Ketamine can attenuate pain associated with IV propofol injection through local and central analgesic effects. Ketamine is gradually being transitioned to its S-enantiomer, esketamine, which has a similar mechanism of action. The purpose of our study is to determine the half effective dose  of propofol was given. Patient perception of pain was scored with the verbal rating scale (VRS) every 5 s after the start of the propofol infusion, and the evaluation was stopped once the patient became unresponsive. The dosage of esketamine was increased or decreased up or down according to the patient’s pain response. The initial dose of esketamine was 0.2 mg/kg, and the gradient of adjacent dose was 0.02 mg/kg. If the pain response assessment of the upper patient was positive (+), the dose of esselketamine in the next patient was increased by 0.02 mg/kg; if the pain response assessment of the upper patient was negative (−), the dose of esselketamine in the next patient was decreased by 0.02 mg/kg. The tests were carried out sequentially, with the pain response changing from positive to negative or from negative to positive, and the tests were stopped after at least 6 crossover points, and the effective dose of esticketamine was calculated using probit probability regression analysis.50 = 0.143 mg/kg , ED95 = 0.176 mg/kg , and ED99 = 0.189 mg/kg . The esketamine dose and VRS score during propofol injection were significantly different between the two groups (P < 0.05), whereas surgical duration, emergence time, visual analogue scale (VAS) score of postoperative uterine contraction pain, and Riker sedation/anxiety scale (SAS) score were not significantly different. Bradycardia occurred in only one patient during anesthesia induction, while hemodynamics was stable in the rest of the patients without obvious adverse reactions.The ineffective group comprised patients with a positive pain response and the effective group comprised patients with a negative pain response. The 95% CI was set as the confidence interval of effective dose ED value，and we found esketamine’s EDSmall doses of esketamine combined with propofol can be safely and effectively used for hysteroscopic surgery. We recommended a dose of 0.2 mg/kg IV esketamine before induction of anesthesia to reduce the pain of propofol injection.Chinese Clinical Trial Registry ChiCTR2100048951. Date of registration: July 19, 2021. Propofol is an intravenous (IV) anesthetic medication widely used in for procedural sedation, in operating rooms, and intensive care units (ICUs). Propofol is particularly suitable for outpatient and same-day surgeries because of its strong sedative and hypnotic effects, fast onset, quick recovery, and low incidence of postoperative nausea and vomiting (PONV). However, the incidence of pain from IV propofol injection can reach 28–90% and averages about 60–70% , 2. The The purpose of this study was to use Dixon’s up-and-down method , 14 to dhttps://www.chictr. org.cn/abouten.aspx). The study was plan to recruit 200 subjects from different populations according to the actual surgical order. At present, our team had completed the recruitment of 120 subjects, and had completed the dose study of esketamine to eliminate pain in adult propofol injection, which was exactly the experiment reported in this paper. At the same time, our team was currently conducting a dose study of esketamine to relieve pain from propofol injections in children and the elderly, and two other drugs  were also being studied. We were planed to complete all the trials by December 2023. As esketamine was a newly marketed drug in China in recent years, the effect of esketamine on the pain of injection of propofol was not clear, and the adult test was safer than that of children and the elderly. Therefore, our team first choose to conduct the trial of esketamine on the pain of injection of propofol in adults, which was also the reason why we first reported this trial. Thirty gynecological patients who planned to undergo hysteroscopy were included in this trial，and all patients were writted informed consent before participation in this trial. All procedures of this trial followed the tenets of the Helsinki Declaration.Our team was conducting a double-blind, prospective, single-center dose-response clinical study, which was study on effective dose of esketamine, remifentanil and lidocaine in relieving pain of propofol injection in patients of different ages, and the study was a large research project of the effective dose of three drugs  to eliminate the pain of propofol injection in different populations . The Ethics Committee of the Affiliated Boai Hospital of Zhongshan  gave ethical permission for the study on June 15, 2021 , and the study  was been registered in the China Clinical Trials Registry  American Anesthesiologists Association (ASA) Physical Status I or II and Mallampati grade I or II; (3) no contraindications for esketamine, opioids, or propofol; (4) no history of drug abuse; and (5) no systemic neurological, cardiac, pulmonary, hepatic, or renal disease.We used the following inclusion criteria: (1) female aged 18–40 years old with a body mass index (BMI) of 18.5–24.9 kg/mWe used the following exclusion criteria: (1) difficult airway; (2) patients with hypertension, hyperthyroidism, myasthenia gravis, schizophrenia, or epilepsy; (3) severe cardiopulmonary or cerebrovascular diseases; (4) patients who had recently taken psychotropic medications or analgesics; and (5) those who were allergic or addicted to opioids or esketamine.2) were monitored. Patients rested for 5 min after entering the operating room. IV anesthesia was induced and the target dose of esketamine was given first, followed by a fixed dose of propofol at 2.0 mg/kg 30 s later, infused at 1 ml/s using a syringe pump. After the propofol solution was given, the patient’s pain response was assessed every 5 s with the verbal rating scale (VRS) [Dixon’s up-and-down method was a classical method to determine the effective dose of drugs , 14. Usule (VRS)  and the Painless – when asked, the patient reported no pain, score = 0; (2) Mild pain – when asked, the patient reported pain and no painful expressions or movements were observed, score = 1; (3) Moderate pain – the patient reported pain voluntarily, or when asked, and there were movements such as withdrawing hands, score = 2; and (4) Severe pain – the patient reacted strongly and there were movements such as frowning, withdrawing hands, and crying, score = 3. For our study, patients were divided into two groups (effective or ineffective) based on their reaction to esketamine as measured with the VRS score. We designated 0 points as a negative pain response (−) for the effective group and 1–3 points on the VRS as a positive pain response (+) for the ineffective group.The esketamine dose was titrated across study participants based on Dixon’s up-and-down method. The initial target dose was 0.2 mg/kg and the next sequential dose was adjusted up or down by 0.02 mg/kg. If the pain response assessment of the previous patient was positive (+), the dose of esketamine in the next patient was increased by 0.02 mg/kg. If the pain response assessment in the previous patient was negative (−), the dose of esketamine in the next patient was reduced by 0.02 mg/kg, and the tests were carried out sequentially. Patient pain response ranged from positive to negative or from negative to positive, and the test was stopped after at least six intersections , 14. PaiAtropine 0.01 mg/kg iv if bradycardia is present, and ephedrine 0.1 mg/kg iv if hypotension is present, repeated as necessary. Esketamine solution was diluted with normal saline to control the total volume to 10 mL, which was prepared by a dispenser who did not know the test protocol before induction of anesthesia. An anesthesiologist who did not know the dose of the esketamine solution performed propofol IV. And another anesthesiologist judged the pain response, and reported the pain reactions to the dispenser, so as to obtain the next patient esketamine solution. Our study was double-blind in order to reduce the interference of human factors and obtain the effective dose of esketamine more accurately.2 in the effective and ineffective groups were recorded at the following time points: 5 min after entering the room (T0), 1 min before propofol administration (T1), 1 min after propofol administration (T2), 3 min after the administration of propofol (T3), and 5 min after recovery (T4). The mean esketamine dose, VRS score of propofol injection pain, surgical duration, emergence time, visual analog scale (VAS) score of postoperative uterine contraction pain [2 < 90%), delayed emergence, nausea and vomiting, and postoperative agitation.Baseline blood pressure and HR were defined as the average of two measurements spaced within 5 min (T0) before the onset of anesthesia. The changes of HR, MAP, and SpOion pain , and Rikion pain  were recP > 0.05 indicates that the data conform to normal distribution. Student’s t test was used for normal distribution data as mean ± standard deviation (−x ± s). And there were no non-normal variables in the chart data listed in this paper. We assume that the P value is two-sided, and P < 0.05 was considered statistically significant.According to previous sequential method studies, the sample size usually requires 20–40 patients , 14. In P > 0.05).The sequential trial was carried out according to the operation sequence of patients，The timeline of the wholes study was shown as Fig. 2 between the two groups between the T0–T4 time points (P > 0.05). There was no significant difference in surgical duration, emergence time, VAS score of postoperative uterine contraction pain, or SAS score between the two groups, but there were significant differences in esketamine dose and VRS score of propofol injection pain between the groups (P < 0.05)  mg/kg, ED95 as 0.176  mg/kg, and ED99 as 0.189  mg/kg. Our results showed esketamine at 0.2 mg/kg to be > 99% effective in reducing pain from propofol injection. The sequential test of esketamine to attenuate propofol injection pain and the dose-response relationship was shown in Figs. The 95% CI was set as the confidence interval of effective dose ED value, according to the sequential analysis, the probit method was used to obtain esketamine’s ED0.143 0.10, 0.162 During the trial, only one patient in the effective group had an adverse cardiovascular reaction, while the other patients did not have hypotension, hypertension, tachycardia, etc. There was no incidence of other types of adverse reactions such as allergic reactions, nausea, vomiting, postoperative agitation, or hallucinations.50, ED95, and ED99 of esketamine for mitigating propofol injection pain were 0.143  mg/kg, 0.176  mg/kg, and 0.189  mg/kg, respectively, identified using a sequential method. The mechanisms behind propofol injection pain are still unclear. It is currently believed that high concentrations of free propofol can induce pain through direct stimulation and activation of the kallikrein-kinin system, activation of nociceptive cis-receptor potential ion channels, and changes in osmotic pressure [The EDIntravenous lidocaine, which has the dual effects of local anesthesia and central analgesia, is commonly used at a dose of 0.5–1 mg/kg to reduce the pain of propofol injection. Nonetheless, there is a failure rate of 13–32%. Continuing to increase the lidocaine dose does not improve effectiveness but instead increases the potential risk of local anesthetic toxicity , 17. IwaEsketamine is a dextrorotatory isomer derived from ketamine through separation and purification. Its mechanism of action and pharmacological characteristics are similar to ketamine, and it primarily exerts anesthesia and analgesia by acting on both NMDA and opioid receptors . EsketamPresently, esketamine is increasingly replacing ketamine in clinical practice in China, especially in the application of short-duration and same-day surgeries , 21, 24.50 of 0.143  mg/kg, ED95 of 0.176  mg/kg, and an ED99 of 0.189  mg/kg. The ED50 and ED95 of esketamine were significantly lower than the ED50 (0.227) and ED95 (0.283) of ketamine determined by Wang et al [50 (0.143) and ED95 (0.176) doses of esketamine for reduction of propofol injection pain were not 1/2 of the doses of ketamine ED50 (0.227) and ED95 (0.283) determined by Wang et al [. Nonetheless, the smaller doses of esketamine used in our study resulted in a good analgesic effect and fewer side effects; however, our findings must be further verified in broad clinical use amongst a more heterogenous population of patients.We determined esketamine’s effective doses for mitigating propofol injection pain include an EDng et al , 11. Sin 0.143 0.0, 0.162  0.176 0.9, 0.320 2 between the two groups of patients before and after induction with propofol. Notably, after intravenous injection of esketamine (1 min before propofol administration), neither HR nor MAP was significantly increased. This may be because the sympathomimetic effect of low-dose esketamine is weak. Neither HR nor MAP was significantly decreased at 1 and 3 min after propofol induction. This may be due to the weaker sympathomimetic effect of esketamine at low doses, which counteract the inhibitory effect of propofol on the cardiovascular system [2 was stable and no respiratory depression was observed, which may be related to the respiratory stimulatory effect of low-dose esketamine, which alleviated the inhibitory effect of propofol on respiration [During this trial, only one patient developed hypotension after propofol induction and no other adverse reactions occurred. There were no significant differences in HR, MAP, and SpOr system , 24. Befpiration , 15. ForOur study had the following limitations: (1) Our study population was entirely female, therefore differences in response to 0.2 mg/kg esketamine between sexes were not evaluated; (2) We did not use an anesthesia depth monitor. It was more clinically meaningful to use the bispectral index (BIS) or Narcotrend to monitor the changes in the degree of sedation and the loss of consciousness during the induction process; (3) No ketamine control group was used. Since ketamine has been essentially withdrawn from our local market and was therefore unavailable, we used previous research results with ketamine as a control. The comparison between the ketamine and esketamine had certain limitations. However, studies have shown low dose esketamine was safe and effective and had a favorable side effect profile; and (4) The sequential method  was a cl50 of 0.143  mg/kg, ED95 of 0.176  mg/kg, and ED99 of 0.189  mg/kg of esketamine were measured using the Dixon’s up-and-down method with no serious adverse events. According to the dose-effect curve, we recommend clinical use of 0.2 mg/kg IV esketamine, which is safe and effective as a pre-propofol injection to relieve pain associated with propofol injection.In our trial of female patients undergoing hysteroscopic surgery, the ED


Background: In today’s world, the upper cross syndrome is growing more common and becoming very prevalent among dental undergraduate practitioners. One of the most important conditions for which dentists seek physiotherapy treatment is neck pain. It is characterized by overactive pectoralis and trapezius muscles. It is frequently linked to poor posture in dental students' daily life, causing them to miss their work.Objectives: The first objective of our study was to find the efficacy of myofascial rollers and post-isometric relaxation technique along with conventional therapy for pain relief and correction of postural deviation in undergraduate dental students. And, the second objective of the study was to compare the effect of myofascial rollers and post-isometric relaxation techniques in upper cross syndrome.Methods: The study was conducted with pre-test and post-test methods. The study consisted of 80 participants who were included based on our inclusion and exclusion criteria. The study sample was randomly assigned into two groups. Each group consisted of a total of 40 participants. Group A was treated using myofascial rollers and hot packs, and Group B was treated using the post-isometric relaxation technique and hot packs. Patients were asked to mark their intensity of pain on the Numerical Pain Rating Scale and an assessment of postural deviations (in mm) was noted through a plumb line in the posture grid. Posture assessment was done in lateral view. The protocol covered four weeks of treatment based on the defined protocol. Finally, the t-square test and Chi-square test were used to compare the difference in the result. Also, the level of significance was kept at <0.05.Result: Statistical analysis was done using descriptive and inferential statistics using student paired, unpaired, and chi-square test. IBM SPSS Statistics for Windows, Version 27.0  was used. The Numerical Pain Rating Scale showed mean deviations of (4.15±1.29) for Group A and (3.30±1.01) for Group B. Plumb line assessment showed mean deviations of (9.09±4.31) for Group A and (6.33±2.36) for Group B. Also, Numerical Pain Rating Scale showed  and Plumb line deviation showed .Conclusion: Through our study, we conclude that statistically no significant differences were found in pre-intervention and post-intervention, but myofascial rollers gave better results as compared to the post-isometric relaxation technique in alleviating pain and correcting postural deviation. Musculoskeletal disorders are the leading cause of disability among people aged 20 to 50 years and are primarily related to their jobs, with headaches and chronic neck pain being the most common complaints worldwide as per WHO literature . An uppeThese stances are associated with differences in the position of the scapula. Overactive muscles and varied kinematics around the neck and shoulder muscles cause gradual changes in muscular tension. Thoracic-four (T4) syndrome has been coupled with back pain along with difficulty in apt functioning and generalized weakness, and other upper body symptoms. Also, T4 syndrome is known to induce chest pain and pseudo angina . PhysicaPhysiotherapy practitioners have been involved in a number of industrial settings to understand work movement patterns and establish appropriate policies to help minimize work-related musculoskeletal disorders as a result of this legislation. Following a thorough review of available texts, several works of literature were found that stated post-isometric relaxation technique as an effective method to treat neck pain and myofascial rollers were found less effective on pain intensity . TherefoAfter receiving approval from the Institutional Ethics Committee of Datta Meghe Institute of Medical Sciences, Deemed to be University, with Ethical Clearance Number DMIMS(DU)/IEC/2021/381), the study was conducted in the musculoskeletal physiotherapy out-patient department of Ravi Nair Physiotherapy College, Sawangi (Meghe), Wardha, India. The inclusion criteria of our study included both male and female dental students of 18-25 years of age, participants working at clinics for at least two years, subjects constantly or frequently suffering from neck-shoulder pain, and those willing to participate in the study. The exclusion criteria included age more than 25 years, those diagnosed with malignancies of soft tissues and joints, congenital neck and shoulder deformities, recent fractures, unstable cardiovascular pathologies, and patients on another clinical trial. The participants were explained the objectives and approaches of the study, and written patient consent forms were signed by them. The participants with musculoskeletal pain due to upper cross syndrome were randomized through simple random sampling and were allocated as randomly those who fulfilled the inclusion criteria into group A and group B. Randomization and allocation were done by the primary researcher, who is an undergraduate student of physiotherapy. Outcome measures were assessed before the beginning of the study, and after the completion of the study, by the same undergraduate student of physiotherapy. Randomization was done based on inclusion and exclusion criteria along with a simple random sampling method and allocated through SNOSE  method. The envelopes were kept with serial numbers. The collected data was stored in a safe, locked area with restricted access, for a biostatistician for further analysis. The registration, treatment, and evaluation schedules for the study bonded to the guidelines in the standard protocol items: a suggestion for conducting intervention trials . The floOutcome measuresA physiotherapy undergraduate student who was aware of the study but blinded to the intervention evaluated the following outcome measures before and after the intervention.Numeric Pain Rating Scale (NPRS)Plumb Line AssessmentIt is a uni-dimensional scale to measure pain intensity, particularly in adults. It is a 10-rating scale and an 11-point numeric scale in the form of a horizontal bar or line. Zero is no pain and 10 is intolerable/ worst pain. A therapist can ask questions verbally or it can be self-scored. It has several merits, like it takes less than one minute to complete, and can be understood in any language; i.e. there is no language barrier. It is a valid and reliable scale that measures pain intensity and experience . Plumb While assessing posture symmetry, rotations should be observed in three views: anterior, posterior, and, lateral. Look for alignment of the head, curvatures of the spine, and shoulder symmetry followed by pelvic, hip, and ankle. This research assessment of posture will be done in a lateral view .InterventionTwo groups were assembled. Demographic data were collected from the patient and each participant underwent the measurement of NPRS score and plumb line assessment Figure . During Group A :The participants in this group underwent treatment through myofascial rollers and conventional therapy. Prior to treatment thorough physiotherapy assessment was done for palpating tenderness, trigger points, and taut bands followed by conventional therapy including the application of hot packs for a period of 15 minutes and subsequently, application of myofascial rollers. Myofascial rollers were rolled on the trapezius, levator scapulae, rhomboid major, and rhomboid minor muscles. The rollers were moved in all directions along the length of a particular muscle. The application time of the roller was 10-15 seconds followed by a relaxation time of 10-12 seconds. For better results and comfort of the patient, treatment was given in a supine lying position. Each session lasted for 20 minutes for four days per week for a duration of four weeks Figure .Group- B The participants in this group underwent treatment with the post-isometric relaxation technique. Prior to treatment, a thorough physiotherapy assessment was done for palpating tenderness and taut bands followed by conventional therapy including the application of hot packs for a period of 15 minutes. Post-isometric relaxation was given for five repetitions, for the trapezius, levator scapulae, and rhomboid, both major and minor muscles. Gentle stretching of the trapezius muscle was given to the patient. The subject was in a sitting position with their back supported and their head tilted towards one side. The patient was asked to contract their muscles for 8-12 seconds along with a gentle stretch to the neck, followed by a relaxation duration of 10-12 seconds. Likewise, five barriers were achieved. The patient was instructed not to hold breaths Figure .The level of significance for the statistical analysis was set at p<0.05, and descriptive and inferential statistics were performed using the chi-square test, student paired and unpaired t-tests, and software from IBM SPSS Statistics for Windows, Version 27.0  and GraphPad Prism 7.0 . The mean age of the patients of group A was 22.95±1.66 and in group B it was 22.85±1.81 and the difference between the two groups is statistically not significant. In group A, 42.5% of the patients and in group B, 52.5% were males, and 57.5% of the patients in group A and 47.5% in group B were females; the difference between the two groups was statistically not significant . The mean NPRS score in group B at pre-treatment was 6.87±1.36 and at post-treatment, it was 3.57±1.73. By using the Student’s paired t-test, a statistically significant difference was found in NPRS scores at pre- and post-treatment . On comparing the mean difference in NPRS scores among patients of two groups statistically, a significant difference was found in NPRS scores among patients of two groups  . The mean plumb line deviation score in group B at pre-treatment was 21.15±5.43 and at post-treatment, it was 14.82±4.84. By using the Student’s paired t-test, a statistically significant difference was found in the plumb line deviation score at pre- and post-treatment . On comparing the mean difference in the plumb line deviation score among patients of two groups statistically, a significant difference was found in the plumb line deviation score among patients of two groups   dental students. Myofascial release  is a technique for improving the range of motion (ROM) and reducing muscle tension by enlarging the sarcomere within muscle fibres by gradually applying pressure to the motor trigger point (MTrP) before the specialist feels the tension release . PhysiotChu and Butler in 2021 presented a case that described the consequences of poor postural positions for a prolonged period on gastroesophageal reflux disease (GERD) . The phyThoracic manipulation is more beneficial for reducing neck pain. And mechanical manipulations benefitted patients in reducing neck disability. Hand and arm disorders, such as carpal tunnel syndrome and tendonitis, are the most common reasons for dentists and dental hygienists to retire due to disability. Practising high velocity oriented approaches like vertebral rotations induces a high probability of risks for internal structures of the area, like injury to the vertebral artery. Therefore, it is advised to practice such approaches with the thoracic spine . A combiThe reason behind the selection of our research topic was the increasing number of UG dental professionals reporting at our physiotherapy outpatient departments (OPDs) with complaints of neck and shoulder pain with high intensities. This report is unique in that several articles were found that stated post-isometric technique as an effective protocol to treat pain associated with the upper cross syndrome, but no previous article was found that has done a study to find the efficacy of myofascial rollers and post-isometric relaxation techniques using plumb line assessment for the upper cross syndrome. Myofascial rollers gave better results in NPRS score as compared to post-isometric relaxation technique in alleviating musculoskeletal pain associated with neck and shoulder. The limitations of the study were a smaller sample of only 80. For generalizing results, larger-scale studies are required. The small duration of the study was another limitation. Also, there were clothing issues in females during the plumb line assessment. Further studies should be conducted with long intervention timings. This study was conducted only on dental undergraduates; similar studies should be conducted in other occupations.In today's era, increasing sedentary lifestyles and lack of exercise are making people suffer from musculoskeletal pain. The major reason behind conducting this study was dental professionals reporting to our physiotherapy hub complaining of musculoskeletal neck and shoulder pain. All awkward chair positions and continuous stress on anatomical structures are making them very prone to developing problems and upper cross syndrome. The findings of our study confirmed that myofascial rollers were more effective than post-isometric relaxation techniques in reducing pain intensity and correcting postural deviations in dental undergraduates suffering from the upper cross syndrome. After the study, participants were educated about the maintenance of healthy postures and repeated stretching intervals in short breaks from work. Both the participating groups showed improvement in pain when results were documented and analyzed after the completion of the intervention duration of four weeks. For generalizing results, larger-scale studies are required. Also, similar studies should be conducted with long intervention timings. This study was conducted only on dental undergraduates; similar studies should be conducted in other occupations to know about their forthcoming risk factors.


Elective implant removal following healed extremity fractures remains controversial. This study aimed to evaluate the reasons and outcomes of implant removal after uneventful healing of limb fractures.This is a prospective single-centre observational cohort study. Patients who sustained upper or lower extremity fractures that were fixed and healed uneventfully were included in the study when they elected to remove the implants. Patients were followed for six months post-operatively. Outcomes were assessed with patient satisfaction, symptoms resolution, and complications.A total of 43 patients were recruited from October 2016 to March 2019. Thirty-six patients (37 implants) were symptomatic. Pain and prominence were the most common complaints, present in 59.5% and 33.3% of patients, respectively. Cold weather pain was also not uncommon (19.0%). Pain improved in 91.3% of the patients who complained of pain. The 94.6% symptomatic patients had at least partial resolution of pre-operative symptoms. All the patients who completed follow-up were satisfied with the procedure. In two patients, there were broken and retained screws intra-operatively. Post-operative complication rate was 23.8%, although no major complications occurred.Implant removal after uneventful healing of extremity fractures is a safe procedure that conferred a predictable relief of symptoms and satisfactory outcomes in most. In patients for whom their fractures were fixed with implants, it is controversial whether routine implant removal is required after uneventful fracture healing. There are currently no guidelines or evidence-based recommendations for this practice. Patients may request for implant removal for a variety of reasons: prominence, pain including cold weather pain, or stiffness. However, it is difficult to link the causality of these symptoms to the implants and is unclear if routine implant removal will resolve the symptoms. Moreover, going through another surgery is not without risks, such as retained implants, iatrogenic fractures, or neurovascular injuries.Implant removal is a frequently performed orthopaedic surgery and has been reported to contribute to almost 30% of all elective orthopaedic operations and 15% of all operations3. However, there were concerns about the high early postoperative complication rate4. A recent systematic review failed to conclude the effectiveness of elective removal of implants5.In studies examining the outcomes of elective implant removal, some showed improved functional outcomes, quality of life and satisfaction after implant removal9. We therefore designed a prospective study aiming to evaluate the reasons and outcomes of implant removal in healed extremity fractures after implant fixation.Most studies on the outcomes of implant removal are retrospective with small study populationsThis is a prospective single-centre observational cohort study performed in a tertiary trauma centre over three years. Ethical approval was obtained from the institutional review board prior to initiating the study . Patients undergoing elective implant removal were invited to participate in the study if the following inclusion criteria were fulfilled: (1) the patients chose to have their implants removed which was not scheduled as part of the management plan; (2) aged 19 to 75 years.The exclusion criteria included: (1) patients with osteomyelitis or infected implants; (2) patients scheduled for revision surgery due to implant failure or peri-implant fractures; (3) patients scheduled for implant removal before weight-bearing (e.g. syndesmotic screw); (4) spine implants, finger and metacarpal implants, osteotomy implants, and external fixators; (5) patients who had secondary procedures done as part of the implant removal process, e.g., tenolysis, nerve release, or extensive adhesiolysis. Patients who had multiple implants removed from different locations in the same sitting were not excluded.The patients were identified from the specialist clinics during their routine follow-ups and eligible patients invited to participate in the study. Informed written consent was obtained for all enrolled patients.The records of the initial injury and surgery were reviewed for the mechanism of injury, and the presence of open fractures. The interval between initial surgery to implant removal, the status of fracture healing, reason(s) for implant removal, and pain score were documented pre-operatively. Surgeon's training level, type of implants removed, and the presence of intra-operative complications were recorded on the day of the surgery.Patients were scheduled for a follow-up visit at two weeks, and either visits or telephonic assessment at three and six months post-operatively to assess outcomes and adverse events. Radiographs were taken during the first postoperative visit to look for retained implants, fractures, and healing complications. Patients' satisfaction was assessed with two questions: Are you satisfied with the implant removal? And would you still choose to remove the implants if you were put in the same situation? Pain was assessed using the visual analog scale (VAS). Other outcome measures were resolution of pre-operative symptoms and complications, which including hypertrophic scar/keloid, infection, neurovascular injury, hematoma formation, retained implant(s), iatrogenic fracture, and re-fractures.A total of 43 patients with 45 implant removal surgeries were recruited for the study . Two patFifteen patients were female, and 25 were male. The mean age was 40.2 years (range: 19–74 years) at the time of implant removal. Twenty-two patients participated in recreational sports pre-operatively, and the rest were not active in sports. Twenty-eight patients were healthy without any co-morbidities. The rest had well-controlled medical conditions. Seven patients were smokers.The initial fractures were all closed. They were at the ankle in 16 cases, clavicle in 9, olecranon in 5, tibia/fibula in 3, distal radius in 3, proximal humerus in 3, distal humerus in one, ulnar in one, and distal femur in one. 17 fractures resulted from road traffic accidents, 14 from sports, 8 were falls from standing height, and 3 were falls from height. Preoperative radiographs showed union of all the fractures.Thirty-six patients (37 implants) were symptomatic. Fifteen patients (37.5%) had multiple complaints. Pain was the most common reason for implant removal. It was present in 25 (59.5%) cases with a mean pre-operative VAS of 3.6 (range: 1–7). Eight (19.0%) cases had pain or discomfort in cold weather or environment. Fourteen (33.3%) implants were removed due to prominence. Other reasons were less common. Four (9.5%) patients complained of stiffness. Three (7.1%) patients felt discomfort at the surgical site without pain. Two (4.8%) patients complained of paraesthesia at the surgical site. One (2.4%) opted for implant removal to avoid triggering airport scanners when travelling. Five (12.0%) expressed a preference to have the implants removed despite being asymptomatic.The mean time from initial surgery to implant removal was 18.0 months (range: 8–45 months). The implants removed were: 21 locking plates, 18 non-locking plates, 2 intramedullary nails, and cancellous screws for an isolated medial malleolus fracture. Tightropes for syndesmosis fixation in three cases and medial malleolus cancellous screws in two cases were also removed together with the ankle plates.Of the 25 cases whose implants were removed for pain, 23 completed follow-ups. At 6 months post-operatively, pain improved in 21 (91.3%) cases, including 19 (82.6%) with complete resolution. Average VAS score improved from 3.7 to 0.8. Another patient’s pain score remained the same, but the pain was less constant. She had a medial malleolar fracture which was fixed with two cancellous screws. The pain was worse in one patient whose proximal humerus locking plate was removed, which was due to avascular necrosis of the humeral head. The average VAS score of the 23 patients at final follow-up was 0.8 (range: 0-7). Interestingly, cold weather pain or discomfort resolved in all eight patients. One asymptomatic patient with a clavicle fracture fixed with a reconstruction plate developed pain after implant removal, and his VAS was four at the final follow-up.A total of 94.6% (35/37) symptomatic cases experienced at least partial resolution of the symptoms. Two patients' symptoms did not improve. They are the above-mentioned patients who had persisting kneeling difficulty kneeling and humeral head avascular necrosis.At the final follow-up, all 38 patients did not express any regret regarding the procedure. However, one patient (2.6%) was not satisfied with the results. He had a proximal tibia fracture which was fixed with a proximal lateral tibial locking plate and had difficulty kneeling after fixation which did not improve with implant removal despite complete resolution of pain. However, he was not disappointed with his decision for the procedure as he did not wish to have any retained implants.Intra-operative complications occurred in two cases. Both were olecranon fracture fixed with an anatomical locking plate. The interval between initial fixation and implant removal were 17 and 26 months. Two and four 2.7mm locking screws were broken during implant removal and were left retained . No majoPost-operative radiographs showed complete removal of implants except for the two cases with broken screws mentioned above. No perioperative fractures occurred.The overall post-operative complication rate was 23.8% (10/42). These were all minor, including hypertrophic scar in 5, neuropraxia in 3, hematoma formation requiring aspiration in 1, and stitch abscess in 1. None required surgical intervention. Of the three patients with neuropraxia, one had a clavicle fracture and the other two had a distal radius fracture. They had infraclavicular nerve and palmar cutaneous branch of the medial nerve neuropraxia. All were improving at the final follow-up, with one recovering fully. The stitches abscess was treated with oral antibiotics. However, an asymptomatic keloid formed at the infection site. Intra-operative or post-operative refracture did not occur in any of the patients.Our study found that the most common reasons for implant removal were pain and prominence, followed by cold weather pain or discomfort. Outcomes of implant removal were satisfactory in most patients. Symptoms improved in 94.6% of patients and 97.4% were satisfied with results. Although the complication rate appeared to be high, there were no major complications, and none required surgical intervention. Implant removal is a safe procedure in our series.10. However, with the advancement of metallurgy and understanding of the correlation between implants and cancer, these risks are now considered as minimal or even non-existent. Currently, indications for removal are mainly "relative" and patient-driven10. In our institution, we do not advocate routine implant removal. This explains why most patients who requested for implant removal in our study were symptomatic.Implant removal has been advocated in the past due to concerns about corrosion and carcinogenesis11. Sidky et al8 found 72.2% (13/18) of the patients’ symptoms improved after removal of tibial nails in his retrospective study. And 77.8% (14/18) would have their implants removed if they were in the same situation. Another prospective study of 59 patients who underwent implant removal of proximal humerus locking plate showed significant improvement of Constant score and pain at three and six months post-operatively. Of the 42 patients who answered the questionnaire at 6 months post-operatively, all were satisfied with implant removal and would choose implant removal again if they were in the same situation7. However, in retrospective series of 72 tibial nail removal in 71 patients reported by Karladani et al9, the pain was reduced in only 39 (54.9%). and only 61.8% (42/68) of patients were satisfied with results. Brown et al12 reported pain relief in only 50% (11/22) of symptomatic patients after ankle implant removal. Moreover, 37.5% (3/8) patients with painless hardware developed pain after implant removal. In our series, the outcomes of implant removal was satisfactory with 94.6% of patients experiencing at least partial resolution of symptoms, and pain relief in 91.3%. The higher rate of symptom resolution in our series is likely attributed to the fact that implant removal is not routinely performed in our country, thus most of the patients who opted for removal had symptoms related to the implants.The outcomes of implant removal in the literature are inconsistent. Most studies are from western populations. In a study of 22 patients who underwent implant removal for pain and impingement on the skin following patellar fixation, 86.4% (19/22) had partial or complete resolution of symptomsOne unique complaint in the Asian population is cold weather pain, especially those living in tropical regions where there are less seasonal variations and year-long warm temperatures. The exact mechanism for cold weather pain is unknown. It may be related to decreased local circulation and increased nerve sensitivity. We notice that this symptom presents not only in post-fixation patients, but also in patients with degenerative joint disease. This negates the correlation between the presence of metal implants and the symptom. We routinely warn our patients that cold weather pain might not be relieved with implant removal. However, in our series, cold weather pain resolved after implant removal in all 8 patients, suggesting that the presence of metallic implants may contribute to the development of this symptom.14 including wound infection, poor scar, nerve damage, and refracture. The complication rate was higher with junior surgeons13. Thus, implant removal was recommended to be performed by senior surgeons. It is commonly concerned that the holes left after implant removal are potential stress risers predisposing to refracture. Davison et al15 reported 27% (4/15) refractures within ten weeks of distal femur plates removal during normal functional activities. Forearm refracture rates after implant removal were reported at around 20%17. Contrary to the previous studies, our study found implant removal to be a rather innocuous procedure without any serious complications.The complication rate of implant removal has been reported as high as 40%–42%There were two cases with broken screws which were left retained. In both cases, variable angle locking plate was used to fix a olecranon fracture and the size of all the broken screws was 2.7mm. We believe that the smaller gauge polyaxial screws in the modern designed locked plates may predispose to a higher risk of screw breakage and retention. The strength of this study is that it is the first prospective study of routine implant removal in Singapore. Additionally, we reported cold weather pain as a unique feature of the Asian population. However, there are limitations. Firstly, this study involved a small number of patients with heterogeneous fractures. This is because implant removal is not routinely advocated and is a rare procedure locally. Secondly, patient function was not assessed as part of the study.Our study has shown that the most common reasons for elective implant removal after uneventful healing of long bone fractures were pain, prominence, and cold weather pain or discomfort. Implant removal is a safe procedure that confers a predictable relief of symptoms and satisfactory outcomes in most. Cold weather pain, although presenting in only a minority of our patients, resolved after removal of the implants.


Pneumocephalus may be responsible for post-craniotomy headache but is easily overlooked in the clinical situation. In the present study, the relationship between the amount of intracranial air and post-craniotomy headache was investigated.A retrospective observational study was performed on 79 patients who underwent minimal invasive craniotomy for unruptured cerebral aneurysms. Those who had undergone previous neurosurgery, neurological deficit before and after surgery were excluded The amount of air in the cranial cavity was measured using brain computed tomography (CT) taken within 6 h after surgery. To measure the degree of pain due to intracranial air, daily and total analgesic administration amount were used as a pain index. Correlation between intracranial air volume and total consumption of analgesic during hospitalization was tested using Spearman rank correlation coefficients. Receiver operating characteristics (ROC) analysis was used to determine the amount of air associated with increased analgesic consumption over 72 h postoperatively.The mean amount of intracranial air was 15.6 ± 9.1 mL. Total administration of parenteral and oral analgesics frequency were 6.5 ± 4.5, 13.2 ± 7.9 respectively. A statically significant correlation was observed between daily and total parenteral analgesic consumption after surgery and the amount of intracranial air at followed-up brain CT postoperatively within 24 h , within 48 h , and total duration after surgery . The optimal cut-off value of 12.14 mL of intracranial air predicts the use of parenteral analgesics over 72 h after surgery.Pneumocephalus may be a causative factor for post-craniotomy pain and headache with surgical injuries. Pain, especially headache, is a common occurrence following intracranial surgery and a clinically significant problem. Pain after craniotomy is typically throbbing and pounding, similar to a tension headache, and sometimes steady and continuous in the forehead , 6–8. PoMost pneumocephali after craniotomy are minimal and spontaneously resolve as air gets absorbed , 27. How2), end tidal carbon dioxide (EtCO2) tension, and urine output and temperature monitoring. Anesthesia was induced by intravenous propofol or thiopental sodium, tracheal intubation facilitated with rocuronium bromide (Esmeron®), and maintained with oxygen-air-sevoflurane with continuous remifentanil infusion ranging from 0.05 to 0.2 mcg/kg/min. During surgery, the EtCO2 was maintained at 30–35 mmHg, invasive arterial blood pressure within 20% of preoperative values, and pulse oximetry and bispectral index (BIS) values were continuously monitored. All patients underwent minimally invasive craniotomy through trans-eyebrow or pterional route with the head rotated 15–30° to the opposite side depending on the location of aneurysm. Near the end of the operation, neurosurgeons filled the cranial dead space with saline to remove air.After approval from the Institutional Review Board of our hospital’s ethics committee , a retrospective observational study was conducted in patients who underwent minimally invasive craniotomy for unruptured cerebral aneurysm during a 3-year periods between June 1, 2016 and July 1, 2019. Informed consent was waived because of the retrospective nature of the study and the analysis used anonymous clinical data. Subjects who previously received a craniotomy or had neurological deficit before or after surgery were excluded. All craniotomies were performed under general anesthesia with standard monitoring including non-invasive and invasive blood pressure monitoring, peripheral oxygen saturation . The intensity of postoperative pain, including headache, was measured using a verbal numeric rating scale (NRS) every 4 h by trained NS-ICU nurses and level of consciousness based on the Glasgow coma scales recorded. The NRS scores range from 0 to 10, with 0 representing no pain and 10 representing the worst possible pain . For pain relief, neurosurgeons prescribed parenteral analgesics including non-steroidal anti-inflammatory drugs (ketorolac), tramadol, or opioids  on an as-needed basis and to all patients with NRS score ≥ 4. On the day of surgery and the first postoperative day, ketorolac 30 mg was regularly administered twice per day if the NRS score was ≥ 4 or patients requested analgesics for pain relief after trained nurses determined the pain level on the NRS was ≥ 4. Then, on the second postoperative day, when patients were able to take oral medications, two tablets of oral analgesic (ULTRACET®-Tramadol Hydrochloride 75 mg/Acetaminophen 650 mg) were given regularly three times a day. Despite pain control with the above listed drugs, when patients complained regarding persistent pain and the NRS score was ≥ 4, oral analgesics such as acetaminophen, or tridol were given preferentially. Parenteral analgesics ketorolac 30 mg, pethidine 25 mg, fentanyl 25 mcg, or tramadol 50 mg were administered in that order when pain was not able to be controlled with oral analgesics. The number of analgesics administered until the 3rd day after surgery was counted daily and estimated as an index of pain  6 h after surgery and the images archived in the hospital picture archiving communication system (PACS). The amount of intracranial air was measured from the CT scan image in PACS. The cross-sectional area of air density was manually traced as a region of interest and the area was automatically calculated in the PACS and presented as cmData were collected from the electronic medical records of patients. Patient-related factors included age, sex, weight, medical history , anesthesia-related factors such as the American Society of Anesthesiologist (ASA) classification, hospital stay, and surgical procedure data including surgical approaches  and duration of surgery.The statistical analysis was performed using SAS version 9.4 . Continuous variables were expressed as mean ± standard deviation (SD) and categorical variables were counted in numbers . Correlation between the daily and total analgesic use, total duration of analgesic use from the day of surgery to discharge day, and the amount of intracranial air were analyzed using Spearman rank correlation coefficients (r). Bifrontal pneumocephalus was compared with unifrontal pneumocephalus using Wilcoxon rank sum test. A receiver operating characteristics (ROC) analysis was performed to assess whether greater analgesic use over a 48-h period was associated with increased intracranial air volume . The area under the ROC curve was calculated as well as sensitivity and specificity, and optimal cut-off values were determined using Youden index on ROC analysis. P-value < 0.05 was considered statically significant.A total of 103 patients were enrolled in this study, however, 24 patients were excluded during the study period due to the following reasons: postoperative irritability or delirium (9), inappropriate response to pain estimation or pain expression (7), wound abscess (1), postoperative hyponatremia with syndrome of inappropriate diuretic hormon, incomplete brain CT images (2), or incomplete medical records (4). A total of 79 consecutive patients were eligible for final analysis. Demographic characteristics are presented in Table Pneumocephalus is commonly observed after intracranial surgery , 17, 22.Several factors may contribute to the development of pneumocephalus during craniotomy such as nitrous oxide administration (anesthesia), conditions which reduce the brain bulk including use of osmotic diuretics, moderate hyperventilation with subsequent hypocapnea, and subsequent drain of CSF , 22. TheIn the present study, the volume of air varied from 2 to 59.7 mL (mean 15.7 ± 9.1 mL) based on the computed volume of air using head CT scans, which can detect as little as 0.5 mL air , 17. MosAcute headache following craniotomy is a frequent complaint due to surgical procedures and meningeal irritations . PreviouAcute headaches following craniotomy within the first day are predominantly superficial (86%), indicating a somatic pain rather than visceral pain , 18. TheAlthough pneumocephalus after craniotomy is clinically asymptomatic and spontaneously resolved as air gets absorbed, sometimes excessive volume can cause several symptoms such as headache, nausea, vomiting, irritability, lethargy, dizziness, or neurologic deficits . HeadachIn the present study, daily analgesic consumption decreased with time but the total duration of analgesic consumption was longer with greater volume of intracranial air. Differentiating the pain due to intracranial air from surgical injury in the acute period is not possible. To quantitatively analyze pain, the amount of analgesics rather than NRS score was used as an indicator of pain. The NRS score decreased after taking analgesics, thus, it did not reflect the degree of headache. In the present study, a statistically significant correlation between daily and total analgesic consumption and amount of intracranial air, especially bifrontal pneumocephalus, was observed compared with unifrontal pneumocephalus Table . In addiThe present study had several limitations. First, consensus or standard treatments for pain control after craniotomy do not currently exist. Because neurosurgical patients require frequent neurologic examinations, excessive postoperative pain management may lead to an unintended risk of over-sedation of patients which could mask new neurologic deficits. Therefore suboptimal pain control using both oral and parenteral analgesics on an on-demand basis, especially oral analgesics, preferentially if possible, were provided in our study. In addition, patients undergoing craniotomy were treated with on-demand analgesic medication when the patient complained of pain ≥ 4 on NRS and were not allowed the same medication within 4 h after intravenous administration of drugs. Second, the potency of analgesics was not unified. Therefore, the effect of drugs may vary. Third, the presence of headache prior to surgery is an important risk factor for postoperative headache occurrence, as previously reported in several studies , 8, 15, Acute postoperative pain and headache following craniotomy are important clinical issues but have been underestimated and poorly managed. Pneumocephalus is a frequently observed imaging finding on routine postoperative examination and may be a causative factor for post-craniotomy pain and headache with surgical injuries. To minimize the accumulation of intracranial air, several efforts including less CSF loss during surgery, filling the cranial cavity with saline as much as possible at the end of the surgery to avoid entrapment of air may be warranted.


Background and Objectives: Rotator cuff tear is the most common cause of shoulder pain. If nonsurgical treatment fails, arthroscopic rotator cuff repair (ARCR) is recommended. Since the standards for rehabilitation after ARCR are not clear, various rehabilitation methods have been suggested. This study intends to investigate the effect on the recovery phase of ARCR patients through a postoperative rehabilitation protocol (PRP) that considers the healing process and rehabilitation trend. Materials and Methods: This single-arm, pragmatic intervention study was conducted on 30 patients, two weeks postoperative day (POD) after ARCR. ARCR patients received intervention for six weeks from POD two-week, and pain intensity and shoulder function were evaluated at two-week intervals until POD 12-week, and range of motion (ROM) was evaluated at POD four-week and eight-week. Results: In this study, all variables improved over time (p < 0.05). As a result of the comparison between time points, a significant improvement was found in shoulder function at POD 6-week. In addition, the effect size had a large effect on ROM  and shoulder function. Conclusions: Management through the PRP based on scientific evidence in the strategy of postoperative rehabilitation of patients with ARCR is effective for pain intensity, ROM, and shoulder function. Shoulder pain accounts for 7–26% of the total population . The mosThe goal of rehabilitation following ARCR is to normalize the biomechanics and function of the shoulder complex by promoting the recovery of muscles and tendons and balancing the movements of the scapula and humerus . HoweverPhysical therapy interventions, such as manual therapy and exercise, are the main methods of nonsurgical management of the rotator cuff. This aims to correct by removing the factors that contribute to pain and dysfunction rather than treating specific pathological factors . SimilarHowever, a conclusive therapeutic basis for various physiotherapy interventions has not been identified ,9,10. ThTherefore, this study aimed to investigate the effect on pain intensity, ROM, and shoulder function through a postoperative rehabilitation protocol (PRP) following rotator cuff repair.ClinicalTrial.gov (accessed on 19 April 2022): NCT04711616).This study was designed according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines as a prospective, open-label, single-group, interventional study. The study was conducted from March to September 2021, and the protocol was registered on 13 January 2021 . Informed consent was obtained from all participants before the start of the study.Population estimation using standard deviation with a single group design was performed using a power calculator . It was calculated using the standard deviation (1.3) at the time point when a significant change in pain appeared in the early mobilization group . Fo. Fo17]. Manual therapy was divided into soft tissue mobilization for 20 min and joint mobilization for 10 min and was performed 5 times a week for 6 weeks. Soft tissue mobilization was applied to the upper extremities and peri-scapular muscles because it effectively improved the pain and function of impingement syndrome . Joint mThe exercise was divided into simple ROM exercises and therapeutic exercises, and the intensity of the exercise was tailored to the healing process . For conParticipants received six assessments at 2-week intervals during the 10-week study period. Pre-test before intervention (T0), mid-test twice , post-test after intervention (T3), and follow-up twice after discharge . Only shoulder ROM was assessed by an assessor, meanwhile, all other outcome measures were assessed using self-report questionnaires.The intensity of the pain was divided into the usual and worst pain groups. A numeric pain rating scale (NPRS) consisting of 0 points (no pain) to 10 points (most severe pain) was used . AdditioActive ROM was evaluated for shoulder joint ROM using a goniometer. ROM evaluation using the goniometer was reported to have high intraobserver reliability (intraclass correlation coefficient [ICC] = 0.91–0.99) . The motShould function was analyzed using disabilities of the arm, shoulder, and hand (DASH), shoulder pain and disability index (SPADI), and a simple shoulder test (SST). The DASH has 30 items on a 5-point scale per item, and the reported MCID ranges from 8.1 to 13 . The SPAp < 0.05.All statistical analyses were performed using SPSS . The general characteristics of the participants were expressed using descriptive statistics. For each evaluated variable, repeated measures analysis of variance was used to analyze the change over time. It is expressed as partial eta squared   for quane, 0.14) . All stap > 0.05). Similarly, there was a change with time in the worst pain     .p < 0.01), and in particular, the effect size in motion, except for horizontal adduction and internal rotation, had a large effect (d > 0.80)  were performed. A significant improvement was observed in all motions ( > 0.80) .p < 0.001). In DASH, the effect size was found to have a large effect (p < 0.001). In SPADI pain, the effect size was found to have a significant effect (p < 0.01). In SPADI-disability, the effect size had a large effect (p < 0.001). In the SPADI-total, the effect size was found to have a large effect (p < 0.001). In SST, the effect size had a large effect (p < 0.05)    .p < 0.05). When comparing the effect size based on the statistical method, ROM  and shoulder function  had a large effect , and the effect size also showed a moderate effect. In MCID (1.1–2.2 points), the usual pain did not show a significant decrease, but there was a significant decrease of 1.24 points in the worst pain. In the study by Duzgun, et al. [Regarding pain intensity, a primary outcome measure, both usual pain and worst pain showed significant improvement , but no difference between time points . These results were similar to those of subacromial corticosteroid injection after ARCR in the study by Ha, Kim and Kim [In the results of shoulder ROM, a significant improvement was found in all motions ( and Kim  at three and Kim . Therefop < 0.001). In the comparison between time points, a significant improvement was observed between POD six-week and POD two-week (p < 0.01). In addition, it showed a difference of approximately twice as high as the previously reported MCID of DASH, SPADI, and SST. In the Duzgun, Baltaci and ATAY [As a result of shoulder function, DASH, SPADI, and SST all showed changes over time (and ATAY  study coand ATAY . These rAlthough this was a prospective study, there was a limitation in the interpretation of the results due to the vulnerability to bias with a single-group design. Furthermore, although it is a longitudinal design, the long-term effect is unknown because the entire study period was 10 weeks. However, it can be said to be pragmatic as a rehabilitation protocol implemented in a real clinical setting. Furthermore, it would have been more beneficial if comparisons with historical groups were added. As in this study, various protocols are still proposed for postoperative rehabilitation following ARCR, so the prognosis that can be predicted by comparing the results with long-term follow-up studies will be positive. Further studies recommend a randomized controlled trial using PRP.This trial confirmed pain control, increased ROM, and improvement in shoulder function in participants with postoperative rehabilitation after ARCR consisting of six weeks of physical therapy intervention. In particular, large and significant changes in shoulder function questionnaires, along with a high increase in ROM, suggest that rehabilitation had a positive effect on patients’ daily life and participation in leisure activities.


We compared the individual PROMIS scores between the 2 groups using linear regression, adjusting for sex, nationality, marital status, education level, employment, family history of RD, income, and chronic comorbidities. There were 1024 individuals (512 with RD and 512 without RD). The most common RD was systemic lupus erythematosus (51.6%), followed by rheumatoid arthritis (44.3%). Individuals with RD reported significantly higher PROMIS T-scores for pain  and fatigue  compared to those without RD. Moreover, RD individuals reported lower physical functioning  and social interaction . Patients with RD in Saudi Arabia, particularly those with systemic lupus erythematosus and rheumatoid arthritis, have significantly greater impairment in physical functioning and social interaction and report higher levels of fatigue and pain. Addressing and ameliorating these negative outcomes is necessary to improve quality of life.Rheumatic diseases (RD) are chronic diseases that significantly affect the lives of patients. Assessing health outcomes through a patient-reported outcome measurement information system (PROMIS) is essential for RD management. Moreover, these tend to be less favorable among individuals than among the rest of the population. This study aimed to compare PROMIS between RD patients and other patients. This cross sectional study was conducted in the year 2021. Information about patients with RD was obtained from the RD registry at King Saud University Medical City. Patients without RD were recruited from family medicine clinics. Patients were contacted electronically through WhatsApp Patients with RD have significantly greater impairment in physical functioning and social interaction.Patients with RD report higher levels of fatigability and pain.Sex, nationality, marital status, level of education, employment, family history of RD, income, and chronic comorbidities were all confounding variables. The impact of these illnesses on patients extends far beyond the biomedical component, and affects their quality of life and wellness.–4 Many patients with RD experience pain, disability, and social impairments. Biological, socioeconomic, and lifestyle choices can also contribute to the impairment in the quality of life of these individuals.Rheumatic diseases (RD) are lifelong chronic illnesses that have been subject to increased prevalence in recent years. These tools vary in validity, ease of use, and comprehensiveness. Among these tools is the patient-reported outcomes measurement information system (PROMIS), which was developed to assess different aspects of patient-reported outcomes (PRO), such as pain, fatigue, physical functioning, and social interaction. PROMIS is used in patients with RD in many international settings, and is considered a good tool for enhancing the understanding of different PROs in the clinical management of RD.There is a growing need to appropriately quantify the impact of RD on patient quality of life. Such assessments usually focus on several domains of patients’ lives, including psychological well-being, pain, functional disability, and social interaction, and use both generic and disease specific self-administrative tools.,10 However, research on other RDs in Saudi Arabia is lacking. Recently, PROs research in patients with RD has increased in Saudi Arabia, with interesting findings compared to global reports.–13 However, aspects of pain, fatigue, physical functioning. and social interactions in the RD have not been sufficiently explored in the Saudi population. Expanding the knowledge on PROs in relation to RD is of great importance to the medical and clinical rheumatological communities to improve the management of RD towards a more holistic and patient-centered approach. Therefore, this study aimed to measure PROs among individuals with RD at one of the largest tertiary medical centers in Saudi Arabia and compare them with the PROs of patients without RD.In Saudi Arabia, RD is a growing area of research interest. The prevalence of the most common RDs, rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE), was explored and reported at 2.2 cases per 1000 population and 19 cases per 100,000 population, respectively. KSUMC is a tertiary university hospital in Riyadh, whose beneficiaries are mostly the King Saud University faculty, students, and staff, along with their dependents, in addition to a few individuals referred from other governmental hospitals.This cross sectional study was conducted in 2021 at King Saud University Medical City (KSUMC), in accordance with the guidelines for strengthening observational studies in epidemiology.© . Electronic informed consent was obtained and self-administered questionnaires were sent to the participants.As the purpose of our study was to compare PROs between individuals with RD and those without RD, we sampled equal proportions of patients with RD and those without RD from the KSUMC patient lists. Patients with RD were recruited from a clinical registry. This registry was first initiated in March 2020, and includes patients diagnosed with RD by a charitable association for RD, the Saudi Inflammatory Disease Patient Support Group, and specialized rheumatology clinics at KSUMC. Data collection for this registry is ongoing at the time of writing this manuscript. RD-free patients were recruited from a family medicine clinic. Patients mobile numbers were identified and randomly selected from the list. Patients were invited to participate in this study using text messages sent via WhatsApp, which assessed standardized PROMIS scores for individuals with rheumatological conditions. In that study, the mean T-scores were 40 (±8) for physical functioning, 58 (±10) for fatigue, 47 (±9) for ability to participate in social roles, and 55 (±8) for pain behavior. Considering these assumptions and assuming a desired precision of 1, the respective sample sizes required to achieve a confidence level of 95% would be 246 for estimating physical functioning PROMIS scores, 385 for fatigue PROMIS scores, 312 for the ability to participate in social roles PROMIS scores, and 246 for pain intensity PROMIS scores. Therefore, a minimum sample size of 385 participants per group was required to calculate PROMIS scores for all 4 domains. Assuming a response rate of 75%, the required sample size for each group is 514.We estimated the sample size with reference to a study conducted by Nagaraja et al This tool consists of 8 items pertaining to fatigue, 10 items pertaining to physical functioning, 3 items pertaining to pain intensity, and 3 items pertaining to social interaction. The pain questions were scored on a 10-point Likert scale, while the other domains were scored on a 5-point Likert scale. For each domain, item scores were summed to create 4 separate composite scores. Finally, each of these composite scores was transformed into a T-score using the metric system website for PROMIS for each patient (https://www.assessmentcenter.net/ac_scoringservice). The score was calibrated using an average US score of 50 and a standard deviation of 10 as the reference group. The T-score was then categorized according to the PROMIS standardized cutoff points on the health measures website as normal, mild, moderate, and severe for fatigue, pain, and physical functioning, while social interaction was categorized as very high, high, average, low, and very low.In this study, the outcome measures were the PROMIS scores for fatigue, physical functioning, pain, and social interaction. These were measured using questions from the 29-item PROMIS profile version 2.1, which assessed these 4 domains.The survey also collected data on age, sex, marital status, nationality, education level, employment status, monthly household income in Saudi Riyals (SAR), family history of RD, and comorbidities.The data were collected electronically using Google Forms. Participation in the survey was voluntary. Patient identifiers were excluded from this study.The study was approved by the ethical approval of King Saud University Institutional Review Board No. E-20-4787), and information was managed with extreme confidentiality, without any participant’s identifiers in the data collection form. In addition, the study complied with the ethical standards of the Declaration of Helsinki and all participants provided written informed consent. We calculated the means and standard deviations for age and PROMIS scores were calculated, whereas frequencies and percentages were calculated for categorical measures. Categorical variables were compared between the 2 groups (patients with RD vs patients without RD) using chi-square tests, whereas continuous measures were compared using independent t tests. Finally, the association between RD status and PROMIS was assessed using linear regression analyses, in which each PROMIS sub score and t score were added as dependent variables, while RD status and covariates were added as independent variables. For these models, we controlled for sex, nationality, marital status, education level, employment, family history of RD, income, and chronic comorbidities. An alpha level of 0.05 was used for significance testing. Data was done by complete case analysis.Data analyses were performed using IBM statistical package for social sciences (SPSS) Statistics version 27.0 .http://links.lww.com/MD/I575. Participant without RD attended clinics for different disorders including diabetes mellitus (significantly higher than patients with RD), chronic obstructive pulmonary disease, peptic ulcer disease and peripheral vascular disease. Disorders that were significantly common in participants with RD were: fibromyalgia, chronic obstructive pulmonary disease, other connective tissue disease, medullary cystic kidney disease, and cerebrovascular accident. RDs were distributed as follows: 264 (51.6%) cases of systemic lupus erythematosus, 227 (44.3%) rheumatoid arthritis, 7 (1.4%) scleroderma, 3 (0.6%) Wegner granulomatosis, 2 (0.4%) Bechet’s disease, 2 (0.4%) polychondritis, 2 (0.4%) Sjogren’s syndrome, 1 (0.2%) spondylarthritis, 1 (0.2%) sarcoidosis, 1 (0.2%) gout, 1 (0.2%) antiphospholipid syndrome, and 1 (0.2%) case of vasculitis. Overall, the mean age was the same in both groups. However, most of the participants in the RD group were female. Moreover, individuals with RD differed significantly from the other patients in terms of sociodemographic characteristics   Table . The per1) Table .Multivariate linear regression analyses revealed that sub-scores and T-scores for pain and fatigue were positively associated with RD, while sub-scores and T-scores for physical activity and social interaction were negatively associated with RD. More precisely, controlling for other covariates, RD was associated with 6.2 points increase in the T-score for pain , 2.9 points increase in the T-score for fatigue , 5.4 points decrease in the T-score for physical functioning , and 4.5 points decrease in the T-score for social interaction  compared to those without RD (Table The burden of RD is reflected in PROs, which include fatigue, physical function, and social interaction. This finding was also observed in the present study. The findings of our study can be summarized as follows: First, PROMIS scores were significantly poorer among patients with RD than among those without RD. Second, even when controlling for potential confounding factors, RD was positively associated with higher PROMIS sub scores for pain and fatigue and negatively associated with higher PROMIS sub scores for physical functioning and social interaction, all of which suggest a significantly poorer quality of life among individuals with RD compared to the rest of the population.,13 However, it is unclear whether this degree of impairment differs significantly from that in the general population. Therefore, this significant difference was reflected in the present study.A recent large time series event study during the COVID-19 pandemic highlighted the prevalence of impairment in psychosocial and functional domains among patients with inflammatory arthritis living in Saudi Arabia. Most of the patients were female, with significant differences in employment, income, and marital status, favoring the general population. This is particularly important, given the impact of social determinants on health and patient-reported outcomes. In support of this notion, a recent study by Izadi et al showed that social disparity is associated with higher functional decline in patients with RA, which is partially mediated by disease activity.SLE and RA comprise most patients with RD, which is consistent with the 2 most common inflammatory arthritis conditions in Saudi Arabia and globally. Obviously, Disease activity is a key factor. However, other centrally driven causes, such as fibromyalgia, which was more commonly observed in our cases, tended to be another important factor. Pain also tends to be more prevalent in patients with co morbidities. Our data supports these findings. Identifying all potential factors associated with pain among patients with RD is paramount to understanding their pain, which significantly impairs their quality of life and likely affects other aspects of their quality of life, such as physical function, social interaction, and even mood. In addition, one should keep in mind other contributing factor that may affect physical function and social interaction as the chronicity of rheumatic diseases that is Disease duration.,21As expected, the pain score was much higher in the patients with RD. Pain is a complex phenomenon, and the sources of pain can be multifactorial. This was evident in the close relationship between fatigue and social interaction scores, as well as the higher prevalence of impairment in social interaction among rheumatic patients compared to the general population. In a qualitative assessment of the impact of fatigue on patients with SLE by Sterling et al, work and family engagement were frequently found to be affected in patients with SLE.Fatigue is more prevalent in patients with RD than in the general population. In this study, Saudi patients with RD experienced significantly more fatigue, affecting almost 50% of the patients in the general population. Furthermore, almost 1-third of patients living with RDs experience moderate to severe fatigue, which is likely to affect their engagement with society and productivity at work.With a high burden of fatigue, impaired social interaction, and increased prevalence of pain and fibromyalgia, it is not surprising to see significant impairment in physical function. In our recent work on the impact of the COVID19 pandemic on the quality of life of patients with RD in Saudi Arabia, a very tight relationship between fatigue, physical function, and social interaction exists, such that 1 may influence the other. Physical function has also been associated with the development and worsening of multimorbidity, which is more prevalent among patients with RD. Hence, it is crucial to address exercises even in their simple and regular forms in patients suffering from RD, knowing that the benefits extend to various domains including mood, metabolism, pain, and even chronic inflammation.This study was conducted to address the unmet need to understand the burden of RD, particularly RA and SLE, in patients compared with the general population. Both cases and controls were sampled from the same pool of populations, and the tools used to assess patient-reported outcomes were validated and universally used. However, this study has some limitations, including unmeasured confounders, such as disease activity or formal assessment of mood disorders. This must be considered during the interpretation of regression models. In conclusion, this study sheds light on the burden of RDs in patients compared with that in the general population. Patients with RDs have impaired physical function, social interactions, fatigue, and pain. These findings are consistent with global reports and highlight the need for population-based interventions to improve the quality of life.We would like to thank the patients and Charitable Association for Rheumatic Diseases for their assistance and support.Conceptualization: Ibrahim Almaghlouth, Rufaidah Dabbagh, Abdulaziz Alkhalaf, Mohamed Bedaiwi, Mohammed A. Omair.Data curation: Haya M. Almalag, Ibrahim Almaghlouth, Rufaidah Dabbagh, Abdulaziz R. Alsalem, Fahad N. Alrajban, Saleh A. Algarni, Faisal N. Alosaimi, Meshal I. Alassaf, Muhammad A. Alshamrani, Sulaiman Alzomia, Boshra Alanazi, Tareq Alalwan, Abdulaziz Alkhalaf, Mohamed Bedaiwi, Mohammed A. Omair.Formal analysis: Haya M. Almalag, Ibrahim Almaghlouth, Rufaidah Dabbagh.Investigation: Abdulaziz R. Alsalem, Fahad N. Alrajban, Saleh A. Algarni, Faisal N. Alosaimi, Meshal I. Alassaf, Sulaiman Alzomia, Boshra Alanazi, Tareq Alalwan.Methodology: Haya M. Almalag, Ibrahim Almaghlouth, Muhammad A. Alshamrani.Software: Haya M. Almalag.Supervision: Abdulaziz Alkhalaf, Mohamed Bedaiwi, Mohammed A. Omair.Visualization: Haya M. Almalag.Writing – original draft: Haya M. Almalag, Ibrahim Almaghlouth.Writing – review & editing: Haya M. Almalag, Ibrahim Almaghlouth, Rufaidah Dabbagh, Abdulaziz R. Alsalem, Fahad N. Alrajban, Saleh A. Algarni, Faisal N. Alosaimi, Meshal I. Alassaf, Muhammad A. Alshamrani, Sulaiman Alzomia, Boshra Alanazi, Tareq Alalwan, Abdulaziz Alkhalaf, Mohamed Bedaiwi, Mohammed A. Omair.


Chronic tension-type headache is the primary headache with the highest prevalence. The present study is aimed at analyzing the associations between patient self-efficacy and headache impact with pain characteristics, kinesiophobia, anxiety sensitivity, and physical activity levels in subjects with chronic tension-type headache.  An observational descriptive study was carried out. A total sample of 42 participants was recruited at university environment with diagnosis of tension-type headache. Headache characteristics , physical activity levels, pain related-self-efficacy, kinesiophobia, anxiety sensitivity, and headache impact were measured. r = 0.47) and moderate negative correlations with the self-efficacy in the domains of pain management  and coping with symptoms . ASI-3 score had a negative large correlation with self-efficacy in the domains of pain management (r = −0.59), physical function , and coping with symptoms (r = −0.68). Physical activity levels showed positive moderate correlations with the self-efficacy in the domain of physical function (r = 0.41). Linear regression models determined that the self-efficacy and anxiety sensitivity with showed a significant relationship with the HIT-6 score  and with the ASI-3 score . In addition, no correlations were found between pain intensity, duration or frecuency with psychosocial factors, or headache impact.  The HIT-6 (61.05 ± 6.38) score showed significant moderate positive correlations with the ASI-3 score (17.64 ± 16.22;  The present study showed that patients with chronic tension-type headache had a great negative impact on daily tasks and physical activity levels, which were associated with higher anxiety levels and lower self-efficacy. Headache is considered the second cause of disability worldwide in people between 10 and 24 years old and ranks fifth between 25 and 54 years, according to the 2019 Global Burden of Disease Study. Besides, this report shows how depression is ranked fourth and fifth, and anxiety sixth and fourteenth for both ranges of age, respectively [According to the International Headache Society (IHS) classification (third edition), Tension-Type Headache (TTH) is considered the most common primary headache . TTH lifMain comorbidities linked with TTH are stress, anxiety, and depression . PrevaleSome studies evaluated kinesophobia as a factor associated with TTH, although no clear data has been drawn regarding this issue –13. KineIn regard to physical activity levels, self-efficacy seems to have a relevant role. Self-efficacy is defined as an individual's belief in his/her capacity to produce an adequate yield in daily life activities. Self-efficacy has a direct connection with headache, and it refers to the confidence level a subject has to prevent and/or control pain episodes . This feA number of neuroimaging studies have demonstrated that morphological changes in corticolimbic structures and emotional systems are associated with persistent pain. Patients with chronic pain conditions show reductions in gray matter volume in the hippocampus and amygdala. Given the functions of these two regions, this reduction suggests that the development of chronic pain may be correlated with emotional and cognitive changes .In summary, functional and structural changes in the corticolimbic system and corticolimbic interactions in patients with chronic pain can contribute to emotional and cognitive problems .To date, few studies have been conducted with patients with TTH that report a broad analysis of the associated psychosocial aspects, analyzing their impact on the severity of this pathology –22. In aThe present study is aimed at analyzing the associations between patient self-efficacy and headache impact with pain characteristics, kinesiophobia, anxiety, and physical activity level in subjects with TTH.An observational study following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines  was condThe participants were university employees recruited through the occupational health unit, when they fulfilled the following criteria: (1) adults aged 18-65 years and 2) diagnosed with chronic TTH (duration > six months) by their neurologist, following the criteria of the International Headache Society classification of headaches, in its third edition [ diagnose2) following Shephard's protocol [Anthropometric variables were age in years, height in centimeters (cm), and weight in kilograms (kg). Height was measured with a measuring rod  and weight with a mechanical scale . Body mass index (BMI) was calculated as weight (kg)/height  of 7 days was used, validated, and adapted to Spanish , 29. TheHeadache duration (hours/day), intensity  to 10 (the worst pain ever possible), and frequency (episodes per month) were measured following previous research .The Headache Impact Test (HIT-6) measures the impact that headaches have on daily activity tasks. Regarding the severity of the impact, ≥60 means very severe impact; 56-59, significant impact; 50-55, moderate impact; and ≤49, little impact .The Tampa Scale for Kinesiophobia (TSK) is one of the most widely used measures to assess pain-related fear in patients with pain. Factor analysis reveals a 2-factor model of 11 elements replicated in both samples, called TSK-11. The instrument shows good reliability  and validity (convergent and predictive), with the advantage of brevity. Evidence is provided on the discriminant validity between both TSK factors . TSK-11 was validated by Gómez-Pérez et al. . Items oThe Anxiety Sensitivity Index-3 (ASI-3) measures the dispositional tendency to fear the somatic and cognitive symptoms of anxiety due to a belief that these symptoms may be dangerous or harmful. ASI-3 is a new 18-item self-report scale designed to assess the three most replicated facets of anxiety sensitivity, the physical, cognitive, and social dimensions. For ASI-3, the study by Beghi et al.  was follThe Chronic Pain Self-Efficacy Questionnaire, which assesses the patient's belief about their ability to perform certain activities, was originally developed by Anderson  and valir ≤ 0.1), small (r = 0.1–0.3), moderate (r = 0.3–0.5), large (r = 0.5–0.7), very large (r = 0.7–0.9), and almost perfect (r ≥ 0.9) [R2 change coefficient to state the quality adjustment. HIT-6 and ASI-3 were considered dependent variables, and self-efficacy was considered an independent variable. Graphs of standardized predicted value against standardized residuals were analyzed to assess linearity and homoscedasticity. The multicollinearity was assessed by VIF and tolerance statistics. Finally, a multiple linear regression was performed among variables that already showed significant correlations. The statistical significance was set at an alpha level of <0.05. All analyses were conducted using IBM SPSS for Windows .The Shapiro-Wilk test was employed to assess the normality . A descrr ≥ 0.9) . After BN = 42) with chronic tension-type headache were analyzed. Most of the participants were female (76%) and had a healthy body weight and low-moderate physical activity levels.Adults  or moderate (24%) anxiety levels. Regarding self-efficacy, the participants showed a high score in the physical function domain, but moderate scores in pain management and coping with symptoms.r = 0.47; p = 0.002) and moderate negative correlations with the self-efficacy in the domains of pain management  and coping with symptoms  (The HIT-6 score showed moderate positive correlations with the ASI-3 score (= 0.005) .r = −0.59; p < 0.001), physical function , and coping with symptoms   .r = 0.41; p = 0.005)  . Finally= 0.005) .p < 0.05) for headache impact and anxiety sensitivity. Furthermore, self-efficacy and anxiety sensitivity (predictors) showed a significant relationship with the HIT-6 score  and self-efficacy with the ASI-3 score   .The present study was aimed at examining the associations between patient self-efficacy and headache impact with pain characteristics, kinesiophobia, anxiety, and physical activity level in middle-aged individuals with TTH. Our hypothesis, based on the belief that larger anxiety or kinesiophobia levels, lower physical activity level, and lower self-efficacy, would be related to greater pain, and higher headache impact was partially supported. Lower self-efficacy and higher anxiety were associated with higher headache impact. In addition, this study identified that higher physical activity levels were related with higher self-efficacy.Pain is complex and can rarely be explained purely by a single variable. However, the present study demonstrated the importance of considering self-efficacy when evaluating pain in patients with TTH. In fact, both lower self-efficacy and higher anxiety were related to higher headache impact in participants with TTH. Indeed, HIT-6 questionnaire score was >60, which is considered a severe impact of headaches on patients' quality of life. This finding matched with other research groups with wider study populations and similar aged-based features , 41.Self-efficacy is considered a core component in self-management, yet there is a lack of knowledge about the association between self-efficacy and health-related outcomes in patients with TTH. Low self-efficacy is related to a variety of poor outcomes in both nonsurgical management and postoperative rehabilitation of musculoskeletal conditions –44. SeveWe hypothesize that pain responses such as resting and guarding the craneocervical region have been described as passive coping and viewed as reflecting patient-perceived helplessness in controlling pain or reliance on others for pain management. Resting and guarding consistently have been found to be associated with worse outcomes and thus have been considered maladaptive for chronic pain . Even thKinesiophobia has been studied as a clinically relevant factor linked to several extracranial pathologies such as isolated neck or shoulder pain . SeveralContradicting our hypothesis, headache characteristics were not related to psychosocial factors or headache impact in people with chronic TTH. A possible explanation for this finding in that evidence regarding pain intensity, duration, or frequency in people with chronic TTH compared to asymptomatic controls is limited and conflicting , suggestThe present study has several limitations. Its observational nature does not allow causation, and results should be interpreted with caution. Another limitation of the study is that 76% of the sample are women and future research should determine if these results would be similar in men population. Moreover, the sample size was small, complicating output of regression models. The lack of a control group makes the results to be taken with caution. All data were self-reported and may be subject to information bias. In addition, outcomes related to depression and pain catastrophizing may be interesting, as well as other physical variables such as somatosensory, motor control, or cervical range of motion. Further studies should consider these variables to strengthen this study.In summary, the present study showed that chronic TTH patients had a great negative impact on daily tasks, which was associated with higher anxiety and lower self-efficacy. In contrast, higher physical levels could enhance self-efficacy and attenuate the headache impact of this type of patients. Therefore, physical activity management and improved self-efficacy should be taken into account in chronic TTH patients.


Post-operative pain is the main problem of hemorrhoidectomy. An adequate pain management can promote early mobilization, fast recovery, and reduce hospitalization costs. This study aimed to investigate the role of preoperative anal dilatation using a standardized anal dilator in reducing post-operative pain.This study was conducted using randomized prospective trial with a total of 40 subjects, who were divided into 2 groups. The first group received preoperative anal dilatation using a 33 mm anal dilator for 20 min, while the second group did not. The post-operative anal pain, edema, bleeding, and incontinence were observed in the first, second, and seventh day.p < 0.05). The difference of post-operative bleeding and edema between groups were not significant. Fecal incontinence was initially significantly higher in the preoperative anal dilatation group, but the difference was insignificant at the seventh day (p = 0.500).The post-operative pain was significantly lower in the preoperative anal dilatation group for all days of observation  with TCTR identification number TCTR20220314002, on 14/03/2022 (retrospectively registered). Pain is a common complication in patients after undergoing hemorrhoidectomy.This study found preoperative anal dilatation significantly reduced post-operative pain. Post-operative pain is one of the main issues of hemorrhoidectomy and remains a distressing problem, for patients and physicians. A sufficient pain management can lead to higher satisfaction, earlier mobilization, faster recovery, and lower health care cost . SeveralAnal dilatation was first described by Lord PH to treat hemorrhoids and anal fissures using six fingers , 6. Howerd grade hemorrhoid with 2 to 3 piles were selected. However, patients with preoperative fecal incontinence, history of colorectal cancer, anal fissure, colitis, previous anorectal bleeding, previous hemorrhoidectomy, hemorrhoid with thrombus, and other anorectal surgery were excluded from the study. The subjects were randomly assigned into two groups using simple randomization technique.This was a randomized prospective trial using a total of 40 subjects. A total sampling with convenience sampling was used to determine sample size. The current study was performed between January and December 2021. Patients with a 3Anal dilatation was performed before surgery using a dilator with diameter of 33 mm. Dilator was lubricated with water based sterile gel before inserted into anal canal. After anesthesia agent was administered and the patient was relaxed, the dilator was gently inserted into anal canal and rectum Fig. . The dilThe post-operative anal pain, edema, bleeding, and incontinence were evaluated in the first, second, and seventh day after surgery. Post-operative anal pain was evaluated using the Visual Analog Scale (VAS), categorized as mild pain (VAS 1–4), moderate pain (VAS 5–6), and severe pain (VAS 7–10) . We usedThe procedure of surgical hemorrhoidectomy and the postoperative care were performed based of the Clinical Pathway published by The Indonesian Surgeon Collage. This study was approved by the Institutional Review Board of the Faculty of Medicine, Public Health and Nursing, Gadjah Mada University/Dr. Sardjito General Hospital, Yogyakarta, Indonesia, Ref. No: KE/FK/0083/EC/2022 according to the Declaration of Helsinki. This trial was registered on Thai Clinical Trials Registry (TCTR) with TCTR identification number TCTR20220314002, on 14/03/2022 (retrospectively registered).p < 0.05. Multivariate analysis of the variables was calculated using logistic regression  between dilatation and no dilatation groups Table .p-values of all days of observation < 0.05 . The post-operative edema was lower in the preoperative anal dilatation group of all days of observation, which were statistically insignificant with p-value > 0.05. In addition, fecal incontinence was higher in the preoperative anal dilatation group with p values 0.011 and 0.004 for the first and second day, respectively. However, the result of the seventh day showed insignificant result with p-value 0.500. In addition, the severity of fecal incontinence found in this study was only minor with flatus and liquid stool incontinence.There was only one post-operative bleeding observed in this study, which was found in the group without preoperative anal dilatation (p-value < 0.001 (Table Multivariate analysis showed that on the first day of observation, preoperative anal dilatation contributed 46.9% for the reduction of anal pain with 01 Table .p-values 0.005 and 0.018, respectively. In addition, on the last day of observation, preoperative anal dilatation contributed 18% for the reduction of anal pain.On the second day of observation, preoperative anal dilatation contributed 37.2% for the reduction of anal pain and the occurrence of fecal incontinence with The majority of hemorrhoid cases, especially for the third degree and above, were surgically treated . The paiThe reduction of post-operative pain might be due to reduced anal sphincter contraction. Relaxed anal sphincter reduced the risk of anal spasm and subsequently reduced post-operative pain . The dilThe only significant side effect found in this study was fecal incontinence. The stretched anal sphincter is weakened in function and subsequently caused fecal incontinence . HoweverAnal dilatation was also reported to reduced pain in other anorectal surgeries. The study about anal dilatation in perianal fissure also showed significant reduction in pain and fecal incontinence as its temporary short-term complication . The sidPreoperative anal dilatation significantly reduced pain after hemorrhoidectomy. Post-operative bleeding and edema were not significantly reduced by preoperative anal dilatation. The side effect of fecal incontinence was only temporary until the seventh day after surgery.