than 0.05 was performed to identify independent predictors of the intercept and slope parameters and determine the final predictive model. The goodness of fit was assessed using a root mean square error of approximation (RMSEA) and a comparative fit index (CFI), and the values of RMSEA < 0.1 and CFI > 0.9 implied an acceptable fit to the data [Patient attributes and maximal daily pain scores during the first five POD were expressed as mean ± SD or count with percentage. Comparisons of patient characteristics among the three PCA groups were performed using a one-way analysis of variance or a chi square test, as appropriate. Three types of latent curve models—basic, single predictor, and multiple predictor—were used to characterize the variations in pain scores over time, and to evaluate the effects of covariates on postoperative pain trajectories. The technical details of latent curve analysis refer to the previous literature ,28. In bthe data . Accordithe data . We haveWe included 861 patients with 3850 pain score observations in the analysis. Patient characteristics are presented in p < 0.001). The estimated intercept and slope parameters of the basic model were 1.98 and 1.01, respectively. Accordingly, the estimated daily mean pain score during the POD 1 and 5 can be calculated as follows:In the basic latent curve model, the estimated slope parameters , and PCA users tended to have faster pain relief, while patients with more surgical blood loss were associated with slower pain relief. Our analysis was based on a large number of patients to strengthen statistical power, which ensures more accurate and reliable results.The extensive extraperitoneal incision, with or without rib resection, in the open nephrectomy usually induced severe pain. In the study of Kim et al., they performed open nephrectomy through a subcostal incision from the 12th rib to the suprapubic area . The numA few studies have examined the influential factors on acute postoperative pain trajectory in patients undergoing RCC surgery. Compared with isolated scores, trends in pain assessment scores over time are more helpful to improve pain research and optimize postoperative pain monitoring ,25. Our With regard to the influence of aging on postoperative pain trajectory, previous studies had shown that older patients have either lower postoperative pain intensity or slightly slower pain relief from analgesics, compared with younger patients ,14,37. TFor major surgery, the use of IVPCA and PCEA to effectively alleviate postoperative pain is well established. Furthermore, our study shows that patients using PCA are likely to have faster pain resolution. Recently, multimodal analgesia and the opiate-sparing technique, used within an enhanced recovery after surgery (ERAS) pathway, were advocated . FurtherOur study has several limitations. First, this was a retrospective review of patients with RCC undergoing surgery at one institution. Patients were not randomized, and postoperative care was not standardized. Various unmeasured confounding factors such as preoperative pain, perioperative consumption of opioids, anxiety, and postoperative complications could not be further evaluated due to difficulties in data acquisition ,20,24,41Our findings suggested that the factors of female sex, age ≥ 60, PCA use, advanced cancer, and surgical blood loss jointly influenced the postoperative pain trajectory in patients undergoing surgery for RCC. Applying this model to clinical practice may possibly facilitate personalized optimization of postoperative pain management based on individual characteristics after RCC surgery. Latent curve analysis provides insights into the dynamic features of the variations in pain trajectories and their determinants after surgery for RCC. Further studies may be needed to clarify the relationship between more variables, such as psychosocial factors and comorbidity of patients, and the postoperative pain trajectory in patients for RCC surgery.


To prospectively audit the first year of the North Manchester infectious diseases AMS and Consult service June 2020 to June 2021 to: (i) characterize the number of patients who had antibiotic treatment narrowed, duration reduced and/or switch to oral options; (ii) assess documentation of indication and duration of antibiotic prescriptions; (iii) determine whether or not the appropriate microbiological specimens have been performed and with the lab; (iv) identify the impact on antibiotic consumption measured in defined daily dose (DDDs); and (v) establish whether base teams act on the advice given by the Consult/AMS team (data over a 6 week period).On weekdays an electronic prescribing list of all patients prescribed piperacillin/tazobactam, meropenem and ciprofloxacin was generated, and the consults team performed either a bedside or notes review. Data was collected prospectively on 730 patients on which infection was treated, which specialty managed the patient, microbiology samples sent, duration and indication of treatment documentation, and advice given by consults team. Data was then collected over a further 6 weeks looking at whether the base specialty carried out the advice of the AMS team.The main indication for broad spectrum antibiotic use was urinary tract infection (151/720) and hospital acquired pneumonia (104/720). Poor documentation of antimicrobial indication and duration was observed across all specialties (277/720). Just over 50% of appropriate microbiology samples were sent (422/726). For 42% of cases (311/730), colleagues were advised to stop or reduce antibiotic duration. In 30% of cases (220/730), narrowing of antibiotic spectrum was advised. Thirty percent (219/730) were advised on IV to oral switch. There was a modest reduction in antimicrobial consumption in some specialties comparing the year prior to the introduction of the service 2019–20 to 2020–21; 17.4% reduction respiratory (7810/9137), 0.2% increase in medicine (272698/267351) and 2.1% surgery (68722/67309). In 81 patients reviewed to look at outcomes over 6 weeks, 88% of Consult/AMS team advice was actioned by the lead specialties involved in the patients’ care.(i) There is a substantial need for an AMS service within the hospital. (ii) Outcome data shows the ward teams engage with the service and most follow advice. (iii) The service contributed to limiting inappropriate prescribing during the COVID-19 pandemic. There was a modest rise in hospital-wide consumption. (iv) The AMS service needs to be available to provide patient equity across Manchester Foundation Trust, fostering a city-wide AMS strategy that encompasses education, guidelines, audit and quality improvement.


Clinical trials face major barriers such as under-enrollment and selective enrollment, which threaten study completion and undermine validity and generalizability. Thus, we conducted a prospective preference assessment (PPA) prior to commencing the Comparison of Analgesic Regimen Effectiveness and Safety in Surgery (CARES) trial—a randomized controlled study comparing the outcomes of managing acute postoperative pain between opioid-sparing and opioid-based therapies. This PPA aimed to (1) determine the patients’ willingness to participate in the CARES trial, (2) identify the areas for improvement, and (3) assess the differences between willing and unwilling patients.Patients undergoing elective laparoscopic cholecystectomy were recruited between August 2019 and February 2020 from two academic hospitals. A survey was administered to each patient consisting of (1) a vignette describing the trial, (2) an assessment of the patients’ understanding of the trial, (3) open-ended questions assessing the attitudes towards the trial, and (4) patient-completed questionnaires. Data were analyzed qualitatively with thematic analysis and quantitatively with the Wilcoxon signed-rank and chi-square tests.Forty-two patients were enrolled and grouped based on the 6-point Likert scale into willing  and not willing  to participate in the CARES trial. There were no significant differences with respect to all variables: age, education, sex, visible minority status, previous research, previous surgery, regular use of pain medications, surgical concerns, previous discussions on pain management, significant pain within the past 3 months, and significant use of pain medication within the past month. Factors that motivated participation were contributing to scientific research (45%), altruism (29%), and improving personal pain (24%). Common discouraging factors were negative perceptions of opioids (29%), side effects (21%), being blinded to the study medication (21%), and poor pain management (19%).This PPA revealed that two key discouraging factors for patients were being blinded to the type of pain medication being taken and the potential for poor pain management as a consequence of participation. Modifications to improve patient acceptance of the CARES trial include ensuring sufficient rescue medicine and follow-up visits consistent with current standards of care for all patients, as well as patient education surrounding safe administration and side effects of the study medications.The online version contains supplementary material available at 10.1186/s13063-022-06123-0. While prescription opioids are often assumed to represent the most effective treatment and the standard of care for pain management after discharge from surgery, data to support their superiority over other analgesic medications such as non-steroidal anti-inflammatory drugs (NSAIDs) is lacking. Thus, the balance of benefits versus risks when prescribing opioids for acute surgical pain is currently unclear. We propose to fill this critical gap in evidence by conducting a randomized controlled trial comparing two clinically relevant prescribing strategies—opioid-based  or opioid-sparing —for acute postoperative pain. The Comparison of Analgesic Regimen Effectiveness and Safety in Surgery (CARES) trial will evaluate multiple patient-centered pain and safety outcomes for patients undergoing surgery. Participants will be adults from multiple centers located in Canada and the USA who undergo one of the following outpatient surgical procedures: gallbladder removal, inguinal hernia repair, and breast lumpectomy.In order to assess the feasibility of the CARES study design, we conducted a prospective preference assessment (PPA) prior to conducting the trial. This is a method first described by Halpern which allows the investigators to assess the views of the proposed study design and garner suggestions of how the study could be made more appealing . The aimThe objectives of this PPA were to (1) determine the patients’ willingness to participate in the CARES trial, (2) identify the areas for improvement in the trial protocol to better patient enrollment and acceptability, and (3) assess for the differences in characteristics between patients willing to participate and those who would decline the trial.A purposive sampling framework was used to recruit participants undergoing elective laparoscopic cholecystectomy between August 2019 and February 2020 from the preoperative clinics at two academic hospitals in Toronto, Canada: St. Michael’s Hospital (SMH) and Women’s College Hospital (WCH). Laparoscopic cholecystectomy was selected as the procedure of interest as it is a common procedure with small incisions for which there is uncertainty regarding optimal analgesic management after discharge. The surgical and anesthetic techniques for the procedure are also relatively standardized across practice settings.To best assess the potential barriers to study participation, the inclusion criteria consisted only of patients undergoing this operation and adults aged 18–70 years old. Patients who did not have a working knowledge of the English language were excluded from the survey. This study was approved by the research ethics board at each participating institution prior to the start of the study, and informed consent was obtained from each patient prior to conducting patient interviews.A survey was administered to each patient consisting of four sections found in a typical PPA: 1) a brief vignette of the CARES trial, (2) an assessment of the individuals’ understanding of the trial, (3) open-ended questions assessing the attitudes towards the trial, and (4) a structured patient-completed questionnaire. The patient questionnaire included a 6-point Likert scale to quantify the patient’s willingness to participate by asking the question, “How willing would you be to participate in this study?” The possible responses were definitely not (1), probably not (2), maybe not (3), maybe (4), probably (5), and definitely (6). It also consisted of 11 questions to characterize the baseline demographic characteristics, as well as factors which could have potentially influenced the patient’s decision to participate in the trial, including previous surgical experience and regular use of pain medication , and 95% confidence intervals (CI) were computed for continuous variables and percentages for categorical variables. The Wilcoxon signed-rank tests for continuous variables and chi-square tests for categorical variables were employed to detect the significant differences between subjects who were willing and not willing to participate in the trial.Thematic analysis was used to examine the patterns, codify, and extract meaning from patient interviews to identify motivating and discouraging factors associated with the CARES trial . InitialOverall, 62 participants were approached and assessed for eligibility see Fig. . Twenty p = 0.53), years of education (p = 0.22), sex (p = 0.09), identification as a visible minority (p = 0.47), previous experience with research (p = 0.84), previous surgery (p = 0.10), use of regular pain medications (p = 0.75), concerns with the surgery (p = 0.49), previous discussions on pain management (p = 0.91), significant pain in the past 3 months (p = 0.67), and significant use of pain medication in the past month (p = 0.36).Based on the responses to the 6-point Likert scale, subjects were grouped into willing  and not willing  to participate in the CARES trial for the statistical analysis. The Wilcoxon signed-rank tests revealed no statistically significant differences between these two groups with respect to all 11 variables  or discouraged (5) participation in the CARES trial  compared to the not willing subjects (15%). Despite this disparity, the same motivating factors were stated by both groups, with no theme unique to either group. Within the theme of benefit to personal pain management, 2 concepts were specific to the CARES trial protocol: the use of rescue medication and scheduled postoperative follow-ups. Three subjects felt the inclusion of follow-up checks was a positive reason to participate in the trial as it contributed to improved pain management. In addition, 5 subjects felt reassured by the use of rescue medication and were more confident they would have adequate pain management if they participated in the trial. In contrast to the motivating factors, the proportion of the 44 total responses for discouraging factors was similar between willing (55%) and not willing (45%) subjects. Participants from both groups stated the same reasons for why they were discouraged from participating in the CARES trial, and there was no one factor that was unique to either group. Within the theme of being blinded to medication, 2 concepts were identified, where participants wished to know which medication would be given to them (7) and desired the option to choose which medication they wanted to take (2).This PPA study assessed the willingness of individuals to participate in the proposed CARES study, a large randomized controlled trial. Overall, we found that our results reassured the current study design of the CARES trial as the majority of participants, 71%, were willing to participate and only 29% were unwilling. Furthermore, there were no significant differences in the patient characteristics between the two groups to explain the unwillingness to participate.p = 0.09) and previous surgical history (p = 0.10) trended towards not willing to participate. Although a clear association is not established, previous studies by Kerman et al. [Previous history with research participation, use of pain medication, and significant pain did not seem to influence whether individuals would participate. However, female sex  A vignette describing the trial; 2) An assessment of the patients’ understanding of the trial; 3) Open-ended questions assessing attitudes towards the trial; 4) Patient-completed questionnaires.Additional file 2:. EQUATOR Network Reporting Checklist.