In the absence of an interdisciplinary service for pediatric chronic pain in Manitoba, pain management has been offered through a single provider outpatient setting with consultative services from physiotherapy, occupational therapy, and psychiatry since October 2015.The aim of this study was to characterize the patient population of this clinic to understand needs and inform future service development for pediatric chronic pain.Demographics and disease characteristics of all patients seen in this clinic between October 1, 2015, and February 28, 2019, were analyzed retrospectively from electronic medical records.A total of 157 patients, mean age 13.1 (sd ±3.0) years, 75.2% female, with a median duration of pain of 20.5 (interquartile range [IQR] = 10.0–45.8) months at their first visit were included in the study. At baseline, 74.0% of patients experienced insomnia, 76.6% fatigue, 86.5% symptoms of anxiety, and 58.69% symptoms of depression; 80.1% showed withdrawal from physical activity, 67.1% missed school, and 10.2% reported opioid usage. Throughout their care in clinic, 83.4% of patients received physiotherapy, 17.8% occupational therapy, 49.7% mental health support, and 51.6% care from multiple services. The clinic experienced a significant increase in median referrals from 1.0 to 5.0 (IQR = 2.0–9.0) per month and wait time from 35.0 to 97.0 (IQR = 88.0–251.0) days during the observation period.Developing an interdisciplinary service for pediatric chronic pain will provide an opportunity to improve access, coordination, and comprehensiveness of care and to employ culturally sensitive services to improve care for children and youth living with chronic pain in Manitoba and possibly other jurisdictions with similar demographics and needs. Collaborations were developed to include consultative services from physiotherapy, occupational therapy, and psychiatry.The objective of this study was to characterize the patient population of this single-provider clinic to understand Manitoba’s needs for pain management and guide the planning of an interdisciplinary service to provide the standard of care to Manitoban children and adolescents living with chronic pain.A retrospective review of electronic medical records of the clinic for chronic pain in children and adolescents at Children’s Hospital of Winnipeg was conducted in 2019. The chart documents included information received by the pain clinic such as referral letters and reports from consulted health care services and information documented in the pain clinic. Ethics approval was granted by the University of Manitoba ethics board (H2019:161 (HS22796)). An informed consent waiver was accepted 90 following the Canadian Tri-Council Policy Statement “The research involves no more than minimal risk to the subjects.”12Children’s Hospital of Winnipeg is the sole referral center for subspecialists for pediatric patients in Manitoba, Northwestern Ontario, and parts of Nunavut, Canada. The clinic for pediatric chronic pain was held one half-day a week by a single provider who by training is a pediatric rheumatologist. The clinic received referrals directly from primary care providers and pediatric subspecialists; the pain clinic provider and the second staff pediatric rheumatologist also identified patients with chronic pain who were initially referred to the rheumatology clinic to exclude a rheumatologic disease and referred them to the pain clinic. All patients referred to the clinic were triaged and seen by the pain clinic provider. Referrals for a diagnosis of complex regional pain syndrome were deemed as urgent and usually seen within 1 to 2 weeks as per recommendations of the International Association for the Study of Pain (IASP) on wait times.Nursing was available to measure youth’s vital signs in new patients. A physiotherapist (K.W.) and an occupational therapist (D.H.) were available to accept direct referrals and provide care during clinic visits on an on-call basis. For about 12 months a psychiatrist (P.A.) was available through the Consultant Liaison Service of Children’s Hospital and provided care during clinic visits. If allied and mental health services were unavailable in clinic and/or close follow-up was needed in the community, patients were referred to respective services affiliated with Children’s Hospital or to community public services or recommendations to access private community services were made. Clinic care was coordinated with community-based therapy services as possible.13 patient and family education about chronic pain as a diagnosis in its own right14 and its biopsychosocial model was provided by the physician and allied health providers in clinic at the first and subsequent visits. Further management was based on physical, occupational, and psychological therapies. If indicated, relaxation techniques such as deep breathing were introduced by the physical therapist in clinic. If underlying physical conditions showed active disease, disease-specific treatment was optimized by the caring subspecialist. Primary care providers or subspecialists managed medications for specific pain conditions such as migraines or abdominal pain or for mental health disorders that were started prior to entry in the clinic. If indicated, pharmacological treatment for a mental health disorder was initiated or optimized after a more in-depth assessment by the psychiatrists of the Consultant Liaison Service or by the adolescent medicine specialists of Children’s Hospital in close collaboration with the pain clinic.During the initial clinic visit, a complete history and comprehensive physical exam were conducted. If a main diagnosis of chronic pain was not confirmed or differential diagnoses were not fully considered prior to entering the clinic, further diagnostics were initiated as appropriate. In keeping with recommended practice,A treatment plan was developed together with the patient and their family during the first visit. Follow-up visits were made as required.14 All patients referred to the clinic from October 1, 2015, with a first visit on or prior to February 28, 2019, who fulfilled these criteria were included in the study. Following the 2016 census data of Statistics Canada,15 Manitoba has a population of almost 1.3 million people; 19% were under the age of 15 years, about 18% were immigrants, and about 18% of the population reported an Indigenous identity. The catchment area of the clinic encompassed large, medium, small, and rural communities, including remote communities16 throughout Manitoba, Northwestern Ontario, and parts of Nunavut, Canada.The clinic accepted referrals for patients who fulfilled the following criteria for chronic pain: (a) onset of pain before 17 years of age, (b) pain persisting >3 months, and/or (c) pain whose biological etiology could not be determined by standard biomedical assessment and imaging.The child’s intake and follow-up history was taken by the pain clinic physician by using open-ended, nonstandardized questions. The child was preferably addressed during the interviews; the caregiver was invited to provide their perspectives as appropriate. The intake interview was comprehensive as outlined below; the interim history at follow-up visits focused on symptoms and major concerns that arose from the intake or previous follow-up visit(s) as well as on daily functioning, pain-alleviating factors, and evaluation and coordination of ongoing or further necessary therapies.During the intake visit, the history about the child’s pain included the circumstances before and at pain onset such as acute illnesses and injuries; time of onset; pain duration and frequency; location; character; accompanying symptoms such as tingling, numbness, and light-headedness; aggravating and alleviating factors; previous diagnostics; and previous and current pharmacological, alternative, physical, and psychological therapies.Across patients, symptoms of insomnia, fatigue, anxiety, mood disorders, and daily functioning were assessed using similarly formulated introductory questions; typical questions were as follows: (1) Sleep: “How is your sleep?” (2) Fatigue: “Do you feel tired or exhausted during the day?” (3) Anxiety: “Do you get easily nervous?”; “Do you worry about some things?” (4) Mood: “How is your mood?” (5) Daily functioning: “How is school for you?”; “Do you participate in any sport?”; “What is your favorite activity for fun?” Depending on the responses, in-depth questions followed and allowed for an open talk about sleep , fatigue (including daytime napping), symptoms of anxiety , mood , daily functioning , and possible adverse childhood events prior to or around the onset of pain.no pain and 10 = the worst pain imaginable. Similarly, fatigue scores were captured on a 21-point NRS with 0 = no fatigue and 10 = the worst fatigue imaginable. A defined timeline for the minimum and maximum pain and fatigue scores such as “last 7 days” was not consistently used. Proxy scores were only taken for children younger than 6 years of age or for children with respective developmental delay.Patient self-reported pain scores were captured on a 21-point numeric rating scale (NRS) with intervals of 0.5, with 0 = Symptoms were documented in the patient’s note and summarized in the problem and diagnoses section of the note.The social history captured also living circumstances such as household members and caregiver relationship and employment. A standardized list of conditions was used across patients to assess the medical family history; this list comprised physical, mental health, and pain disorders.Data were collected from electronic medical records by an independent investigator (A.L.); data and coding of 1/10 charts were validated by a second investigator (K.G.). Data extracted included referrer specialty; referral and visit dates; patient demographics; history of pain and accompanying symptoms, including symptoms of insomnia, fatigue, anxiety, and depression; and functional limitations including withdrawal from physical activity and school. Symptoms documented in the history and impression section and in the problem list of the patient’s note were compared and further validated with the physician in case of inconsistency before being coded as being present for data extraction. Medications and services used for disease management prior to and during clinic enrollment and past medical and family history were recorded.17 and analyzed using the Statistical Package for the Social Sciences v25.18 Descriptive measures applied depended on the data distribution. Kruskal-Wallis analysis was used to compare referral frequency and wait time over the observation period from 2015 to 2019; the significance level was set with α = 0.05.Data were entered into REDCapData for patients who did not attend the clinic were only included in referral frequency and wait time analyses. To avoid generating artificially low wait times, patients referred by the pain clinic provider out of her rheumatology clinic were excluded in the wait time analysis, because she covered the first clinic visit in her rheumatology clinic and booked the patient as a follow-up visit into the pain clinic. To be transparent, we calculated the wait time between the referral and the first originally booked appointment as well as the wait time between the referral and the actual first visit a patient attended. Wait times between the referral and the originally scheduled appointment versus the actual first visit differed if a patient (a) did not attend their originally scheduled first appointment but was rebooked after a follow-up call by the clinic, (b) had called in advance and rebooked their first appointment, or (c) was rescheduled on the initiative of the clinic.A total of 181 patient charts were screened; 13 were excluded because the time of the referral was outside the study period and 2 because their diagnosis did not meet the inclusion criteria. Of 166 patients triaged and booked into the clinic, 9 patients did not attend the clinic at any time. These 9 patients had a mean age of 12.3 years old (SD ±3.3); 6 were females; they were referred from five specialties. Six of these patients were referred for management of musculoskeletal pain, 1 for abdominal pain, and 2 for pain in several locations. Four patients were from large communities, and 4 patients were from small and rural communities; 1 patient could not be located. A total of 157 patients attended the clinic between October 1, 2015, and February 28, 2019.P = 0.036).The number of referrals to the clinic increased significantly during the observation period with a median of 1.0 per month in 2015, 2.5 (interquartile range [IQR] = 2.0–4.0) per month in 2016, 5.5 (IQR = 2.8–7.8) per month in 2017, and 5.0 (IQR = 2.0–9.0) per month in 2018 (n = 7) days for patients seen in 2019 (P = 0.012). The increase in wait time between the referral date and the initially scheduled first appointment was similar, from 35.0 days in 2015 to 88.5 (IQR = 80.5–100.3) days in 2019 (P = 0.008).Of the 166 triaged patients, 67.5% were referred by pediatric subspecialists affiliated with Children’s Hospital . Thirty-The mean age of the 157 patients seen in the clinic was 13.1 (SD ±3.0) years; 75.2% were female . More thPatients were experiencing pain for a median of 20.5 (IQR = 10.0–45.8) months at baseline , with maMusculoskeletal pain was the most common main pain type (72.6%), followed by abdominal pain (17.1%), headaches (8.9%), chest pain (0.6%), and pain in other locations (0.6%); patients experienced pain in a median of 2.0 (IQR = 1.5–3.0) different locations. Accompanying symptoms of insomnia, fatigue, anxiety, and/or depression were reported by 84.7% of patients during their first clinc visit; 84.0% of patients experienced at least one domain of functional impairment .Thirty-four percent of patients reported ongoing physical health concerns. Seven patients (4.5%) reported acute illnesses that had resolved by their first visit. Thirty-four patients (21.7%) were noted in the referral letter to have at least one mental health diagnosis or reported such a diagnosis during their intake visit; among them, 17 patients (10.8%) were documented to have an anxiety disorder, 10 patients (6.4%) a depressive disorder, 5 patients (3.2%) attention deficit hyperactivity disorder, and 12 patients (7.6%) self-harm behavior and/or a previous suicide attempt. One-third of patients reported potential psychosocial stressors at their first visit ; howeverPrior to their first clinic visit, 143 (91.1%) patients reported usage of at least one medication. Among them, 100 (69.9%) patients reported use of nonsteroidal anti-inflammatory drugs, 51 (35.7%) acetaminophen, 31 (21.7%) antidepressants, 16 (11.2%) opioids , and 8 (5.6%) gabapentin; in addition, 5 (3.5%) patients reported use of medical cannabis.Prior to their first visit, 23.6% of patients received treatment by more than one allied health service. During their period of care in our clinic, 83.4% of patients received physiotherapy, 17.8% occupational therapy, and 49.7% mental health support ; 52.2% rPatients had a median of 2.0 (IQR = 2.0–3.0) visits in the pain clinic; 33 patients (21.0%) were seen only once, and 11 were lost to follow-up. Improvement in symptoms was documented in about one-third of patients at discharge .Figure In the absence of an interdisciplinary pediatric pain clinic in Manitoba, we aimed to characterize the patient population of our single-provider pain clinic to understand the needs and inform the planning of an interdisciplinary provincial service to provide the standard of care to Manitoban children and adolescents living with chronic pain.14 Those clinics have been shown to be effective in lowering pain, improving function including school attendance, and being cost-effective.20 Widely discussed barriers of implementing such a service include a lack of clearly defined admission criteria and distinct treatment approaches particularly for children’s pain, limited resources, competing demands, and payment structures.21 Similar to other international jurisdictions, the information from this study may aid in understanding our province’s unique needs and help to guide advocacy and planning for a provincial interdisciplinary service for chronic pain in children and adolescents.22IASP, the Canadian Pain Society, and the national action plan for pain in Canada, endorse the need for interdisciplinary clinics to treat chronic pain in adults and children using a functional rehabilitation approach.22 most patients with chronic pain referred to our clinic were adolescent females experiencing pain for over a year before entering the clinic, as well as mental health concerns, functional impairment, and exposure to potential psychosocial stressors. Further research on the longer symptom duration prior to treatment in males in our cohort will need to consider sex and gender differences in pain perception, illness behavior, and cultural and social viewpoints of patients and providers.23Comparable to other regions,8 is likely related to a pediatric rheumatologist running the clinic. A greater awareness of the pain clinic within the province’s pediatric tertiary care facility may explain why most patients were referred by subspecialists working in the same facility. Practice and referral patterns of these subspecialists likely affected characteristics of the patient population referred to the pain clinic.That more patients cited musculoskeletal pain as the main pain type compared to headaches and abdominal pain in other centers24 The significant opioid usage in our pediatric clinic population may reflect the burden of pain and the lack of resources for pain management. A recently found decline in opioid prescriptions in adult patients with fibromyalgia was attributed to opioid monitoring programs, rising awareness of the addictive and harmful effects of opioids, and the growing evidence of nonopioid therapies that are effective in treatment of chronic pain.25 However, functional rehabilitation programs have been shown to reduce opioid usage in patients who were taking opioids when they entered such a program.26 Whether a functional rehabilitation approach through an interdisciplinary pain service will help reduce opioid usage in our children and adolescents experiencing chronic pain will need to be evaluated.In our cohort, 91.1% of patients reported the use of at least one medication at their baseline visit, among whom 11.2% reported the use of opioids. A very recent population-based study on management of chronic non-cancer musculoskeletal pain showed that opioids were rarely prescribed for children and adolescents under the age of 18 years but in 22.9% of visits of young adults of over 18 years of age.15 The coexistence of anxiety in younger children and depression in older children/adolescents with chronic pain is well described in the literature.28 Mental illness in youth with chronic pain is more likely associated with functional impairment, such as limited school attendance.5 In our clinic, 84.0% of patients presented with symptoms of insomnia, fatigue, anxiety, and/or depression; a formal mental health diagnosis was not made without involvement of psychology or psychiatry services. Almost half of our patients (48.4%) did not receive mental health support at any time prior to or during their clinic enrollment; unfortunately, we did not document the proportion of patients on a wait list or denied enrollment into the service. The relatively high proportion of 32.5% of patients seen by psychiatry was related to the availability of our colleague from the Consultant Liaison Service during clinics and the overall shorter wait times to psychiatry compared to psychology services.About 15% to 25% of Canadians experience mental illness prior to the age of 19 years.29). Though our pain service functioned to support timely communication between providers , the constraints of a half-day clinic with services provided through consultation lessened the chances for consistent messaging and integrated planning with families. Reflecting these challenges, our clinic discharged only about a third of its patients due to improvement of symptoms; however, about a quarter of patients continued therapy beyond the study period.Treatment challenges without mental health and rehabilitation services consistently available in clinic included additional wait times for patients referred to these services  of our patients were living in small, rural, and remote communities. Further, even though a small number in total, four of nine patients who never showed to our clinic were from small and rural communities. Small, rural, and remote communities in Manitoba may have limited access to health care services such as physical therapy and mental health services; visiting health care facilities providing these services may be difficult due to availability of transportation and/or harsh weather conditions. A particular challenge for a provincial pediatric pain center will be service coverage of these areas. Outreach clinics, virtual care, and the Extension for Community Healthcare Outcomes model to educate frontline health care providers in pain management have been developed and may improve access, outcomes, and service use of a pediatric pain center with its main location in the capital.15 Our clinic population of 8.6% Indigenous peoples may reflect the fact that the clinic was relatively unknown to community providers. This discrepancy may also reflect the multiple barriers to accessing health care for Indigenous peoples that exist because of systemic racism and colonialism34 rather than a lesser pain prevalence.35 Cultural competence, cultural relevance, safety, and equity in access to care must be an integral part of a future interdisciplinary pediatric pain clinic in Manitoba.Patient demographics differed from the Manitoba population particularly concerning its Indigenous population. About 18% of the Manitoba population are Indigenous peoples.8 The median wait time for a new assessment in pediatric pain clinics in Australia has been estimated with 32.5 days.36 The wait time in our clinic was increasing from 35.0 days (or 1.2 months) in 2015 to 97.0 days (or 3.2 months) for patients seen in 2019. The relatively lower wait time compared to the current average of Canadian pain clinics was likely related to the clinic being relatively unknown. The IASP-recommended wait time is 8 weeks at the most.12 The wait time experienced by families in this cohort has been above this indicator since 2017. The increase in referrals and subsequently wait time likely demonstrates an increased awareness of the clinic and mirrors the demand of such a service in Manitoba with its total population of about 300,000 children up to the age of 17 years.16 The increasing demand must be considered when planning clinic hours and staffing for a provincial center.The estimated median wait time for a first appointment in publicly funded adult and pediatric pain centers in Canada is 6 months.37 A review on implementation of these domains in recent research showed that only the domain of pain intensity was consistently used as outcome measure.38 Due to the limited uptake of these suggested domains, a revised core set of outcomes for clinical trials in pediatric chronic pain clinics was suggested very recently.39 The mandatory domains of the core set included pain severity, pain interference with daily living, overall well-being, and adverse events; optional domains were emotional functioning, physical functioning, and sleep. During intake visits, the content of these domains was captured in our clinic by assessing pain intensity and limitations due to pain, social and mental well-being, sleep and fatigue, daily functioning, and psychosocial stress factors including childhood adverse events. However, we used nonstandardized, open-ended questions, and follow-up visits included these areas only as indicated from the intake visit or previous follow-up visits or if new concerns were voiced by the patient or caregiver. Therefore, one major limitation of our study is the retrospective nature with visits being not standardized. Consequently, questions were not consistently asked the same way or asked at all to every patient; resulting missing values may have limited the study’s internal validity. To address the lack of standardized outcome measures in our clinic, we envision incorporating validated patient reported outcomes of the pan-Canadian pediatric pain registry as key initiative to inform the next iteration of our program.40 In conclusion, our data suggest a demand for a service for children and adolescents living with chronic pain throughout the province of Manitoba and its catchment area of neighboring provinces. Such a service will ideally comprise a team of dedicated physicians, nurses, physiotherapists, occupational therapists, psychologists or psychiatrists, and social worker with expertise in family therapy available for all patients entering the clinic. Developing a pediatric clinic for chronic pain following such an interdisciplinary, rehabilitative model will provide an opportunity to improve coordination and comprehensiveness of care, to implement culturally sensitive services, to increase access to care in rural and remote communities, to aim for suitable wait times to improve care for children and adolescents living with chronic pain, and to reduce costs related to health care utilization in pediatric chronic pain.19 Whether such a clinic will reduce the transition of pediatric to adult chronic pain or opioid use in adulthood remains to be seen.In 2006, the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials identified eight core outcome domains for clinical trials and registries in pediatric chronic pain, including pain intensity, physical functioning, symptoms/adverse events, global satisfaction with treatment, emotional functioning, role functioning, sleep, and economic factors.


The Lichtenstein hernioplasty has long been seen as the gold standard for inguinal hernia repair. Unfortunately, this repair is often associated with chronic pain, up to 10–35%. Therefore, several new techniques have been developed, such as the transinguinal preperitoneal patch (TIPP) and the endoscopic total extraperitoneal (TEP) technique. Several studies showed beneficial results of the TIPP and TEP compared to the Lichtenstein hernioplasty; however, little is published on the outcome when comparing the TIPP and TEP procedures. This study aimed to evaluate outcomes after the TIPP vs the TEP technique for inguinal hernia repair.A single-center randomized controlled trial was carried out between 2015 and 2020. A total of 300 patients with unilateral inguinal hernia were enrolled and randomized to the TIPP- or TEP technique. Primary outcome was chronic pain (defined as any pain following the last 3 months) and quality of life, assessed with Carolinas comfort scale (CCS) at 12 months. Secondary outcomes were: wound infection, wound hypoesthesia, recurrence, readmission within 30 days, and reoperation.A total of 300 patients were randomized (150 per group). After a follow-up of 12 months, we observed significantly less postoperative chronic groin pain, chronic pain at exertion, wound hypoesthesia, and wound infections after the TEP when compared to the TIPP procedure. No significant differences in quality of life, reoperations, recurrence rate, and readmission within 30 days were observed.We showed that the TEP has a favorable outcome compared to the TIPP procedure, leading to less postoperative pain and wound complications, whereas recurrence rates and reoperations were equal in both the groups. Inguinal hernia repair is one of the most commonly performed surgical procedures worldwide with approximately 20 million cases every year , 2. The Between February 2015 and December 2020, patients with unilateral primary inguinal hernia were enrolled for participation and included patients were randomized, either for the TIPP or TEP. Patients younger than 18 years of age and patients with recurrent or bilateral hernias were excluded. Cases in which preperitoneal surgery had previously been performed were also excluded.The TIPP technique involves a standard anterior inguinal approach, with high dissection and preperitoneal reduction of the hernia sac through the internal ring. Blunt dissection of the preperitoneal space is carried out using one finger or large dissection gauze through the internal ring. Subsequently, the preperitoneal space is extended deep towards the epigastric vessels and transverse fascia in the direction of the pubic tubercle. The hernia patch is introduced in the preperitoneal space through the internal orifice. External oblique aponeurosis repair was performed superficial to the spermatic cord to restore normal anatomy. In this study, we used a 16 × 9.5 cm Polysoft™ BARD Hernia Patch with memory ring .The TEP technique is performed using a subumbilical port for retromuscular and preperitoneal access. Carbon dioxide is insufflated to a pressure of 10 mmHg. Two 5-mm trocars are placed in the midline or one trocar in the midline and the other laterally in Bogros’ space. The hernia sac was reduced and the peritoneum mobilized to expose the triangle of doom  and laterally to the Bogros’ space. An unfixed non-absorbable 15 × 12 cm mesh  was placed to cover the inguinal and femoral areas.Primary outcome was chronic pain as assessed with the VAS score  and defined as any pain following the last 3 months. Pain was classified as mild pain (VAS 10–30), moderate (VAS 40–60), or severe (VAS > 60) . Qualityα = 0⋅05, power of 90%). With an anticipated dropout rate of 33%, 150 patients were to be included in each group. The allocation ratio was 1:1. The randomization sequence used for the allocation of patients was created. The randomization took place when the patient was scheduled for operation. The patient was informed of the allocated procedure and surgeons were informed about the study and the enrollment of patients.The sample size was based on the hypothesis that 5% of the patients having TEP  and 10% ® Statistics version 25 . Mean and standard deviation was given in evenly distributed results, whereas median and interquartile range (IQR) was given in unevenly distributed results. Categorical variables were analyzed using Fischer’s exact test (2-sided). The absolute risk reduction (ARR) is the arithmetic difference between the rates in the TIPP vs TEP procedure, thereby calculated by: ARR = event rate in the TIPP group − event rate in the TEP group. The number needed to treat (NNT) is the number of patients one needs to treat to prevent one additional chronic inguinal pain patient. The NNT is calculated by 1/ARR. A p value < 0.05 was considered statistically significant.Statistical calculations were done with IBM SPSSThe trial was approved by the Regional Ethical Review Board in Amsterdam, The Netherlands, and informed consent was signed by all the patients.A total of 300 patients were included, 150 for the TIPP and 150 for the TEP procedure. At 1 year, 80% of the patients responded to the questionnaire, leaving 122 patients in the TIPP group and 117 patients in the TEP group    Fig. . More in05) Fig. . Furtherp = 0.63) and also movement limitations were not statistically different between the TIPP and TEP .Besides chronic pain, no statistical differences were found in quality of life between the TEP and TIPP after 12 months. Overall, mesh sensation was similar . Also, lesser wound infections were seen after the TEP , where infections were mainly caused by superficial wound infections  and deep wound infections were rare (TEP 0% vs TIPP 0.8%)  Table .Table 2Cp = 0.28). The latter, leading to additional operative treatment in two patients for both groups (1.7% and 1.6%). In total, three patients in the TEP group and five patients in the TIPP procedure went for reoperation   and six patients after the TIPP procedure (4.9%, This study indicates that patients with inguinal hernias have less chronic groin pain after the TEP procedure than after the TIPP. The difference in the proportion of postoperative chronic groin pain in the two groups appears to be clinically important, given the effects on QoL and the need for additional treatments –27.It has previously been thought that nerves are protected from contact with mesh during preperitoneal procedures; however, a Mesh placed in the preperitoneal space might abut the genital branch of the genitofemoral nerve, depending on the exact location of the prosthesis . Chen etIn addition to this, we hypothesize that the difference in approach between the TIPP and TEP might explain the difference in postoperative chronic pain after the TIPP vs TEP. The approach of the TEP procedure involves a subumbilical incision and two incisions placed in the midline or one in the midline and the other laterally in Bogros’ space, while the open anterior inguinal approach during the TIPP procedure provides access to the internal inguinal ring by dissecting through the abdominal wall. Given the anatomical location of the ilioinguinal and iliohypogastric nerves in the abdominal wall at this region, we consider that the ilioinguinal and iliohypogastric nerves are at risk for unintentional damage during the open anterior approach and unlikely during the TEP approach , 13.In our study, we observed no statistically significant differences in recurrence rates. This was in line with other studies, where the specific operation technique does not influence recurrence rates , 30, 31,This randomized controlled trial revealed significantly better results in postoperative chronic pain after 12 months for the TEP procedure as compared to the TIPP procedure for inguinal hernia repair, whereas we observed no significant differences in: recurrence, readmission within 30 days, or reoperation.


P < .05), extension ROM (P < .01), and SLR height (P < .05) while MM treatment did not. Both treatments significantly decreased the values of VAS, Oswestry disability index, and Patient Health Questionnaire-9 (P < .01). Compared to the MM treatment, the FSM treatment showed a much more significant improvement in VAS score (P < .01), range of motion of extension (P < .01), and SLR of both sides (P < .05). At the 1-year follow-up, VAS scores in both groups decreased significantly compared to pretreatments; however, there was no significant difference between the 2 groups. Our data suggested that the FSM treatment can provide better efficacy than MM in CNLBP patients, improving the VAS scores, lumbar extension ROM, and SLR height in a shorter time.Feng spinal mobilization (FSM) is one of the most widely practiced techniques in traditional Chinese osteopathy, especially in China. However, whether this FSM technique is more effective than the Maitland posteroanterior mobilization (MM), which is widely used all over the world, is still unknown. The purpose of this study was to retrospectively analyze and compare the efficacy of these 2 treatments in patients with chronic nonspecific low back pain (CNLBP) as to provide a basis for the clinical treatment of chronic low back pain. A total of 83 patients, including 43 patients in the FSM group and 40 in the MM group, were enrolled in this cohort study. FSM or MM was performed on patients 3 times during a period of 2 weeks. Changes in the subjective and objective measurements were measured before and after the third treatment. The subjective symptoms recorded included the visual analogue scale (VAS), Oswestry disability index, and Patient Health Questionnaire-9. The objective symptoms, including the lumbar range of motion (ROM), and straight leg raise (SLR) height were also checked for any changes. The VAS scores were reassessed at the 1-year follow-up visit. The results showed that 2 weeks of FSM treatment significantly improved CNLBP patients modified Schober test ( Chronic nonspecific low back pain (CNLBP) is defined as lumbar pain persisting for longer than 3 months with no suspected pathology. It is reported that up to 84% of people have experienced low back pain at some time in their life, and the incidence of CNLBP reached 23%. In addition, CNLBP has many adverse effects on patients, including pain, dysfunction, and even disability which can seriously affect patients quality of life and social participation.Low back pain is one of the most prevalent diseases of the skeletal muscle system in the adult population worldwide. which might be due to complex interactions among the biological, psychological, and social factors. It is proven that one of the key pathomechanisms of CNLBP is sensitization of the nervous system. Structural and functional changes in the brain have also been identified in CNLBP patients. Studies have shown that white and gray matter regions, such as the dorsolateral prefrontal cortex, thalamus, temporal lobes, insula, primary somatosensory cortex, change in the brain of CNLBP patients, and suggesting that CNLBP may have an association with the structural reorganization of the brain. Besides, alterations in the blood flow and metabolism also indicate changes in brain functions.Compared to the defined pathology of LBP, the pathologies of CNLBP are relatively less remarkable, In recent guidelines and reviews, evidence has confirmed mobilizations as an effective treatment and has had a positive effect. Notably, all manual techniques have more pronounced neurophysiological and less mechanical effects than previously thought. In fact, mobilization techniques can promote sympathoexcitation, decrease mechanical hypoalgesia, and normalize muscle activity via the central pathway. It can also stimulate the myelinated alpha-beta and alpha-delta fibers to transmit impulses faster, thereby inhibiting the pain symptoms via altered signal transmission through C fibers. Additionally, mobilization can inhibit pain by increasing endorphin secretion. In summary, the neurophysiological and biomechanical mechanisms and the interaction between them can explain the reason for the effectiveness of the spinal mobilization despite its implementation heterogeneity.Spinal mobilization, a frequently used conservative manual technique for CNLBP, is defined as low-velocity, nonthrusting, and passive movement within or at the limit of the joint range of motion.Among all the mobilization techniques, Feng spinal mobilization (FSM), Maitland posteroanterior mobilization (MM) are widely used techniques in China and around the world. The FSM technique is performed when the patient is in a seated position. One of the therapist hands holds the patient superior shoulder to stabilize and rotate the lumbar spine, while the therapist thumb of the other hand applies gentle pressure to the specific spinous process and correct its deviation so as to relieve the postarticular joint capture. No cracking sound is produced during this technique. This technique has the advantage of quick response and has been proven effective for people with low back pain and leg pain due to lumbar disk herniation. However, evidence of its effectiveness on CNLBP is still insufficient. According to the theory of Professor Feng, the founder of FMS, this technique can correct the minor positional faults of the vertebrae and joints, which lead to neuromuscular disorders. Recently, FSM has been shown to alleviate pain by regulating the TRPV4/NO pathway in the dorsal root ganglion neurons, indicating the neurophysiological involvement in the FSM mechanisms.FSM is traditional Chinese osteopathy that is still popular in China today. It was created by professor Feng Tianyou in the 1970s. It is performed when the patient is in a prone position. Passive and posterior-anterior oscillation forces are given by the therapist to the affected spinal vertebrae to improve neuromuscular pain and stiffness. The MM regulates the neurophysiological mechanisms. It has been revealed that nonsegmental hypoalgesia and sympathoexcitation appear after the MM treatment, indicating the involvement of the central nervous system in suppressing pain symptoms. And an increase in the nociceptive flexion reflex suggests alterations in the spinal cord excitability.MM has been widely recognized all over the world. psychological state, and range of motion in patients with CNLBP. Consequently, this study aims to provide evidence for the clinical treatment of CNLBP.Until now, there have been no studies comparing the efficacy of these 2 treatments for CNLBP, so which method has better short-term and long-term results is still unknown. Hence, this study aims to compare the effects of the FSM and MM on pain, back pain-related functional disabilities,:This is a retrospective cohort study. Between September 2020 and September 2021, outpatients diagnosed with CNLBP in the Beijing Friendship Hospital, Capital Medical University with the following eligibility criteria were studiedMales and females ages between 18 and 68 years old; Suffering from low back pain for more than 12 weeks; With or without leg pain above the knee; Pain on the visual analogue pain scale (VAS) ≥ 2/10; In clinical practice, patients randomly received FMS or MM, and they all received exercise therapy.Patients with any of the following symptoms were excluded: spinal cord and nerve root compression irritation, spinal cord and nerve root tumors, cauda equina injury and other neurological pathology symptomatic period; spinal pathology including spinal tumors, fresh fractures of spinal vertebrae and accessories, severe osteoporosis, and spinal instability; cardiovascular diseases including severe hypertension, cardiovascular disease symptomatic period, and aortic aneurysm; metabolic diseases; recovery from larger surgical operations; acute infection or pregnancy. The study was approved by the institutional ethical committee of Beijing Friendship Hospital, Capital Medical University, Beijing, China (Ethics Number: 2022-P2-190-01). All participants signed the informed consent before the data collection.In clinical practice, patients randomly received either FMS or MM, and all of the patients received the same exercise therapy. That is, each treatment session consists of FMS and exercise, or MM and exercise. In addition, patients were treated once every 4 days for 40 minutes at each treatment session. Each patient received a total of 3 treatment sessions during a period of 2 weeks.Measurements were taken and recorded before the first treatment and immediately after the third treatment. The outcome measures were assessed by another therapist who was not involved in treatment and was blind to which treatment the patient received. Telephone follow-ups were conducted on patients pain scores 1-year after the end of the third treatment. It was developed by Professor Feng Tianyou in the 1970s. This technique was performed on a deviated lumbar vertebra with a minor positional fault diagnosed by clinical examinations. Different from other mobilization used, this technique is conducted in a sitting position rather than a prone position. The therapist pushes against the spinous process of involved segments from behind with the thumb of 1 hand, and the other hand holds the opposite shoulder from the front of the body and slowly rotates the lumbar spine so as to get the apex of the rotational torque to reach the involved segments, then slowly returns the patient returned to the neutral position. The same procedure is repeated by rotating in the opposite direction to complete the mobilization  assesses the impacts of low back pain or leg pain on physical function and activities of daily living. There are 11 questions in the questionnaire, and the resulting score ranges from 0% to 100%; the higher the score, the more severe the disability. The PHQ-9 has 9 questions in total, representing 9 symptoms of depression. Each question is rated 0 to 3, the total score is added to equal 0 to 27. The higher the score, the more serious the depression state.PHQ-9 is a widely used scale tool for screening, diagnosing, monitoring, and assessing the severity of depression.The lumbar range of motion (ROM) was measured by the modified Schober test (mSchober test) and finger-to-floor test. Each patient stood with their feet positioned 8 cm apart on a box. A blinded assessor made 2 skin markers, including 5 cm below the lumbosacral junction and 10 cm above the lumbosacral junction. Then, each patient was instructed to actively bend forward as far as possible within the limit before pain and with the knees extended. The change of distance between the 2 skin markers was measured by a tape and recorded. According to other study references, this is an exceptionally reliable assessment for lumbar ROM.The modified Schober test (mSchober test) includes a way to measure the active lumbar flexion ROM. The patient was instructed to stand on a box 20 cm high. First, a tape measure was used to measure the fingertips to the floor. Then the patient was asked to bend forward, reaching toward the floor, and the distance of the fingertips to the floor was measured again. The change in the distance is the flexion ROM of the patient. The extension and side bending ROM was measured in the same way.The fingertip-to-floor test was conducted to measure the patients ROM.The patient was in a supine position. The patient was asked to raise the lower limb actively, then the height of the lateral malleolus to the bed was measured with a tape measure. The SLR test can be restricted by the muscles or nerve tension.t test. Paired t tests were used for comparison within the group before and after the treatment. Any analysis with a P < .05 was considered statistically significant.Data analysis were done using SPSS 20.0 software . Data values were presented in mean ± S.D. The chi-square test was used to compare the sex of the 2 groups. The other demographic characteristics were compared between both groups by independent Eighty-three patients met the inclusion and exclusion criteria and participated in this study. Among all, 43 patients received the FSM approach, and 40 patients received the MM approach. The baseline information collected from both the FMS group and MM group is outlined in Table P < .01), the ODI value was significantly reduced from 26.26%±16.76% to 17.08%±11.70% (P < .01), and the PHQ-9 score was significantly reduced from 6.30 ± 5.42 to 3.07 ± 3.64 (P < .01) (Table P < .05), the extension ROM increased from 5.57 ± 4.06 to 6.87 ± 3.68 (P < .01), the left SLR height increased from 80.03 ± 7.41 to 82.30 ± 5.78 (P < .05), and the right SLR height increased from 80.09 ± 7.91 to 82.04 ± 5.79 (P < .05). Mild improvements in flexion ROM and side flexion ROM was observed after FMS treatment; however, the changes were not considered significant (P > .05) , the ODI value was significantly reduced from 26.94%±14.76% to 20.31%±11.19% (P < .01), and the PHQ-9 score was significantly reduced from 4.80%±5.26% to 3.13%±3.37% (P < .01)(Table P > .05) , extension ROM , left SLR height , and right SLR height . However, no statistically significant differences were found between FSM and MM treatment for ODI score, PHQ-9, the mSchober test, flexion ROM, and side flexion ROM (P > .05) . In the MM group, the VAS score was also significantly reduced from 4.47 ± 1.62 to 1.42 ± 2.06 when compared to pretreatment (P < .01). Although the VAS values decreased more in the FMS group, there was no significant difference in the comparison of changes between the 2 groups  after FSM treatment. The results of MM treatment did not show significant effects on ROM in this study that are consistent with those of Allison and Goodsell.,34 These results are in contrast to those of Lee and Ali.,36 These discrepancies may be explained by the differences in the Initial ROM measurements among the patients. Stamos-Papastamos found that those who have more initial ROM limitations seem to gain more improvement after treatment. Ali found ROM improvement after the MM treatment, the subjects in their study all had initial ROM limitations, and although the patients with CNLBP in our study did not all display initial stiffness. Furthermore, variations in the mobilization time may also help explain the conflicting results. The mobilization protocol differs from 2 minutes to 9 minutes, which resulted in different outcomes.,35,38 Ali found significant increases in lumbar ROM after MM treatment lasting 6 minutes. The 3-minute protocol in our study may not be long enough to cause a significant change. Though no significant objective outcomes were observed, we can still note a trend that some measurements mildly improved when compared with the initial results.Previous studies on the effect of MM on ROM have been controversial. The FMS can improve the VAS scores and the lumbar curve. Zhang found that after the FMS, a patient with LDH had a more symmetrical body shape and improved spinal mobility. Our study confirmed that FSM could remarkably improve the lumbar extension ROM and correct the lumbar joint function. These results may be related to biomechanical reasons because when doing the extension movement, the muscle and ligament around the joint are loose. The joint then glides down, and the pressure in the joint increases, so the extension ROM increase means the joint dislocation is improved. The better result of SLR may be due to the increase in posterior chain neurodynamics and hamstring extensibility. Our study also found a significant improvement in overall pain in the FMS group at the 1-year follow-up. This result is probably because of the correction of misaligned joints by FMS manipulation, which facilitated the recovery of pain.Our results found that the FMS treatment provided better improvements in VAS scores, lumbar extension ROM, and SLR height than the MM treatment. Feng found that patients whose lower back pain had a longer duration always are seen to have lumbar curve kyphosis, spinal scoliosis, and muscle spasms with more serious limitations of lumbar extension.There are a few limitations in this study. Though there were no significant differences between the 2 groups, the patients with FSM started with a higher mean VAS value and therefore it is normal to expect a higher improvement than patients treated with MM; besides, the preintervention sporting or fitness habits of the patient sample were not evaluated. Hence future studies are expected to consider these parameters in CNLBP patients. What more, a large sample and multicenter study can be conducted, more observables such as gait tests, ultrasound evaluations, and surface EMG tests can be added for further investigating the mechanism details.In summary, our study demonstrated that FSM treatment significantly improved CNLBP patients Modified Schober test, extension ROM, and SLR height, while MM treatment did not. Both treatments significantly decreased the values of VAS, ODI, and PHQ-9. Compared to the MM treatment, the FSM treatment showed a more significant improvement in VAS score, range of motion of extension, and SLR of both sides. Our data suggested that FSM treatment can provide better efficacy than MM in CNLBP patients, improving the VAS scores, lumbar extension ROM, and SLR height in a brief time.Conceptualization: Ying Xie.Data curation: Cheng Gong, Shiyin Dai, Bing Jin.Funding acquisition: Cheng Gong.Methodology: Ying Xie.Supervision: Ying Xie.Writing – original draft: Cheng Gong.


Gynecological surgery has many impacts on women’s physical and mental health, and efforts to improve recovery from surgery are constantly under evaluation. Resilience is an ability to overcome stressors and adversities, such as traumas and surgeries. This study aimed to explore patients’ resilience and psychological symptoms in relation to recovery, health-related quality of life (HRQoL), and pain one year after gynecological surgery.In a prospective cohort study, we enrolled consecutive elective gynecologic surgery patients who completed questionnaires before and at one year after surgery: the Resilience Scale-25, the 15D instrument of HRQoL (15D), the Life Satisfaction Scale-4, and the Hospital Anxiety and Depression Scale. Their mean 15D scores were compared to those of an age-matched sample of women from the general Finnish population (n = 2743).We enrolled 271 women who underwent gynecological surgery due to benign (n = 190) and malignant (n = 81) diagnoses. Resilience was equally high in women with benign and malignant diagnoses at both time points. Higher resilience associated with less pain, analgesic use, and better pain relief from the use of pain medication at 12 months after surgery. Pain intensity was similar in the two groups, but patients with benign diseases had less pain at 12 months than before surgery. Before surgery, patients’ HRQoL was worse than that of the general population, but at 12 months the mean HRQoL of patients with benign diseases had improved to the same level as that in the general population but had decreased further in patients with malignant diseases. Anxiety was higher and life satisfaction was lower in patients with malignant diseases before surgery. At 12 months, anxiety had decreased in both groups, and life satisfaction had increased in patients with malignant diseases. Depression was similarly low in both groups and time points.Resilience correlated with less pain one year after surgery. After surgery, HRQoL improved in patients with benign diseases but deteriorated in patients with malignant diseases. Patients with low resilience should be identified during preoperative evaluation, and health care professionals should give these patients psychological support to enhance their resilience.Trial Registration ClinicalTrials.gov; registered October 29, 2019; identifier: NCT04142203; retrospectively registered. Gynecologic surgery is a common procedure  that hasResilience is an ability to adapt to adversity, such as surgeries, health-related issues, or other sources of stress in life . Most peSome data indicate that the health-related quality of life (HRQoL) often improves after gynecologic surgery in both benign and malignant conditions , 7, 18. The aim of this prospective, one-year follow-up study was to investigate how gynecologic surgery in both benign and malignant conditions may affect psychological factors, including resilience, anxiety, and depression, and how they relate to recovery, HRQoL and pain. We also evaluated how the HRQoL of surgical patients compared with that of the general population. The primary outcome measures were HRQoL and pain intensity one year after surgery. We hypothesized that higher resilience before surgery is associated with lower anxiety and depression, less pain, less need for pain medication, and a better HRQoL one year after surgery.This study was a prospective cohort study of gynecological patients undergoing surgery for benign and malignant conditions in Kuopio University Hospital (KUH), Kuopio, Finland, between June 2017 and October 2019. It was a part of a larger study [Patients were enrolled during their preoperative gynecologist’s visit or, if no preoperative visit to the hospital occurred, on the morning when they arrived for surgery. Patients were given oral and written information about the study and enough time to consider their participation. They were also encouraged to contact the researchers if they had anything to discuss about the study. Patients who agreed to participate in the study gave their written informed consent. Eligible participants were 18 years old or older, under consideration for elective gynecology surgery in KUH, and able to understand the study protocol and complete questionnaires in the Finnish language. We did not enroll patients with serious mental illnesses, such as schizophrenia, bipolar disorder or major depression, low cognitive functions, e.g., dementia, or alcohol or drug addiction.We recruited consecutive elective gynecologic surgery patients from KUH during a two-year period and compared the outcome based on whether the diagnosis was benign or malignant. This was expected to give a representative sample of both groups and minimize selection bias. No formal study size calculations were performed, but approximately 300 patients were expected to give a representative sample of women undergoing surgery with both benign and malignant diseases.The questionnaires comprised background data, questions about pain and pain medication, and questionnaires about resilience, life satisfaction, anxiety, depression, and HRQoL. The questionnaires were completed before surgery and at 12 months after surgery. The questionnaires were web-based, but hard copies were available based on patient preferences. In these cases, the 12-month follow-up questionnaires had a prepaid envelope for return to the researchers.Patient data Table  were colResilience Scale-25 . It. ItResil15D instrument [Health-related quality of life was measured with the strument . It is astrument .We compared the HRQoL of gynecologic surgery patients to a sample from the general Finnish population. The data were derived from the National Health 2011 Health Examination Survey representing the adult population (18 years and older) . For theLife Satisfaction Scale-4 . The LSHospital Anxiety and Depression Scale . It. ItHospiPrimary outcomes were HRQoL and pain intensity one year after surgery. Secondary outcomes were anxiety, depression, and life satisfaction one year after surgery. Resilience before surgery was hypothesized to be a predictor of good HRQoL and low pain intensity.2 or Fisher’s exact test. Paired-samples t-tests and Wilcoxon tests were chosen for continuous variables of dependent samples, and McNemar tests were chosen for dichotomized variables. Correlations between variables were evaluated with Pearson’s r: values indicating a weak correlation were between − 0.29 and + 0.29, moderate between − 0.49 and − 0.3 or 0.3 and 0.49, strong between − 0.89 and − 0.5 or 0.5 and 0.89, and very strong between − 1.0 and − 0.9 or 0.9 and 1.0. Cronbach’s alpha was calculated to measure the internal consistency for each questionnaire. The data are displayed as the number of cases, mean (SD), median (min–max), 95% confidence interval (CI), and mean difference, as appropriate. A p value of < 0.05 was considered statistically significant.The data were entered and analyzed with SPSS software version 27 . We compared the means of continuous variables between the groups using independent-samples t-tests and distributions (medians) with Mann–Whitney U tests, and the categorical variables were compared using χThe patient baseline characteristics are listed in Table Gynecological cancers (n = 81) comprised uterine (n = 50), ovarian (n = 17), vulvar (n = 6), cervical (n = 5) and tubal cancer (n = 2), and unknown origin (n = 1). Common benign diagnoses (n = 190) included gynecological prolapses (n = 59), ovarian tumors and cysts (n = 40), uterine tumors (n = 31), endometriosis (n = 18), and menstrual disorders, including menorrhagia, postmenopausal bleeding, and pain (n = 12).The success rate of the short-stay surgery process was moderate; in the day surgery and 23-h surgery model, 85% (n = 120) of patients were discharged from the postanesthesia care unit (PACU) on the same day or within 24 h as planned, and 21 patients were admitted to the ward. Of the patients scheduled for inpatient surgery 129 were admitted to the ward as planned, one woman with extensive cancer surgery and major intraoperative bleeding was admitted to the intensive care unit after the surgery.Perioperative adverse events were common, but most were mild. One hundred nine patients (40%) had at least one adverse event, and the most common were nausea and vomiting (n = 93), dizziness (n = 18), itch (n = 7), arrhythmia (n = 5), and high or low blood pressure (n = 5). Other complications (n = 6) included acute coronary syndrome (n = 1), falling and fracture (n = 1), vocal cord hematoma (n = 1), hemorrhage (n = 1), anaphylaxis (n = 1), and unintended cutting during surgery (n = 1).One-year mortality was 1.8% (n = 5), and mortality for a mean of 36 months follow-up time was 3.7% (n = 10).The questionnaire total scores and number of observations in the dichotomized questionnaire scores are listed in Table p = 0.640) but was lower than in the population . At 12 months after surgery, the mean HRQoL score had increased in patients with benign diseases  but decreased in patients with malignant diseases . Therefore, at 12 months after surgery, the mean 15D score was lower in patients with malignant diseases (p = 0.020) and similar to that in the population in patients with benign diseases (p = 0.929). The difference between the two groups (0.042) was clinically important, as was the increase in patients with benign diseases (0.018) and the decrease in patients with malignant diseases (0.018). Patients with malignant diseases had more distress before surgery than those with benign diseases, and at 12 months their movement, distress, vitality and sexual activity scores were worse  before surgery was similar in patients with benign 0.902) and malignant diseases   Table . Before Before surgery, weak to moderate correlations were observed between HRQoL and anxiety (r = − 0.263), depression (r = − 0.416), and life satisfaction (r = − 0.399). At 12 months after surgery, these correlations were more prominent; HRQoL had a strong negative correlation with anxiety (r = − 0.540), depression (r = − 0.624), and life satisfaction (r = − 0.528).The data on pain and analgesic use are listed in Table p = 0.749) and intensity (p = 0.789) of preoperative pain and pain at 12 months after surgery  were similar in the two groups. However, pain decreased in women with benign diseases both at rest (p = 0.007) and during movement (p < 0.001) but not in women with malignant diseases . In patients with malignant diseases, preoperative pain (n = 34) persisted at 12 months after surgery in 20 (25%) patients, 10 (12%) had pain before surgery but not at follow-up, 17 (21%) had new pain one year after surgery, and 24 (30%) patients had no pain before or at 12 months after surgery. For patients with benign diseases, the numbers were 42 (22%) for persistent pain, 33 (17%) for pain resolution, 27 (14%) for new pain, and 65 (34%) patients for no pain before or at 12 months after surgery (p = 0.385 between groups).The prevalence (p = 0.099) had surgery-related pain at 12 months after surgery. In most patients with PPOP, the pain intensity was mild; four (13%) of them had moderate or severe pain (NRS 5–7) at rest, and three (10%) had moderate or severe pain during movement (NRS 5–8). The prevalence of moderate or severe pain was higher in patients with no PPOP at 12 months, 15 (20%) patients at rest (p = 0.401) and 13 (17%) patients during movement (p = 0.328).The prevalence of persistent postoperative pain (PPOP) was similar in both groups; 18 out of 171 patients with benign diseases (11%), and 13 out of 71 patients with malignant diseases  and during movement (r = − 0.170) and with a lower number of different analgesics in use (r = − 0.194) and regular pain medication (r = − 0.127) at 12 months after surgery. Higher resilience correlated weakly positively with better pain relief by analgesics before surgery (r = 0.290) and moderately positively at 12 months after surgery (r = 0.355).Anxiety (r = 0.214) and depression (r = 0.239) before surgery correlated weakly positively with having pain one year after surgery.p = 0.099) on NRS 0–10. However, there was only a weak positive correlation between the expected and observed most pain score after surgery (r = 0.252). Patients with benign and malignant diseases were willing to accept similar pain before taking analgesics when asked before surgery, 4.4 (2.0) vs. 4.2 (2.1) (p = 0.357), and at 12 months after surgery, 6.2 (2.0) vs. 5.7 (2.4) (p = 0.172).The expected postoperative pain was similar between the two groups; patients with benign diseases expected to have the most postoperative pain score of 6.5 (2.3) and patients with malignant diseases 7.0 (1.9) (p = 0.089), but at 12 months after surgery, 40 patients with malignant diseases (56%) used analgesics more commonly than 74 patients with benign diseases (43%) (p = 0.018).Before surgery, two-thirds (n = 169) and at 12 months after surgery, half (n = 114) of the patients used analgesics. There was no difference in preoperative pain medication use between the two groups (p < 0.001).Opioid analgesic use was low; at 12 months, there were eight (3%) new patients on opioids, eleven (5%) had stopped opioid use, opioid use persisted in four patients (2%), and 219 (90%) patients used opioids neither before nor at 12 months after surgery (p = 0.540), but one year after surgery, patients with malignant diseases experienced better pain relief than those with benign diseases (p = 0.004)  Table .Pain medication-related adverse effects before surgery (n = 18) and at 12 months (n = 22) were relatively rare. The most common adverse effects were gastrointestinal and comprised constipation, stomachache, and diarrhea.p = 0.008). Anxiety decreased during the 12-month follow-up in both groups, and at 12 months, there were no differences between the two groups (p = 0.972). Depression scores were similarly low in both groups and at both time points.The anxiety and depression scores are listed in Table p = 0.011). Life satisfaction increased in patients with malignant diseases (p = 0.023) but not in patients with benign diseases (p = 0.249) and was thus similar in the two groups at 12 months after surgery (p = 0.335).Life satisfaction was similarly high in both groups Table , but patp = 0.457), resilience (p = 0.755), anxiety (p = 0.240), depression (p = 0.277), or life satisfaction scores (p = 0.06) between the respondents and non-respondents.A post hoc sensitivity analysis showed that patients lost to follow-up (n = 29) had similar mean preoperative questionnaire scores to other patients. No difference existed in HRQoL , the benign and malignant diagnostic groups differed significantly in size (190 vs. 81), and both included multiple different diagnoses that led to gynecologic surgery. Moreover, patients with malignant diagnoses were not grouped based on adjuvant therapy, nor did we account for neoadjuvant therapy, which can impact symptoms and quality of life. Consequently, these results cannot be generalized to specific diagnoses. Nonetheless, the purpose of this study was to form a general concept and compare resilience, pain, and HRQoL in non-selected groups of benign and malignant gynecological diagnoses.Second, the questionnaires were self-administered, and individuals could interpret the survey questions differently. Nevertheless, the questionnaires in our study have been validated and are commonly used. We assumed that questionnaires with closed-end questions could be easier for individuals to answer, especially when evaluating sensitive issues. Interviewer bias is minimized in self-report questionnaires, and this approach is thus less likely to have the Hawthorne effect. The questionnaires were web-based, which can make older people more reluctant to answer, but paper copies were available on request. Adherence to questionnaires and the participation rate to the follow-up were high and decreased the possibility of compliance bias. Moreover, the post hoc analysis found similar characteristics between respondents and non-respondents in the preoperative assessment.Third, we measured pain with no pain interference measures. Previous studies showed that in patients with low resilience, pain has more interference with activities of daily living and life satisfaction than in more resilient patients , 45, 46.Finally, our study had multiple variables that increases a potential for researcher bias. Postoperative pain has a multifactorial origin and associates with pre-operative patient conditions, surgical procedure, duration of surgery, and postoperative analgesic therapy. In the present study laparotomy was used more commonly in women with malignant diseases and none had vaginal surgery, compared to women with benign diseases having only a few laparotomies and one-third having vaginal surgery, moreover the duration of surgery was two times longer in women with malignant diseases compered to women with benign diseases. Minimally invasive techniques and vaginal approach are assumed to reduce postoperative pain, and the need of analgesics , but theIn our study, resilience was moderately high in the majority of gynecology patients undergoing surgery for benign or malignant diagnoses, but one out of four patients reported low resilience. The HRQoL of all patients was lower than that of the general population before surgery, but at 12 months, it increased in patients with benign diseases and was therefore similar to that of the age-matched general female population. Higher resilience correlated with better HRQoL and less pain 12 months after surgery. Patients with low resilience should be identified during preoperative evaluation, and health care professionals should give these patients psychological support to enhance their resilience.


The study aims to determine whether there is a relationship between fibromyalgia (FM) disease and depression, anxiety, anxiety sensitivity, fear-avoidance beliefs, and quality of life in female patients with a diagnosis of fibromyalgia. 37 female patients followed up with FM diagnosis in pain medicine clinic and a control group consisting of 37 healthy women were included in the study. Sociodemographic and Clinical Characteristics Data Form, Quality of Life Form, fear-avoidance beliefs questionnaire, Anxiety Sensitivity Index-3, Beck Anxiety Inventory, Beck Depression Inventory, and Visual Analogue Scale was applied to the participants. When the patients in the FM group were compared to the control group; Statistically lower scores in all Quality of Life Form subscales except emotional role difficulty and social functionality scores; statistically higher scores in both physical and work activity subscales in fear-avoidance beliefs questionnaire; statistically higher scores in cognitive symptoms subscale in Anxiety Sensitivity Index-3, Beck Anxiety Inventory, Beck Depression Inventory, and Visual Analogue Scale scores were found. In FM patients, it has been determined that anxiety, depression and perceived pain severity reduce social functionality and quality of life in areas such as mental health, physical function, and emotional role difficulties. It was determined that the functionality and quality of life of patients diagnosed with FM decreased in daily life. An important contribution of the study to the literature is that it shows that the behavior of avoiding activity due to pain-induced fear exacerbates the pain and even contributes to its chronicity. These results, which show the effects of anxiety, depression, anxiety sensitivity, and fear-avoidance behavior on the prognosis of the disease in FM patients, indicate that psychiatric evaluation and treatment in FM patients is an important factor that determines the functionality and quality of life. FM often coexists with other chronic pain conditions with overlapping clinical features: chronic fatigue syndrome, irritable bowel syndrome, tension-type headache, migraine, temporomandibular disorder, multiple chemical sensitivity, restless leg syndrome, primary dysmenorrhea, interstitial cystitis, post-traumatic stress disorder, myofascial pain syndrome. The terminology of “central sensitivity syndromes” or “chronic overlapping pain conditions” describes this group of conditions.Fibromyalgia (FM) is a common and devastating syndrome that causes pain in the musculoskeletal system, sleep disturbance, fatigue, psychiatric disorders, and social dysfunction.In addition to physical complaints such as pain, FM patients have also been shown to experience cognitive dysfunctions such as attention problems, problems in planning, difficulty in remembering, concentration difficulties, decreased vocabulary, poor verbal fluency, mental slowness, difficulty in thinking and making decisions. Moreover, it has been shown that a significant portion of FM patients has various psychiatric comorbidities such as depression, panic disorder, and anxiety disorder. These cognitive and psychiatric aspects may have a predictive value on somatic symptoms such as pain.FM syndrome also has many emotional and affective effects. Fibromyalgia syndrome patients tend to experience high levels of stress, anger, and pain catastrophizing and these also contribute to the worsening of existing symptoms.In this study, an answer was sought to the question of whether there was a difference in the quality of life, fear-avoidance beliefs, anxiety, anxiety sensitivity (AS), and depression between female patients with FM who were followed up with the complaint of widespread pain and the control group without FM diagnosis.The study was carried out by cross-sectional examination of the patients followed up with the diagnosis of FM in the Pain Medicine Clinic of the Research Hospital, with the permission (dated 11.07.2017 and numbered 2017-593) from the local clinical research ethics committee. 37 female patients with FM and age-sex matched 37 healthy women participated in the study.Inclusion criteria for the patient group were determined as 18 to 70 years old, female, being treated with FM diagnosis, voluntarily agreeing to participate in the study, and being literate.Exclusion criteria for the patient group were determined as being under the age of 18 and over the age of 70, male, not in the FM diagnosis spectrum, illiteracy, mental retardation, alcohol, and substance use disorder.Sociodemographic and Clinical Characteristics Data Form, Anxiety Sensitivity Index-3 (ASI-3), Quality of Life Form (SF-36), Visual Analogue Scale (VAS), Fear-Avoiding Beliefs Questionnaire (FABQ), Beck Depression Inventory, and Beck Anxiety Scales (BAI) were applied.In the sociodemographic information form, the patients and the control group included age, gender, education status, and habitual status.The SF 36 questionnaire is a tool consisting of 36 items and 8 sub-titles that evaluate physical and social functions and mental health. These 8 sections are Physical Function, Physical Role Difficulty, Emotional Role Difficulty, Energy, Mental Health, Social Functioning, Pain, and General health. Subscales evaluate health between 0 and 100, with 0 indicating poor health and 100 indicating good health. It was developed by Ware et al. has two subheadings: physical activity and work activity. Its main purpose is to show the effect of activity-induced fear and avoidance belief on pain and disability.The FABQ, a 16-question questionnaire created by Waddel et al,Fear of an event or situation is defined as AS to avoidance motive. ASI-3, the most commonly used scale to evaluate AS, which consists of three subscales  and a total of 18 items, was first developed by Reiss and McNally. to measure students’ anxiety levels. It is a Likert-type assessment tool in which scores ranging from 0 to 3 are given on the 21-item scale. A high total score indicates an increase in anxiety severity.BAI was developed by Beck et al On the scale consisting of 21 items, mood, pessimism, sense of failure, dissatisfaction, guilt, punishment, self-hatred, self-blame, desire to punish oneself, crying spells, irritability, social introversion drowsiness, indecisiveness, bodily image, impaired ability to work, sleep disorders, fatigue, fatigue, decreased appetite, weight loss, somatic complaints, and loss of sex drive. A high total score indicates an increase in the severity of depression.Beck Depression Scale, which was developed by Beck et al, is used to diagnose depression; it has been used both to measure its severity and to follow treatment-related changes.It is a valid and reliable scale that measures the severity of pain in one dimension. Pain severity definitions are written on both ends of a 10 cm line and the patient indicates where the pain severity status is appropriate on this line with a sign. For pain at one end, “I have no pain,” at the other end, very “severe pain” is written and the patient marks his current condition on this line. According to the VAS, I have no pain 0 points, severe pain is graded as 10 points.t test was used in the comparisons between two groups of the variables in which the parametric assumptions were met, and the Mann–Whitney U test was used in cases where the parametric assumptions were not met. In the study, Spearman’s rho was used for the variables that did not show the normal distribution in the analysis of qualitative and quantitative relationships. Although the significance was evaluated at P < .05 and P < .01 levels, Bonferroni correction was used where necessary and the significance values were determined according to this correction.While evaluating the findings obtained in the study, SPSS  24 for Mac was used for statistical analysis. Descriptive statistical methods  were used while evaluating the study data. The chi-square test was used to compare qualitative data, and the Fisher exact chi-square test was used in case the expected frequencies were not met. The conformity of the data to the normal distribution was evaluated with the Kolmogorov–Smirnov test. The Student’s  according to power analysis the statistical power of the analysis was 0.81, the minimum required sample size for the study was 20 subject with a given an alpha level of 0.05, an anticipated effect size of 1.17 (large), and a desired statistical power level of 0.80.The sample size of this study was determined based on a previous study,According to Table P < .006).According to Table P < .025).According to Table P < .016).According to Table P < .05). Beck Depression Scale scores of the patient group were statistically significantly higher than the control group (P < .05). The VAS scores of the patient group were statistically significantly higher than the control group (P < .05).According to Table P < .05). There is no statistically significant relationship between other variables.According to Table P < .01) and Beck Anxiety (P < .05) scores. ASI-3 Cognitive symptoms scores show a statistically significant positive correlation with Beck Depression and Beck Anxiety scores. (P < .01). ASI-3 social symptoms scores show a statistically significant positive correlation with Beck Depression (P < .01) and Beck Anxiety (P < .05) scores.According to Table P < .01). ASI-3 Cognitive symptoms scores show a statistically significant positive correlation with Beck Anxiety (P < .05) Beck Depression and VAS scores (P < .01). ASI-3 social symptoms scores show a statistically significant positive correlation with Beck Depression and VAS scores (P < .01).According to Table  and 90% of the FM patients are women. The cause of FM is not clear. However, it is generally estimated that dysregulation in central sensory activity. There is no objective imaging or laboratory test for its diagnosis, and the diagnosis is generally made according to clinical markers. Although the main symptom is chronic widespread pain, it contains many symptoms accompanying the pain. Among them, fatigue, weakness, forgetfulness, morning stiffness, sleep disturbance, and some psychological comorbidities can be counted. As a result, FM significantly affects the quality of life negatively. However, evaluating FM, which has many physical and psychological components other than pain, by focusing only on the locomotor system and reducing it to pain only means denying the multidimensionality of the disease. FM is a disease in which psychological effects have an important place in the prognosis. Our study, it evaluated whether there was a significant difference between the FM patients and the control group in terms of the scales used and if there was a correlation in the sub-parameters of the scales in FM patients to investigate this relationship.FM is a chronic pain syndrome that affects approximately 2% to 3% of the general population These sub-headings are Physical Function, Physical Role Difficulty, Emotional Role Difficulty, Energy, Mental Health, Social Functioning, Pain, and General Health. Picavet et al evaluated patients with many different diseases that cause chronic pain in the Dutch population with SF 36. It was observed that FM patients got the lowest score in terms of all parameters except physical role difficulty, compared with the others. In our study, FM patients scored significantly lower than the control group in 6 sub-headings, except for emotional role difficulties and social functionality. In terms of emotional role difficulty and social functionality, P values were found to be .010 and .008, respectively, and the results were very close to the Bonferroni-corrected statistical significance limit (P < .006). Buskila et al in their study in which patients with FM were divided into two groups according to their gender, found that male patients had lower SF-36 scores than female patients. Although this result is less common than in female patients, it is consistent with the fact that male FM patients have a severe clinical condition, higher VAS scores, and a worse quality of life than females, which is consistent with being more resistant to treatment. In our study, the fact that all of the individuals in the patient and control groups were women, constitutes a limitation in this respect.The SF 36 is a tool that evaluates physical functions, social functions, mental health, and consists of 8 sub-titles. on activity-induced fear and avoidance behavior on low back pain and chronic disability and was then tested in terms of different pain syndromes. Tezcan et al thought that exaggerated cognitive pain response caused fear and anxiety in patients and this would have reflections on behavior. With this prediction, they obtained similar results in their research in which they evaluated whether there was a difference between different chronic pain syndromes such as rheumatoid arthritis, hand osteoarthritis, and FM. FM, is a chronic pain syndrome that causes serious decreases in quality of life. According to the results of our study, in terms of both physical activity and work activity, the patients had significantly higher scores in FABQ than the healthy group without FM. The behavior of avoiding activity due to the fear induced by the pain exacerbates the pain and even contributes to its chronicity. Therefore, according to Turk and Wilson, fear and avoidance behavior should be questioned in the evaluation of patients with pain, and these behaviors should be recognized, confronted, and corrected as well as biological factors in the treatment of pain.FABQ is created by Waddel et al anxiety was found to be 87.5% and 23.6%, and depression 72.5% and 5%, respectively, between FM patients and the control group. This study indicates that anxiety and depression occur more frequently in FM patients. Pernambuco et al also found that the frequency of anxiety and depression was statistically significantly higher in FM patients. FM symptomatology does not only include pain, but also includes symptoms such as weakness, sleep disturbance, and forgetfulness. From this point of view, comorbid psychological conditions such as anxiety and depression that may affect all these symptoms may cause more severe FM clinic and symptoms in general, and therefore they should be considered in the evaluation of patients. ASI-3, BAI, and Beck Depression Inventory scores, which were found to be higher in FM patients in our study compared to the control group, support the aforementioned literature. In general, the opinion in the literature that the severity of pain in patients with FM is directly related to the anxiety and depression of the patient is predominant. For example, Celiker et al showed that the intensity of pain in FM patients was correlated with the anxiety level and depression of the patients.In the study by Singh et al According to this model, processes called “anxiety expectation and AS” play a role in the basis of people’s instinct to avoid a fearful event or situation. People with high AS are prone to misinterpreting sudden onset, relatively severe, and unexplained physical symptoms of anxiety as dangerous, and they often tend to avoid it. In our study, there was a significant difference with the control group only in terms of cognitive symptoms, among the three sub-headings of ASI, but no difference was found in terms of physical and social symptoms.Similarly, AS was found to be higher in the patient group than in the control group, according to the ASI results. AS was defined as “an extreme fear of anxiety-related sensations and symptoms believed to have harmful physical and/or social consequences.”When the correlation between the quality of life evaluated with SF 36 and the results of the ASI-3 test is examined, the quality of life in terms of energy, mental health, general health, and physical function decreases as the physical symptoms, cognitive symptoms, and sensitivity to social symptoms increase in the patient group in terms of ASI-3. In addition to these partnerships, it was determined that as the sensitivity to cognitive symptoms increased in the patient group, the quality of life in terms of emotional role difficulty, social functionality, and pain decreased. According to these results, while the dimensions of quality of life determined and reduced by physical and social symptoms are the same, cognitive symptoms cause a more comprehensive decrease in quality of life. Considering that the main difference between the patient and control groups in terms of ASI-3 is in cognitive symptoms, the importance of the second decrease in quality of life for FM patients is clear. In our study, VAS scores were found to be significantly higher in FM patients. The increase in pain level determined by VAS decreases the quality of life in terms of physical role difficulty, social functionality and pain, just like anxiety level. As a result, it can be said that anxiety, depression and perceived pain severity of the FM patient group impair their social functionality more than healthy individuals.Pain is a subjective and unmeasurable symptom. Some pain assessment methods are used to compare and evaluate them numerically. Among these, the most frequently used one in clinical practice and the literature is the VAS, and VAS was found to be high in FM patients.The limitations of our study include the fact that male patients were not included in the study, no clinical evaluation was made in terms of psychiatric comorbidities other than the scales, and the number of years of FM complaints during the study was not included in the evaluation.In this study, it was determined that the functionality and quality of life of the patients diagnosed with FM decreased. An important contribution of the study to the literature is that it shows that the behavior of avoiding activity due to pain-induced fear exacerbates the pain and even contributes to its chronicity. In addition, it has been determined that anxiety, depression, and perceived pain intensity decrease social functionality and quality of life in common areas such as mental health, physical function, and emotional role difficulties in FM patients.When the results of the relationship between AS and quality of life were evaluated, it was observed that while the dimensions of quality of life determined and reduced by physical and social symptoms were the same in the patient and control groups, cognitive symptoms caused a more comprehensive decrease in quality of life in patients. In terms of ASI-3, the main difference between the patient and control group is the cognitive symptoms and the second decrease in quality of life indicates the importance of the psychological component of the disease.Similar studies determining the effect of AS and fear avoidance behavior on the prognosis of the disease in FM patients are needed in larger samples and different cultures. All these results emphasize the importance of psychiatric evaluation and treatment in FM patients.Conceptualization: Sera Cetingok, Oznur Seker.Data curation: Oznur Seker, Halil Cetingok.Formal analysis: Sera Cetingok, Oznur Seker, Halil Cetingok.Methodology: Sera Cetingok.Project administration: Sera Cetingok, Oznur Seker, Halil Cetingok.Resources: Oznur Seker, Halil Cetingok.Supervision: Halil Cetingok.Validation: Sera Cetingok, Halil Cetingok.Writing – original draft: Sera Cetingok, Oznur Seker, Halil Cetingok.Writing – review & editing: Sera Cetingok, Halil Cetingok.


Adequate postoperative pain control is an essential factor for the success of rehabilitation programs after anterior cruciate ligament reconstruction (ACLR). The genicular nerve radiofrequency ablation (GNRF) is a recently developed method.This study aimed to evaluate the use of GNRF in patients who underwent ACLR.We performed GNRF guided by ultrasonography for patients who underwent ACLR with aggravated pain. GNRF was performed following ACLR a day after surgery. The pain was evaluated using the Visual Analogue Scale (VAS), and the Euroqol-5 Dimension (EQ-5D) measured the quality of life on the day of one, three, and seven after surgery.In this study, two patients participated. In the postoperative days first, third, and seventh, the mean VAS was decreased after providing the intervention . The mean EQ5D improved from 0.48 to 0.52, 0.56, 0.66, respectively.We concluded that GNRF is an adequate and safe procedure for managing postoperative pain after ACLR. It may enhance the postoperative rehabilitation program. Anterior cruciate ligament (ACL) tear is a common sports injury. The overall age- and sex-adjusted annual incidence of ACL tears was 74.6 per 100,000 person-years. Anterior cruciate ligament reconstruction (ACLR) surgery is frequently performed by orthopedic surgeons worldwide. It is estimated that approximately 400,000–500,000 cases of ACLR are carried out each year in the United States (US) based on implant usage Recently, ACLR techniques advance with various graft utilization and deeper insight of graft biomechanics. Hamstring tendon, patellar tendon, quadriceps tendon, peroneus longus tendon, and also allograft could be used as a choice of graft in ACLR with comparable biomechanics and outcome The success rates of ACLR are high, which is more than 95%. However, the pain remains the most common postoperative complication delaying patient discharge and increasing the costs associated with patient care Since successful postoperative pain management is often correlated with improved patient outcomes, developing an effective strategy to provide adequate pain relief is needed Radiofrequency therapy is a medical procedure mainly used to reduce pain with a low complication rate (less than 1%), ease of application, and low cost (1). The electric current generated by radio waves is used to heat a small nerve tissue area, thereby inhibiting or reducing pain signals from that particular area. Radiofrequency has been developed for diseases related to the spinal functional unit in the few years Successful management of knee pain by radiofrequency (RF) has been shown The purpose of this study is to evaluate the use of GNRF in patients who underwent ACLR and describe the role of GNRF in practice as a part of a multimodal regimen in pain management after ACLR.In this prospective study, GNRF was performed a day after surgery on patients underwent ACLR with aggravated pain. Seven days follow up was worked up. The study was conducted in 2021. The inclusion criteria were: male, 18 to 40 years old, the patient who underwent isolated ACLR, using triple hamstring tendon graft, complained of severe pain a day after surgery, willingness to participate, and signing the informed consent form. The exclusion criteria were having a multi-ligament injury, involving in multiple surgery procedures, and using the addition of analgesic drug besides the drug in this protocol .GNRF was performed using RF device . Patient in supine position with a pillow under the popliteal fossa to minimize discomfort. After applying the ground pad on the contralateral side and disinfecting the skin surrounding the affected site, we identify the three entry sites of the cannulas' insertion at the base of the medial and lateral femoral condyles and the base of the medial tibial condyle using ultrasonography . Utilizing a 12-MHz linear transducer, we identify the superior lateral, superior medial, and inferior medial genicular artery and nerve. The location of the needle tip should be within the vicinity of each genicular artery. After identifying the genicular artery, the skin and subcutaneous tissue were anesthetized with 1 mL of 1% lidocaine at each target point. The needle was inserted using the long-axis view of the ultrasound probe. Next, we insert the cannulas with a 10-mm active tip percutaneously targeting the superior lateral genicular nerve, the superior medial genicular nerve, and the inferior medial genicular nerve . We alsoAll procedures were performed by a single orthopedic surgeon-pain interventionist (RD) experienced in pain intervention guided with ultrasonography and fluoroscopy. Patients received an analgesic drug  during the study period.The Visual Analogue Scale (VAS) score was used to evaluate the patients' pain during the follow-up study in the postoperative days (POD) first, third, and seventh. In addition, we also assessed the score of quality of life using Euroqol-5 Dimension (EQ-5D).Two patients participated in the present study and completed the informed consent form. The subject's characteristics are presented in The mean of VAS pain scores and EQ5D were presented in This study aimed to evaluate the use of GNRF in patients who underwent ACLR. This study found that the mean VAS pain score after GNRF was decreased, and the mean of EQ5D was improved. These results concluded that GNRF is an adequate and safe procedure for managing postoperative pain after ACLR, and it may enhance the postoperative rehabilitation program.GNRF was known to give promising results for knee pain treatment. Numerous studies, however, yielded concerns about chronic knee pain, osteoarthritis, and post-total knee arthroplasty procedures In this study, we performed GNRF by ultrasonography-guided rather than fluoroscopy-guided only. A growing body of knowledge described that GNRF by ultrasonography-guided more accurate and safer than fluoroscopy guiding GNRF is a safe procedure with minimal complications As it still is a relatively advanced method, the information about the long-term efficacy and adverse events is still largely lacking. A commonly raised question is whether this procedure precipitates a Charcot-type joint in the long term The current study has limitations, including the sample size is not large enough, performed only in a single-centre study, and not comparing other treatments, such as femoral nerve block or adductor canal block, that are more familiar for managing postoperative pain after ACLR. Hence, the authors suggest performing multi-centre prospective studies in many patients and comparing the outcomes with other studies.GNRF is an adequate and safe procedure for managing postoperative pain after ACLR. It may enhance the postoperative rehabilitation program.