Even though anastomotic leakage after colorectal surgery is a major clinical problem in need of a timely diagnosis, early indicators of leakage have been insufficiently studied. We therefore conducted a population-based observational study to determine whether the patient’s early postoperative pain is an independent marker of anastomotic leakage.By combining the Swedish Colorectal Cancer Registry and the Swedish Perioperative Registry, we retrieved prospectively collected data on 3084 patients who underwent anastomotic colorectal surgery for cancer in 2014–2017. Postoperative pain, measured with the numerical rating scale (NRS), was considered exposure, while anastomotic leakage and reoperation due to leakage were outcomes. We performed logistic regression to evaluate associations, estimating odds ratios (ORs) and 95% confidence intervals (CIs), while multiple imputation was used to handle missing data.In total, 189 patients suffered from anastomotic leakage, of whom 121 patients also needed a reoperation due to leakage. Moderate or severe postoperative pain (NRS 4–10) was associated with an increased risk of anastomotic leakage , as well as reoperation . Severe pain (NRS 8–10) was more strongly related to leakage . These associations were confirmed in multivariable analyses and when reoperation due to leakage was used as an outcome.In this population-based retrospective study on prospectively collected data, increased pain in the post-anaesthesia care unit is an independent marker of anastomotic leakage, possibly indicating a need for further diagnostic measures.The online version contains supplementary material available at 10.1007/s00384-021-03984-w. Anastomotic leakage is still a frequent complication after surgery for colorectal cancer , 2, withThe numeric rating scale (NRS) is the easiest, most frequent and responsive pain variable in clinical practice for describing postoperative pain –17. It hSwedish Perioperative Registry (SPOR) with the Swedish Colorectal Cancer Registry (SCRCR) and eligible for inclusion if they had undergone any colorectal cancer surgery in which an anastomosis was fashioned in 2014–2017. Exclusion criteria were emergency surgery or direct admission to the intensive care unit after surgery, as well as hospitals with fewer than 50 yearly registrations, or more than 50% missing data on postoperative pain recordings, as we deemed data from such institutions to be of uncertain reliability. This study was approved by the regional ethical review board at Umeå University, Sweden (protocol number: 2018/425–31).This is a retrospective, population-based, cohort study, based on prospectively collected data. Patients were identified by cross-referencing the SPOR was created in 2013 and by the end of 2017 had a coverage of 85%, retrieving data from 60 of Sweden’s 90 surgical units [SCRCR was originally created in 1995, with a coverage of at least 97%, and is regularly validated [SCRCR except for data on postoperative pain, length of stay at the post-anaesthesia care unit (PACU), and admission to the intensive care unit.The alidated . Data onSPOR, data was collected on maximal pain experienced by the patient at the PACU, as gauged by the staff, using the NRS, ranging from 0 to 10, a frequently used and thoroughly validated method of pain documentation [PACU, every pain registration into the case record is automatically entered into the SPOR. Hence, we could retrieve each patient’s single highest pain score recording and use as our exposure variable, whether it was movement-evoked or at rest. The main outcome was anastomotic leakage, which is recorded in the SCRCR, given that it is diagnosed within 30 days or during the same admission as the index operation. Additionally, we used reoperation due to leakage as our outcome, in order to include only the clinically most significant anastomotic leaks.From the entation , 22. As 2), neoadjuvant therapy (yes/no), clinical tumour stage , tumour site (colon/rectum), intraoperative bleeding , operation time , the presence of a defunctioning stoma (yes/no), surgical approach (laparoscopy/laparotomy/converted) and hospital volume . Identical analyses were then performed with reoperation due to leakage as outcome.In the primary analyses, pain was categorized dichotomously (NRS 0–3 versus NRS 4–10) , and itsTo account for missing data and minimise bias compared to complete cases analysis, we used multiple imputation with chained Eqs. , 24 whenPACU were excluded, since a prolonged stay in itself is a strong indicator of a troublesome postoperative course.The initial surgical approach strongly influences the planned pain treatment, since epidural anaesthesia is preferred in open surgery, while spinal or no regional anaesthesia is more commonly used for laparoscopic procedures. We therefore performed stratified analyses on open, laparoscopic and converted surgery. However, we did not have any data on the actual pain treatment. In addition, due to the difference in incidence and mechanisms behind especially extraperitoneal and intraperitoneal anastomotic leakage, stratification according to tumour site (colon or rectum) was made, where the rectum was defined as the most aboral 15 cm of the large bowel. Subgroup analyses were formally carried out using interaction terms, based on the imputed values of postoperative pain and surgical approach or tumour site, respectively, allowing the estimations to be done using the original multiple imputation, without violating the underlying assumptions of the imputation process. In a sensitivity analysis, the minority of patients who spent more than a full day at the Stata 15.1 Categorical variables were measured as proportions or frequencies. Continuous variables were presented as means and standard deviations, or medians and interquartile ranges if normal distributions could not be assumed. Multilevel mixed-effects logistic regression analyses were performed using odds ratios (ORs) with 95% confidence intervals (CIs), adjusting the standard deviations for clustering of patients within a hospital, since these observations could not be considered independent. Among other things, background characteristics, surgery and pain management tend to be more uniform within than between hospitals. The level of statistical significance was set at 0.05, and all tests were two-tailed. All analyses were made using A flowchart of the inclusion and exclusion of patients in the study is found in Fig. A total of 189 (6.1%) patients suffered from anastomotic leakage and 121 (3.9%) patients underwent reoperation due to leakage. All main analyses are displayed in Table PACU (data not shown) significantly altered the association between pain and leakage or reoperation. Finally, similar point estimates were found in our complete cases analyses as when multiple imputation was used Below is the link to the electronic supplementary material.


Exposure in vivo (EXP) is an effective treatment to reduce pain-related fear and disability in chronic pain populations. Yet, it remains unclear how reductions in fear and pain relate to each other. This single-case experimental design study attempted to identify patterns in the individual responses to EXP and to unravel temporal trajectories of fear and pain. Daily diaries were completed before, during and after EXP. Multilevel modelling analyses were performed to evaluate the overall effect. Temporal effects were scrutinized by individual regression analyses and determination of the time to reach a minimal clinically important difference. Furthermore, individual graphs were visually inspected for potential patterns. Twenty patients with chronic low back pain and complex regional pain syndrome type I were included. On a group level, both fear and pain were reduced following EXP. Individually, fear was significantly reduced in 65% of the patients, while pain in only 20%. A decrease in fear was seen mostly in the first weeks, while pain levels reduced later or remained unchanged. Daily measurements provided rich data on temporal trajectories of reductions in fear and pain. Overall, reductions in fear preceded pain relief and seemed to be essential to achieve pain reductions. Chronic pain is characterized by a complex interaction between physical and psychosocial factors, and therefore remains a therapeutic challenge . PsychosPain-related fear has been considered an important contributing factor in chronic musculoskeletal pain populations ,5,6. ForConsequently, it is important to address pain-related fear in the rehabilitation of patients with chronic pain. Exposure in vivo (EXP) is a cognitive-behavioural treatment that stimulates patients to perform threatening movements and activities, in order to modify their expectations about movement and injury, and to reduce their avoidance behaviour . CombiniTherefore, the primary aim of this study was to examine the temporal relationship between changes in pain-related fear and pain intensity during EXP in patients with chronic pain. Daily diaries were used to scrutinise the chronology of treatment effects and to identify individual patterns. These insights could help clinicians to improve patient-tailored treatment approaches. Our hypothesis was that decreases in fear during EXP would precede pain relief.A sequential single-case experimental design (SCED) was used in this study, in which several outcomes per participant were repeatedly assessed throughout different phases . ParticiThis SCED study is part of a larger study investigating effects of EXP on chronic pain, “BrainEXPain”. BrainEXPain was approved by the Medical Ethical Committee of Maastricht University Hospital/Maastricht University (MUMC+/UM). The protocol is registered at ClinicalTrials.gov [NCT02347579]. Previous papers of the “BrainEXPain” project focused on fMRI ,26, in rPatients were recruited via the department of Rehabilitation Medicine at MUMC+/Adelante Rehabilitation Centre, between January 2015 and August 2017. They were referred by a physiatrist to a multidisciplinary screening procedure and were requested to fill out an online screening questionnaire . Eligible patients, for whom pain-related fear was suspected to be a major contributing factor, were briefed on the study procedure, daily diaries, and treatment approach, and were asked to sign the informed consent. If both the multidisciplinary team and the patient gave a green light, information about EXP and an introduction to pain education was provided. Prior to the first study visit in which an MRI scan was performed, patients were requested to fill out online questionnaires and to start with filling out daily diaries  for five consecutive days or more, which resulted in a pseudo-randomized baseline period. Three days prior to the first treatment session, patients were requested to start completing daily diaries again and to continue throughout the whole treatment period. Daily diaries were consistently sent out at 9:00 am. The online questionnaires were repeated post-treatment and the patients were asked to continue filling out the diaries for another two weeks .The study included patients with cLBP as well as patients with CRPS, between 18 and 65 years old. To be included, patients had to experience non-specific LBP for at least 6 months or to be diagnosed with complex regional pain syndrome type-I (CRPS-I) based on the Budapest criteria . PatientExposure in vivo (EXP) is standard care for patients with chronic pain and elevated pain-related fear at MUMC+/Adelante. This treatment exposes patients to feared movements and activities, in order to challenge and adjust their exaggerated expectations related to harm and (re-)injury. EXP aims to modify fear-avoidance beliefs by increasing knowledge about pain, encouraging to perform threatening activities, and challenging patient’s expectations about consequences of movement. A detailed description of the EXP-protocol can be found in Vlaeyen et al. . First, Daily levels of pain intensity and self-reported fear of three personally relevant daily-life movements/activities were assessed using electronic diaries. These individually tailored activities were selected based on a ranking of movements/activities (PHODA) by the participant as being threatening and personally relevant. Participants received a daily reminder to complete a brief questionnaire. Participants were requested to complete the daily assessments from baseline until two weeks after the end of treatment. Due to variations in scheduling, the baseline period differed for each participant and hence was pseudo-randomized. All items were rated on a visual analogue scale (VAS) ranging from 0 to 100. The daily questions are described in Online questionnaires were filled out at baseline and post-treatment. The following standardised questionnaires were included: Pain Disability Index , photogrhttp://34.251.13.245/MultiSCED/; 1 October 2021). MultiSCED has been developed in R to provide the possibility to investigate intervention effects at the individual level and to combine SCED data across cases through multilevel modelling [Initially, descriptive statistics of baseline characteristics, including the average fear and pain levels, were examined. Our statistical analyses of daily diary data were conducted with the MultiSCED app  and post-intervention results (phase C) to examine the effect of EXP per individual.(1)Different phases were created to be used in a sliding window approach. We started comparing baseline data (phase A) with all intervention and post-intervention data (Phase B + C). Afterwards, we systematically added one week to phase A to obtain a timeline for treatment effects , until phase B consists of less than five measurements.(2)The time to reach the minimal clinically important difference (MCID) was scrutinized. To unravel the relevance of EXP to patient care, it is useful to not only focus on statistically significant changes, but also on clinically important differences. Even if the statistical result is not significant, the patient might still feel meaningful pain relief or physical improvement due to treatment. A reduction of 30% in pain intensity on a 11-point numeric rating scale has been considered as a MCID in chronic pain populations ,47. Ther(3)Individual visual graphs and descriptive values were explored to divide the patients into clusters based on their response to EXP. Patterns in temporal changes were analysed within these clusters and compared to the results of the sliding window approach, the time to reach the MCID and the differences between baseline and post-intervention questionnaires.In order to investigate when treatment effects occur during the intervention:t-test and the paired Wilcoxon-test was used for non-normally distributed variables.Pre- and post-intervention questionnaires were analysed using SPSS (version 27). First, normality was checked with the Shapiro-Wilk test. Treatment effects of normally distributed variables were analysed with the paired Student’s At last, moderator variables for treatment effectiveness were also exploratively scrutinized, by including them one by one in the pre–post multilevel model .The recruitment period resulted in 38 included patients in BrainEXPain, of which 23 initiated and completed EXP. Based on the completeness of the daily diaries , 20 patients were analysed as single-cases in this study , includiPatients initially received two sessions per week, which was reduced to one session per week in the generalisation phase. Total treatment duration ranged from 5 to 14 weeks, with an average of 9 weeks, which was determined by a common decision between the therapist and the patient .An overview of the diary completion per patient and period can be found in p ≤ 0.001) and pain intensity  .Multi-level analyses of pre- and post-intervention diaries were performed to evaluate overall treatment effects . CompariThe evolution of individual daily measurements of pain-related fear and pain intensity across all participants is shown in Therefore, a schematic overview of the one-level analyses is presented in Consequently, it was analysed during which week a significant change in trend appeared by comparing all data before the respective week with all further data . These results were rather variable, but visual inspection of An overview of these findings is given in Closer inspection of the individual graphs in Cluster 1: Quick decrease in fear, pain followsPatients in this cluster showed a decrease in pain-related fear quickly after the start of EXP, while a decrease in pain intensity only occurs later. Seven patients  showcase this pattern in greater or lesser extent.Cluster 2: Decrease in fear, pain unaffectedThis pattern is characterized by a decrease in pain-related fear, while the pain remained unchanged. This phenomenon is recognisable in the graphs of five patients .Cluster 3: Late effect in fearThree patients  showed a rather late decrease in pain-related fear, reflecting that they needed multiple treatment sessions and repeated exposure before the effect occurred. While patient 8 has a sudden drop in fear after four weeks, patient 11 had enormous fluctuations until far in treatment, and patient 16 had an initial early drop but relapsed before improvements slowly occurred again. Patient 8 showed no change in pain intensity, while the pain of patient 11 followed the same pattern of the fear and patient 16 described no pain throughout the whole treatment period.Cluster 4: No clear effectBased on visual inspection of the graphs, five patients  showed little to no change in pain-related fear or pain intensity.p = 0.003), pain-related disability , pain-related fear , fear of movement , pain catastrophizing , pain vigilance , pain rating , and resilience , but not on anxiety and depression .Before and after treatment the patients filled out online questionnaires. All results can be found in Based on the distribution into the four clusters, differences can also be exploratively inspected in questionnaires results. Baseline average pain scores were the highest in cluster 4 compared to the other clusters, while the gain by EXP was the lowest. Baseline PDI scores were higher in cluster 3 and 4, while cluster 2 and 4 showed smaller improvement in disability after treatment. No differences between the clusters were seen in baseline PHODA and RS scores, yet cluster 4 showed again the least improvement in these questionnaires. Other between clusters results were comparable.p = 0.001), showing a lower reduction of fear in women compared to men, but not by age, population, or any of the questionnaire results. None of the baseline characteristics significantly moderated the effect of EXP on pain intensity.In order to evaluate which characteristics influenced the effect of EXP on the outcomes, the baseline scores were included as moderator variables in the pre–post multilevel model . TreatmeThe text continues here. Proofs must be formatted as follows.The primary aim of this SCED study was to disentangle individual patterns in the temporal effect of EXP on pain-related fear and pain intensity. SCEDs have proven to be valid for demonstrating intervention effectiveness at an individual level and to observe these changes over time . The strWhen considering the temporal trajectories by the sliding window approach, it is remarkable that none of the patients showed an improvement in pain without an improvement in fear. This suggests that it is necessary to lower fear to obtain an effect on pain. This fits the idea to predominantly treat fear, as it is more disabling than pain itself  and contquick decrease in fear, pain follows—underscores our hypothesis. The sliding window approach showed that the patients in this cluster benefited already in the first two weeks concerning fear. This pattern is in accordance with the objective of EXP: to target fear and not pain itself. It is also in line with anecdotal reports of clinicians that many patients experience an early eye-opener, after which they manage to “flip the switch”. This group also showed the largest improvement in disability. Their questionnaires results support the daily diaries, which showcases that SCEDs are appropriate to capture individual effects. Concerning the goal of EXP to lower fear, patients in cluster two—decrease in fear, pain unaffected—still responded well. Clusters one and two demonstrate an effect in the early phase, what may suggest that pain education and limited exposure sessions already affect fear. Patients in cluster three—late effect in fear—needed more EXP sessions before their fear levels distinctly decreased. Remarkable is that this cluster had the highest initial disability and fear. This group may have needed more persuasion before they let go of their avoidance and/or safety behaviours. The difference with cluster one could lay in what they are afraid of. For instance, fear of what can happen during threatening activities could be quickly reduced by EXP, while fear of not being able to handle the pain could be more persistent. However, this remains speculative and would need to be further investigated. Based on the diaries, patients of cluster four—no clear effect—did not respond positively. However, questionnaire scores still improved remarkably. Various explanations of why they did not respond as strongly as the others could be considered. First, it cannot be ruled out that their treatment period was too short or delayed treatment effects were not captured within the follow-up period. Delayed effects on pain-related fear have also been seen in youth with chronic pain [Scrutinizing daily assessments showed that each patient responded differently. However, based on the chronology of treatment effects, four patterns could be identified. The pattern of the first cluster—nic pain . Contradnic pain . Second,nic pain ,63.No moderating factors were revealed, except for gender. Men’s fear levels benefited more from EXP than women’s. Noteworthy, they had higher baseline fear. This is in contrast with the fact that women are more likely to have higher fear levels , but it It is noteworthy that the Body Mass Index of these patients was rather high. Obesity can interact with disability, whether as cause or result . This coOne of the strengths of this SCED study is the high number of examined cases. Twenty patients filled out daily diaries with a total of 1136 observations, while previous research established that most SCED studies have an average of three to four cases . Daily dThe overall findings of this SCED study indicate that EXP reduced pain-related fear as well as pain intensity in patients with cLBP and CRPS-I. However, not all patients responded similarly and different patterns of treatment responses were identified. On an individual level, a reduction in fear was seen in most cases, prior to or in absence of a reduction in pain. For most patients, fear reduced already in the early stage of EXP, and it seemed that fear reductions are necessary to achieve pain relief. The idea that reductions in fear might be necessary to lower pain should encourage clinicians to target fear during rehabilitation. Future research should examine long term effects and should further unravel the benefits of patient clustering for screening and treatment approaches.


Chronic low back pain is considered to be one of the main causes of absenteeism from work and primary and specialized consultations. The symptoms of nonspecific chronic low back pain may be accompanied by the activation of myofascial trigger points in the muscles, together with local and/or referred pain. Electrical dry needling is increasingly used in the treatment of lumbar myofascial pain. Conventional physiotherapy, however, is a popular approach to chronic pathologies, and there is evidence of different modalities of physiotherapy being used in the treatment of chronic low back pain. The aim of this study has been to determine the effectiveness of electrical dry needling versus conventional physiotherapy when applied to active and latent myofascial trigger points in patients with nonspecific chronic low back pain.n = 40) to receive treatment of low back pain with electrical dry needling and conventional physiotherapy . A total of 6 sessions will be administered once a week for 6 weeks. Pain intensity, disability, fear of movement, quality of life, quality of sleep, anxiety and depression, pressure pain threshold, abdominal strength and lumbar mobility will be recorded at 6 weeks (post-immediate) and 2 months after the end of treatment.This is a controlled, randomized, two-arm, double-blind study. A total of 92 patients with chronic low back pain  will be recruited from the University of Almería. Participants will be divided into two study groups (We believe that an approach including electrical dry needling to chronic low back pain dysfunction will be more effective in these patients. The results of this study will inform clinicians on which type of treatment is more beneficial for patients with chronic low back pain.ClinicalTrials.gov NCT04804228. Registered on 14 January 2021The online version contains supplementary material available at 10.1186/s13063-022-06179-y. Low back pain is a major public health problem in industrialized countries that causes individual suffering, absenteeism from work and, in some cases, early retirement. Since it is a common pathology that is difficult to treat effectively, low back pain represents a high economic burden for both society and the health system –3 and isBack pain, which affects up to 23% of the population worldwide, is the most common chronic disease in people under 65 years of age. With a lifetime prevalence of up to 85% in industrialized countries .Pain intensity, degree of pain interference with activities of daily living (resulting in disability), and health-related quality of life are among the primary outcomes in studies in patients with low back pain . In the The symptoms of CLBP may be accompanied by the activation of myofascial trigger points (MTrPs) in the lumbar and proximal muscles, together with local and/or referred pain , 12. CliThe MTrPs of each muscle have their own characteristic pain pattern; therefore, the spread of the pain can help identify the muscles that may contain active and latent trigger points . CLBP isNoninvasive treatment options for CLBP remain controversial, and there is no general consensus on the best approach . Some trDry needling is typically used to treat soft tissues, such as muscles, ligaments, tendons, fascia, scar tissue, peripheral nerves and neurovascular bundles involved in a variety of neuromusculoskeletal pain syndromes , 22. DryVarious treatment approaches beyond the scope of physiotherapy have been proposed to reduce the recurrence of low back pain and its associated care costs. Clinical practice guidelines provide strong evidence that cognitive behavioural therapy, exercise, spinal manipulation and rehabilitation with various physiotherapy procedures are all moderately effective in chronic or subacute low back pain (> 4 weeks duration) –36. ReceThe objective of this randomized controlled trial is to evaluate the effectiveness of electrical dry needling versus conventional physiotherapy in the treatment of patients with nonspecific chronic lower back pain.The specific objectives are (i) to compare the effectiveness of electrical dry needling versus conventional physiotherapy in improving pain, functionality, lumbar spine mobility and quality of life in patients with nonspecific chronic low back pain and (ii) to evaluate the effect of this therapy on active myofascial trigger points in terms of the pressure tolerance threshold following electrical dry needling versus conventional physiotherapy.This is a controlled, randomized, two-arm, double-blind study comparing (i) patients with chronic low back pain treated with electrical dry needling and (ii) patients with chronic low back pain treated with conventional physiotherapy consisting of ischaemic compression, analytical stretching and a dossier of home lumbar spine exercises. Study participants will be randomly assigned to two groups  with a 1: 1 ratio.ClinicalTrials.gov (protocol number NCT04804228).This protocol has been drawn up following the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT)  and not receiving any other physiotherapy treatment are eligible for inclusion.Patients with sensory and/or coagulation disorders, a history of spinal surgery, heart complications, concurrent severe central or peripheral nervous system disease, epilepsy, needle phobia, serious pathologies that can be the main cause of chronic low back pain , or patients contraindicated for transcutaneous electrical stimulation (TENS) will be excluded.Participants will be randomized to two groups using a computer-generated (Epidat 4.2) table of random numbers generated. After randomization, participants will be assigned to either the experimental electrical dry needling group or the conventional physiotherapy control group in a ratio of 1:1. Randomization will be performed by the principal investigator.There will be 46 participants in each group. The randomly generated group allocations will be placed in sealed opaque envelopes before being delivered to the participants and stored in locked cabinets.The outcome assessor and study statistician will be blinded to the entire process. The outcome assessor will make no attempt to guess the participant’s treatment group. The computer-generated outcome measures transmitted to the statistician will not contain any information that identifies the patient’s group.After the initial evaluation, 92 patients with CLBP will be randomly assigned to one of the two groups and will receive electrical dry needling  or conventional physiotherapy (control group). All participants will receive 1 session per week for 6 weeks, until they have received a total of 6 sessions. Patients must complete 100% of their scheduled face-to-face treatment sessions, and those in the control group must also complete 80% of the home exercise sessions in order to remain in the intention-to-treat analysis.During the study, participants can only receive their assigned treatment; they cannot combine the study treatment with medications or any other treatment. Any interference in the treatment will be grounds for exclusion. Patients may abandon the study at any time, and the assigned interventions may be suspended or modified in a particular trial patient in response to improvement or deterioration (adverse effects) of low back pain. Adverse events will be reported to the principal investigator, who will monitor the affected patients and the possible causes of these events.n = 46) will receive up to three 30-min treatment sessions (1 session per week for 6 weeks). Electrical stimulation will be applied bilaterally to the active and latent myofascial trigger points of the following muscles, following the MTrPs maps described by Travell and Simons: [Patients assigned to the electrical dry needling group . The needle will be inserted until it reaches the active or latent MTrP or taut band that causes the local twitch response . The neen = 46) will receive ischaemic compression and analytical stretching of the quadratus lumborum, multifidus and iliocostal muscles once a week for a total of 6 weeks.Patients assigned to the conventional physiotherapy group  and an evaluation 2 months after the end of the intervention (short-term follow-up).Roland Morris Disability Questionnaire (RMDQ): This self-reported questionnaire consists of 24 items that rate limitations in different activities of daily life attributed to low back pain, such as walking, bending over, sitting, lying down, dressing, sleeping, personal care and daily activities. Disability is rated from 0 points (best) to 24 points (worst) .Oswestry Disability Index (ODI): The Oswestry Disability Index assesses the limitations in activities of daily living in 10 dimensions, each rated on a 6-point scale (0–5 points). The higher the score, the greater the disability. The overall score is expressed as a percentage and is used to classify people as minimally disabled (0–10%), moderately disabled (20–40%), severely disabled (40–60%), crippling back pain (60–80%) or bedridden (80–100%) .Visual analogue scale (VAS): Study participants will indicate the intensity of their pain on a 100-mm VAS. They are asked to situate their pain on a 100-mm horizontal line, where 0 mm indicates “no pain”, and 100 mm indicates “the worst pain imaginable” .The following are the primary outcome measures:Quality of life using the SF-36 Questionnaire: The SF-36 is a short-form, multipurpose health survey with only 36 questions. The instrument contains eight subscales  and two summary scores: physical and mental health. Scores range from 0 to 100% and indicate the self-perceived health-related quality of life , 50.Tampa Scale for Kinesiophobia (TSK): This is a 17-item questionnaire that measures fear of movement and (re) injury. Patients rate their beliefs about their kinesiophobia on a 4-point scale ranging from strongly disagree to strongly agree , 52.Pittsburgh Sleep Quality Index (PSQI): This is a 10-item questionnaire with a total of 19 questions related to sleep habits in the previous month. The questions are divided into 7 areas, each with a score of between 0 and 3 points. The overall score ranges from 0 (no difficulty sleeping) to 21 points (severe difficulty sleeping) .Hospital Anxiety and Depression Scale (HADS): This scale consists of 14 items related to emotional distress  in populations suffering from a physical illness. It consists of two subscales (HADA: anxiety and HADD: depression) with seven items each that score from 0  to 3  , 55.McQuade Test: This test evaluates the isometric resistance of the flexor muscles of the trunk. The patient is placed supine and asked to flex the head and shoulders until the scapula is lifted off the table. The number of seconds they hold that position is recorded .Anterior trunk flexion. Standing, with legs straight, the patient is asked to bend forward and attempt to touch the ground. They are told to stop when pain or limitation of movement appear. The distance, in centimetres, between the fingers and the ground is measured .Spinal Mouse®: This is a safe, practical and easy-to-use instrument to measure the curvature of the spine in the frontal and sagittal planes and to assess the segmental mobility of the lumbar region .Pressure algometry (Wagner FPI 10 Algometer) in MTrPs: The algometer consists of a rubber tip and a dial that measures the pressure applied to the MTrP in increments of 0.5 kg. The pressure pain threshold will be assessed following the illustrations published by Travell and Simons .The following are the secondary outcome measures:α) of 0.05 and a target power (beta) of 85%.The sample size was calculated according to the specifications established by Willian . The calα = 0.05, statistical power of 85% and loss to follow-up of 15%. The sample size calculation yielded a total of 92 participants to be randomized to two intervention groups.The following specifications will be considered: Statistical analysis will be performed using SPSS© version 21.0 and STATA 14 using the principles of intention to treat. Comparisons will be made between the two study arms. We will calculate the difference between the groups after the final treatment session and at 2 months post-intervention (short-term results).The efficacy variable for this clinical trial is the difference between continuous variables  at baseline and at predetermined time points :The Kolmogorov-Smirnov test will be used to assess the normality of continuous variables.t test for paired clinical variables in the case of parametric distributions and the Kruskal-Wallis H test in the case of nonparametric distributions.The equality of means of the intragroup hypotheses will be analysed using Student’s H test will be used in nonparametric distributions.One-way analysis of variance (ANOVA) will be used to test the intragroup hypothesis in the case of parametric distributions, and the Kruskal-Wallis U for nonparametric distributions.Post hoc analysis will be obtained for parametric distributions and Mann-Whitney The confidence interval will be set at 95% and the level of significance at 0.05.No potential risks have been described so far, given that these can be prevented by the operator’s knowledge of anatomy, training and experience . ResearcAll participants will receive verbal and written information about the study before giving their consent to participate. They will be informed that they can leave the study at any time. Participants who agree to take part in the study will sign two copies of the informed consent form, one for the research and evaluation team and one for the participant.All hard copies will be confidential and stored in a locked filing cabinet in the research group office and in electronic format in a password-protected database. The research team will monitor the integrity of the trial data. All participants, group assignments, treatment records and sociodemographic data will be coded, and the results of the questionnaires will be scored.The data collected on each participant will be kept under lock and key by the evaluator. If the data are in digital format, they will be stored in a computer with a secret access code known only to the evaluator.The eligibility criteria, results and analyses will not be modified once the first participant has been enrolled in the study. Any amendment to the protocol, including changes in the eligibility criteria, the results or the analyses, will be communicated to the Institutional Research Committee of the University of Almería and reported in articles and presentations disseminating the results of the trial.The feasibility results will be published in peer-reviewed journals and presented at academic, clinical and health services conferences.Although physiotherapy with dry needling and electrical dry needling has proven positive effects on chronic low back pain –31, the This study can contribute to our understanding of the effectiveness of electrical dry needling versus conventional physiotherapy in patients with nonspecific chronic low back pain at short term. The results can help physiotherapists understand whether low back pain treated with electrical dry needling can significantly reduce disability and absenteeism due to chronic low back pain. Improving chronic low back pain without absenteeism will reduce labour costs and waiting lists for rehabilitative physiotherapy.Due to the growing prevalence of chronic conditions such as low back pain and their impact on individuals, their circumstances and society in general, it is becoming increasingly important to provide evidence-based, cost-effective interventions , 64. ThePatients will be recruited between May 2021 and August 2021. The study is expected to be completed in November 2021. Data analysis, writing of the scientific manuscript and submission to peer-reviewed scientific journals will take place from January 2022. A summary of the study outline is shown in Table Additional file 1:. Analytical stretching exercise protocol (lumbar segment).Additional file 2:. Dossier of exercises for low back pain (home program).Additional file 3:. Informed Consent. Information sheet for participants.Additional file 4:. Reporting checklist for protocol of a clinical trial.


Introduction: Various modalities are now being used to manage postoperative pain, such as regional nerve blocks techniques, continuous epidural analgesia, patient-controlled analgesia, opioids, and systemic non-steroidal anti-inflammatory drugs. This study compared the mean postoperative pain score between ultrasound-guided transversus abdominis plane (TAP) block and a local anesthetic wound infiltration at the surgical incision site.Methodology: A prospective, comparative, randomized controlled trial (RCT) was carried out from February 2021 to September 2021. The study was conducted in the anesthesia department of Dow University of Health Sciences, Karachi, Pakistan. Patients aged 18-80 years presenting with elective surgery of (both direct and indirect) inguinal hernia repair were enrolled in the study. Participants were randomly assigned into one of the two groups that are local anesthetic wound infiltration (Group A) and TAP block (Group B). The mean pain score was assessed using a visual analog scale and compared between the two groups.Results: The study included 168 patients grouped in two different groups. The mean age in Group A was 43.87 (+17.21), and Group B was 47.01 (±15.37). Mean pain scores in groups A and B were 6.36±1.94 vs 4.51 ± 1.99 . The pain rescue medications were given to 57.14% of patients in Group A and 34.52% of patients in Group B, and it was significantly different in the two groups . It was found that patients in Group A reported more severe pain (41.67%) than patients in Group B (10.71%).Conclusion: When compared to local anesthetic wound infiltration, ultrasound-guided TAP block had better analgesic activity compared to local anesthetic wound infiltration. Acute postoperative pain is a prevalent condition that pain specialists and all healthcare practitioners face daily . Pain maVarious modalities are now being used to manage postoperative pain, such as regional nerve blocks techniques, continuous epidural analgesia, patient-controlled analgesia, opioids, and systemic non-steroidal anti-inflammatory drugs . One of Traditional local anesthetic wound infiltration (WI) is another method in which local anesthesia is injected into the surgery site. Surgeons also favor it because of its convenience, and it is utilized for postoperative analgesia in many regions . HoweverMany clinicians have recently begun to utilize TAP block and compare it to WI to decide which block is better in adults because of the significant advancement of ultrasound methods; nonetheless, the results are still ambiguous. Thus, the study compares the mean postoperative pain score between ultrasound-guided TAP block and a local anesthetic drug’s WI at the surgical incision site.MethodologyIt was a prospective, comparative, randomized controlled trial (RCT) from February 2021 to September 2021. The study was conducted in the anesthesia department at the Dow University of Health Sciences, Karachi, Pakistan. After getting ethical approval from the Institutional Review Board (IRB) of Dow University of Health Sciences, the study was conducted.Sample size and sampling techniqueThe same size was calculated using OpenEpi by considering absolute population proportion in groups A and B as 0.55 and 0.33, respectively , 95% CI,Eligibility criteria2, existing neurologic disease, ASA (American Society of Anesthesiologists) grade ≥III patients, previous history of abdominal surgeries, and patients having a history of hypersensitivity of local anesthesia agents.The inclusion criteria included patients aged 18-80 years presenting with elective surgery of (both direct and indirect) inguinal hernia repair under general anesthesia with the endotracheal intubation. The exclusion criteria were body mass index > 35 kg/mInterventionAfter identifying eligible patients, written consent was taken from them. Participants were randomized in a parallel design with a computer-generated assignment to either local anesthetic WI group (Group A) and TAP block (Group B) in a 1:1 ratio. Study drugs were prepared in the hospital pharmacy by trained pharmacists. It was placed in envelopes containing medications for groups A or B. The envelopes were sealed, and the name of the project and consecutive numbers were marked as per a computer-generated block randomization list prepared by the hospital pharmacy. Boxes were opened, and syringes were filled by operation theater nurses who were not a part of the study and postoperative care of patients.Intravenous access was obtained inside the operation room and a monitor was attached. Baseline blood pressure, heart rate, and respiratory rate were obtained. Induction was done utilizing injection. Midazolam 0.02 mg/kg, while inj. fentanyl 3 μg/kg and propofol 2 mg/kg were used for analgesia. Anesthesia was maintained by a 50:50 mixture of air and oxygen, as well as 1-1.5% of isoflurane.Patients in Group A were provided with local anesthetic infiltration at a surgical wound site at the end of surgery. The anesthesiologist provided 10 ml of 0.25% bupivacaine through an aseptic method to the operating surgeon, who deposited 5 ml of bupivacaine above and 5 ml of bupivacaine below the surgical incision site.Group B patients received ultrasound-guided TAP block after surgery with 10 ml of 0.25% bupivacaine. Patients were lying in a supine position and TAP block was performed unilaterally using ultrasound guidance and placed in a transverse plane perpendicular to the line joining the iliac crest and the inferior rib on the anterolateral part of the abdominal wall between the iliac crest and costal margin. A transverse view of abdominal muscle layers was obtained, and subcutaneous tissue, external oblique muscle, internal oblique muscle, and transversus-abdominis muscle were identified, superficial to deep, respectively. The fascia was recognized between the internal oblique muscle and transversus-abdominis muscle. As a block needle, a 22 G spinal needle was used, which was inserted anteriorly through an in-plane approach and advanced under ultrasound observation. The drug was injected, and the placement was confirmed by hypoechoic injectate deposition and hydrodissection of the TAP.Outcome measuresAll the patients who recovered from general anesthesia and pain were assessed at 2, 4, and 6 hours. Postoperative pain was assessed using a visual analog scale (VAS) ranging from 0 to 10, on which 0 means no pain and 10 showed worst pain. A higher score indicates the worst outcome. A score of 0 was taken as no pain, a score of 1-3 was considered mild pain, 3-6 was considered moderate pain, and 7-10 as severe pain. The nurse assessed the outcome, and both the nurse and patients were blinded and unaware about the group they were in to prevent any bias in the study. Secondary outcomes included a number of patients requesting pain-relief medications and the mean time to first pain-relief medication.For pain-relief medications, intravenous morphine was provided to the patient on request for the first 2 hours in the postoperative care unit. The initial dose of morphine was 5 mg, with subsequent doses of 2.5 mg and a minimum of 10 minutes between them. From 2 to 6 hours postoperatively, oral ketobemidone 2.5 mg was given based on the patient’s decision. For nausea complain, ondansetron was administered with the first dose of 4 mg followed by 1 mg if required. No prophylactic antiemetics were administered.Statistical analysisFor data analysis, STATA version 16.0  was used. Normality of mean pain score and mean time to first pain-relief medication was assessed using Shapiro-Wilk test. Both followed the normal distribution. Mean and standard deviation were reported for continuous variables including mean pain score and mean time to first pain-relief medication, while frequency and percentages were reported for categorical variables. Characteristics of the two groups were compared using impendent t-test and chi-square independence test for continuous and categorical variables, respectively. A p-value less than 0.05 was considered significant.The study included a total of 168 patients grouped in two different groups. The mean age in Group A was 43.87 (+17.21) and Group B was 47.01 (+15.37). There was no statistically significant difference in the age of the patients of both groups . The study had enrolled patients only of ASA I and II grades, and ASA grades of patients were significantly different in two groups . Patients’ weights were not significantly different in the two groups  as shown in Table Mean pain scores in groups A and B were 6.36+1.94 and 4.51 ± 1.99, respectively . The pain-relief medication was given to 57.14% of patients in Group A and 34.52% of patients in Group B, and it was significantly different in the two groups . The mean time to the first pain-relief medication requirement was significantly lower in Group A (2.65+1.51) than in Group B (5.33+2.17) as the p-value was less than 0.05. As shown in Table One of the key concerns of both surgeons and their patients is postoperative pain control. Several methods have been used to achieve pain-free recovery of patients after surgery, such as peripheral nerve block, epidural analgesia, TAP block, and WI. TAP block can be performed using a landmark-based approach or under ultrasound guidance, and nowadays, it is commonly used in different surgical procedures. However, the current study has determined whether this technique is effective enough among patients who undergo lower abdominal surgery. Meanwhile, WI is a simple postoperative analgesic technique that has been frequently used. As a result, determining which technique is more effective in controlling postoperative pain would be beneficial.The current study was conducted to compare the efficacy of TAP and local anesthetic WI in controlling pain among adult patients undergoing hernia repair in daycare procedures. In the current study, TAP block proved to be a better quality of analgesia than local anesthetic infiltration of surgical incision with less postoperative analgesic requirements. TAP block is efficient in patients undergoing abdominal surgeries like appendicectomy, open prostatectomy, cesarean section, abdominal hysterectomy, and laparoscopic cholecystectomy -11. TAP In the current study, pain relief concerning VAS and the requirement of pain-relief medication was assessed in both groups. Mean pain scores were significantly different in Group B than in local anesthetic WI. Our findings are consistent with those of other research regarding analgesia and postoperative opiate demand. Past studies have also shown that side effects are lower in Group B that can jeopardize the recovery of patients -14.Decreasing postoperative requirements of morphine and associated side effects are desirable as these are vital to the recovery of patients . TAP bloA study was conducted by Petersen et al. to determine the beneficial impacts of TAP block after laparoscopic cholecystectomy in day-case surgery. The study found that patients who received TAP block after surgery had reported less coughing, lower pain scores along with decreased consumption of morphine. However, these reductions were small. The procedure has no reported complications and might be used as part of a multimodal analgesic treatment plan for day-case surgeries . Khan etNo TAP block-related consequences were identified in the current study; nevertheless, block failure, vascular injury, nerve injuries, and abdominal visceral are recognized as TAP block-related complications. TAP is better identified with ultrasound guidance, unproven needle control, and drug deposition is well guided under imaging. As a result, there were fewer problems and more clinically significant outcomes.The current study determined pain score up to 6 hours after surgery. In the future, more trials need to be conducted to determine the long-term pain-relief effect of TAP block and WI. Second, this study was conducted only in one tertiary care hospital. In the future, more hospitals need to be involved in getting evident findings that can be incorporated into the practice setting.Compared to local anesthetic WI, ultrasound-guided TAP block has been demonstrated to be an effective method for providing appropriate postoperative analgesia among adult patients undergoing hernia repair in daycare procedures. However, more studies need to be conducted in the future, including large sample size and multiple centers, to get more generalizable findings.


A Preferred Reporting Items for Systematic Reviews and Meta-Analyses approach was used to report the results of the literature search.n = 19). Eight studies involved devices and interventions directed at blocking nerve sensations . Five studies reported on vasectomy reversal as a modality to relieve post-vasectomy pain syndrome (PVPS), while two studies explored the outcomes of orchidectomy on pain relief in patients with CO.: A total of 34 studies were included for qualitative analysis. Most of the studies explored microsurgical spermatic cord denervation (MSCD; : Several treatment methods are available in the urologist’s armamentarium for the treatment of CO. MSCD appears to be an appealing treatment modality with encouraging outcomes. Neuropathic pain can be managed with a number of relatively non-invasive modalities. Vasectomy reversal is a sound treatment approach for patients with PVPS and ultimately orchidectomy is a terminal approach that can be discussed with patients suffering from intractable pain. Chronic orchialgia (CO) has been an escalating complaint in the past few years, commonly affecting young men and interfering with their daily and sexual activities. It is defined as continuous or intermittent, uni- or bilateral testicular discomfort of at least 3 months’ duration . The chaThe prevalence of CO has not been clearly defined; however, it is believed to have an increasing trend. In the United States, up to 100,000 men are diagnosed with CO each year . While sThe pathophysiology of CO is believed to be secondary to a phenomenon known as sensitisation of peripheral nerves that occurs after repeated noxious stimulation of nociceptors resulting in permanent changes in the peripheral as well as the central nervous system (CNS) . The perN-methyl-D-aspartate receptors. Even neurones adjacent to those involved in responding to the painful stimulus begin to fire on their own ; subinguinal [n = 3]; The present review identified 19 individual studies including 1676 testicular units for which MSCD was performed. In most cases an open approach for surgery was performed  for pain to monitor the outcome of surgery. With a follow-up duration of up to 48 months; overall, the reported pain-free status after surgery was between 52% and 100%. Side effects were minimal and included hydrocele (0.1–12.5%), haematocele (1.9%), testis atrophy (2.1–12.5%), and other wound-related complications.P = 0.03). Out of the 71 patients investigated, a durable response to MSCD was observed in 13 (57.3%) patients who had a 50–75% improvement after the cord block and in 57 (74.6%) there was a 76–100% improvement after the cord block. In another study by Kavoussi et al. [Almost all the included studies performed a spermatic cord block treatment with a long acting or long- + short-acting local anaesthetic agent prior to the definitive MSCD procedure. The available evidence indicates that the patient response to the spermatic cord bock is an independent predictor of MSCD success rate. A retrospective study by Benson et al.  particuli et al. , the aetSeveral treatment modalities directed at inhibiting or obliterating the sensory impulses from the testis have been investigated. These include nerve blocks with anaesthetics and steroids, cryoablation, radiofrequency and transcutaneous vibratory or electrical nerve stimulation.Pulsed radiofrequency stimulation is a well-established treatment modality for a number of neurogenic and non-neurogenic painful conditions. It is a non-nerve destructive, minimally invasive modality in which electrical pulses are released from the tip of an electrode to create an impulse without causing thermal injury . Unlike 2-adrenergic receptors [Transcutaneous electrical nerve stimulation is an electro-analgesia modality that is non-pharmacological and non-invasive, and which has been utilised in several chronic painful conditions ,45. It ieceptors .n = 36) and a control group . The TENS was performed five-times per week for 4 weeks, where the anode electrode was placed in the suprapubic area medial to the iliofemoral ligament and the cathode 5 cm proximal to it. A mean TENS intensity of 25 mA was used. The results revealed that a significant reduction in the VAS pain score was noted only in the study group  2 months after the intervention and not in the control group. Furthermore, a significant improvement in patients’ quality of life (QoL) was also only reported by the study group.A single randomised clinical trial by Tantawy et al.  was condP < 0.001). The side effects were minimal and included wound infection in two patients and penile pain in four.Cryoablation is a treatment modality that utilises low temperatures to obliterate nerve fibres thereby blocking pain sensation. It has been utilised for a long time particularly for nerve entrapments . In the P = 0.009) and maximum  daily pain was observed in 78% of patients. A reduction in the frequency of pain was also reported by 56% of patients.Vibratory treatment is another non-invasive therapeutic modality implemented in non-urological painful conditions such as fibromyalgia, muscle pain and diabetic neuropathy ,49. MechMechanical and electrical stimulation techniques are promising non-invasive treatment methods with no risk profile. However, further studies are still required to demonstrate their benefit in clinical practice.P = 0.014). This result highlights the relationship between vasectomy and the development of pain after the procedure and hints that an obstructive pathophysiology is the most likely mechanism for PVPS.A distinct subset of patients with CO are those who develop their symptoms following a vasectomy procedure for elective sterilisation. Chronic pain following this procedure, termed PVPS, has been identified as a late complication occurring in up to 15% of cases . It is dA proportion of patients with CO may not benefit from any form of treatment. An integrative literature review by Quallich et al.  revealedChronic orchialgia is a debilitating clinical condition with a significant impact on patients’ wellbeing. A variety of therapeutic modalities can be offered to patients with persistent pain despite conservative treatment attempts. MDSC is an effective treatment option with success rates ranging between 52% and 100%. A more favourable outcome can be expected in patients having a positive response to preoperative spermatic cord block and in patients with idiopathic CO. Patients who fail MSCD may be offered several nerve-blocking devices or interventions including PRF, cryoablation, TENS, and mechanical vibratory stimulation. Persistent pain despite all measures is not uncommon and, in such cases, orchidectomy may be a final resort. However, adequate counselling and psychological support is required before undergoing such an invasive approach.


Background: Osteoarthritis (OA) is a complex disease associated with chronic pain. Many patients treat their joint pain at a symptomatic level with over-the-counter (OTC) pain medications, often without the knowledge of their physicians. The aim of this study was to provide physicians with data about osteoarthritic patients’ habits of pain management and to examine the explanatory factors of various ways of self-treatment. Methods: A cross-sectional study involving 189 patients with hip or knee OA and scheduled for joint replacement surgery was carried out. Participants filled out a self-administered questionnaire consisting of the Western Ontario and McMaster Universities Osteoarthritis Index and questions about their methods of alleviating pain. Results: 2.6% of patients did not use anything to alleviate their pain, while 63% practiced a non-pharmacological method. Diclofenac was the most frequently used drug, followed by ibuprofen. Profession had the greatest impact on medication habits; patients doing manual work were significantly more likely to take OTC non-steroidal anti-inflammatory drugs and use topical analgesics. Conclusions: Patients utilized a wide variety of pain management techniques. They seemed to use well-known painkillers, even if their side effects were less desirable. Such patients require comprehensive pain management, including educational and behavioural interventions, complemented by topical and oral medication.  Osteoarthritis (OA) is a complex disease defined by the American College of Rheumatology (ACR) as “A heterogeneous group of conditions that lead to joint symptoms and signs which are associated with defective integrity of articular cartilage” . ClinicaAs stated in the Global Health Estimates 2000–2019 study, OA was the 17th leading cause of total years lived with disability (YLD), with 1.8% of YLDs in 2000, but by 2019, it had become the 13th leading cause of YLDs at a global level with 2.3% of YLDs ; becominOA remains a relatively unaddressed public health concern compared to such chronic diseases as cancer, diabetes, and heart disease. There is a certain level of complacency and a fallacy that joint pains are an inevitable part of aging. The degradation of articular cartilage is often seen as a condition to be tolerated, not managed . As manyRegarding oral analgesics, paracetamol was favoured previously by major clinical guidelines, recommending it to be the first choice in managing mild-to-moderate OA-related pain ,12,13,14The combination of OA patients’ needs for analgesics, the risk of concomitant use of multiple NSAIDs, and patients’ tendency for self-medication practices emphasizes the need for healthcare professionals to understand osteoarthritic patients’ health behaviour. Unfortunately, many times the attending physicians have no detailed data on what their patients use to alleviate their pain and in what quantities do they take OTC painkillers, a problem we wish to solve.The aim of this study was to investigate osteoarthritic patients’ habits of pain management  and to examine the explanatory factors of various ways of treatment.A cross-sectional study was performed by the Department of Public Health, University of Szeged, based on data collected at the Department of Orthopaedics, Albert Szent-Györgyi Health Care Centre, University of Szeged  and at the Orthopaedic Ward of Réthy Pál Hospital of Békés County Central Hospital  from August 2019 to September 2020.Only patients awaiting total knee or hip surgery were included, while patients receiving unicondylar knee arthroplasty were excluded. No other exclusion criteria were set, and participation was offered for all eligible patients in order to have the full list of eligible subjects, with every subject standing an equal chance of being included to reduce selection bias.Data collection was carried out with the use of a paper and pencil questionnaire 24 h prior to surgery. Patients with knee or hip OA scheduled for joint replacement surgery were involved on a voluntary basis. Patients filled out the self-administered questionnaire in their rooms after receiving a detailed briefing and signing the informed consent form.The questionnaire comprised three basic sections: 1, pain management; 2, measures of pain and functionality by WOMAC; 3, sociodemographic data .To investigate pain management, the name, dose, and frequency of use of OTC and prescription-only medications were recorded. We only took into account regular medication use, that is, painkillers that participants used at least once a week. Based on these data, the following categories were made: total painkiller use (regular use of any type of painkiller), regular use of OTC oral NSAID, regular use of topical NSAID (cream/gel/patch), regular use of oral prescription medication, regular use of per os opioid-containing medication, and regular use of non-pharmacological methods. The dose of a medication was considered high if it reached or passed the recommended daily intake, that is: ibuprofen > 1800 mg/day, naproxen ≥ 1000 mg/day, diclofenac ≥ 150 mg/day, aceclofenac ≥ 100 mg/day, niflumic acid ≥ 750 mg/day, meloxicam ≥ 15 mg/day, piroxicam ≥ 20 mg/day, and nimesulide ≥ 200 mg/day [We also examined non-pharmacological pain management techniques . In this context, “physiotherapy” describes manual therapy and exercise therapy guided by a professional physiotherapist in order to build muscle strength and improve range of motion, while “exercising” includes basic warm-up and stretching exercises carried out by the patients in their homes, typically once a day in the morning to ease the joint stiffness they acquired during sleep. “Massage” specifically refers to massages carried out by the patients themselves. The term “cold wraps” includes chilled gel packs as well as towels soaked in cold water.Pain and functionality were measured by the validated Hungarian version of the disease-specific Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), which contains 24 items, covering 3 dimensions: pain (5 items) during walking, using stairs, in bed, sitting or lying, and standing upright; stiffness (2 items) after waking up and later in the day; and function (17 items) using stairs, rising from sitting, standing, bending, walking, getting in/out of a car, shopping, putting on/taking off socks, rising from bed, lying in bed, getting in/out of bathtub, sitting, getting on/off toilet, heavy domestic duties, and light domestic duties. All items were scored on a scale of 1–10, totalling 24–240, where higher scores indicated increased pain and decreased function ,20. The WOMAC questionnaire was chosen for this study for its good reported internal consistency, excellent test–retest reliability, and experts’ involvement in development .2 were categorised as underweight, those with BMIs between 18.5 kg/m2 and 24.9 kg/m2 as normal, BMIs between 25.0 kg/m2 and 29.9 kg/m2 as overweight, and anyone with a BMI over 30.0 as obese [Regarding level of education, participants without a high school diploma were considered as ‘low’, with a high school diploma as ‘middle’, and with college and university diploma as ‘high’ level. Job profile was considered manual if the person’s job was physically demanding , and non-manual if it was intellectual work . Body mass index (BMI) was calculated as weight in kilograms divided by height squared in meters. Based on the World Health Organization recommendations, patients with BMIs below 18.5 kg/mas obese . p-values for covariates to be included in the model were set at 0.05. Odds ratios (OR) and 95% confidence intervals (95% CI) were calculated, and statistical significance was set at p < 0.05.Data analysis was carried out with IBM SPSS  version 27 . Descriptive statistics including frequency, percentage, mean, median, standard deviation (SD), and interquartile range (IQR) were performed to describe the study sample. After normality testing, the only variable not following a normal distribution was age, as OA predominantly affects the older generation. Association between categorical data was evaluated with a Chi-square test, and with one-way ANOVA for continuous data. Multivariable binary logistic regression analyses using the forward stepwise method were applied to determine the explanatory factors for analgesic use. The independent variables entered into the model were: gender, age group, level of education, job profile, affected joint, BMI category, and WOMAC total score. n = 189) are shown in The baseline characteristics of the patients  practiced a non-pharmacological method to mitigate their pain, with 7.4% using these methods exclusively. Exercise, massages, and cold packs were the most favoured. A total of 29.1% used topical analgesics, all of which had diclofenac as an active ingredient, while 18.5% used a topical herbal cream with comfrey extract. Only 7 patients took part in physiotherapy, and of them, only 2 reported it as a regular (two times per week) activity . p < 0.01), but there were no other differences between the two groups’ demographic characteristics. Even though hip OA patients reported significantly worse HRQoL in the WOMAC total score (mean ± SD: 152.76 ± 41.23) than knee OA patients (139.62 ± 45.12) (p = 0.038), they were less likely to regularly use NSAIDs, either in tablet or cream form (42.2%), than were knee patients (59.8%), .While assessing the differences between knee and hip OA patients, knee patients were found to have significantly higher BMI  and had a greater tendency to use non-pharmacological methods of pain management. Knee OA patients were significantly more likely to use topical analgesics  from the 2011 Five European Countries National Health and Wellness Survey, as reported by Kingsbury et al. Our results for prescription medication use (38.1%) and paracetamol (1.0%) were comfortably within the range of the survey’s result of 33.0–53.2% and 0–6.0%, respectively. On the other hand, we experienced two major differences. On average, the use of opioid medications and COX-2 inhibitors was higher in the participating countries  with 35.6% and 6.6%, compared to our results, 6.9% and 0.5%, respectively . Results.5% from The distribution of active ingredients indicates that patients tend to use well-known pain medications even if their side effect profiles are less desirable. But questions arise even in case of professionally recommended medications, as some guidelines warn against the use of the previously favoured paracetamol, recommending it only conditionally, and stressing the importance of personalised therapies . Knee OAThe importance of using topical analgesics cannot be overemphasised, given the advanced age of our patients, the high risk of co-morbidities, and the additional drug use associated with these conditions involving the risk of potential drug interactions. Beyond the well-known GI side effects caused by NSAIDs, with diclofenac being the most favoured OTC painkiller, the possibility of adverse cardiovascular events must not be overlooked. Schmidt et al. found that people taking diclofenac had a 20% increased rate for a major adverse cardiovascular event, such as a myocardial infarction, compared to patients taking paracetamol, and 30% compared to those who took naproxen .Our study also showed high prevalence of the use of non-pharmacological techniques, which is fortunate, although typically limited to herbal creams, cold compressions, and in one case, warm baths, as Hungary has a long history of balneotherapy . AlthougFor both hip and knee OA, the core treatments are exercise, education, mechanical interventions, and weight loss . Given hIn order to help patients maintain their exercise programmes, group-mediated cognitive behavioural physical activity intervention is advised .By postponing non-urgent elective surgery during the COVID-19 pandemic, waiting times increased and the number of operations decreased. Compared to 2019, the median number of days on the waiting list before surgery increased by 88 days for knee replacements and by 58 days for hip replacements in 2020 . In thisAs data collection was carried out by self-administered questionnaires, inaccuracies in patients’ memories have the potential to distort our data. Although this study was carried out in two different health centres, findings may not be generalizable to the overall population since the population was not very large, only representing part of the country, and only consisting of severe OA patients. The limitations of our study are consistent with the nature of observational studies and the bias on patient selection, for which we tried to correct by selecting a large number of participants from two different counties of the country and enrolling consecutive patients. Also, the potential adverse effect of the NSAID use could not be determined because of a lack of data on such factors as antacid use. We wish to expand on this current study in the future by gathering information regarding the use of antacids to support risk assessment, and also the effect a successful replacement surgery has on the amount of medication patients take.The use of NSAIDs in OA treatment, either planned by a medical professional or taken of the patients’ own accord, is very high. Two-thirds of the population affected by OA are over 65 (which is the standard age of retirement in Hungary), which carries the risk of comorbidities and the parallel use of several medications, but a considerable fraction of OA patients is still active, for whom immediate and long-lasting pain management is both medically and financially important. Both general practitioners and specialists need to familiarise themselves with their patients’ pain management habits and make a comprehensive and personalized plan for the management of OA patients.


Pain during and after COVID-19 is common. In China, infection spread was swiftly brought under control, and pain management was incorporated into widely accessible treatment protocols combining traditional Chinese medicine and modern medicine. The coronavirus disease 2019 (COVID-19) global pandemic poses a major threat to human health and health care systems. Urgent prevention and control measures have obstructed patients' access to pain treatment, and many patients with pain have been unable to receive adequate and timely medical services. Many patients with COVID-19 report painful symptoms including headache, muscle pain, and chest pain during the initial phase of the disease. Persistent pain sequela in patients with COVID-19 has a physical or mental impact and may also affect the immune, endocrine, and other systems. However, the management and treatment of neurological symptoms such as pain are often neglected for patients hospitalized with COVID-19. Based on the China's early experience in the management of COVID-19 symptoms, the possible negative effects of pre-existing chronic pain in patients with COVID-19 and the challenges of COVID-19 prevention and control bring to the diagnosis and treatment of chronic pain are discussed. This review calls to attention the need to optimize pain management during and after COVID-19. Importantly, to reallocate resources to the emergency department, many nonemergency departments at medical institutions have been completely or partly closed, including many pain management departments.16 This review, based on the Chinese experience, attempts to uncover the increased risk of pain that patients with COVID-19 may face and outline that pain may not only be a symptom of COVID-19 but also one of the risk factors that influence the improvement of COVID-19 and other patients. This review will highlight and discuss China's early experience in the management of COVID-19 symptoms, including pain, and apply this in a global context.The coronavirus disease 2019 (COVID-19) pandemic has dramatically changed the way people live around the world. In particular, it has had a profound impact on normal medical activities and required repositioning health care personnel to front line services. To cope with the risk of hospital-acquired infection, medical institutions have had to multiply health care costs and resource use.41 In some patients, neurological symptoms may be the first or only manifestation of COVID-19.2 In addition, patients with more severe SARS-CoV-2 infection are more likely to show neurological symptoms.41 Although severe pain is rare, different forms of pain are important clinical manifestations. In a large study based on 1,099 patients (926 nonsevere and 173 severe) collected in 552 Chinese hospitals, 150 (13.6%) had headache and 164 (14.9%) had muscle or/and joint 30 pain and 153 (13.9%) with sore throat.24 Because of the differences in study objectives, a very wide range of pain prevalence was reported.Although pulmonary infection is the major symptom of SARS-CoV-2 infection, more than a third of the patients with COVID-19 had different neurological symptoms which may involve the central nervous system  and the peripheral nervous system  and skeletal muscle damage/pain or chest pain.58 Whether the headache is caused by the virus invading the nervous system directly or indirectly remains uncertain. An autopsy report showed damage to the central nervous system (CNS) as evidenced by brain edema and partial neuronal degeneration.63 The presence of SARS-CoV-2 in the cerebrospinal fluid was confirmed by genome sequencing, indicating that the virus may penetrate and cause damage to the CNS.4 Existing knowledge about coronaviruses suggests that the coronavirus family has a certain tropism for the CNS.8 Neuronal pathways allow the virus to enter the CNS.1 The virus can infect sensory and motor nerve endings to migrate, then achieve retrograde or anterograde transport by movement protein, dynein protein, and dynamic neurons to invade nerve tissues and cause infection of immunocompetent microglia, astrocytes, and macrophages in the CNS.57Headache is one of the most frequent forms of pain during SARS-CoV-2 infection. The exact incidence of headaches caused by the virus needs further study, while most studies suggest headache prevalence ranged between 6% and 21%.66 Since the target receptor of SARS-CoV-2, ACE2, is present in almost all tissues, including muscle tissues, the virus can attack skeletal muscle cells directly, causing skeletal muscle weakness, fatigue, pain, and injury.53 Rhabdomyolysis has been found in patients with severe SARS-CoV-2 infection.58 Apart from the direct cause, the inflammatory response induced by SARS-CoV-2 infection may be another important cause of muscle pain.59 Muscle injury caused by COVID-19 is characterized by a significant increase in the levels of creatine kinase and lactate dehydrogenase, and its pathophysiology is primarily believed to be caused by excessive inflammation.33Muscle pain is another common symptom in patients with COVID-19. When comparing the existing studies, the incidence of muscle pain ranged between 7% and 32%.7 A descriptive study of the epidemiology and clinical characteristics of 99 cases of new coronavirus pneumonia in Wuhan in 2019 showed that when admitted to the hospital, most patients had fever or cough, and some patients had chest pain (2%).11 Compared with the patients with mild symptoms, the incidence of chest pain and dyspnea is higher in critical patients. In the severe patients, chest pain may be caused by the inflammatory reaction of the pleura. Their alveolar tissue is severely damaged, resulting in dyspnea.Chest pain, while relatively rare, generally occurred in patients with more severe symptoms especially when lesions are close to the pleura with abundant nerves.34 Sore throat was reported in 5% to 17.4% of patients with COVID-19 in China.60 Of 76 patients with acute abdominal pain, 9 patients (11.8%) were eventually diagnosed with COVID-19.54Other types of pain are also found during the process of clinical diagnosis. Researchers from Anglia Ruskin University found that among 83 interviewees, there was a significant increase in eye pain in the confirmed patients; 16% reported eye pain as one of their symptoms.39 Unfortunately, in the ICU, pain is often overlooked as being low priority and thus poorly managed, even in a well-staffed and skilled environment.50 It is important to consider how to implement effective pain management in the ICU to reduce acute pain and reduce the risk of chronic pain in patients with COVID-19.50 Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU have been developed and adopted in many ICUs.14 This strategy can obviously strengthen pain management of patients through multidisciplinary management of symptoms, mobility, and communication. Although there is not yet substantial evidence to support the statement that pre-existing chronic pain may worsen the pain during and after COVID-19, many severe chronic diseases such as coronary artery disease, diabetes, cancer, and chronic obstructive pulmonary disease are often accompanied by pain and also heighten the risk of death during COVID-19. Patients with chronic pain already experiencing depression, inattention, fatigue, and insomnia may find COVID-19 symptoms especially disturbing.Those patients with COVID-19 who experience intense pain and distress during their stay in the intensive care unit (ICU) seem to be at a higher risk of developing chronic pain after discharge.55 Besides the increased burden on the medical staff, patients with severe chronic pain, the disabled, and the elderly had reduced access to psychological and interdisciplinary treatments.30 A lack of face-to-face counseling services complicates individual assessment of analgesic use risk. When pain cannot be effectively assessed and treated, quality of life is reduced and treatment of underlying diseases may be impaired.64 The presence of chronic pain can activate the hypothalamus–pituitary–adrenal axis and alter the function of the immune and endocrine systems.68 At the Renmin Hospital of Wuhan University, a total of 663 patients with COVID-19 admitted between January 2020 and February 2020 were enrolled in a retrospective cohort study. Muscle pain was significantly associated with severe COVID-19 (P = 0.028) and to the patients' hospital course (P < 0.001). Muscle pain, expectoration, and decreased albumin were believed to be independent risk factors influencing patients' improvement during follow-up.66 Furthermore, groups such as the poor, the widowed elderly, and the homeless are more likely to suffer from chronic pain and comorbidities,42 have less access to health care, and are a high-risk group for severe COVID-19.6To concentrate available resources during the initial wave of COVID-19, most medical institutions had to close nonintensive care services including pain management departments.62 Online resources can disseminate pain education and can develop online training programs on pain self-management for health care professionals, patients with pain, and relevant personnel. Although much of the existing research is optimistic about eHealth Care, studies may not adequately assess groups without access or ability to use these services, including children, the elderly, or those with intellectual disabilities.16Online pain management programs where patients are in contact with health care providers remotely are promising.China's response to COVID-19 has been rigorous. After the outbreak, the Central Government's Leading Group for Epidemic Work swiftly formulated a response plan which put people's lives as the top priority. With the precise decision of the Chinese government and the joint efforts of volunteers from all over the country, the further expansion of the epidemic was finally controlled, which laid a solid foundation for the Chinese control of the epidemic throughout the country. Many of China's practices are worthy of discussion and reference.13 It is worth noting that new media platforms, which are more easily accepted by the people, have played a huge role in the prevention and control of the epidemic. Only when most people are familiar with the correct knowledge and prevention measures of COVID-19 can epidemic prevention work be performed more effectively.Popularizing science and improving citizens' scientific quality are long-term concern of the Chinese government. This ensures that the public can properly understand and scientifically protect against the COVID-19 epidemic. In the very early days of the epidemic, China published the basic knowledge of novel coronavirus, the key points of self-protection, and the relevant national epidemic prevention and control policies to the public on the official government media, such as the Xinhua News Agency and China Central Television. At the same time, authoritative medical organizations, such as the Chinese Medical Association, China Preventive Medicine Association, and Chinese Association for the Study of Pain, educated the public through their official information release platforms. Through their professional guidance, self-health management of patients during the epidemic period was strengthened. For example, the Chinese Association for Science and Technology issued an article on home care and rehabilitation guidance for patients with shoulder joint pain during the epidemic.45After the SARS epidemic and experience in 2003, China set up professional fever clinics in general hospitals grade II and above (grade III is the highest grade). All patients with fever, cough, and pain were to be admitted to the fever clinic for diagnosis and treatment. During the period of regular epidemic prevention and control, the registration, imaging examination, nucleic acid testing, isolation, reporting, treatment, and referral of patients with fever and pain can be conducted in this department. The fever clinics performed strict terminal disinfection operations. On December 3, 2020, the State Council's Joint Prevention and Control Mechanism Press Conference announced that more than 7,000 fever clinics had been completed nationwide.17 Meanwhile, the National Health Committee issued the “Expert Consensus on the Management and Guidance of the Rational Use of Home Medications for Common People During the Epidemic Period”18 and provided pain management and pain medication training to all medical staffs. The purpose of these measures is to guide both medical staffs and patients on the correct use of medicines and correct reporting of early symptoms.Fever and pain are important early diagnostic indications for most patients with COVID-19. The China National Drug Administration issued an administrative order to further regulate the use of analgesic and antipyretic drugs, even those not typically thought of as drugs of abuse.25 In January 2021, a few local cases were reported in Beijing, Shanghai, Hebei, and other places of China. The local governments immediately organized large-scale epidemiological follow-up. Most subsequent confirmed cases were close contacts identified by epidemiological means. The scattered outbreaks were controlled in only 1 month. Fever, pain, and other symptoms of patients with COVID-19 after infection clearing and discharge should also be included in the epidemiological follow-up.Finding close contacts of confirmed patients can help detect potentially infected persons by identifying trajectories and early symptoms, clearly describe the entire transmission chain and transmission network, and make epidemic control more effective.52 In addition, to encourage the public to receive the COVID-19 vaccine and ensure that low-income groups can also get the vaccine fairly, China has announced free vaccination for all citizens, the cost of which will be covered by the national public medical insurance fund.In developing countries, even in many developed countries, the cost of treatment is a heavy burden for most patients with COVID-19. This may lead some patients to report their symptoms untruthfully. The Chinese government has designated special medical hospitals in each city to treat patients with COVID-19. In these institutions, free treatment including pain management for people infected with COVID-19 is provided. All the treatment costs are covered by the national public health insurance fund. This measure has helped implement the “early detection, early isolation, early treatment” guideline and fully guarantees the right of every citizen to have fair access to medical services. According to statistics from the China Medical Insurance Administration, in the first quarter of 2020 alone, China's public medical insurance invested more than 19.3 billion yuan (approx. 3.1 billion US dollars) for the treatment of patients with COVID-19.35China has adopted multiple channels to ensure the pain control needs of patients without COVID-19 are addressed. The National Ministry of Civil Affairs continues to purchase social medical services for poor people and actively encourages relevant companies to provide pain management services. For example, the Nationwide Hospice Service Program supported by Li Ka-shing Foundation provided free pain management and other services to approximately 15,000 patients with cancer pain during the COVID-19 epidemic.44As COVID-19 has changed the original medical treatment model, pain management measures have been adjusted to minimize the impact of COVID-19 on patients with pain and the probability infection spread by patients with pain receiving unsupervised medical treatment. Based on the experience of effective prevention and treatment of SARS and MERS, 8 updated versions of Diagnosis and Treatment Protocol for Novel Coronavirus Pneumonia have been issued by the National Health Commission of China.55 After classification of diagnosis and treatment planning, outpatients with moderate and below pain received prescription drugs and received telemedicine support at home. Outpatients with severe pain were sent to clinic for rapid treatment. Any outpatients with confirmed or suspected COVID-19 infection will be sent to the quarantine area for further observation and treatment. For in-patients with severe pain, the necessary pain treatment was ensured as much as possible on the basis of minimizing contact.The experts in the Department of Pain Medicine in Wuhan and Shenzhen have implemented a series of measures to take better care of the most vulnerable patients.55 According to reports, the medical staff in Wuhan mobile cabin hospitals organized patients to conduct collective social activities, lead patients to practice square dances and increased theatrical performances.61Telemedicine is a convenient and safe way of providing pain management service during and after COVID-19, including instructions for taking medicine, relief of psychological symptoms, and at-home exercises.67 Recently, a book cowritten by Chinese doctors and scientific researchers in the field of COVID-19 prevention and treatment named COVID-19: The Essentials of Prevention and Treatment was released worldwide. This book recorded China's experience in prevention, control, and treatment for global reference.51After discharge from hospital, patients should be followed up to see if sequelae are present.9 The main symptoms of the patients with COVID-19 are fever, fatigue, pain, cough, myalgia/arthralgia, gastrointestinal symptoms, and “thick fur on tongue” which can be classified into dampness subtype on the basis of TCM theory.65 In TCM, the core pathogenesis of COVID-19 is the discomfort of the lungs and spleen caused by damp cold distemper. Early corresponding treatment should aim at eliminating moisture, thereby releasing lungs and eliminating pathogenic factors, so as to shorten the duration of fever, relieve symptoms including pain, and reduce mortality.40 There are many prescriptions and proprietary Chinese medicines which have been used in relieving COVID-19 symptoms in China. Most Chinese medicine guidelines define COVID-19 as an endemic, toxic, humid, or warm infectious disease.48 Licorice is the most frequently used Chinese medicine. Ephedra, bitter almond, astragalus, scutellaria, patchouli, and honeysuckle are also medicines that are frequently used. In Guangdong, a case study of Tou-jie-qu-wen granules was conducted and promoted to 30 designated hospitals as the standard treatment for patients with COVID-19.22 Pharmacological analysis showed that most of the active components of these herbs have antiviral, immunomodulatory, anti-inflammatory, and analgesic effects.23 In the process of treating patients with COVID-19, the use rate of traditional Chinese medicine in patients accounted for 90.6%, and the total effective rate was reported as over 90%.52Another highlight of COVID-19 treatment in China is the use of traditional Chinese medicine (TCM). Traditional Chinese medicine plays an important role in the treatment of patients with COVID-19 in China. China's Diagnosis and Treatment Protocol for Novel Coronavirus Pneumonia has included guidance on using TCM to treat patients with COVID-19 at all stages. The essence of Chinese medicine is applying medicine according to symptom-based diagnosis.67 According to reports, stimulating the acupoint such as Tianzhu (BL10), BL12, and GV14 can eliminate nasal discharge, pain of the shoulders, and the back, while Neiguan (PC6) and Lieque (LU7), or Juque (CV14), Qımén (LR14), and Zhaohai (KI6) can relieve chest pain or/and shortness of breath.37 The traditional exercises named Taiji and Ba-Duan-Jin et al. are also used in rehabilitation training.38 The combination of TCM and modern medicine is used to treat patients with COVID-19 in China, giving full play to the respective possible strengths of TCM and modern medicine therapy.In addition, physicians use traditional nondrug methods such as acupuncture and massage as adjuvant therapy for patients.The authors have no conflicts of interest to declare.