The role of postoperative pain in incidence of shoulder stiffness (SS) after shoulder arthroscopy has not been thoroughly investigated. The present study was conducted to assess the effects of early postoperative pain (EPOP) on onset of SS after arthroscopic rotator cuff (RC) repair.In a retrospective analysis of a prospectively collected database, 335 patients who underwent arthroscopic RC repair were evaluated. RC tendons were sutured to the bone using the double-row technique. EPOP was evaluated 1 week after surgery using the visual analog scale (VAS). SS was assessed 3 months after surgery and was categorized into moderate or severe based on shoulder range of motion (ROM). Each type of complication including SS was identified and recorded.p < 0.001). Diabetes and traumatic tear were found to be associated with postoperative stiffness . Similar associations were found on multivariate analysis of data. VAS pain score was higher in the patients with severe stiffness compared with those with moderate stiffness (p < 0.001).Postoperative shoulder stiffness (POSS) was identified in 121 patients (36.2%) that was moderate in 86 patients (70.1%) and severe in 35 patients (28.9%). After 1 week, VAS pain score was equal to 7.7 ± 3.1 and 4.5 ± 2.1 in the patients with and without stiffness, respectively (Our findings revealed that EPOP is associated with shoulder stiffness after arthroscopic RC repair. Therefore, strategies to ameliorate EPOP could be opted to decrease rate of POSS.Level IV Surgical intervention is widely used for treatment of rotator cuff (RC) tear, which is generally associated with good outcomes and low rate of complications , 2. PostInability to perform early shoulder movements after arthroscopic RC repair has been suggested as a determining factor in incidence of POSS . It is hThe role of postoperative pain in the incidence of stiffness following shoulder arthroscopy has not been thoroughly investigated. Therefore, the present study was carried out to assess the effects of postoperative pain on onset of SS after arthroscopic RC repair.n = 13). Of 493 patients who underwent arthroscopic RC repair in our center during the study period, 335 patients met the inclusion criteria and were selected for this study.This study, which was a retrospective analysis of a prospectively collected database, was approved by the review board of our institute under the code IR.IUMS.FMD.REC.1398.471, and informed written consent was obtained from the patients to publish their medical data. During 2012–2018, patients who underwent arthroscopic RC repair were identified in our university hospital. Exclusion criteria were POSS, arthritic shoulder, revision repair, previous shoulder surgery, and concurrent spinal cord lesions. SS was categorized into moderate or severe levels according to passive range of motion (ROM) as defined in the study by Tauro et al. [Surgeries were performed by the same senior surgeon (ASA) on the patients in beach chair position and under general anesthesia. RC tendons were sutured to the bone using the double-row technique . We perfThe patients were discharged within 24 h after the operation. For controlling postoperative pain, pregabalin (75 mg BID) and celecoxib (200 mg BID) were administered for 2 weeks after operation. A tramadol tablet (25 mg) was administered for further pain control between days 3 and 7, in 82 (24.4%) of the patients.The operated shoulder was immobilized in a sling for 2 weeks. Pendulum exercises and passive flexion up to 90° in sleeping position were started after 2 weeks. Active-assisted ROM exercises were started after 4 weeks. Strengthening exercises were performed after 2 months. Exercises were supervised by a musculoskeletal physiotherapist.Follow-up visits were performed after 1 week (7.3 ± 1.6) and 3 months (95.1 ± 6.3). Pain level was evaluated using the visual analog scale (VAS), ranging from 0 (no pain) to 10 (extreme pain). Each type of complication including SS was identified and recorded.t-test or its nonparametric counterpart (Mann–Whitney U test) was used for comparison of mean values between two independent groups. The χ2 test was used for evaluation of statistical association between categorical variables. For eliminating the confounding effects, significant factors in univariate analysis were included in a binary regression model. A p-value of < 0.05 was regarded as statistically significant.SPSS software for Windows version 16  was used for statistical analysis of the data. Descriptive data were reported as mean with standard deviation or number and percentage. Shapiro–Wilk test was used for evaluation of normality of the data. The independent-samples Characteristics of the patients are presented in Table p < 0.001), respectively. Diabetes and traumatic tear were found to be associated with incidence of POS . The subgroups of the patients with and without POS were similar in terms of other characteristics, including mean age (p = 0.71), gender (p = 0.85), and tear size (p = 0.57) (Table POSS was identified in 121 patients 36.2%). After 1 week, VAS pain was equal to 7.7 ± 3.1 and 4.5 ± 2.1 in the patients with and without stiffness (6.2%. Aftp < 0.001). Rate of severe stiffness was higher in the patients with traumatic RC tear compared with those with atraumatic (p = 0.04). Tear size did not influence severity of stiffness (p = 0.41) (Table Stiffness level was moderate in 86 patients (70.1%) and severe in 35 (28.9%). VAS pain score was higher in the patients with severe stiffness  were used for controlling postoperative pain in the present cohort. These medications potentially contribute to reduction of the pain and stiffness through their antiinflammatory activity . HoweverHerein, all the surgeries were performed under general anesthesia. However, a combination of general and regional anesthesia  is known to facilitate postoperative pain management in shoulder surgeries . TherefoSimilar to our study, Namdari et al. introduced diabetes mellitus as a risk factor of SS . DiabetiHuberty et al. reported SS in 24 (4.9%) out of 489 patients who underwent arthroscopic RC repair. According to their results, patients less than 50 years of age and with larger tears were less likely to develop SS after arthroscopic RC repair . Chung eSeo et al. evaluated risk factors of POSS in 119 patients who underwent arthroscopic RC repair. Based on their results, a higher percentage of stiffness was seen in full-thickness tears in comparison with a partial-thickness tear. In addition, patients with a traumatic tear had a statistically higher rate of POSS . Herein,Several studies have investigated the risk factors of SS after arthroscopic RC repair –26; howeManagement of POSS after arthroscopic RC repair is a controversial issue . The neeThis study has some limitations. The retrospective design and the data of only two follow-up time-points are the main limitations of the study.EPOP seems to play a prominent role in incidence of SS after arthroscopic RC repair, probably through reducing compliance with rehabilitation programs. Appropriate strategies of postoperative pain control could significantly reduce the risk to develop a stiff shoulder.


Post-Market Clinical Follow-Up has been integrated into the new Medical Device Regulations since 2020. The CD Horizon Solera 4.75 mm instrumentation (CD-Solera) was introduced worldwide in 2009, and specifically intended for surgical treatment of pediatric and adolescent scoliosis patients. The objective of this study was to evaluate the safety and efficacy of the CD-solera 4.75 instrumentation in surgical treatment of adolescent idiopathic scoliosis (AIS).94 consecutive AIS patients, 82 female, 12 male, who underwent posterior correction with CD-Solera instrumentation between 2010 and 2016 at age 14.8 ± 1.6 years, were retrospectively included. The minimum follow-up was two years. On pre- and postoperative biplanar full spine radiographs Cobb angles of the primary and secondary curves and sagittal profile were measured before surgery, immediately postoperative, and at two-year follow-up. Medical records were reviewed for complications. Clinical outcome was analyzed using theSRS-22r questionnaire.In this study 77% of the patients had a structural thoracic curve (type Lenke 1 or 2), and 23% had a structural (thoraco-)lumbar curve (Lenke 3-6). A correction of 55.1% and 51.7% was achieved respectively immediately post-operative, and at last-year follow up for the primary curve. The mean loss of correction was 2°. Health related quality of life was 4.0 (good) on the SRS-22r-questionnaire. In total six revision operations were executed, of which one was related to the material (rod breakage). Other reasons for revision operation were not due to the material. No neurological problems were encountered.In patients with AIS the initial correction and maintenance of correction as achieved by posterior spinal fusion using the CD-Solera instrumentation, is comparable to other reported devices. Complication rates are low and health related quality of life comparable to literature. The CD-Solera can be regarded as a safe and effective instrumentation in surgical treatment of AIS. The assessment of quality in health care and in orthopedics has become more important in the last decade In scoliosis surgery, correction of the deformity is not solely related to the preoperative magnitude and rigidity of the curve, but also to the quality of the instrumentation used. Thus, the advantages and disadvantages of new instrumentation should be considered critically In 2017 Europe's new Medical Devices Regulations (MDR) were published. These regulations state that Post-Market Clinical Follow-Up will be integrated into the MDR to provide vital clinical evidence. Full implementation of the new MDR became a requirement in 2020 ,11. AmonThe CD Horizon Solera 4.75 mm Spinal System  (CD-Solera) was introduced worldwide in 2009. In our clinic, this instrumentation is used since 2010 for posterior operative correction of adolescent idiopathic scoliosis (AIS). The system consists of cobalt chrome multi-axial screws with dual lead thread form, two cobalt chromium extra strong (CoCr Plus) rods, standard laminar and pedicle hooks and modular crosslink plates. The presumed improvement of the CD-Solera system relative to its predecessors, the CD Horizon Legacy 4.5 and 5.5 systems, is a reduction in overall volume of the Multi-Axial Screws of 12% and 26%, respectively. The lower profile construct makes it more suitable for the younger and thinner patients. The dual lead thread form of the pedicle screws  enables enhanced fixation with reduced risk of screw pullout As yet, there is no published clinical data available about the CD-Solera instrumentation. With Europe's new MDR in mind, the purpose of this study is to determine the safety and efficacy of the CD-Solera instrumentation in the surgical treatment of AIS by means of a post-marketing surveillance with a minimum follow-up of two years.The used instrumentation in all patients was the CD Horizon Solera 4.75 mm Spinal System  (CD-Solera). The system consists of cobalt chrome multi-axial screws with dual lead thread form, two cobalt chromium extra strong 4.75mm (CoCr Plus) rods, standard laminar and pedicle hooks and modular crosslink plates.For this retrospective single center cohort study, we assessed clinical data from all consecutive patients with AIS who underwent surgical correction with the CD-Solera instrumentation from January 2010 until December 2016.Inclusion criteria were (1) age below 19 years at the time of surgery, (2) AIS (3) surgical correction with the CD-Solera instrumentation (4) standing full spine posterior-anterior and lateral radiographs pre-operative, immediately postoperative and at two-year follow-up. No patients who met the inclusion criteria were excluded or lost to follow-up. Threshold to operate in these AIS patients was a structural primary curve over 45°. This decision was made by the treating spine surgeon.We included 80 patients with AIS, 71 female, 9 male. The minimum length of follow-up was two years. Median length of follow up was 27 months (24-88 months).Demographic and surgical data were obtained from clinical records. These data included gender, age at surgery, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, operated segments, number of fused spinal levels, implant density (we consider double fixation (left and right) per vertebra as an implant density of 100% An exploratory search in PubMed was performed to compare our results with the current literature.. Hybrid posterior instrumentation was performed with hooks cranially and pedicle screws caudally  with motor evoked potentials (MEP) and somatosensory evoked potentials (SSEP) monitoring ,15. Hybrally see . Curve cStanding full spine AP and sagittal radiographs were examined pre-operatively, post-operatively and at two-year follow-up. We measured the thoracic and thoracolumbar/lumbar curves and thoracic kyphosis (from superior endplate of T5 to the inferior endplate of T12) and lumbar lordosis (between lower endplate of T12 and upper endplate S1) using the Cobb method Radiographic measurements were carried out by a medical student (LS) and verified by an orthopedic spine surgeon (PW). These measurements were comparable within 3°, which is within the range of 0° to 5° what is commonly mentioned as an acceptable variation ,20. To d[21]Direct correction rate: (Pre-operative Cobb angle - Post-operative Cobb angle) / Pre-operative Cobb angle * 100 = … %Maintenance of correction: (Post-operative Cobb angle – Last follow-up Cobb angle) / Post-operative Cobb angle * 100 = … %Flexibility rate: (Pre-operative Cobb angle - Pre-operative side-bending Cobb angle) / Pre-operative Cobb angle * 100 = … %The Dutch Scoliosis Research Society-22r questionnaire (SRS-22r) was sent at minimum 2 years post-operative to the patients. Informed consent was obtained before sending out the SRS-22r questionnaires. The SRS-22r is a revised version of the older SRS-22 and its Dutch translation was earlier assessed as reliable and valid Statistical analysis was performed using IBM SPSS Statistics version 24. Descriptive statistics were used to determine the means, standard deviations (SD), and ranges. Means and SD were calculated for baseline characteristics, sagittal correction and SRS-22r. Ranges were calculated for the coronal correction. Prior to statistical analyses distribution of continuous variables were tested by skewness and kurtosis. P values were based on the paired samples T test for continuous variables. P-values equal to or below 0.05 were considered statistically significant.This study was approved by the Institutional Review Board of the Maastricht University Medical Centre, no. 2017-0253.Demographic and specific surgical data are listed in The mean number of fused levels was 10.5 ± 1.9 and the mean implant density was 76.4 ± 7.8%. Mean surgery time was 255 (± 64) minutes. Median blood loss was 400ml (100 – 1700 ml).The mean pre-operative primary angle was 58.7 ± 10.5⁰ and was corrected to 26.5 ± 10.6⁰ average, direct post-operative and to 28.5 ± 11.0⁰, at last follow-up. Mean pre-operative secondary angle was 39.2 ± 10.0⁰ and corrected to 21.8 ± 11.5⁰, direct post-operative and to 22.1 ± 12.2⁰, at last follow-up. A mean correction of 51.7% and 44.6% was achieved at last follow-up for the primary and secondary curve, respectively .Table 2PMean pre-operative kyphosis (T5-T12) was 22.2⁰ and reduced to 17.8, at last follow-up. Mean pre-operative lordosis was 54.5⁰ and 54.7⁰, at last follow-up .Table 3MIn In total nine complications were observed , for whiOne patient had a painful protruding hook which was covered by hardly any soft tissue, and therefore removed. In one patient the entire material was removed in two stages at 36 and 51 months follow-up because of invalidating pain and in one patient the total material was removed at 43 months follow-up due to mental health problems. This patient felt burdened with the back instrumentation and suffered from invalidating pain. She requested removal of the material.One revision surgery was performed because of ventral screw protrusion, which was fortuitously found at regular follow-up. The sixth revision surgery was performed because of deep wound infection two months post-operatively. Two patients had a superficial wound infection (2.1%) which resolved after three to four weeks of antibiotic treatment. No peri-operative or neurological complications were encountered.Apart from one case of rod breakage, none of the complications could be attributed to the CD-Solera instrumentation specifically.The current study was conducted to evaluate the safety and efficacy the CD Horizon Solera 4.75 mm Spinal System, used in AIS in our hospital, bearing Europe's regulations for introduction of medical implants in mind. The system consists of two cobalt chromium extra strong 4.75mm (CoCr Plus) rods, cobalt chrome multi-axial screws with dual lead thread form, standard laminar and pedicle hooks and modular crosslink plates.A correction rate of 51.5 % (48.0% - 54.9%) was found for the primary Cobb angle. These results are comparable with the range of correction rates (50% to 67.6%) as described in literature for similar instrumentation .A correction rate of 45.1% (39.3% - 50.9%) was found for the secondary Cobb angle. The results in literature vary between 43.7% and 63%. 3 studies show comparable results to ours and 4 studies show higher results compared to ours ,28,29.In some reports higher primary curve correction rates compared to this study, varying from 60 to 64% for the primary curve at two-year follow-up, were described, which might be explained by implant density, but these results are missing in these studies . In thisGenerally, a flattening of the thoracic spine has been reported in AIS patients We found nine complications in our study of which two (rod breakage) could potentially be attributed to the instrumentation. In total six revision surgeries were required in which total or part of the instrumentation was removed. Reasons for revision surgeries were rod breakage, invalidating pain, skin irritation, mental health problems, ventral screw protrusion and a deep wound infection. Two superficial wound infections and one rod breakage, which was coincidentally found, did not require revision surgery. Revision surgery rate in comparable literature ranged from 0% to 15.5% ,57,59,60The most common revision indications in posterior spinal correction and fusion in AIS are deep wound infection, pseudoarthrosis, pain, prominent implant and dislodged instrumentation In literature material breakage and dislodgement has been described to occur in 0.93% to 10.5% ,57,59,60This study was limited because of its retrospective design and its lack of a control group preventing direct comparison to other instrumentation devices. Study strengths are the relatively large sample size and the homogeneity of the group. Importantly, there was no conflict of interest by the operating surgeons or researchers. Future studies should contain a larger cohort, if feasible with a control group and longer follow-up of radiographs and prospective HRQoL questionnaires pre- and postoperatively. Preferably, clinical data should be gathered in a well-monitored and controlled setting before the introduction of a spinal device to the market.In patients with AIS the initial correction and maintenance of correction as achieved by posterior spinal fusion using the CD-Solera instrumentation is comparable to other reported devices. Complication rates are low and health related quality of life is comparable to literature. The CD-Solera can be regarded as a safe and effective instrumentation in surgical treatment of AIS.The authors declare that informed patient consent was taken from all the patients.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper


Conclusions: Low frequency of pain assessment emphasises the need to provide better training in the use of various pain rating scales and protocols. What is more, non-pharmacological methods (cooling and immobilisation) used for reducing pain in injured children still remain underutilized.Background: The all-too-frequent failure to rate pain intensity, resulting in the lack of or inadequacy of pain management, has long ceased to be an exclusive problem of the young patient, becoming a major public health concern. This study aimed to evaluate the methods used for reducing post-traumatic pain in children and the frequency of use of such methods. Additionally, the methods of pain assessment and the frequency of their application in this age group were analysed. Methods: A retrospective analysis of 2452 medical records of emergency medical teams dispatched to injured children aged 0–18 years in the area around Warsaw (Poland). Results: Of all injured children, 1% (20 out of 2432) had their pain intensity rated, and the only tool used for this assessment was the numeric rating scale (NRS). Children with burns most frequently received a single analgesic drug or cooling (56.2%), whereas the least frequently used method was multimodal treatment combining pharmacotherapy and cooling (13.5%). Toddlers constituted the largest percentage of patients who were provided with cooling (12%). Immobilisation was most commonly used in adolescents (29%) and school-age children ( Emergency teams (ETs) most frequently provide medical assistance to children with injuries at risk of pain related to the mechanism of such injuries. One of the most important interventions performed at the place of accident is to rate the intensity of pain and the adequacy of pain treatment. Failure to rate pain intensity and adequately manage acute pain leads to both immediate and long-term consequences. Among the short-term consequences should be mentioned, for example, delayed wound healing, while long-term consequences range from hypersensitivity to pain stimuli to the development of post-traumatic stress disorder (PTSD) ,2. The sAlthough there are barriers significantly limiting the measures used by ETs to reduce pain , the barriers should not justify untreated acute pain in children ,5,6.The widespread availability of age-appropriate pain rating scales, non-intravenous administration of effective drugs and non-pharmacological methods of pain relief, such as cooling and immobilisation, enable effective pain management as early as at the pre-hospital stage ,8,9,10. This study aimed to evaluate the frequency, quality and methods of acute post-traumatic pain management in children at the pre-hospital stage.A retrospective study and analysis of medical records was conducted of patients with injury, aged between 1 month and 18 years, who were attended to by ETs. The primary intent of the analysis was to identify whether ETs assessed pain in children and whether traumatic pain was treated by them; if ETs treated traumatic pain, the study identified the drugs used in pain therapy and whether treatment included non-pharmacological agents in pain therapy, such as immobilization and cooling. Ambulances were equipped with analgesic drugs intended for administration by intravenous , oral (tablets only) or rectal (suppositories and enemas) routes. The available immobilization equipment included: Kramer splints, orthopaedic board, c-spine collars and head blocks, Kendrick extrication device (KED), elastic and triangular bandages, and for cooling: burns dressings. The retrospective analysis covered medical records of 2452 injured patients, aged between 1 month to 18 years inclusive, who were attended to by ETs. The analysed ET interventions took place between 1 January 2016 and 31 December 2018 in an operational area around Warsaw  with one million inhabitants. A total of 18 ETs, of which 5 were specialized ETs (S-ETs) comprising at least three persons, including a doctor and a medical nurse or paramedic, and 13 are basic ETs (B-ETs) comprising at least two persons qualified to perform medical rescue services, including a nurse or paramedic, were involved in those interventions .We analysed all the patients who met the inclusion criteria . The medical records of a final group of 2452 patients were analysed. Medical records were selected containing diagnoses from the following groups according to the International Classification of Diseases 10 (ICD 10): (a) S00–S99 , (b) T00–T32 , (c) T90–T98 .The analysis included all data ambulance service medical documentation such as patients’ age, sex, mechanism of injury, accident site, vital signs , decision concerning transport to hospital and information concerning the treatment used . The low-energy injury mechanism included a hit or a fall from the height of one’s own body, while the high-energy included traffic accident, a fall from a height greater than the victim, a blow from an object, beating or biting by an animal. During the study period in Poland, there were no formal protocols in force for rating pain intensity and for pain management. ETs had no pain rating scale imposed. They could freely choose from among the scales known to them from the numerical and behavioural groups.This study was approved by the independent Bioethics Committee of the Wroclaw Medical University (decision no. 424/2018). The study was carried out in accordance with the tenets of the Declaration of Helsinki and recommendations of good clinical practice. For reporting, the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines were followed.p < 0.05.The statistical analysis was performed using Statistica 13 software . Arithmetic means, medians, standard deviations and the range of variability  were calculated for measurable variables. In the case of qualitative variables, their frequency (%) was calculated. All analysed quantitative variables were verified, with the Shapiro–Wilk test used to determine the type of distribution. Qualitative variables were compared between groups using the chi-squared test (χ2). The results were considered statistically significant at n = 2452) consisted of 898 females, representing 37% of the entire group, and 1554 males (63%). The age across the group ranged from 1 month to 18 years (mean (The study group (n = 1022), followed by school-age children . Preschool-age children and toddlers represented approximately 11% of injured patients. Infants were the least numerous age group . In the analysed group, ETs provided medical assistance most frequently to patients with low-energy injuries: 65% (n = 1606). A total of 31% of cases (n = 737) were high-energy injuries and 4% of ET interventions involved child burn victims (n = 89).Five age categories were identified: infants (aged 0–12 months), toddlers (aged 1–3), preschool-age children (aged 4–6), school-age children (aged 7–12) and adolescents (aged 13–18). In the analysed group, adolescents represented more than 40% of injured patients , followed by school , public places  and street and road traffic . A comparative analysis by type of injury was conducted. The prevalence of a specific type of injury depended on factors such as sex, age group and accident site.Dispatch location for ET, medical history and description of circumstances of the accident, which were included in medical records, indicated that the most common accident site was home . All types of injuries were more common in males compared with females. Adolescents were the group most likely to be injured, with as much as 40% of low- and high-energy injuries occurring in that age group. More than 60% of injuries in adolescents were burn-related. Infants and toddlers were the least likely to sustain injuries.Low-energy injury was the most common mechanism of injury in both males and females . Pain was rated in 20 patients (1% of the study population), with NRS used as the assessment tool in all of them. Behaviour rating scales (BRS) were not administered to any patient. The type of ET providing medical assistance was nonsignificant  and morphine . None of ETs administered acetylsalicylic acid to children. As far as sedatives are concerned, diazepam and midazolam were used.Of all tested children, 16% received some kind of drug. From the group of analgesics including acetaminophen, ibuprofen, acetylsalicylic acid, ketoprofen, metamizole, fentanyl and morphine, the drugs that were most commonly administered to children were acetaminophen —more frequently than in low- and/or high-energy injuries. Morphine was administered to 40% of children with burns, 5% of children with high-energy injuries and 5% of children with low-energy injuries. Those differences were statistically significant, just as in the case of ibuprofen intake . Over 70% of interventions were carried out by B-ETs . This result may have been affected mainly by both the disproportion between the number of B- and S-ETs in the analysed area  and the dispatching system which shows the nearest available ET to the emergency medical dispatcher.The vast majority of injured patients (70%) were transported to the hospital (n = 538), while cooling in 3% of cases (n = 62). S-ETs were more likely to use cooling  than B-ETs . Immobilisation, on the other hand, was statistically more frequently used by B-ETs  compared with S-ETs   .n = 56, 63%). In the case of low- and high-energy injuries, the number of patients who received cooling was very small—4 and 2 patients, respectively. Those differences were statistically significant. When it comes to immobilisations, the highest number of this type of interventions was used for low- (22%) and high-energy injuries (23%). In the case of burns, immobilisation was used in only 3 patients (n = 3)  .B-ETs were by far most frequently dispatched to patients with low-energy injuries . S-ET interventions usually concerned low- (49%) and high-energy injuries (43%). Accident site also affected the type of ET dispatched by the Emergency Communication Centre (ECC). In the case of S-ETs, most interventions occurred at home (37%), while B-ETs provided medical assistance at home (33%) with approximately the same frequency as at school (33%).The use of comprehensive analgesic treatment by ETs combining pharmacotherapy and cooling was also analysed. The use of cooling was statistically significant mainly in burns, as was the use of pharmacologic analgesia involving one or more drugs. A very high percentage of patients with low- and high-energy injuries  did not receive any analgesic drug. One-third of children with burns did not receive analgesia, and more than half of them were provided with an analgesic drug or wound cooling. Comprehensive treatment was used only in 13.5% of cases .There were differences in relationships between age category and sex or accident site. Male patients predominated in each age category. High-energy injuries were most common in infants, while low-energy injuries predominated in other age groups. As regards the accident site, infants, toddlers and preschool-age children were most frequently injured at home (>50%). In other age categories, school was the most common accident site .n = 34, 12%), while immobilisation was most commonly used in adolescents  and school-age children   .The analysis of the frequency of the use of individual analgesics in selected age groups of patients revealed statistically significant differences in the use of a particular type of analgesic depending on patient’s age. Acetaminophen, ketoprofen, metamizole and fentanyl were drugs statistically significantly more often administered to older children (school-age children and adolescents) . The sedThe problem of inadequate analgesic treatment of children is of interest to an increasing number of scientists, but in the available literature it is most often about finding barriers to diagnosis and treatment without documenting the numerical scale of the problem.An analysis of the presented material showed that variables such as the patient’s age, sex, accident site and the decision about transport to the hospital did not affect the frequency of pain assessment during the study period. When comparing the results of the presented study with other available results, the difference in the number of performed pain assessments is surprising. It should be emphasized that ETs did not have an imposed pain evaluation protocol. They could freely choose from among the scales known to them from the numerical and behavioural groups.According to the present study, pain intensity was rated only in 1% of all interventions provided by ETs to children with acute post-traumatic pain. Brown et al. presented significantly better results: in their study, pain intensity was rated in 25% of children. In a study by Murphy et al., however, as many as 32% of children had their pain intensity rated ,13,14. RIt should be emphasized that during the analysed period, Polish ETs were not equipped with any protocols for pain assessment and pain management. When comparing the period before and after the implementation of such a protocol, Brown et al. found that its implementation did not increase the percentage of children with documented pain assessment or the frequency of analgesic intake ,13. Simip = 0.004) and opioids such as morphine (p < 0.001) and fentanyl (p < 0.001). Despite many scientific reports on the efficacy of nasal administration of fentanyl, none of the analysed ETs administered it by this route [In the group of children with acute post-traumatic pain and rated pain intensity, 55% of patients received analgesics, while in the group of children without pain assessment, only 16% received analgesia. The assessment of pain intensity significantly increased the intake of ibuprofen . In other words, the drugs started to be administered at appropriate doses .An analysis by Murphy et al. shows that 32% of children with pain documented by the Emergency Medical Service (EMS) were transported to hospital. A total of 26% of them received an analgesic drug. In this group, acetaminophen was administered in 35%, ibuprofen in 23% and inhaled methoxyflurane in 11% of cases .p < 0.001). Children with burns received as many drugs as possible . The above-mentioned mechanism of injury also significantly increased the frequency of administration of sedatives such as diazepam  and midazolam . A study by Nadolny et al. showed that those drugs were administered in 16.5% of all interventions involving children with burns [The drugs most commonly administered by ETs to injured children included morphine (7%) and acetaminophen (4%)  and non-steroidal anti-inflammatory drugs (NSAIDs—metamizole) were drugs preferred by S-ETs. According to the collected study material, opioid analgesics such as morphine and fentanyl were administered equally frequently by both types of ETs, which is why their intake was more affected by the mechanism of injury and the use of a pain rating scale than by the type of ET. S-ETs tend to use multimodal analgesia, especially analgosedation. Midazolam was administered by S-ETs 10 times more frequently than by B-ETs, whereas the administration of diazepam by S-ETs was 8 times more frequent than by B-ETs. As Bayat rightly points out it should be noted that although benzodiazepines have an excellent sedative effect, they cannot be used as a substitute for analgesics .In an analysis of the non-pharmacological methods of pain relief, a statistical survey of the analysed medical records of the entire study population showed that immobilisation was used in 22% of cases, while cooling was used in only 3% of all interventions; however, in the case of patients with burns, cooling was used in as many as 63% of cases. Whitley shows that 9.6% of children with injuries from his study population received other forms of non-pharmacological pain relief such as splinting, dressing or slings . StrobelAs noted by Häske et al., immobilisation of fractured limbs is of analgesic value, especially in displaced fractures or joint dislocations in which perfusion abnormalities occur and the risk of necrosis of the surrounding tissues increases. However, pharmacological anaesthesia should be taken into consideration before the affected limb is repositioned in its longitudinal axis using traction. This is because, in many cases, the use of immobilisation itself will be insufficient to reduce pain. Topical cryotherapy may also be used even though there is low evidence for its effectiveness. Non-pharmacologic methods of pain relief should not be prioritised in the case of life-threatening injuries . At the Our study has several limitations, principally related to the EMS documentation available to us for analysis. The main shortcoming was the lack of reported time at which the patient’s pain intensity was rated by ETs. Additionally, there was no information on whether the use of non-pharmacological methods of pain management was preceded by the assessment or, on the contrary, whether the pain was rated only after such methods were applied.It was also impossible to determine the criterion according to which a B- or S-ET was dispatched to the injured patient. According to generally applicable rules, an emergency medical dispatcher who sees the location of ambulances on maps should dispatch a team that can arrive at the accident site within the shortest possible time. The disproportion between the number of specific types of ETs in the analysed operational area  should also be taken into consideration in this analysis as it may directly translate into the medical intervention undertaken, especially for patients with serious life-threatening injuries. Future studies need to be designed to address these important outcomes and to improve the documentation of pain management within the EMS system.Neither basic nor specialist emergency medical teams rate pain intensity in paediatric patients using pain rating scales. In individual cases, the numeric rating scale is applied. Behaviour rating scales are not used by ETs. In post-traumatic pain management in children, opioids are used equally frequently by both types of ETs, while multimodal therapy is used more frequently by S-ETs.The decision about the administration of analgesics in children with post-traumatic pain is mainly affected by the mechanism of injury (burns). It is not, however, affected by factors such as the patient’s age (except for infants), the decision on whether or not to transport the patient to the hospital or abnormal vital parameters.Toddlers with burns, in whom analgosedation combined with cooling is frequently used, are the patient group that is the best protected from pain. Cooling is applied by ETs only for burns/scalds, and it is not used for treating other injuries. The analysis confirmed the low incidence of pain assessment by the ETs, which further supports the need to continue training among medical staff.


Conservative therapies are typically offered to individuals who experience mild or intermittent symptoms of carpal tunnel syndrome (CTS) or postoperatively to subjects who have undergone carpal tunnel release. Although long-term studies report mostly positive results for carpal tunnel release, knowledge on the need for conservative treatments following surgery is scarce. The aim of this retrospective cohort study was to examine the use of conservative therapies before and after carpal tunnel releasing surgery.Of 528 patients who underwent carpal tunnel release surgery in the study hospital during the study period, 259 provided sufficiently completed questionnaires (response rate 49 %). The patients completed a questionnaire battery including a sociodemographic, medical history and symptom questionnaire, the Boston Carpal Tunnel Syndrome Questionnaire, 6-item CTS symptoms scale and EuroQoL 5D. Frequencies of conservative therapies pre- and postoperatively were calculated. Association between Pain VAS and satisfaction with treatment were examined in patient groups according to the use of conservative therapies.p = 0.002), but postoperatively no significant gender difference was observed. The patients who received conservative therapies were younger than non-users in both the preoperative  and postoperative  phases. The patients reported high satisfaction with their treatment and simultaneous improvement in Pain VAS scores. Those receiving conservative therapies only preoperatively reported the highest satisfaction.Of all patients, 41 (16 %) reported receiving only preoperative, 18 (7 %) reported receiving only postoperative, 157 (60 %) reported receiving both pre- and postoperative conservative therapies and 43 (17 %) did not receive any therapies. Preoperative use of conservative therapies was more common in females than males (82 % vs. 64 %; While the use of conservative therapies decreased after surgery, a large proportion of the patients received these adjunct interventions. Patients reported high satisfaction with their treatment one year post surgery. Pain outcome seems to be closely related to satisfaction with treatment.Level III. Carpal tunnel syndrome (CTS) is a common complaint causing hand disability in people of working age –3. CTS iThe incidence of CTS has been reported to vary between 105 and 419 per 100 000 person-years peaking around 50 years of age , 3, 6, 7Non-surgical treatment is one option in the management of mild and moderate CTS . Non-surThe aim of this retrospective cohort study was to examine the use of conservative therapies before and after carpal tunnel releasing surgery.All patients fulfilling the inclusion criteria and who underwent carpal tunnel release surgery (procedure code ACC51) at the Central Finland Central Hospital, Jyväskylä, Finland from January 2016 to February 2017 were invited to participate in the study. Inclusion criteria were age over 18, a moderate to severe primary idiopathic diagnosis of CTS, and sufficient ability to understand Finnish in completing the questionnaires. CTS diagnoses were extracted from the patient records of an extensive physical examination by a surgeon using electroneuromyography (ENMG) or nerve conduction with a handheld measuring device [Carpal tunnel release was performed under local anesthesia. An incision was made from Kaplan’s cardinal line to the first wrist crease following the medial palmar crease. After blunt dissection of subcutaneous tissues, the palmar aponeurosis and flexor retinaculum were dissected sharply to reach the transverse carpal ligament. The transverse carpal ligament was then dissected sharply with simultaneous median nerve protection. The landmark of the distal edge of the transverse carpal ligament was fatty tissue parallel to the deep palmar arch where the proximal part of the ligament was released. After complete release of the transverse carpal ligament, the wound was closed using nonabsorbable sutures.On discharge, all patients received printed instructions. These had earlier been reviewed with the patient by a nurse and physiotherapist and included information on wound healing, medications, and rehabilitation exercises. Patients were instructed on a postoperative rehabilitation exercise program to be performed daily at gradually increasing intensity until use of the operated hand returned to normal. Patients were instructed to move their fingers and wrist immediately after the operation. Extreme movements of the wrist were to be avoided until removal of sutures from the wound. The operated hand was limited to carrying a maximum weight of 1.5 kg for the first 4 weeks after the operation. The movement exercises were instructed to begin on the first postoperative day and included finger stretching and the moving of all fingers and wrist. All exercises were performed four times a day for 4–5 weeks or until the hand was symptomless. Length of sick leave was 4–5 weeks depending on the patient’s occupation. Supervised physiotherapy was not prescribed as a routine. If the patients encountered any problems during rehabilitation, they were advised to contact their physiotherapist in primary health care. Acetaminophen or a non-steroidal anti-inflammatory drug was prescribed against postoperative pain.Invitation letters along with questionnaires and a blank informed consent were mailed to patients one year after surgery. The questionnaire battery included a sociodemographic and a medical history questionnaire with items on mean hand and wrist pain intensity during the last week before surgery and after surgery on a visual analogue scale . Time with symptoms before surgery and therapies received before and after surgery were elicited with direct questions and multiple choice questions with a single or multiple response options. Satisfaction with treatment was investigated with a question “Did the surgery improve the condition of your hand or wrist?” with a five-point response scale from “No improvement” to “Eliminated symptoms completely” (scores 0–4). In addition, the Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) –20, 6-itThe results are presented as frequencies, means with standard deviations (SD) or medians with interquartile ranges (IQR). Change in the frequency of conservative therapies pre- and postoperatively and change in Pain VAS scores were calculated. The association of the use of conservative therapies pre- and postoperatively with age was examined using the Mann-Whitney U-test, and the association with gender was examined using a chi-square test. Pre- and postoperative Pain VAS scores were compared using the Mann-Whitney U-test. Patients were further divided into five subgroups according to the response categories of the subjective improvement question, and the change in Pain VAS scores was examined in each of the five subgroups. Differences in Pain VAS scores and satisfaction with the use of conservative therapies were examined in the patient subgroups using the Kruskal-Wallis test. R version 3.6.1 statistical software was used in statistical analysis .A total of 528 patients underwent carpal tunnel release surgery during the study period. Of these, 259 returned sufficiently completed questionnaires, yielding a response rate of 49 % Table . FemalesOverall, 41 (16 %) patients reported receiving only preoperative, 18 (7 %) reported receiving only postoperative, 157 (60 %) reported receiving both pre- and postoperative conservative therapies and 43 (17 %) did not receive any therapies. The most commonly received preoperative therapies were splinting, stretching, pain medication and massage. The most commonly used postoperative treatments were stretching and pain medication Table . Use of p = 0.08; Fig. p < 0.001) and postoperatively .A statistically significant gender difference was found in the use of preoperative conservative therapies  whereas postoperatively the difference did not reach statistical significance . In 38.1 % of patients, symptoms were completely eliminated after surgery, and an additional 33.1 % reported major improvement in the condition of their hand . In females, both satisfaction with treatment and improvement in Pain VAS were higher than in males. The patients who were working were more satisfied than retirees (p = 0.017) and also reported higher Pain VAS improvement than retirees (p = 0.014).Pain VAS scores improved significantly from the pre- to one-year postoperative measurements .The patients who received conservative therapies preoperatively only (median satisfaction 3) reported higher satisfaction with treatment than those in the other patient groups  . The patients completed the questionnaires one year after surgery, and thus information on the preoperative state was collected postoperatively. This might have predisposed the answers to recall bias. However, the questions on preoperative interventions were designed to mitigate recall bias by offering direct and dichotomous response options (“yes” or “no”). With regard to Pain VAS, direct comparison of the pre- and postoperative phases offered opportunity to observe perceived change. The reasons why about half of the invited patients did not respond to the questionnaires remain unknown. It can be assumed that nonrespondents would experience less discomfort and symptoms at the one-year follow-up after surgery whereas morbidity would be higher in respondents, thereby explaining their willingness to participate. Nevertheless, the response rate of 49 % in our study is comparable to the 42 % reported by Schwartzenberger et al. (2020) for a mail survey of the BCTQ at 1 year after CTS surgery .The present study shows that use of conservative therapies decreased after carpal tunnel release. Although the patients reported high satisfaction with the surgery, a large proportion of the patients were continuing with conservative therapies one year after surgery. It is important to inform patients of this, as it may affect their acceptability of conservative therapies in an early stage.


While pain is often the focus of clinical interventions, other clinical outcomes  might also contribute to patients’ functionality and well-being. Although researchers and clinicians may view discomfort, pain and stiffness as different constructs, it remains unclear how patients perceive and differentiate between these constructs. Therefore, the purpose of this study was to explore patients’ perceptions of pain, discomfort, and stiffness.Chiropractic patients were invited to complete an online cross-sectional survey and describe what ‘discomfort’, ‘pain’ and ‘stiffness’ meant to them using their own words. Lexical and inductive qualitative content analyses were conducted independently and then triangulated.Fifty-three chiropractic patients  responded. The most common combinations of words to describe discomfort were “can be ignored” and “less severe than”. “Cannot be ignored” and “sharp shooting” were used to describe pain. “Limited range of motion” was used to describe stiffness. Qualitatively, five themes were developed: impact, character, feeling, intensity and temporality. Stiffness was described as limited movement/mobility. Although discomfort and stiffness impacted patients’ activities, patients remained functional; pain was described as stopping/limiting activities. Discomfort was described as dull and tingling, pain as sharp and shooting, and stiffness as tight and restricted. Patients felt displeased and annoyed when experiencing discomfort and stiffness but hurt and in danger of harm when experiencing pain. Discomfort and stiffness were described as less intense than pain, with shorter/intermittent duration; however, all constructs could be experienced constantly.Patients perceived discomfort, pain and stiffness as different, yet overlapping constructs. This preliminary work advances our knowledge of how patients conceptualize these constructs, contributing to better understanding of what patients mean when reporting these experiences, potentially improving the clinician-patient communication.The online version contains supplementary material available at 10.1186/s12891-022-05214-y. Health care professionals, including chiropractors, provide clinical care to patients, aiming to improve pain or other relevant clinical outcomes in order to enable patients’ achievement of functional activities. While pain has been the main clinical outcome investigated to date, other clinical outcomes, such as discomfort and stiffness, might also contribute to patients’ functionality, making them equally important. Clearly delineating these constructs may add precision to patient assessment, enhance clinician-patient communication, and enable more targeted and personalized treatment and outcome measurement.Although pain is often associated with discomfort, it seems that discomfort can be experienced independent of pain. Other non-pain-related experiences that are subjectively unpleasant, such as fatigue, are commonly associated with discomfort –3. DespiPain and discomfort, however, are not always differentiated. In fact, previous investigations did not make a distinction between these two constructs, and studies either measured discomfort together with pain –6, used In addition to discomfort and pain, stiffness is another experience commonly reported by patients with musculoskeletal conditions. As with discomfort, previous investigations have not differentiated between stiffness and pain, and have measured these two constructs together . StiffneWhile clinicians may view discomfort, pain and stiffness as different constructs, it is not known if patients share the same view. Different understandings can lead to miscommunication and misunderstandings in the clinical encounter, where clinicians and patients interpret different experiences based on their own definitions. By elucidating patients’ perceptions towards discomfort, pain and stiffness constructs, clinicians would better understand what patients actually mean when using these concepts, enhancing the clinician-patient communication. Consequently, more accurate interpretation and utilization of such patient reported experiences will be possible, potentially advancing the quality of care.Therefore, the purpose of this study was to explore patients’ perceptions of discomfort, pain and stiffness concepts and if/how patients differentiate between them.This study used a cross-sectional online survey and was approved by the Canadian Memorial Chiropractic College (CMCC) Research Ethics Board (#2006X03) and performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.A convenience sample of adult patients (≥ 18 years old) receiving care at three private chiropractic clinics in the Toronto area and at CMCC’s campus clinic were invited to participate by their clinician. If interested, the patient was introduced to the principal investigator who provided detailed information about the study. If the patient agreed to participate, the survey link was sent via email.th November and 23rd December 2020 via the SurveyMonkey electronic data capture platform . The opening page of the survey provided information regarding the purpose and content of the study, potential risks and benefits of participation, expected duration to complete the survey, voluntary participation, confidentiality and the research team’s contact information. All participants provided their informed consent electronically after reading the study information and prior to participating in the study.The survey was specifically developed for this study and was available electronically between 4The survey included three main sections  were calculated. Means ± standard deviations (SD) were calculated for demographic characteristics as well as for each experience’s VAS score. Counts and percentage of participants reporting each experience in each body part were also calculated.https://www.lextutor.ca/vp/eng/) . One participant compared discomfort and pain and explained that, while discomfort can be ignored: “A sensation out of the ordinary that can be ignored” [025], pain cannot: “A negative sensation that cannot be ignored” [025]. Another participant agreed: “Pain is like a headache in any part of your body. It hurts and is constantly on your mind. […] When pain is occurring, it is always at the forefront of my mind” [040].The impact theme described how discomfort, pain and stiffness impacted activities. Specifically, patients reported that, when they experienced discomfort, it required only partial attention and that they were consciously aware of it: “Can function during activities of daily living but it doesn’t feel ‘normal’” [012]. Pain, on the other hand, was described as stopping or limiting their activities: “stops you performing the activities you need to do” [009]. Most participants also described stiffness as limiting their movement and mobility: “When the movement in certain parts of the body are restricted” [033].There was an overlap between discomfort and stiffness and while both were described as affecting participants’ activities, they allowed participants to remain functional: , pain was described as sharp and shooting , and stiffness was described as tight and restricted . One participant compared all three experiences in terms of their character: “Discomfort to me is almost a dull ache. Not something that is debilitating but something that is noticeable and is not usual. Pain to me is when there are sharp shooting sensations or feelings of discomfort that become unbearable. Stiffness to me is when something is a bit tight or hasn’t been stretched properly. When I move a certain way and there is resistance but no pain” [044]. Interestingly, there was an overlap between discomfort and pain: both were described as having a throbbing and aching character, whereas discomfort was “Mild ache” [049] and pain was “aching, pinching, throbbing, stabbing feeling” [004].Participants recognized that each construct had a particular character and specific adjectives were commonly used to describe each construct. Discomfort was described as having a dull and tingling character “A general unease, a feeling of unsettledness” [032]. They also described discomfort and stiffness as unpleasant and annoying. For instance, one participant reported that discomfort was “When I’m unable to find a position that relieves the sensation, an uncomfortable feeling that is more so annoying than painful” and stiffness was “Usually in a joint region, maybe a decrease in ROM [range of motion], annoying during everyday activities but doesn’t cause me to stop doing them” [024]. On the other hand, participants indicated that pain made them feel hurt “Feeling of hurt” [037] and in danger of harm: “[…] I feel like pain often goes deeper than discomfort and to me signals damage or something wrong with the area. To me when I think of pain it is associated with an injury or harmful stimulus” [027].Participants reflected on the emotional experience of how each construct made them feel. Most participants described they felt not at ease when experiencing discomfort: “hurting but less severe than pain, can be ignored or distracted from fairly easily” [042] and stiffness being “A symptom less serious than pain that, although uncomfortable, generally does not restrict your ability to carry out activities of daily living” [016]. However, one participant described stiffness being “Between discomfort and pain” [036]. Pain was described as more intense: “Hurt, intense” [047]. One participant compared discomfort and pain, and described discomfort as an “adjective, less severe than pain” and pain as the “strongest adjective to describe aches, soreness” [039].Participants often compared and differentiated between discomfort, pain and stiffness in terms of intensity. Discomfort and stiffness were both described as less intense than pain, with discomfort being “on-going, annoying reminders” [043], pain being a “Constant ache sensation” [017], and stiffness being “Feeling uncomfortable constantly, make me move slowly” [038]. However, some participants perceived discomfort to be short in duration: “Discomfort to me is somewhere beneath pain. Its an uncomfortable or unpleasant sensation, often very short in length. Discomfort to me is usually brought on by a stimulus, like a pair of pants that are too tight” [027]. Stiffness was described as both constant and intermittent: “Constant as well as intermittent achiness” [049].Participants also considered the temporality of each construct. All constructs were described as potentially constant, with discomfort being With a cross-sectional survey, this study explored chiropractic patients’ perceptions of three constructs commonly reported in clinical practice: discomfort, pain and stiffness. Lexical and qualitative analyses revealed that patients perceived discomfort, pain and stiffness as somewhat different constructs, although overlap was identified. Specifically, discomfort and stiffness were described as impacting patients’ activities, however, they remained functional; whereas pain was described as stopping/limiting activities. Patients described feeling displeased and annoyed when experiencing discomfort and stiffness, but hurt and in danger of harm when experiencing pain. Discomfort and stiffness were described as less intense than pain, with shorter/intermittent duration; however, all constructs could be experienced constantly. This study contributes to better understanding what patients actually mean when using these concepts in the clinical encounter.The techniques employed in this study demonstrate that it is practical to conduct a lexical analysis of patient free-text entries, and to characterize the lexicons used by patients to describe different clinical constructs. In the small corpora derived in this study, patients appeared to use ‘general’ rather than ‘technical’ language to describe their experiences, and used lexicons which were largely specific to the different constructs under investigation. Thus, while our own corpora were too small to justify statistical comparisons, the trends that we saw toward lexical closure suggest that with samples from hundreds, not thousands or millions, of patients, we would have corpora which were convincingly representative of the broader language. Therefore, lexical analysis of adequately sized corpora appears practical, and the results could assist in facilitating patient-clinician communications, including history-taking and formulation of diagnoses.Although lexical and qualitative analyses were conducted independently to avoid cross-contamination, results from the lexical analysis provided quantitative support to themes developed from the qualitative analysis. Specifically, while the qualitative analysis provided a more in-depth description of patients’ experience related to discomfort, pain and stiffness, lexical analysis provided quantitative support, emphasizing the Intensity, Character and Impact themes with the words patients chose to use to respond to our survey.There is limited evidence regarding the concept and perceptions of discomfort, especially in musculoskeletal conditions, which limits our ability to compare our results with the literature. This lack of research related to discomfort is likely due to the investigative focus on pain. In fact, our results show that patients usually remain functional when experiencing discomfort. Given that most rehabilitative research is focused on bringing the patient to a functional state, relief of discomfort might not be perceived as an important outcome in rehabilitation. However, a high level of musculoskeletal discomfort has been reported to be a predictor of future musculoskeletal pain in workers , highligInterestingly, self-report questionnaires commonly used in clinical investigations, such as the McGill Pain Questionnaire and Musculoskeletal Health Questionnaire, do not clearly differentiate between discomfort, pain and stiffness. Our results indicate that patients make specific distinctions between these constructs, which might not be captured by these questionnaires. This highlights a limitation of currently available questionnaires and revisions could potentially be implemented to better align questionnaires with patients’ nuanced understandings of these constructs, enhancing clinical assessment and interpretation of patients’ responses.Our results suggested that patients perceived that pain was an indicator of potential injury or harm; however, some patients also described pain as the feeling of being hurt, which can be interpreted in a non-physical context. It is well known that pain is multifactorial and that it cannot be solely inferred from the state of bodily tissues –28. IndeResults from this study indicate that participating patients perceived the concept of stiffness to be closely related to reduced or restricted movement, mobility and range of motion. This is in accordance with previous findings reporting that stiffness was described as a perceived resistance to movement and a lack of movement velocity , 32. StaLexical closure, the linguistic equivalent of a power analysis, revealed that the corpora of free-text entries used in this exploratory study were much too small to permit meaningful statistical comparisons among the 3 constructs. Our study used a convenience sample, where clinicians’ selection bias is possible. Therefore, our results are specific to our sample and might not represent the perceptions of the general patient population. Our qualitative data contained enough information to develop thematic categories and fulfill our exploratory study aim . HoweverFindings from this study suggest that although patients perceive discomfort, pain and stiffness as different constructs, there is some overlap. This preliminary work contributes to better understanding of how patients conceptualize these constructs. By advancing our knowledge regarding what patients actually mean when reporting these experiences in the clinical encounter, a more accurate interpretation and utilization of such reported experiences is facilitated, which may improve clinician-patient communication.Additional file 1. Complete survey that was used in this study.


Pain management is a key issue in prehospital trauma. In Switzerland, paramedics have a large panel of analgesic options. Methoxyflurane was recently introduced into Switzerland, and the goal of this study was to describe both the effect of this medication and the satisfaction of its use. This was a retrospective cohort study, performed in one emergency ambulance service. It included adult patients with traumatic pain and a self-assessment of 3 or more on the visual analogue scale or verbal numerical rating scale. The primary outcome was the reduction in pain between the start of the care and the arrival at the hospital. Secondary outcomes included successful analgesia and staff satisfaction. From December 2018 to 4 June to October 2020, 263 patients were included in the study. Most patients had a low prehospital severity score. The median pain at arrival on site was 8 and the overall decrease in pain observed was 4.2 (95% CI 3.9–4.5). Regarding secondary outcomes, almost 60% had a successful analgesia, and over 70% of paramedics felt satisfied. This study shows a reduction in pain, following methoxyflurane, similar to outcomes in other countries, as well as the attainment of a satisfactory level of pain reduction, according to paramedics, with the advantage of including patients in their own care. Acute pain is a frequent symptom in prehospital care. Its prevalence reaches 42%, with 73% of patients receiving analgesics and approximately 50% experiencing an adequate reduction in pain ,2. TraumMethoxyflurane is a halogenated derivative with strong analgesic properties at sub-anaesthetic doses ,11. It wIn the emergency department, trials have shown that methoxyflurane was better than a placebo, without any signs of toxicity . AnotherThe purpose of this study was to describe the characteristics of the patient population that received methoxyflurane for acute traumatic pain in the prehospital setting, its effect on the intensity of pain, and the satisfaction of prehospital care providers.This was a retrospective observational study reporting the use of methoxyflurane in prehospital care for traumatic pain, in a unique emergency ambulance service  in Geneva, Switzerland, between December 2018 and October 2020, based on prospectively collected data. As a result of the burden related to the first COVID-19 wave, the data collection was suspended from 25 March to 4 June 2020.In Switzerland, the main component of the emergency prehospital response system is an advanced life-support (ALS) ambulance staffed by two paramedics . AmbulanIn this study, paramedic pain treatment protocols include different steps. The first one is pain assessment with VAS or VNRS. In traumatic cases, paramedics can administer methoxyflurane if the pain is evaluated to be more than 3/10. This administration is performed using a 3 mL inhaler with a concentration of 99.9%. Then, paramedics have different options, depending on pain intensities. If the pain is severe (>7/10) and the patient needs to be moved or if a fracture needs to be realigned, paramedics can use midazolam and ketamine. As soon as the previous painful procedures have been completed and the patient has been scooped, analgesia can be continued by titrating opiates and administering paracetamol. As for any intervention, patients can refuse any treatment they do not want to receive.Inclusion criteria were patients 18 years or older with traumatic pain. Exclusion criteria were (1) self-evaluation of the pain not possible, (2) visual analogue scale (VAS) or verbal numerical rating scale (VNRS) ≤ 3, and/or (3) contraindications to methoxyflurane.Following each intervention, the lead paramedic recorded (in a web-based case report form) all the information regarding the patient and the intervention: age, sex, clinical features, intervention features, treatment administered, and satisfaction of the paramedic team. Clinical features included pain localization, systolic and diastolic blood pressure, heart rate, and oxygen saturation at arrival on site and upon arrival at the hospital’s ED. Treatment administrated was categorized in four groups: methoxyflurane alone, methoxyflurane combined without opioids, methoxyflurane combined with opioids only, and methoxyflurane combined with a mix of opioids and non-opioids. Intervention features included timing (night (defined as between 7:00 PM and 7:00 AM) and weekends), location , and the severity of the emergency using the National Advisory Committee for Aeronautics (NACA) score. Pain intensity was measured using the VAS or VNRS . These sThe primary outcome was the decrease in VAS from T0  to T3 . Secondary outcomes were a successful analgesia (defined as a T3 VAS or VNRS ≤ 3) and an overall good paramedic satisfaction level (defined as satisfied or very satisfied).p-value below 0.05 was considered significant.Demographic data are expressed as means ± standard deviation or frequency and proportion, based on the type of variables. As the main goal was a descriptive analysis, no sample size calculation was performed prior to this study. For all the tests, a two-sided As this study was considered a quality improvement project on previously collected data, the ethics approval was waived by the institutional review board.From 13 December 2018 to 25 March 2020 and from 4 June to 14 October 2020, paramedics responded to 7120 calls, of which 1866 involved patients with trauma. Of these, 35% of them required pain management. After the exclusion of 378 patients , 263 patients were included .The median VAS or VNRS on arrival on site was 8 (IQR 6–10). Methoxyflurane was given alone in 35.4% of patients, in combination with non-opioid medication in 11.3%, with opioids only in 12.5%, and with a mixed combination to the remaining 41.1%.Overall, the paramedic satisfaction was good, with 30.0% of paramedics satisfied and 41.4% of them very satisfied with methoxyflurane pain management.This retrospective cohort study demonstrated that methoxyflurane appears to participate in pain reduction following trauma. It also showed that paramedics were satisfied or very satisfied in the majority of cases with the use of this medication.To the authors knowledge, this is the first study reporting the use of methoxyflurane in a Swiss prehospital setting. Based on a larger number of patients, it showed an average of 4.2-point decrease in pain after the use of methoxyflurane. While other causes, such as anxiety reduction, could explain these results, this study demonstrated a greater improvement, compared with other recent studies which looked at intra-hospital analgesia . The recOligo-analgesia, which is defined as failure to provide sufficient analgesia, is an important issue in prehospital care . In prevThe present study demonstrated an overall good level of satisfaction. This could be explained by the simplicity and usability of the device, especially in situations where security equipment cannot be immediately removed, thus compromising iv access. Buntine et al. showed a higher satisfaction than this study did (over 80%) . This caImportantly, although data was prospectively collected, it was a retrospective study with only one EAS included. Nevertheless, these results should match other, similar EAS in Switzerland, as the patients and the paramedic training are comparable. Secondly, there was no comparator. The goal of this study was to describe characteristics of the patients, as well as the evolution of their pain and satisfaction. Further comparative studies should be performed to ascertain the efficiency and efficacy of methoxyflurane, compared to other analgesics in prehospital setting. Another limitation is the fact that only patients with traumatic pain were included. While recent studies showed that methoxyflurane could also be used in non-traumatic pain, such as renal colic pain or the exacerbation of chronic back pain , it was To summarize, this study shows similar results in pain reduction following methoxyflurane in a Swiss cohort as in other countries, with a good paramedics satisfaction. This new medication is, therefore, an additional tool that will contribute to the continuous improvement of pain management, especially in the prehospital setting, where proper training and delegated medical interventions to paramedics has greatly improved care these last 20 years.Methoxyflurane seems to offer a similar reduction in pain in Switzerland as in other countries and a good paramedic satisfaction, with the advantage of including the patients in their care.


This study aims to investigate chronic widespread pain with the 1990 (CWP1990) and 2019 (CWP2019) definitions 6 years after the onset of rheumatoid arthritis (RA), in one patient cohort with tight controls and one conventional cohort, and factors associated with reporting CWP1990 and CWP2019, respectively.A cohort of 80 RA patients with monthly visits to the physician the first 6 months was compared to a cohort of 101 patients from the same clinic with conventional follow-up. Both cohorts had early RA (< 13 months). The prevalence of CWP1990 and the more stringent CWP2019 were in a 6-year follow-up investigated with a questionnaire, including a pain mannequin and a fear-avoidance beliefs questionnaire.p = 0.026). There was no difference when using the CWP1990 definition . When adjusted for important baseline data, the odds ratio for having CWP2019 was 2.57 (95% CI 1.02–6.50), in the conventional group compared to the tight control group (p = 0.046). A high level of fear-avoidance behaviour towards physical activity was associated with CWP2019, OR 10.66 (95% CI 1.01–112.14), but not with CWP1990 in the tight control cohort.In the tight control cohort, 10% reported CWP2019 after 6 years compared to 23% in the conventional cohort (A more stringent definition of CWP identifies patients with a more serious pain condition, which potentially could be prevented by an initial tight control management. Besides tight control, caregivers should pay attention to fear-avoidance behaviour and tailor treatment.CWP2019 is a more stringent definition of chronic widespread pain and identifies patients with a more serious pain condition.• Patients with a serious pain condition could be helped by frequent follow-ups.• This study suggests that a special attention of fear-avoidance behaviour towards physical activity in patients with RA is needed.•  Chronic musculoskeletal pain, lasting 3 months or more, is common in the adult general population , 2. The For fibromyalgia (FM), defined with the 1990 criteria (CWP1990 and 11 of 18 tender pressure points), the estimated prevalence in the general population is around 2% .It is well-known that patients with rheumatoid arthritis (RA) often suffer from concomitant CWP and FM, with prevalence numbers around 30% for CWP1990 and 20% for FM –14. StudTo our knowledge no studies have investigated CWP and FM prevalence in RA patients that have received tight control regimen early in the disease. There are some data supporting an association between a high level of fear-avoidance behaviour regarding physical activity and higher pain levels in RA, but the possible connection to CWP in this group of patients has not been studied . FurtherThe primary aim of this study was to investigate the prevalence of CWP1990, CWP2019 and FM 6 years after the onset of rheumatoid arthritis and compare two patient cohorts, one with tight control and one with conventional follow-up early in the disease. The secondary aim was to explore factors associated with reporting CWP1990 and CWP2019, respectively.For this single-centre 6-year follow-up study, we recruited patients from two cohorts: the tight control cohort and the conventional BARFOT cohort . The incThe patients in the conventional cohort were sent a questionnaire in 2010, in median 6 (IQR 4.5–7.0) years after disease onset. The response rate was 83%. The questionnaire contained questions about pain and fatigue on a visual analogue scale (VAS) and comorbidity including patient-reported diagnosis of FM. Additionally, the Swedish version of Stanford Health Assessment Questionnaire (HAQ) –25 to meThe patients in the tight control cohort were sent a questionnaire in 2019–2020, in median 6 (IQR 4.0–7.0) years after disease onset. The response rate was 74%. The questionnaire contained the same questions as the questionnaire used in 2010 mentioned above. Additionally, it had a Fear-Avoidance Beliefs Questionnaire (FABQ) , 28, an In this study, we use two definitions of CWP, CWP2019 based on the new WP2019 definition  and CWP1The Fear-Avoidance Beliefs Questionnaire, originally developed to evaluate back pain but thereafter used for many patient groups including RA, consists of two subscales , 28, 31.The AUDIT-C is a short version of AUDIT with 3 questions connected to alcohol consumption. The total score range is 0–12, and a total score ≥ 4 in women and ≥ 5 in men is considered a risk consumption of alcohol .The questions used for physical activity were taken from the 2016 Swedish national health survey and included questions on the number of minutes spent each week on moderate and vigorous activity .All patients signed a written consent to participate in the study. Ethical approval was obtained for the tight control cohort  and for the conventional cohort (LU 398–01) from the regional ethical review board at Lund University, Lund, Sweden. The study followed the guidelines from the Helsinki Declaration, and the management of the database was according to ISO 9001.U test and Pearson’s chi-square test. For continuous variables, the median value has been given with the first and third quartiles, as dispersion measures. When n < 5 in any of the groups, Fisher’s exact test was used instead of chi-square. Regarding the questionnaire data from the 6-year follow-up, the tight control cohort and the conventional cohort were compared using Mann–Whitney U test and chi-square test. Patients fulfilling the CWP1990 criteria were compared to patients fulfilling CWP2019 criteria. The groups were compared by clinical baseline data and questionnaire data with Mann–Whitney U test and Pearson’s chi-square test.Statistical analyses were carried out using SPSS Statistics 26 software, IBM, USA. The significance level in the analyses was set to < 0.05, and non-parametric methods were used since many of the variables were not normally distributed. The normality of the data was tested with Shapiro–Wilk normality test. Comparisons were made between patients with and without CWP2019 at baseline using Mann–Whitney p < 0.3 were then included in multiple logistic regressions for having CWP2019 at follow-up [To investigate factors associated with fulfilment of CWP1990 criteria and CWP2019 criteria at 6-year follow-up, a multiple regression controlled for study cohort, gender, age, disease duration and VAS pain at inclusion was also performed. To investigate the association of FABQPA, AUDIT-C and physical activity on CWP2019 in the tight control cohort, univariate logistic regressions were performed with these variables as well as gender, age, disease duration and VAS pain at inclusion. Variables with ollow-up . ThereafTables p = 0.026). For CWP1990, the prevalence was 27% in the tight control cohort and 31% in the conventional cohort (Table p = 0.058) . The HAQ was also significantly lower in the tight control cohort with a median of 0.0625 compared to 0.375 in the conventional cohort (p = 0.018)  compared to 30  in the conventional cohort . No patients were treated with bDMARD, and 69% vs. 71% in the tight control group and conventional group were treated with methotrexate, respectively. The patients did not report their pharmacological treatment in the questionnaire at 6-year follow-up. However, the clinical data from the 2-year follow-up shows that 84% of patients in the tight control cohort and 86% in the conventional cohort had methotrexate as a part of their pharmacologic treatment. Similarly, 8% of the tight control cohort and 9% of the conventional cohort were on bDMARD at the 2-year follow-up. More combination therapy with csDMARDs was used in the tight control cohort with 21% of patients on combination therapy vs 8% in the conventional cohort (p = 0.010). The tight control cohort also received more glucocorticoids at 2 years, 39% vs 18% in the conventional cohort (p = 0.002).At inclusion, there were no differences in pharmacological treatment between the groups (n = 52) than the more stringent CWP2019 (n = 31) (Table p = 0.073)  Table . There w1) Table . The pat3) Table .Table 4BTo investigate factors associated with having CWP1990 and CWP2019 at 6-year follow-up, multiple logistic regressions were performed with patients from both cohorts. The odds ratio for patients in the conventional cohort of having CWP2019 was 2.57 (95% CI 1.02–6.50), compared with the patients in the tight control cohort (Table p = 0.049) when adjusted for alcohol use, duration and VAS pain at inclusion (Table A high score (≥ the median 8) on the FABQPA, indicating a fear-avoidance behaviour concerning physical activity at follow-up, was associated with also having CWP2019 but not with having CWP1990. In the multivariate model, the odds ratio for patients with high FABQPA to have CWP2019 was 10.66 (95% CI 1.01–112.14, In this 6-year follow-up study, patients in a tight control cohort with monthly clinical visits the first 6 months had less CWP2019 6 years later than patients in a conventionally managed cohort. The odds ratio for having CWP2019 after 6 years if participating in the conventional cohort was more than twice as high compared to being in the tight control cohort, when adjusted for gender, age, disease duration and VAS pain at inclusion. The same pattern could not be seen in the odds ratio for CWP1990. The more stringent CWP2019 criteria include patients with more widespread pain since CWP in the older 1990 definition can be fulfilled with as little as 3 painful regions. Pain can affect physical function, but there were no differences in HAQ between those reporting CWP2019 or not in this study. However, worse physical function could be caused by pain with and without inflammation . There aInterestingly, no patients in the tight control cohort reported a diagnosis of FM at 6-year follow-up, although previous studies have shown a prevalence of FM around 20% in RA patients , 13. HowMany studies have shown that early intensive treatment is important for the achievement of remission, but can the same apply for development of chronic pain , 37? In The limitations of the present study are of course the lack of randomization to tight control or conventional follow-up, as well as the fact that the two cohorts were included during different time frames. This could potentially affect their pharmacological treatment, but at least at the 2-year follow-up, both cohorts had similar proportions of patients on methotrexate and bDMARD. In this study, we only had baseline pain in the form of VAS pain. It would have been an advantage to have a baseline record of CWP to better describe development of CWP longitudinally in the two cohorts.The strengths of the present study are the fact that we have two cohorts of early RA patients, both included during the biological era of RA treatment and both followed at the same clinic, but with different follow-up schemes the first 6 months. Both cohorts received a questionnaire with the same pain mannequin to investigate the prevalence of CWP and fibromyalgia 6 years after disease onset. To our knowledge, CWP development in tight control management of early RA has not been studied previously.There is a need for future research in the field of CWP, especially longitudinally studies to investigate further what can be done to prevent CWP and fibromyalgia in RA patients, especially since more recent studies in the biological era demonstrates that chronic pain is still a problem for many RA patients , 40. TheTo conclude, we here demonstrate that tight control management of patients with early RA have a positive potential to reduce the prevalence of the more stringent CWP2019 and that RA patients with a fear-avoidance behaviour towards physical activity are at increased risk of having CWP2019. Early efforts by the rehab team to promote physical activity in patients with a fear-avoidance behaviour could be a valuable addition to a tight control management of early RA patients.