The potential of transcranial direct current stimulation (tDCS) as a non-invasive brain stimulation technique for treating pain has been studied. However, its effectiveness in patients with central post-stroke pain (CPSP) and the impact of lesion location remain unclear. This study investigated tDCS’s pain reduction effects in patients with CPSP. Twenty-two patients with CPSP were randomized into the tDCS or sham groups. The tDCS group received stimulation of the primary motor cortex (M1) for 20 min, five times weekly, for two weeks, and underwent evaluations at baseline, immediately after the intervention, and one week after the intervention. The tDCS group had no significant improvement compared to the sham group in pain, depression, and quality of life. Nevertheless, significant changes were identified within the tDCS group, and the pain trends appeared to be influenced by the lesion location. These findings provide important insights into the use of tDCS in patients with CPSP, which could inform further research and development of pain treatment options. Pain is an unpleasant physical sensation or emotional experience that can significantly affect the patient’s quality of life (QOL), motivation for treatment, and functional exercise . Pain caNon-invasive brain stimulation (NIBS) techniques are other treatment methods that have been studied ,18,19,20Four main pain mechanisms are associated with CPSP ,27. The Therefore, this study aimed to clarify the potential benefits of tDCS in reducing pain in patients with CPSP compared to a sham group and explore the impact of lesion location on tDCS effectiveness.This study was conducted until 31 December 2022. The institutional review board in Yangsan Pusan National University Hospital (IRB No. 03-2022-001) and the Korea Food & Drug Administration of the Korea Food & Drug Administration  approved this study. This randomized, single-blind, controlled pilot study was registered at ClinicTrials.gov (NCT0561216).The participants were enrolled through the following screening tests. The selection criteria for the participants were: (1) adults over 19 years of age; (2) those diagnosed with bleeding and first ischemic stroke through clinical observation and brain imaging; (3) those diagnosed with pain after stroke (CPSP); (4) individuals cognitive enough to understand and follow the researcher’s instructions; and (5) voluntary participation in the clinical trial and provision of written consent. Pain diagnosis after stroke was based on the following criteria: (1) a person with lesions in the cortex and subcortex due to bleeding and ischemic stroke regardless of the side ; and (2) pain begins immediately after the stroke, and a person with a visual analog scale (VAS) pain score of ≥3 points in the body area corresponding to the lesion of the central nervous system .Patients were excluded if one of the following criteria was met: (1) a fracture or orthopedic surgery in the pain or related region; (2) accompanying significant underlying diseases such as hypertension, arrhythmia, kidney disease, epilepsy, or cancer; (3) major psychiatric diseases such as major depressive disorders, schizophrenia, and dementia; (4) complex regional pain syndrome by the BUDAPEST Criteria ; (5) an Participants were voluntarily recruited through research recruitment posters at the Yangsan Pusan National University Hospital. The doctor explained the research content to the participants to obtain consent. The doctor conducted interviews and screening tests and assessed the medical records to check for CPSP in patients with stroke and identify the selection criteria. Participants who met the inclusion criteria signed a consent form voluntarily and were enrolled in this study. Subsequently, a third party who did not participate in this study randomly assigned participants to the experimental (tDCS) and control (sham) groups at 1:1. The targeted number of participants was 22, which was calculated using G*Power Program 3.1 based on a previous study by Bae, et al.,  was 0.95) .We used the DC-STIMULATOR PLUS [NeuroConn GmbH (Germany)/license number of the Korea Food & Drug Administration (A16180.02/3rd grade)] tDCS intervention method, based on the 10–20 System  targetinThe primary outcome was assessed using the brief pain inventory (BPI), which evaluated the strength of the overall pain . The BPIThe side effects were assessed each time tDCS was applied for safety evaluation. In addition, the degree of expression was recorded following the abnormal case evaluation criteria , and the causal relationship with the tDCS was evaluated.p-value of < 0.05 was considered significant.All statistical analyses were performed using the IBM SPSS Statistics version 23 . Repeated measures ANOVA was used to control baseline differences in the study group age and covariates and compare the assessment scores before and after the intervention. When analyzing group differences, covariance analysis was performed to rule out the influence of age, years of education, and cognitive assessment scores. Comparisons before the intervention were analyzed using the Wilcoxon signed-rank test. A p = 0.223, Z = −1.219). According to the research dates, no significant difference was observed in the onset period between the tDCS (27.64 ± 10.54 months) and the sham (29.18 ± 13.13 months) groups . The most common mechanism of damage in patients with CPSP patients involved the basal ganglia (BG) , followed by the cortex , and the least common mechanism included the thalamus . All 22 people who were screened were registered in the study. The 22 participants in this study completed the intervention without dropping out. Eleven participants were in the tDCS group , and eleven were in the sham group . No significant difference in age existed between the tDCS (56.00 ± 11.34 years) and the sham (59.91 ± 9.18 years) groups , electrical sensation , and numbness . In the thalamus group, a squeezing sensation  was the most common, followed by freezing , and heaviness . On the other hand, aching  was the most frequently reported condition in the cortex group.n = 6; 54.5%), including the arms or hands, and the lower extremities , including the legs and feet. In the thalamus group, the most frequently reported pain site was the lower extremities , the shoulder , and the head . In the cortex group, the shoulder was the most commonly reported pain site .The pain sites reported based on the damage location are indicated in 1, 20 = 0.004, p = 0.950) . In the sham group, the repeated measures ANOVA did not reveal significant changes (= 0.950) . When th changes .1, 20 = 1.325, p = 0.263). However, when the tDCS group was independently analyzed, the BDI scores according to repeated measures ANOVA between T0 and T2 changed significantly . In the sham group, the repeated measures ANOVA did not present significant changes  . In the sham group, the repeated measures ANOVA did not reveal significant changes (= 0.545) . When th changes .n = 11) was further divided into the BG (n = 5), thalamus (n = 3), and cortex (n = 3) groups to analyze the changes. Pain levels in the BG group decreased until T2. Pain levels in the thalamus group decreased at T1. However, a slight tendency for the pain to increase after completing the intervention existed. The pain levels in the cortex group increased at T1 but decreased at T2. However, none of the groups had substantial changes  side effects. Two of the four participants reported more severe spasticity and muscle spasms on the affected side during the intervention. Two participants reported sleeping more than usual, and one reported a headache. Despite these side effects, all participants completed the intervention and expressed no desire to discontinue the intervention. One week after completing the intervention, none of the participants reported any side effects during the follow-up assessments.We investigated the effectiveness of tDCS in reducing pain and depression and improving the QOL of patients with CPSP. We also explored potential differences in tDCS efficacy based on lesion location. Participants with CPSP were randomly assigned to the tDCS or sham group. The two groups had no significant differences regarding pain, depression, or QOL. However, positive trends were observed within the tDCS group. Additionally, there was no significant change within the sham group. Moreover, the exploratory analysis revealed that tDCS’s effects might vary depending on the lesion’s location, indicating the need for further investigation.A previous study revealed that rTMS and tDCS have short-term effects on pain by modulating specific brain regions involved in pain perception . HoweverWe studied the specific effects of tDCS stimulation on brain lesions located in the BG, thalamus, and cortex. As a result, we found no significant differences in pain, depression, or QOL between groups based on lesion locations following tDCS intervention. However, the pain score change graph revealed distinct patterns across different lesion locations, suggesting that tDCS may have various effects depending on the brain lesion’s location.Patients with BG lesions experienced reduced pain immediately after the intervention and one week after completion. This is noteworthy because the BG is involved in motor control, facilitating the appropriate execution of movements and coordinating the activity of motor neurons . When tDPain levels in patients with cortex lesions tend to increase immediately after tDCS but decrease one week after the intervention. This immediate increase in pain may be attributed to the temporary increase in muscle tone induced by tDCS stimulation, as two patients in the CA-tDCS group reported an increase in spasticity and muscle spasms during the tDCS intervention period. However, it is noteworthy that in an interview conducted one week after the completion of the intervention, these patients reported feeling a sense of lightness and smoothness in their movements. Previous research on the restoration of motor function in stroke patients has suggested that increased muscle tone can serve as an effective predictor of recovery from exercise-related damage . In a rePatients with thalamic lesions experience slightly reduced pain immediately after tDCS. However, the pain levels increased again after one week. Previous studies have reported that the increase in cortical activity resulting from electrical stimuli can alleviate pain by spreading to the thalamic nucleus and inhibiting the bottom-up transmission of pain signals through the thalamus ,49. ThisBased on the discussion above, when investigating the effects of tDCS on pain in patients with CPSP, selecting the optimal stimulation site may depend on the specific brain lesion location. Thus, tailoring the stimulation to the patient’s lesion site may enhance the efficacy of tDCS in managing CPSP. This study’s results were not significant; however, this finding may be due to the limited sample size . NeverthAccording to the secondary outcomes, there was no significant difference in depression and QOL between the two groups. However, a positive trend was observed within the tDCS group, whereas no significant change was observed within the sham group. Several studies have shown that tDCS can be an effective treatment for depression, and it has been found that there is a relationship between pain, depression, and QOL ,53,54. TRegarding safety and tolerability, this study reported that four individuals who underwent tDCS experienced increased somnolence or sleepiness. However, they could tolerate this side effect and expressed a desire to complete the intervention course. The findings of this study are consistent with those of previous studies that investigated the safety and tolerability of tDCS, as they documented similar side effects ,61. NotaThis study had a larger sample size than previous investigations; nonetheless, the number of participants still limits the generalizability and statistical power of the results . AnotherDespite the limitations of this study, the findings provide meaningful insights into the potential benefits and challenges associated with using tDCS to manage pain, depression, and QOL in patients with CPSP. Moreover, this study’s exploration of the differential effects of tDCS across different lesion locations may contribute to our understanding of individualizing treatment for this patient population. To obtain more robust and generalizable results on tDCS’s effects in patients with CPSP, future studies may benefit from utilizing a randomized controlled trial design with a larger sample size, longer intervention periods, and more detailed criteria for stratifying patient groups based on lesion location and other relevant factors. Additionally, incorporating objective measures of pain and other clinical outcomes may help reduce potential biases and increase the validity of the results.In this study, we examined pain, depression, and QOL after tDCS was applied to the M1 area in patients with CPSP. We observed a significant difference within the tDCS group; however, the improvements were not significant compared to the sham group. Furthermore, our exploratory analysis of tDCS’s effects according to stroke lesions revealed that tDCS’s impact on pain in patients with CPSP differed according to the lesion’s location. This study’s results describe some possibilities regarding the clinical efficacy of tDCS for relieving pain and can predict patient reactions to tDCS stimulation. In addition, we believe that the discussions proposed in this study provide an overall framework for gaining insight into the differences in tDCS effects according to the lesions in patients with CPSP. Overall, this study contributes to developing effective and targeted treatment options for patients with CPSP.


Patients with chronic musculoskeletal pain experience not only pain but also abnormal body perception. Such abnormal body perception has been reported to be caused by incongruence between motor intentions and sensory feedback . However, the influence of abnormal body perception with sensorimotor incongruence on pain prognosis in musculoskeletal pain patients has not been investigated.  We aimed at clarifying the influence of abnormal body perception on pain prognosis using an experimental procedure for inducing sensorimotor incongruence in patients with musculoskeletal pain.  We recruited 18 patients within 2 months after limb fracture or ligament injury. In the experiment, patients sat with the intact upper or lower limb reflected in a large mirror aligned with the sagittal plane. A motor task was performed for 20 seconds in each of the congruent and incongruent conditions. In the congruent condition, patients were asked to perform flexion-extension movements with the intact and affected limbs in-phase, while observing the intact limb in the mirror. In the incongruent condition, patients were asked to perform flexion-extension movements antiphase, while observing the intact limb in the mirror. After performing the congruent and incongruent conditions, patients were asked to complete a questionnaire about abnormal body perception. These procedures were conducted within 2 months after the fracture (first), 2 weeks after the first measurement (second), and 4 weeks (third) after the first measurement.  Pain, heaviness, and peculiarity were more likely to be experienced in incongruent conditions. Additionally, structural equation modeling indicated that heaviness at the first time point predicted the pain intensity at the second and third time points.  Heaviness caused by sensorimotor incongruence may predict pain prognosis in patients with musculoskeletal pain after one month. Patients with chronic musculoskeletal pain suffer from not only pain but also abnormal body perception –8. A preSensorimotor incongruence has been suggested to affect not only the upper limbs but also the lower limbs . TherefoThe study was conducted at Setsunan General Hospital and patients were admitted to Setsunan General Hospital from April 2019 to April 2021. Patients were fully informed about the study and provided written consent. The study protocol conformed to the Declaration of Helsinki and it was approved by the Research Ethics Committee. Exclusion criteria were follows: impairment of the somatosensory processing or asymmetric limb disorders unrelated to the current injury  and dementia (23 < MMSE score).Before the experiment, patients completed the brief pain inventory (BPI) (pain intensity items only),  Pain Catp < 0.05 for comparison between the congruent and incongruent conditions. The Bonferroni correction was used to adjust the p value obtained in the post hoc analysis for the comparison of the three evaluation time points. In this study, the significance level was set at p < 0.0167 because three comparisons were conducted across the three evaluation time points. Next, structural equation modeling (SEM) was used to examine the relationship between pain intensity and abnormal perception. Abnormal perception score with a Z score of 0 or more was used in SEM.The results of the total pain scores on the NRS (0–10), PCS-6 (0–24), TSK-11 (11–44), CSI-9 (0–36), and NLS (0–30) questionnaires in each evaluation phase were compared using the Wilcoxon signed rank test. The abnormal body perception data in the congruent and incongruent conditions were not normally distributed in the Shapiro–Wilk test. Therefore, the Wilcoxon Signed rank test was used to compare body perception data between the congruent and incongruent conditions, and multiple comparisons were conducted at three evaluation time points: first, second and third time points. The level of significance was set at n = 5), distal end of radius fracture (n = 5), distal end of femur fracture (n = 3), patella fracture [n = 1], trapezium fracture (n = 1), total knee replacement (n = 1), anterior cruciate ligament injury (n = 1), medial collateral ligament injury (n = 1)) in this study with a mean age of 70.7 ± 16.1 years. There were no interruptions to the study or missing data. The elapsed time from fracture or ligament injury to initial evaluation was 38.6 ± 11.8 days; the second and third evaluations were performed at 53.0 ± 12.9 days and 68.7 ± 14.1 days.There were 18 participants  in the congruent condition were as follows: pain, 0.5 ± 0.9, 0.6 ± 1.1, and 0.7 ± 1.2; heaviness, 1.5 ± 0.9, 0.4 ± 1.0, and 0.0 ± 0.7; temperature change, −0.4 ± −0.6, −0.3 ± −0.5, and −0.1 ± −0.9; discomfort, 0.2 ± 1.0, 0.2 ± 1.2, and −0.3 ± −0.7; peculiarity, −0.1 ± −0.7, 0.0 ± −0.9, and −0.2 ± −0.5; extra limb, −0.7 ± −0.4, −0.4 ± −0.6, and −0.3 ± −0.6; and lost limb, −0.8 ± −0.5, −0.6 ± −0.4, and −0.5 ± −0.2. In the incongruent condition, mean Z-scores ± SD of abnormal body perception  were as follows: pain, 0.4 ± 0.9, 0.5 ± 1.1, and 0.0 ± 0.8; heaviness, 0.7 ± 1.0, 0.6 ± 0.9, and 0.7 ± 1.2; temperature change, −0.3 ± −0.7, −0.3 ± −0.5, and −0.4 ± −0.4; discomfort, 0.0 ± 0.8, −0.3 ± −0.5, and −0.3 ± −0.5; peculiarity, 0.1 ± 0.9, 0.2 ± 0.8, and 0.4 ± 1.3; extra limb, −0.6 ± −0.4, −0.3 ± −1.0, and −0.4 ± −0.6; and lost limb, −0.6 ± −0.4, −0.6 ± 0.3, and −0.5 ± −0.2. The results of multiple comparisons using Wilcoxon Signed rank test showed a significant decrease in heaviness and extra limb between the first time point and the third time point in the congruent condition (p < 0.01) (p < 0.01) (p < 0.01) (The mean  < 0.01) . In the  < 0.01) . In addi < 0.01) .Z-scored abnormal body perception in the incongruent condition, the items of pain, heaviness, and peculiarity were extracted, because subjects experienced abnormal body perception in the sensorimotor incongruence procedure  were used as variables in the congruent condition, the hypothesized model did not hold.The purpose of the current study was to examine abnormal body perception, which is related to pain prognosis in patients with acute musculoskeletal pain, using an experimental procedure for inducing sensorimotor incongruence. The results revealed that patients tended to experience pain, heaviness, and peculiarity as abnormal body perception in the incongruent condition. Importantly, SEM revealed that the intensity of pain at the first evaluation point did not predict the pain prognosis, whereas heaviness in the incongruent condition at the first evaluation time point may predict pain intensity at the second and third evaluation time points.Patients experienced pain, heaviness, and peculiarity in experimental situations in which the motor intention and sensory feedback were incongruent. Previous studies reported that pain sensation and peculiarity can be induced by experimental conditions involving the presentation of visual feedback that is opposite to the direction of body movement , 18, 27.SEM results revealed that pain intensity at the first evaluation time point did not predict pain prognosis, but heaviness in the incongruent conditions at the first evaluation time point may predictive of pain prognosis after one month. Many clinical outcomes have been used to predict pain prognosis , 31. AbnConsidering the findings described above, we present a possible rehabilitation approach using mirror visual feedback  below, on the basis of our results. Mirror therapy has been used to match motor intentions and visual feedback, and then alleviate pain. Although many previous studies have been conducted in patients with chronic pain –42, someThe present study involved several limitations. First, there was no significant difference between abnormal perception in the congruent and incongruent conditions, except for pain and peculiarity at the third evaluation time point, in which pain was more likely to be experienced in the incongruent compared with the congruent condition. These results might depend on muscle weakness in patients in the acute or subacute phase. Thus, there was a slight incongruence between the left and right upper or lower limbs because of muscle weakness in the affected limb. A previous study reported that a slight delay of visual feedback  can cause abnormal body perception . ConsideIn future, it will be possible to determine the cutoff of abnormal perception experienced by patients with prolonged pain to improve the accuracy of prognosis prediction in clinical practice. Although a small sample size is sufficient if the model is simple, a sample size of 100 or more is recommended . This stHeaviness induced by sensorimotor incongruence suggests that it may be predictive of pain prognosis after one month in patients with acute musculoskeletal pain. However, data needs to be collected further because the patients have pain with low intensity and the number of patients is small. Thus, we do not know the long-term prognosis because we have not yet completed the long-term follow-up. This is a matter for further study. As more data become accumulated, the influence of abnormal perception on the pain prognosis will become clearer.


There are no reports on hip kinetics including contact forces and muscle activities during the golf swing after total hip arthroplasty (THA). The aim of this study was to identify the characteristics of three-dimensional dynamics during the golf swing. Ten unilateral primary THA patients participated in motion capture test of their driver golf swing. The driver swing produced approximately 20–30° of rotation in both lead and trail replaced hips. The mean hip contact forces (HCFs) of lead and trail replaced hips were 5.1 and 6.6 × body weight, respectively. Left and right THAs showed similar HCFs of lead and trail hips. More than 60% of the Percent maximum voluntary isometric contraction was found in bilateral iliopsoas muscles in all unilateral THA. Three factors  were associated with the golf-related replacement hip pain. Golf is an admissible sport after THA because driver swings do not contribute excessive rotation or contact forces to hip prostheses. HCF could be reduced through swing adjustments, which may allow patients with golf-related replacement hip pain to develop a comfortable golf game free from pain. Golf is a globally popular sport with participants from a broad range of ages with a significant portion having a hip replacement (1–9.5%)4, making it the most common sport followed by walking, swimming, gymnastics, and cycling6. While golf is not considered to be a high-impact sport and the majority of attending surgeons recommend a return to golf after THA, no previous study has addressed the kinetic data of golfers performing a drive after THA7.Total hip arthroplasty (THA) is one of the most successful orthopedic procedures8. The percentage of TKA patients that felt mild pain during and after playing golf were 16% and 35%, respectively. The pain was greater in the lead knee because of the higher force applied to the lead knee while hitting the ball9. Mallon et al. recorded that 11% and 41% of THA patients have mild pain during and after playing, respectively10. A recent study reports that 98% of patients return to golf after THA, with an improvement in pain visual analog scale (VAS) from 6.4 to 2.5 while playing11.D’Lima et al. showed that a golf swing produces an in vivo contact force of 4.5 × body weight (BW) on the lead knee and 3.2 × BW on the trailing knee in total knee arthroplasty (TKA) patients, similar to the peak load during jogging12.Using image-matching techniques, Hara et al. have demonstrated that the golf swing does not produce excessive hip rotation or cup-head translation after THA. However, there are no reports on hip kinetics including contact force in the golf swing after THAThe present study aimed to address: (1) three-dimensional (3D) motion including hip range of motion (RoM), (2) HCF and hip muscle activation, and (3) the influencing factors for replaced hip pain related golf actions. Query ID="Q4" Text="Please note we have moved the section “Ethics approval and consent to participate, Informed consent” to the end of the methods, as per house style".13.All patients (n = 1197) underwent primary cementless THA in our institution between January 2008 and December 2018. Among them, 766 satisfied each of the following inclusion criteria: (1) alive at the time of the survey and (2) evaluation by a surgeon within the past two years. A review of medical records revealed that 17 patients (2.2%) were recreational golfers. Of the 17 golfers, the following were excluded: three patients with bilateral THAs, one patient hospitalized with a medical condition, one with back pain that made swinging difficult, and one declined participation; the remaining 10 patients signed an institutional review board-approved (IRB Number: 2019–323) informed consent. All THAs were performed using a posterolateral approach, with a uniform protocol for postoperative rehabilitation15.Leg length difference (LLD) and global femoral offset (GFO) before and after THA were assessed using anteroposterior radiographs of the pelvis as described previously17.VAS pain scores in which a respondent selects a whole number (0–10) while playing and after playing golf, and the Modified Harris Hip Score (mHHS) were assessed during the dynamic capturing of the golf swing18. Reflective markers were placed on the full body in accordance with the Plug-in Gait configuration19, with additional markers on the lateral foot and anterior thigh and shank; in addition, a total of six markers were placed—three on the club head and three on the shaft of the driver club, respectively; the club head markers were used to identify the phases of the golf swing20. Each patient was asked to perform a drive swing without a ball using the 285 g driver club . After a minimum of three practice trials, patients repeated the motions until three trials suitable for data analysis were obtained.A 10-camera VICON motion capture system with a sampling frequency of 200 Hz  and two force plates with a sampling frequency of 1000 Hz  were used  was taken into account according to the equation proposed by Frankenfield et al22.The musculoskeletal model used in this study is a standard model  available in the AnyBody Modeling System . The hip joint was modeled as a spherical joint with three rotational degrees of freedom. The knee, ankle, and subtalar joints were simulated as hinge joints. A detailed musculoskeletal model based on the cadaveric data set by Carbone et al26 , adductor magnus, and adductor longus] with greater than 40% of %MVIC during the golf swing were extracted29.Marker trajectories and the GRF data for each trial were used as inputs for inverse kinematic analysis based on third-order polynomial muscle mobilization calculate HCF and muscle force26 Fig. . HCF wasP < 0.05. Power analyses in the HCF difference between left THA and right THA and between with and without hip pain showed that the combined sample size of the two groups were 8 (4 and 4 patients) and 10 (2 and 8 patients) which provided 80% statistical power to detect the 1.6 difference in HCF between the two groups for a ratio one-to-one and one-to-four, respectively. This assumes that the probability value is < 0.05 and the standard deviation is 0.730.Continuous variables were expressed as mean ± standard deviation (range or 95%CI). Statistical analysis was performed using JMP software v.14.0 . The Wilcoxon rank-sum test was used to compare demographic data  and kinematics and kinetics data  between left THA and right THA patients, along with the same factors between painful and painless patients during and after playing golf. The chi-square test was used to compare sex and diagnosis. Statistical significance was set as This study was approved by the Clinical Research Ethics Review Committee, Department of Medical Sciences, Kyushu University (IRB Number: 2019-323). All patients gave informed consent for the use of their demographic data, clinical score data, dynamic data, and images in motion in the study. The study was carried out in accordance with the principles of the Helsinki declaration. All authors agree to participate and consent to the manuscript.Informed consent obtained from all study participants for publishing identifying information/image for this study.P > 0.05; Table P > 0.05; Table Demographic characteristics  were similar between L-THA and R-THA patients  and analysis method (image matching vs. motion capture)37. The motion capture system was reported to underestimate hip rotation by approximately 20° in motion involving large hip rotation compared to shape matching technique37. However, hip rotation during the golf swing was not an excessive RoM of the Int-Ext rotation, after accounting for this underestimation. RoMs of the Flex-Ext and Add-Abd during the driver swing in this study were similar to those of the golf swing in healthy participants35. In other words, club head speed and 3D hip RoMs were comparable to those of healthy participants, suggesting that THA had a positive effect on golf performance, including distance and handicap; this is supported by previous reports that most patients are able to play golf after THA, and mostly with an improvement in performance38.The 31 m/s of mean maximum head speed in unilateral THA patients was equivalent to that of a similar aged healthy cohort: mean 28.3–38.9 m/s24. The use of a musculoskeletal modeling system has the advantage that data can be safely collected from a larger number of cases rather than using implants with built-in devices to measure loading data in THA. The mean HCFs of the lead and trail replaced hips during the golf swing  were comparable, with a tendency of larger HCF of trail hips in both left THA and right THA, which was somewhat lower than the HCF while jogging at 6–8 km/h: 5.4–8.5 × BW39. Although jogging has been classified as a high-impact sport, it has been reported to have no adverse effect on mid-term survival outcome in THA40. The number of golf swing motions is much less than the number of steps taken while jogging and the repetition of loading cycles is significantly smaller. In addition, no negative effects on mid-term survival rate of implants have been previously observed in golfers41. Thus, it is suggested that the golf swing is an acceptable motion in patients with unilateral THA, although it produces a high HCF for both lead and trail replaced hips, comparable to that of jogging. There have been no previous reports of HCF in normal participants and THA patients during a golf swing, the proximo-distal component of HCF showed a similar pattern and magnitude as the resultant HCF, consistent with the reported HCF of daily activities in THA patients24.Advances in computational techniques using musculoskeletal modeling systems have shown the comparability of estimating hip contact force (HCF) data to in vivo HCF26. It has been reported that more than 60% of MVIC intensity should be used for effective muscle strengthening and that the range should be at least 40–60% to stimulate muscle strength adaptation29. The driver swing may be useful as an iliopsoas strengthening exercise, because the %MVIC of the bilateral iliopsoas muscles is greater than 60%. Marta et al. demonstrated that the driver swing activated hip extensors in the order of strength of the biceps femoris long head, gluteus maximus, and semimembranosus in the lead leg (51–83%) and gluteus maximus, biceps femoris long head, and semimembranosus in the trail leg (67–100%), indicating a higher muscle activity of the trail leg42, which was consistent with the present study, where more than 40% of %MVIC was found in the hip extensors  of the trail leg, except in the bilateral iliopsoas muscles. However, overall, %MVIC values were higher in the Marta et al. report5 than in the present study, which may have been influenced by differences in the participants , handicap (< 5 vs. 8–45), and analysis methods . The biceps femoris long head and medial hamstring on the right side had approximately 40% of MVIC. Therefore, opposite-direction driver swings may be required to provide a level of muscle activation that balances the bilateral biceps femoris long head and medial hamstring muscular adaptations.The musculoskeletal modeling system can estimate the activation of each muscle around the hip joint which is in agreement with the measured activation44. A significantly higher proportion of males were found in the patients without golf-related replaced hip pain compared to patients with pain, consistent with previous reports on the association between sex and persistent pain after THA9. Of golf swings, the minimalist golf swing and partial golf swing are designed to reduce the loading that hips experience throughout the swing46. The minimalist golf swing, which requires torso rotation to be completed in a more upright position during the set-up, results in less hip extension and abduction moments while maintaining golf performance47. The partial golf swing, which is adjusted to approximately 80% of full swing distance, requires limiting the natural weight shift of the swing to reduce lateral motion, resulting in a significant reduction in the peak horizontal ground reaction force of both legs47. This reduction in joint loading resulting from swing adjustments may provide relief from hip pain during and after playing golf.A significantly higher proportion of males were found in the patients without golf-related replaced hip pain compared to patients with pain, consistent with previous reports on the association between sex and persistent pain after THAThere are several limitations to the present study. First was the limitation of the small number of study patients. Although power analysis is done, number could be insufficient for groups with and without hip pain. A larger number of patients might have revealed further kinematic and kinetic differences. In addition, we recruited recreational golfers from unilateral primary THA patients; therefore, findings in this study cannot be generalized to amateur or professional golfers. Furthermore, we only analyzed swings using a driver for our data collection. Therefore, we cannot make inferences as to kinematics and kinetics produced using other clubs. Finally, the patients performed their golf swing while barefoot and without a golf ball, which could have altered swing mechanics.The driver swing of unilateral THA patients did not contribute excessive hip contact forces to the right and left hip prosthesis, with a maximum club head speed and hip RoMs comparable to those of healthy participants. The driver swing activated more than 60% of %MVIC at bilateral iliopsoas muscles and could be useful as a strength exercise for those muscles. The replaced hip pain related to golf activity was associated with male female, a lower mHHS, and higher HCF of the surgical side; in particular HCF could be reduced through swing adjustments, which may allow for the development of a comfortable golf game free from pain.


BRCA) alterations who had progressed on prior androgen signaling inhibitor therapy and taxane-based chemotherapy.Niraparib is a highly selective poly (adenosine diphosphateribose) polymerase-1 and poly (adenosine diphosphate-ribose) polymerase-2 inhibitor indicated for select patients with ovarian, fallopian tube, and primary peritoneal cancer. The phase 2 GALAHAD trial (NCT02854436) demonstrated that niraparib monotherapy is tolerable and efficacious in patients with metastatic castration-resistant prostate cancer (mCRPC) and homologous recombination repair (HRR) gene alterations, particularly those with breast cancer gene  and with pathogenic alterations in other HRR genes (other HRR cohort) were enrolled and received niraparib 300 mg once daily. Patient-reported outcome instruments included the Functional Assessment of Cancer Therapy–Prostate and the Brief Pain Inventory–Short Form. Changes from baseline were compared using a mixed-effect model for repeated measures.Eligible patients with alterations to (HRQoL) improved in the BRCA cohort by cycle 3  and was maintained above baseline until cycle 10 , whereas the other HRR cohort showed no early change in HRQoL from baseline  and declined by cycle 10 . Median time to deterioration in pain intensity and pain interference could not be estimated in either cohort.On average, health-related quality of life BRCA alterations treated with niraparib experienced more meaningful improvement in overall HRQoL, pain intensity, and pain interference compared with those with other HRR alterations. In this population of castrate, heavily pretreated patients with mCRPC and HRR alterations, stabilization, and improvement in HRQoL may be relevant to consider when making treatment decisions.Patients with advanced mCRPC and  There are limited treatment options available for patients with prostate cancer that has spread to other parts of the body. Niraparib helps patients with certain genetic changes who previously had disease progression on standard treatment for prostate cancer. We looked at the impact of niraparib on the quality of life in these patients. Treatment with niraparib maintained or improved quality of life and decreased pain. Implications for managed care pharmacyNiraparib showed antitumor activity and manageable safety in patients with advanced metastatic castration-resistant prostate cancer, especially those with breast cancer gene 1/2 alterations. Niraparib treatment improved or maintained overall health-related quality of life, pain intensity, and pain interference in these heavily pretreated patients with metastatic castration-resistant prostate cancer and homologous recombination repair alterations. Stabilization and improvement in health-related quality of life are associated with improved survival and decreased medical resource use, including hospital stays to manage signs and symptoms of disease progression.1 For most patients who progress to metastatic castration-resistant prostate cancer (mCRPC), the median overall survival is approximately 3 years with current standard-of-care therapies. Patients who progress beyond androgen signaling inhibitors and taxane-based chemotherapies have limited treatment options.10Prostate cancer is a leading cause of morbidity and mortality in men worldwide.13 which are associated with increased risk of cancer progression and a more aggressive disease course.14 Cancers with HRR gene alterations have been shown to be highly susceptible to inhibition of single-strand break repair mechanisms, such as those mediated by poly (adenosine diphosphate-ribose) polymerase (PARP) inhibition.15 Breast cancer gene (BRCA) mutations, in particular, have clinical implications because they are associated with adverse clinical features in primary tumors and particularly poor outcomes in patients with mCRPC. PARP inhibitors have demonstrated efficacy in patients with BRCA alterations in multiple malignancies and in patients with advanced mCRPC and HRR gene alterations, particularly BRCA2 mutations.20Approximately one-quarter of tumors in patients with metastatic prostate cancer harbor homologous recombination repair (HRR) gene alterations (germline and/or somatic),23 The phase 2, open-label, multinational GALAHAD trial evaluated niraparib monotherapy in patients with mCRPC and alterations in HRR-associated genes who had progressed on prior androgen signaling inhibitor therapy and taxane-based chemotherapy. In the final analysis, niraparib showed meaningful clinical activity, with an overall response rate of 34.2% in the primary efficacy population of patients with germline pathogenic or biallelic somatic BRCA mutations and measurable disease.24 Patient-reported outcomes (PROs) are increasingly used in clinical trials to assess the potential real-world impact of a medical treatment or intervention on patient health and well-being.25 Here, we report the prespecified analysis of PROs from the GALAHAD study.24Niraparib is a potent and highly selective (targeted) inhibitor of PARP-1 and PARP-2 that is US Food and Drug Administration– and European Commission–approved for the maintenance treatment of select patient populations with ovarian, fallopian tube, and primary peritoneal cancer.24 The GALAHAD study (NCT02854436) was a multicenter, open-label, phase 2 study conducted at 115 sites in 15 countries. Patients aged 18 years or older with mCRPC were eligible if they had a predefined HRR gene alteration and had experienced previous disease progression on an androgen signaling inhibitor and a taxane-based chemotherapy. Patients provided informed consent and were prescreened using a tumor tissue (Foundation Medicine) or plasma circulating tumor cell DNA (Resolution Bioscience) sample to evaluate for HRR gene alterations as previously described.24 In this analysis, patients with alterations in BRCA1 or BRCA2 (BRCA cohort) were compared with patients with pathogenic alterations in other HRR genes (other HRR cohort), including the following: ataxia telangiectasia mutated, BRCA1 interacting protein C-terminal helicase 1 gene, checkpoint kinase 2 gene, Fanconi anemia complementation group A gene, histone deacetylase 2 gene, and partner and localizer of BRCA2 gene. Exclusion criteria for this study included prior treatment with a PARP inhibitor, prior platinum-based chemotherapy for the treatment of prostate cancer, and myelodysplastic syndrome/acute myeloid leukemia.A detailed account of the methods, including all eligibility criteria, has been published previously.Patients received niraparib 300 mg in the form of three 100-mg capsules taken once daily starting on day 1 of cycle 1 (with a cycle defined as 28 days) until treatment discontinuation due to disease progression, unacceptable toxicity, or death. Patients were required to continue with a gonadotropin-releasing hormone analog unless they had undergone a prior bilateral orchiectomy.26 It includes a general functional status scale  and a prostate cancer–specific subscale with items related to urination, bowel movement, and erectile function. The total score is calculated with general function and prostate cancer–specific scores and ranges from 0 to 156  . Side effect burden was evaluated based on patients’ responses to the FACT-P item “bothered by side effects of treatment.” Response categories for this item are not at all, a little bit, somewhat, quite a bit, and very much. The FAPSI-827 is another validated tool that contains 8 key questions derived from the FACT-P questionnaire—pain (3 items), fatigue, weight loss, urinary difficulties (2 items), and concern about the condition becoming worse—and was specifically designed for men with advanced prostate cancer. The BPI-SF28 is a validated measure that is often used to assess pain (Pain Severity Index) and functional interference (Pain Interference Index) as a result of pain in patients with cancer. The BPI-SF Pain Interference Index measures how much pain has interfered with recent daily functions . The Pain Severity Index scores range from 0 to 40, whereas the Pain Interference Index scores range from 0 to 70. At each treatment cycle, patients were classified as “improved,” “stable,” or “worsened” on PROs based on established meaningful change thresholds (MCTs).28PRO instruments included the Functional Assessment of Cancer Therapy–Prostate (FACT-P), the Functional Assessment of Cancer Therapy–Prostate Cancer Symptom Index, 8-item Version (FAPSI-8), and the Brief Pain Inventory–Short Form (BPI-SF) questionnaires. The FACT-P is among the most commonly used validated measure of health-related quality of life (HRQoL) in prostate cancer treatment trials.All PROs were assessed at baseline; on day 1 of cycles 3, 5, and 7; and then on day 1 of every third cycle until the end of treatment. All visit-specific PRO assessments were strongly encouraged to be conducted and completed before any tests, procedures, or other consultations for that visit. PROs were assessed in all patients who completed the baseline screening assessment and 1 or more postbaseline assessments. Assessments were captured on paper, and the results were entered into an electronic case report form.All patients provided written informed consent. Independent ethics committees or institutional review boards of each participating institution approved this study. The study was conducted according to Good Clinical Practice guidelines and the Declaration of Helsinki.Supplementary Table 1. Changes from baseline were compared for the BRCA cohort vs the other HRR gene alteration cohort using a mixed-effect model for repeated measures (MMRM). In each MMRM model, the dependent variable was the change from baseline PRO score. Changes from baselines scores were used to classify patients as improving, remaining stable, or worsening at each time point. Generalized estimating equations (GEEs) were used to calculate odds ratios (ORs) of HRQoL improvement relative to stable or worsening using other HRR as the reference category. In each GEE model, the dependent variable was the binary response of improved or not. For MMRM and GEE models, predictors included the baseline PRO score, visit, gene-alteration group (BRCA vs other HRR), and the interaction between gene-alteration group and visit.PRO assessments, including BPI-SF and FACT-P, were analyzed as prespecified in the study statistical analysis plan in the intent-to-treat (ITT) efficacy population to assess the change in pain symptoms and HRQoL while on treatment. Compliance with PRO assessments (percentage received and percentage missing forms) was tabulated for each visit. Missing PRO assessments were calculated as the expected number of assessments for a particular visit minus the actual number of assessments received for that visit. Descriptive statistics  were provided for each component of the BPI-SF and FACT-P; details for each component are provided in 30 Patients who did not experience deterioration were censored at the last data point collected for the PRO assessment. In cases when median time to event was not reached because too few patients experienced degradation, 25th percentiles were reported and compared.Median time to first deterioration in FACT-P total score, as well as BPI-SF worst pain intensity and pain interference subscale scores, were estimated by Kaplan-Meier methods and determined by the following MCT values: 10-point reduction from baseline for FACT-P total score and 0.5 SD from baseline for BPI-SF worst pain intensity and pain interference subscale scores. MCT values were derived from published literature.24 There were 223 patients included in the ITT efficacy analysis, which consisted of 142 patients with BRCA alteration and 81 patients with other HRR gene alterations. The median follow-up in the BRCA cohort was 10.1 months (range = 0.3-47.4 months); the median follow-up in the other HRR cohort was 8.6 months (range = 0.4-35.3 months). Efficacy results were previously reported.24A total of 385 patients were screened between September 2016 and June 2020; 289 patients were enrolled and included in the safety analysis.BRCA cohort and between 87.5% and 100.0% in the other HRR cohort from baseline through cycle 10  and higher BPI-SF pain (mean = 3.2 vs 2.6) and pain interference scores (mean = 3.5 vs 2.9).Of the 223 patients in the ITT efficacy analysis, 221 completed the PRO evaluations at baseline and had 1 or more postbaseline evaluations. Compliance for PRO assessments was between 84.3% and 97.7% in the cycle 10 . The preBRCA cohort experienced more meaningful improvements in overall HRQoL compared with the other HRR cohort, as measured by FACT-P total score .Overall, consistent with other efficacy outcomes in the GALAHAD trial, patients in the al score . On averBRCA cohort compared with the other HRR cohort at cycle 3  and cycle 5 (50% vs 18.2%) .More patients reported improved FACT-P total score in the s 18.2%) , and thiSupplementary Figure 3).Median time to deterioration in FACT-P total score was longer in the BRCA cohort  compared with the other HRR cohort  . In bothBRCA and other HRR cohorts experienced rapid reduction in pain intensity , as measured by the BPI-SF. This effect was more pronounced for the BRCA cohort compared with the other HRR cohort, with smaller differences reported during later cycles. On average, the BRCA cohort experienced greater early pain relief by cycle 3  than the other HRR cohort , with the largest reduction observed between baseline and cycle 3. Similar mean pain intensity reductions were observed in the 2 cohorts at cycle 10 , but interpretation may be limited by sample size. Pain interference was also rapidly reduced by cycle 3 in the BRCA cohort  and the other HRR cohort , with differences that were maintained until cycle 5.Patients in both the ntensity  and painSupplementary Figure 5), with a more pronounced effect in the BRCA cohort. Specifically, a greater proportion of patients reported reduced pain intensity at cycle 3 (43.8%) compared with the other HRR cohort  (BRCA cohort (41.8%) compared with the other HRR cohort  , with improvements persisting. Patients also experienced stability in pain intensity and pain interference in both the BRCA cohort and other HRR cohort from baseline through cycle 10 .Patients in both cohorts reported reduced pain intensity  and pain64-3.27) . The ratcycle 10  (SupplemWhile on treatment (cycles 3-10), an average of 63.3% of patients in the BRCA cohort (range = 55.8%-70.1%) and 59.6% of patients in the other HRR cohort (range = 49.1%-66.7%) experienced no or mild side effect burden . Across cycles 3-10, rates of stable or reduced side effect bother compared with baseline levels averaged 64.5% for patients in the BRCA gene cohort  and 49.9% for patients in the other HRR cohort .32 In this prespecified PRO analysis of the multicenter, open-label, phase 2 GALAHAD study, niraparib improved or maintained PROs in the majority of patients with HRR-positive mCRPC who had progressed on both androgen signaling inhibitors and taxane-based chemotherapies, with the most pronounced improvements in PROs observed in the BRCA cohort. This study consisted of patients who had been treated with a median of 3 prior lines of therapy, had a high median prostate-specific antigen, had a high median plasma circulating tumor cell count, and had a high proportion of bone and visceral metastasis in patients with BRCA1/2 with measurable disease, indicating advanced disease at study entry.24 Specifically, 40% of patients in the BRCA cohort in our study had visceral disease, which has been associated with poor survival outcomes.24,32 Furthermore, although BRCA alterations are associated with poor prognosis, these alterations are most strongly associated with response to PARP inhibitors, which may explain the differences in response seen in PROs in this study.33,34 Treatment options for these castrate, heavily pretreated patients with advanced disease are limited, so improvements in PROs are both clinically meaningful and likely to reflect the therapy under study. Therefore, in this population of castrate, heavily pretreated patients, stabilization, and improvement in HRQoL may be relevant to consider when making treatment decisions.PROs are increasingly used in clinical trials to assess the impact of a medical treatment or intervention on patient-perceived health and well-being.BRCA cohort (8.31 months) compared with the other HRR cohort (3.71 months), indicating sustained benefit. This finding, along with improvements in pain intensity and interference, as well as an objective response rate of 34.2% and tolerable safety profile, supports the clinical benefit of niraparib in patients with mCRPC, particularly those with the BRCA1/2 alterations.On average, patients in both cohorts experienced rapid decreases in pain intensity and pain interference. These changes were more pronounced in the BRCA cohort than in the other HRR gene-alteration cohort. HRQoL, as indicated by average FACT-P scale scores, rapidly improved in the BRCA cohort, but remained stable or declined across cycles in the other HRR gene-alteration cohort. Furthermore, the median time to deterioration in overall HRQoL  was more than twice as long in the -BRCA HRR gene alterations. In addition, results of studies, such as VISION,35 support the notion that standard-of-care therapies, such as androgen signaling inhibitors, are not adequate to maintain HRQoL, and new therapeutic approaches are urgently needed. PARP inhibitors, in addition to providing clinical efficacy, improve or maintain HRQoL in patients with mCRPC, particularly those with the BRCA alterations as demonstrated in the present study, PROfound,16 and TALAPRO-1.36GALAHAD was a single-arm study and was not designed to allow for direct comparison of results with other studies. In addition, study designs and patient populations, including subgroup cohorts, in other studies of targeted therapies vary from those used in GALAHAD. However, findings from GALAHAD contribute to the evolving body of knowledge that PARP inhibitor efficacy is most robust for patients with BRCA alterations and somewhat less pronounced for patients with non16 TOPARP-A,37 and TOPARP-B.38 In these and other studies , patients with mCRPC and HRR gene alterations, particularly in BRCA, had better responses  to treatment with PARP inhibitor monotherapies. Collective findings from the present and other studies informed the concept and design of the phase 3 MAGNITUDE trial (NCT03748641). Together, results of GALAHAD and MAGNITUDE,39 as well as the other aforementioned studies, support use of genetic testing in patients with mCRPC to identify patients with the greatest unmet medical need and address it with the best treatment  for best outcomes, including in HRQoL, to balance the benefit-to-risk ratio. This approach offers clinicians better predictability and the opportunity to match the treatment with the aggressiveness of the disease, optimize the patient journey and manage risk.The concept and design for GALAHAD were informed by studies such as PROfound,31,40 Fourth, results are very consistent, indicating that patients with mCRPC and BRCA alterations tend to benefit more from treatment with niraparib. Finally, responder analyses using within-person MCTs over time ensured differences were clinically meaningful and relevant to patients.Our study had several strengths. First, the study was conducted at 115 sites in 15 countries, including the United States, Canada, United Kingdom, Europe, Brazil, Russian Federation, Australia, Israel, Taiwan, and Republic of Korea, and should be representative of the spectrum of clinical settings and practices. Second, use of 2 PRO scales to assess both HRQoL and pain burden and the reporting of positive and relatively complete results in a prespecified PRO analysis. Third, both the MMRM and GEE are robust statistical analyses that can provide appropriate and meaningful estimates. The MMRM model, in particular, has been widely applied and validated in PRO analyses among patients with prostate cancer.BRCA alterations and a cohort with varied HRR genes in this study is limited by the small sample size at later assessment time points; few patients received more than 10 cycles of therapy (in both cohorts). Missing data over time due to dropout could contribute to bias  and could lead to variable effects on the BRCA vs other HRR cohorts. We assumed missingness was missing at random, meaning the propensity for a data point to be missing was not related to the missing data. However, if nonrandom missing data (missing not at random) are reported, the MMRM analysis may not be applicable, and bias may be generated. In GALAHAD, patient compliance was generally high and missing was low, except for cycle 13 and end of treatment when few patients remained on treatment. In addition, two-thirds of the patients in the study were White, potentially affecting generalizability of the findings to other races.The long-term comparison between patients with Consistent with the clinical activity previously reported, treatment with niraparib led to improved or maintained overall HRQoL, pain intensity, and pain interference in patients with advanced mCRPC and HRR gene alterations, particularly in those with BRCA alterations. These findings support use of genetic testing in patients with mCRPC to identify patients with the highest therapeutic need and to inform treatment decisions for such patients.


Study objectiveThe ultrasound-guided (US-guided) suprainguinal fascia iliaca block (SIFIB) is a regional anesthesia procedure that targets the lumbar plexus. It offers versatility in clinical practice, serving as both a standalone method for adequate pain management and a primary anesthesia option. Our aim was to present clinical insights gained from the application of US-guided SIFIB, whether as a standalone procedure or in conjunction with another block, across various clinical indications for lower extremity surgeries.MethodologyOur study is a retrospective cohort analysis designed to identify cases in which the SIFIB was used as a component of the main anesthetic method and to determine the success of the anesthetic method in patients undergoing lower extremity surgery between March 2022 and March 2023 in a tertiary hospital. Data such as block success, perioperative additional analgesic need, patients' demographic details, and block characteristics were obtained from electronic and paper-based patient records and analyzed.Main results We analyzed data from 16 patients who underwent lower extremity surgeries under SIFIB. Among these, 10 patients received SIFIB as their sole anesthesia method, while six underwent surgery with a combination of sciatic block and SIFIB. Briefly, the types of surgery were amputations, soft tissue excision, revision of knee prostheses, excision of knee tumors, patella implant removal, patellar ligament repair, patellar fracture repair, distal femur fractures , and vascular surgery. Six patients necessitated additional analgesics. No statistically significant differences were observed in demographic details, block onset time, and surgical duration between patients requiring and not requiring sedoanalgesia during surgery (p>0.05).ConclusionFor patients planning lower extremity surgery, considering SIFIB alone or combined with a sciatic block as part of anesthesia management is a valid option, offering an alternative to a lumbar plexus block. Orthopedic procedures have become increasingly prevalent in clinical practice. Notably, the landscape of perioperative pain management and anesthesia strategies has undergone significant advancement in recent years. The adoption of regional anesthesia techniques, often coupled with multimodal analgesic approaches, has ushered in a transformative era, substantially diminishing the reliance on general anesthesia across a wide spectrum of surgical interventions. Pain management strategies for lower extremity surgeries encompass a range of techniques, neuraxial anesthesia, and occasionally, peripheral nerve blocks and interfascial plane blocks or combinations thereof, emerging as effective and commonly employed approaches . Within The fascia iliaca block was initially described by Dalens et al.  in 1989,Our aim in this proof-of-concept retrospective study was to investigate the feasibility of applying SIFIB as the main anesthetic method, alone or in combination with a sciatic block, in a range of clinical indications for lower extremity surgeries and to present the clinical information obtained.Study designClinicaltrials.gov with NCT06076096. Data collection for patients who underwent lower limb surgeries at Samsun University Education and Research Hospital during the period spanning from March 2022 to March 2023 was executed through the utilization of hospital automation systems  and documentation extracted from perioperative follow-up forms. Patients classified within the American Society of Anesthesiology (ASA) categories I-I who underwent lower limb surgical procedures with the utilization of SIFIB either as the sole anesthesia method or as a constituent of the anesthesia plan were enrolled, and data were systematically gathered. Patients who received anesthesia management via general anesthesia, neuraxial anesthesia, or infiltration anesthesia were excluded. Written informed consent is an essential requirement for all procedures conducted as part of our clinical routine and obtained for all procedures. Due to the retrospective nature of this article, obtaining consent for publication was waived.This study was structured as a retrospective data analysis. Ethical approval for this study was obtained from the Institutional Ethics Committee of Samsun University (SUKAEK-2023 8/7) and was registered to Data collectionDemographic data pertaining to patients, including their age, gender, weight, length, comorbidities, and ASA scores, were documented. Furthermore, the features of the surgical procedure, including its type and duration, as well as additional block or local anesthetic volume administered in milliliters, block onset time in minutes, total surgery duration in minutes, any supplementary analgesic or anesthetic requirements, and reported perioperative pain and its precise location, were all diligently recorded.Block technique and routine analgesia protocolSIFIB is administered approximately 30 minutes prior to the surgical procedure in a designated section within the operating room under standard ASA monitoring. We routinely use premedication prior to the block procedure as intravenous midazolam at a dosage of 0.01-0.02 mg/kg and fentanyl at 0.25 mcg/kg (or ketamine at 0.15 mg/kg).For SIFIB, patients are placed supine, and all procedures are carried out in accordance with the rules of asepsis. SIFIB is performed under the guidance of a high-frequency linear transducer, and sciatic blocks are applied in the lateral position with a convex transducer . In SIFIB, local anesthetic is injected into the compartment between the iliac fascia and iliacus muscle in the suprainguinal region, and the spread of local anesthetic is confirmed by US . We routIn our clinical practice, propofol infusion at a dose of 1 mg/kg/hour is preferred to reduce the patient's awareness and maintain cooperation throughout the surgery and is adjusted according to whether the patient under conscious sedation reports pain. As a general rule, before increasing the dose of propofol, ketamine is administered in divided doses, with each dose being 10 mg, and these instances are meticulously recorded. Detailed records are also maintained for patients necessitating supplementary analgesics during the intraoperative phase, encompassing both the drug doses administered and the localization of pain.Adhering to our standard clinical protocol, we consistently administer a standardized analgesic regimen. Each patient was managed with a multimodal analgesia approach involving the intravenous administration of both paracetamol (1 g) and tenoxicam . Continuous quantitative data were expressed as numerical values along with the mean ± standard deviation. The chi-squared test followed by Yates' correction was used for categorical assessments, while the Mann-Whitney U test was employed for continuous data evaluations. A significance level of p<0.05 was established to determine statistical significance.The data of a total of 16 patients were analyzed, including 10 patients  and body mass index (BMI) from 21.8 to 29.7 kg/m2 (mean BMI 27.0±2.81 kg/m2)) who underwent sole SIFIB and six patients  and with a BMI of 23.8 to 32.8 kg/m2 (mean BMI 29.6±3.4 kg/m2)) who underwent SIFIB combined with sciatic block. The surgical duration averaged 48.5±7.3 minutes. The onset time of the blocks was evaluated with a pinprick test by stimulating the anterolateral of the thigh and surgical incision area and was 29.1±5.1 minutes. In addition to patient demographic data, Table The types of surgeries were above-knee amputations (2), revision of knee prostheses, excision of knee tumors (2), soft tissue excision from the knee with grafting, implant removal from patella, patellar ligament repair, vein ligation and stripping (2), patellar fracture repair, grafting from the mid-thigh, distal femur fractures (3), and femoropopliteal bypass surgery Table . In all During these surgeries, one patient reported mild/moderate pain at the posterior of the knee (case 5), two patients reported mild pain on deep manipulation of the inferomedial of the knee cases 1, 9), and three patients reported mild/moderate pain at the medial of thigh . A very low dose of ketamine was given to these patients who reported pain during surgery  with those who did not (n:10), there were no statistically significant differences observed in terms of age, ASA classification, BMI, block onset time, and surgical duration (p>0.05). It is presented in Table Based on our clinical experience involving 16 patients who underwent lower extremity surgery for various indications, it is evident that the utilization of SIFIB or a combination of SIFIB and sciatic block can be an alternative option for surgical anesthesia.US-guided SIFIB precisely targets the lumbar plexus components situated immediately medial to the spina iliaca anterior superior . The actIndeed, the literature consistently highlights the use of SIFIB for postoperative analgesia in hip and knee surgeries as an integral component of a multimodal analgesic strategy -13. FurtThree patients reported intraoperative mild to moderate pain secondary to the surgical process extending beyond the planned area. Sciatic block or distal selective block applications could have been utilized to address this issue quickly. In case 1, the cause of the mild pain in the inferomedial patella was not due to insufficient obturator nerve blockage but failure to block the terminal branches originating from the sacral plexus of the superior and medial genicular nerves. Considering the complex innervation of the knee, the lumbar plexus block alone may not be enough for complete anesthesia. Similarly, the pain reported in case 5 was due to the area innervated by the sacral plexus. The interspace between the popliteal artery and capsule of the posterior knee block could have been utilized in this case; however, it was not predicted that the surgical procedure would extend to the ⅓ posterior aspect of the knee. It should be noted that in the selected patient group for whom transfemoral amputation will be performed, we are of the opinion that SIFIB+sciatic block may serve as an alternative to lumbar plexus block.In high volume/low concentration SIFIB, the local anesthetic reaches the branches of the lumbar plexus more easily and leads to increased block effectiveness. SIFIB is generally performed using 40 mL of local anesthetic ; howeverWhile anatomical variations may account for variability in pain perception among certain patients, individual patient characteristics also likely exerted influence. Factors such as the presence of chronic illnesses and an individual's recollection of prior pain experiences may be correlated with the perception and intensity of perioperative pain. Contemporary research endeavors are currently investigating the predictability of pain, with hemogram parameters being one of the areas under scrutiny ,21. It mThere are some limitations. The retrospective nature of the study heightens susceptibility to bias, especially considering the number of the study population. Feasibility was not assessed within homogeneous groups, considering the distinct innervation areas associated with each surgical procedure. When assessing surgical anesthesia methods for lower extremity surgery, it is essential to consider not only the surgical site but also the utilization of tourniquets. Anesthesia and analgesia management should be meticulously planned to accommodate these factors. Research studies should be conducted to investigate clinical, anatomical, and cutaneous mapping, specifically focusing on SIFIB and lumbar plexus block techniques.In patients scheduled for lower extremity surgery, SIFIB, as an alternative to lumbar plexus block, appears to be a feasible option that can be used alone or in combination with sciatic block. Of course, if these techniques or combinations are to be used as an alternative to general and neuraxial anesthesia, the cutaneous and osseous innervation areas and the possible blockage area of each technique should be taken into account on a per-procedural basis.


Pain scores at rest and during movement as well as morphine consumption were similar between groups in the 0th, 3rd, 6th, 9th, 12th, and 24th hours (p > 0.05). Conclusions: The study determined that the utilization of TLIP blocks and posterior QLBs prior to anesthesia induction yielded comparable outcomes in terms of reducing postoperative analgesic consumption and enhancing the efficacy of multimodal analgesia in individuals undergoing single-distance lumbosacral spine surgery under general anesthesia.Introduction: The management of postoperative pain following lumbar disc herniation (LDH) surgery is crucial for the quality of recovery. The effectiveness of multimodal analgesia plans increases when interfascial plane blocks are included. This study sought to compare the analgesic efficacy of preoperative ultrasound-guided TLIP  blocks and posterior QLBs (quadratus lumborum blocks) in patients undergoing LDH surgery. Methods: Patients undergoing elective LDH surgery under general anesthesia were randomized into two groups: thoracolumbar interfascial plane block (Group T) and posterior quadratus lumborum block (Group Q). Block applications were performed 30 min before anesthesia induction. In the postoperative period, analgesia control was provided with a patient-controlled analgesia device. The patients’ 24 h cumulative opioid consumption was examined. Pain scores were evaluated in the 0th, 3rd, 6th, 9th, 12th, and 24th hours. Results: The mean 24 h cumulative morphine consumption for patients was statistically insignificant when Groups T and Q were compared (9.14 ± 7.03 mg vs. 8.66 ± 6.58 mg,  Back and leg pain arising from lumbar disc herniations (LDHs) are widespread, and their treatment can range from pharmacotherapy to surgical intervention. Although postoperative pain is less frequent in minimally invasive surgeries when compared to more conventional procedures, it still remains a significant challenge for healthcare providers ,2. A majFollowing spinal surgery, multimodal analgesia strategies are recommended in order to provide optimal pain management and to promote early functional improvement. These strategies encompass several approaches, including neuraxial blocks, local infiltration analgesia, and fascial plane blocks. Additionally, the utilization of pharmacological medicines such as nonsteroidal agents, opioids, and gabapentinoids is encouraged ,4. InterThe ultrasound-guided TLIP block was first described by Hand et al. in 2015 , and theWhile the sonographic target is more challenging to identify with the conventional TLIP technique, the anticipated spread of local anesthetic is confined to a narrow area. This circumstance makes the block application more challenging, but it potentially enhances the block’s success. On the other hand, in the posterior QLB technique, the sonographic target is easier to identify, and the area where the local anesthetic will disperse is broader. While this makes the block application easier, it may reduce the sensory coverage of the block. We aimed to compare these two techniques in this study ,12,14.The study’s primary objective was to assess and compare the analgesic efficacy of preoperative ultrasound-guided TLIP blocks and posterior QLBs in patients undergoing LDH surgery. We primarily assessed 24 h opioid consumption and secondarily examined postoperative pain scores (NRS) as well as potential opioid-related side effects  and complications related to the blocks.This prospective, randomized, and evaluator-blinded study was conducted between August 2022 and August 2023 following ethical board approval  and clinicaltrials.gov registration (NCT05421585).The study comprised individuals aged 18 to 70 who were classified as ASA I-III and were scheduled to undergo single-level lumbar hemilaminectomy/microdiscectomy under general anesthesia. All patients included in the study were operated on with the same surgical technique. The exclusion criteria applied to patients who had a bleeding diathesis, were undergoing anticoagulant therapy, had allergies or hypersensitivity to local anesthetics and opioids, had infections in the block application site, had a history of prior lumbar surgery, had recently used gabapentinoids or corticosteroids within the past three weeks, were unable to cooperate sufficiently to utilize patient-controlled analgesia devices, were suspected to be pregnant, were pregnant or breastfeeding, or had declined to undergo the procedure.Upon admission to the room where the preoperative blocks were performed, patients were randomized using the sequentially numbered, opaque, sealed envelope (SNOSE) technique into two groups, each comprising 30 patients . The blocks were administered to patients by the same practitioner (ST), and all postoperative assessments were conducted by a blinded anesthetist (DA) to ensure study blindness.All block procedures were performed in the block room, 30 min prior to the commencement of surgery. Prior to the block, patients were positioned in the prone position, monitored, and premedicated with 1 milligram (mg) of intravenous (IV) midazolam. Aseptic measures were implemented to maintain sterile conditions, and a lower-frequency ultrasonic transducer  was appropriately covered with a sterile drape. The study employed an 85 mm block needle . The bilateral administration of the blocks involved the use of 20 milliliters (mL) of local anesthetic (%0.25 bupivacaine) for each side.Posterior QLB application: In contrast to the conventional approach, we deviated from the practice of administering this block in the shamrock or supine position. Instead, we repositioned the transducer from the lumbar midline to a lateral orientation. After achieving visualizations of the spinous processes, erector spinae muscle group, facet joints, transverse processes, and the quadratus muscle in succession, we confirmed the plane by injecting 1–2 mL of physiological saline into the interfascial region located posterior to the quadratus lumborum muscle. Upon the verification of the block’s placement, we proceeded to administer 20 mL of local anesthetic into the interfascial plane. This procedure was then replicated on the contralateral side.TLIP block application: The ultrasound probe was oriented in a vertical position relative to the L3 vertebra. To aid in positioning, the spinous process and interspinal muscles were identified as reference landmarks. Following this, the longissimus and multifidus muscles were visualized. The block needle was guided in a lateral to medial trajectory using an in-plane approach. To verify the extent of the block, 2 mL of physiological saline was administered in the interfascial space between the longissimus and multifidus muscles. After confirmation, 20 mL of local anesthetic was administered for the execution of the block. The same procedure was replicated on the contralateral side.−1 iv propofol, 1–1.5 microgram/kg−1 iv fentanyl, and 0.6 mg/kg−1 iv rocuronium. Patients were subsequently positioned in a prone orientation. Anesthesia maintenance was achieved with 0.8–1 MAC  sevoflurane in a 50% oxygen–air mixture and 0.1–0.3 mcg/kg/minute (min) iv remifentanil infusion. The lumbar discectomy/laminectomy technique was consistently executed by an identical surgical team, employing a standardized surgical protocol across all patients. In accordance with the routine analgesia protocol, patients were given 1 gram (g) of paracetamol and 20 mg tenoxicam iv approximately 30 min before the end of the surgery as well as 4 mg of iv ondansetron to prevent nausea and vomiting. Patients with adequate spontaneous respiration were extubated and taken to the postoperative recovery unit.Patients were transported to the operating room, where they were subjected to monitoring procedures in compliance with ASA standards. Subsequently, the patients were intubated following the administration of 2–2.5 mg/kgDuring the postoperative phase, patients received intravenous paracetamol at a dosage of 1 g thrice daily, in addition to intravenous morphine infusion facilitated by patient-controlled analgesia (PCA) devices. The PCA device contained morphine at a concentration of 0.5 mg/mL in normal saline. The device was programmed to administer a bolus dose of 1 mg, with a lockout period of 8 min between doses. Additionally, the device was set with a maximum hourly limit of 6 mg of morphine. The evaluation of postoperative pain was performed using the numeric rating scale (NRS), where a score of 0 represents the absence of pain and a score of 10 signifies the most severe pain imaginable. The NRS was utilized to measure pain levels both at rest and during activity at several time points following the surgical procedure. These time points were the 0th, 3rd, 6th, 9th, 12th, and 24th postoperative hours. The patients were provided with instructions to initiate patient-controlled analgesia (PCA) when their numeric rating scale (NRS) score was ≥4.The primary outcome of this study was 24 h cumulative opioid requirement as delivered from the PCA device. The secondary outcome was pain score at rest and during movement in the postoperative period. Additionally, we also assessed potential negative outcomes, including allergic responses, nausea, vomiting, and other block-related complications.t-test was employed for data that exhibited normal distribution, whereas the Mann–Whitney U-test was favored for data that did not adhere to normal distribution. Chi-square tests were employed to assess the relationships between categorical variables. In addition, mean, standard deviation, median, minimum, maximum; and quartiles (25th and 75th percentiles) were used as distribution measures. A significance level of p < 0.05 was deemed to be statistically significant. For NRS scores, the Bonferroni correction was employed in order to account for the multiple comparisons made across the six time periods, and a statistical significance threshold of p < 0.0083 was set.Prior to conducting the study, G*Power 3.1.9.7 was utilized to establish the appropriate sample size for equal distribution among the groups. The calculations were based on the following parameters: a significance level (α) of 0.05, a power (1 − β) of 0.80, and an effect size of 0.8. Consequently, it was concluded that a sample size of 26 individuals per group would be necessary. In order to account for potential dropouts, a sample size of 30 patients was selected for each group, resulting in a total of 60 patients. Statistical analyses were conducted using IBM SPSS Statistics 21. The normal distribution of data was assessed by the Kolmogorov–Smirnov and Shapiro–Wilk tests. The independent-samples p > 0.05)  .p = 0.788). The morphine consumption at the 0th, 3rd, 6th, 9th, 12th, and 24th hours was also similar between the groups (p > 0.05) (p > 0.05)  . The pai > 0.05) . No blocOur study demonstrated that the use of US-guided TLIP and posterior QLB techniques as part of multimodal analgesia in patients undergoing single-level lumbar disc surgery resulted in comparable postoperative opioid requirements across all time frames. Furthermore, the NRS scores at rest and during movement were similar at all measured time points. Both groups’ postoperative pain levels remained within acceptable limits.Lumbar disc herniation surgeries are procedures notably associated with postoperative pain ,3. The iIn our study, we augmented our multimodal analgesia strategy by incorporating fascial plane blocks to establish an effective analgesic protocol for our patients. To achieve this goal, we employed the recently introduced TLIP block and QLB, assessing the efficacy of postoperative pain relief.The erector spinae muscle group comprises three muscles located in the lumbar region: the multifidus, longissimus, and iliocostalis, collectively known as the paraspinal muscles. The primary fascia in the lumbar region, known as the thoracolumbar fascia, envelops the erector spinae, quadratus lumborum, psoas major, and latissimus dorsi muscles. The thoracolumbar fascia is composed of three layers: anterior, posterior, and middle .In the initial classical form of the TLIP block, a local anesthetic is administered into the plane situated between the multifidus and longissimus muscles, selectively targeting the dorsal ramus and medial branch ,11. SubsThe existing body of literature on the application of TLIP blocks using the classical method in patients undergoing lumbar disc surgery remains limited ,22. NoneIn the posterior quadratus lumborum block (QLB), local anesthetic is administered in a plane immediately lateral to that utilized in the erector spinae plane block (ESPB) ,13,25. TTo the best of our knowledge, this study is the first to compare the efficacy of the TLIP and posterior QLB techniques in the context of single-level lumbar spinal surgeries. While there are a limited number of similar studies utilizing these blocks in the existing literature, our investigation yielded noteworthy findings. Specifically, we observed a statistically significant reduction in 24 h opioid consumption within both the TLIP and QLB groups, and the levels of opioid utilization were found to be comparable between these groups. It is important to note that although we did not incorporate a control or sham group into our study design, the relatively low 24 h opioid consumption observed in our patient cohort, particularly in light of the absence of any scheduled analgesic beyond paracetamol in our postoperative analgesia regimen, is a notable outcome when juxtaposed with the existing literature ,22.Our study was subject to several limitations. Firstly, we did not conduct a dermatome analysis or measure the sensory block area, which could be perceived as a constraint. However, it is worth noting that these assessments were not included in similar studies, primarily due to the nature of the surgical procedures involved, which are not conducive to such analyses. Additionally, we did not record the block performance times, although our clinical observations suggested that the identification process was quicker with the quadratus lumborum block (QLB).Another limitation was that, contrary to the practice of some anesthetists, we implemented all blocks in the preoperative block performance room, even though they could have been carried out in the prone position after induction. Our aim with this approach was to shorten the operating room usage time and identify potential early complications, and we hypothesized a certain time requirement for the local anesthetic to reach the target tissue. In addition to studies investigating the effects of different blocks, research exploring the pros and cons of the two time options could also be beneficial.Furthermore, we did not assess postoperative patient satisfaction scores or quality of recovery scores, both of which should unquestionably be included in future investigations. Additionally, the somatosensory evoked potential (SSEP) and motor evoked potential (MEP) techniques, recently employed to mitigate nerve damage in lumbar surgeries, could potentially be utilized, although it is important to note that they are not standard practice for single-level disc surgeries. Nevertheless, it is advisable to consider future research endeavors aimed at determining the potential impact of the TLIP and QLB techniques on the necessity of monitoring techniques in thoracolumbar spinal surgeries.We determined that the TLIP and posterior QLB techniques applied before anesthesia induction similarly reduced the postoperative analgesic requirement and improved the quality of multimodal analgesia in patients undergoing single-distance lumbosacral spine surgery under general anesthesia.