Pain is often poorly managed in people who have a dementia. Little is known about how this patient population is managed in hospital, with research to date focused mainly on care homes. This study aimed to investigate how pain is recognised, assessed and managed in patients with dementia in a range of acute hospital wards, to inform the development of a decision support tool to improve pain management for this group.A qualitative, multi-site exploratory case study. Data were collected in four hospitals in England and Scotland. Methods included non-participant observations, audits of patient records, semi-structured interviews with staff and carers, and analysis of hospital ward documents. Thematic analysis was performed through the lens of decision making theory.Staff generally relied on patients’ self-report of pain. For patients with dementia, however, communication difficulties experienced because of their condition, the organisational context, and time frames of staff interactions, hindered patients’ ability to provide staff with information about their pain experience. This potentially undermined the trials of medications used to provide pain relief to each patient and assessments of their responses to these treatments. Furthermore, given the multidisciplinary environment, a patient’s communication about their pain involved several members of staff, each having to make sense of the patient’s pain as in an ‘overall picture’. Information about patients’ pain, elicited in different ways, at different times and by different health care staff, was fragmented in paper-based documentation. Re-assembling the pieces to form a ‘patient specific picture of the pain’ required collective staff memory, ‘mental computation’ and time.There is a need for an efficient method of eliciting and centralizing all pain-related information for patients with dementia, which is distributed in time and between personnel. Such a method should give an overall picture of a patient’s pain which is rapidly accessible to all involved in their care. This would provide a much-needed basis for making decisions to support the effective management of the pain of older people with dementia in hospital.The online version of this article (doi:10.1186/s12913-016-1690-1) contains supplementary material, which is available to authorized users. Pain is common in older adults, affecting one third of people living in the community , and repDementia affects more than 35 million people worldwide, and this figure is set to rise . The conIn the UK, an estimated 25–42 % of hospital beds are occupied by older people (over 65) with dementia –20. One An acute hospital ward may be a disorienting and distressing environment for a person with dementia due to heightened/un-escapable noise, bright lighting and unfamiliar staff and surroundings. Poor pain control in the context of this environment is associated with neuropsychiatric symptoms, particularly aggression and anxiety . These sThere are significant challenges for healthcare professionals and clinicians in evaluating pain experiences in people with dementia, primarily due to their patients’ difficulties in recall, interpretation, identification and response to pain. Impairment to memory and insight often leads to pain being reported only at the point of pain being experienced ‘in the here and now’ . Furtherguessing game” by some healthcare professionals [Recognising pain in people living with dementia has been described as a “ssionals  [p5]. A ssionals , 31. A nssionals . Recommessionals . Pain asThis study hypothesised that a rigorously developed decision support tool could help clinicians, carers and people with dementia by improving pain assessment and management in acute hospital settings. To inform the design of such a tool, an exploratory study was conducted to understand how pain is currently recognised, assessed and managed among patients with dementia in representative acute settings in the UK, through the lens of decision-making theory. This paper reports the findings of this exploratory study and discusses the implications for decision support and improvement in clinical practice.The overall aim of this study was to investigate how health care professionals and others recognised, assessed and managed pain in patients with dementia in a range of acute settings. This was to provide the basis for the development of a decision support tool to improve the management of pain for this population.What information is currently elicited and used by clinicians when detecting and managing pain in patients with dementia in acute hospital settings?What is the existing process of decision making for detecting and managing pain in patients with dementia in acute hospital settings?What is the role  of carers in this process?What is the organisational context in which health care professionals operate, with regard to this decision making process?The study addressed the following research questions:Pain is multidimensional, consisting of sensory, cognitive, affective and social components. The focus of this study was physical pain (acute and /or chronic), though we acknowledged that pain and emotional distress are closely linked since distress may exacerbate pain symptoms and vice versa. Pain experiences are associated with a multiplicity of factors which are unique to each individual and even in the absence of cognitive impairment, they are very difficult to communicate meaningfully to other people , 35.assessment or judgement), and taking appropriate actions to ameliorate the pain (making treatment decisions) . There lsewhere . A commolsewhere , 39, indlsewhere . InformaIn investigating how health care professionals and others recognise, assess and manage pain in patients with dementia, the research design and research instruments for this study were focused on information , individuals’ processes of perception, judgement, and decision making, as well as any tools used in the process and documentation of a patients’ pain. A model of judgement and decision making focused on linear processes Fig.  was usedThis study was a multiple case site study with embedded units of analysis , approached with ethnographic methods. Case studies involve an empirical design which focuses on describing phenomena within their real life context  and apprFour case sites  were sampled to provide varying settings for acute care: one in the south of England, two in the north of England and one in Scotland. One of the four organisations used electronic patient record systems while the others used paper for medical and nursing notes. Criteria for sampling included type of hospital  and type of service provision available to health care professionals in the hospital . In each site two wards were initially selected for data collection, with additional wards approached where access to participants was found particularly challenging. The selection was theoretically driven to ensure that there was representation from a variety of clinical settings in acute care where patients with dementia may be cared for  across the sample as shown in Table Data collection was undertaken by research fellows at each of the four sites. Data were collected at three of the sites  by one researcher each , and by two researchers in turn in case site H3 . In each case site a variety of data collection methods were used to provide multiple sources of evidence for addressing the research questions. Non-participant observation of health care professionals (HCPs) and health care assistants (HCAs) interacting with patients who have dementia was used to identify how information appears to be identified and elicited in order to detect and manage pain, and the care processes that currently take place. This included observing patients at bedside, and a focus on how and where pain was discussed and documented, interactions between HCPs/HCAs, patients and carers, interactions between members of the multi-disciplinary team (MDT) and availability of resources such as pain specialist services. An observation protocol derived from the theoretical framework was used to guide data collection  and patients’ family members (‘carers’). Topic guides were used flexibly, with the freedom to explore any other relevant issues specific to the site  was not our concern  and Scotland . The process to recruit patients was informed by the Mental Capacity Act 2005 and the Adults with Incapacity Act (Scotland) 2000; it included written consent by patients or agreement from a carer consultee, patients’ capacity assessment to consent, consultation with staff and assent of carers . InterviData for analysis consisted of verbatim transcripts of observation sessions, field notes of medical and nursing records, notes and transcripts of interviews. Data were indexed using NVivo (v10) qualitative analysis software, and subjected to thematic analysis. Both inductive and deductive approaches were applied, with dimensions of decision making  providing initial categories for indexing data, but with a variety of other themes (e.g. about the context of care) emerging from the data.The strategy for the multi-site qualitative data analysis emerged through a process of team meetings, sharing of documents and reflections among the interdisciplinary team of researchers and investigators. It became apparent that a large number and varied range of themes were emerging from the analysis but it was agreed that a focus on dimensions of decision making was necessary to answer the research questions. The senior research fellow in the team (VL) led the multi-site analysis, which was then discussed with the research team and verified by other researchers . Transcripts were scrutinised to identify themes or categories, which were used to code the data. Subsets of the dataset were coded by three of the researchers . The senior research fellow checked a sample of each subset to verify consistency in the analysis. Data in each theme were examined to look for negative cases or contradictory findings . To incrThirty-one patients with dementia participated in the study and were observed for a total of 170 h at bedside. Fifty-two health care staff and four carers were interviewed Tables –3. AmongPatients included in the study had a mean age of 88 years (range 75–99). A number of challenges were encountered in recruiting patients for all case sites. Among them was the lack of a documented diagnosis of dementia in ward notes despite strong indications that the condition was present, and many patients had no available carer.communicating pain with dementia, carer-clinician communication, trials with therapy and putting a picture together.The analysis identified four over-arching themes which are discussed below; In assessing and managing a patient’s pain, the guiding principle used by staff was to rely on self-report (the patient telling about their pain), with the patient being the main information source.However, for many of the patients observed in the study, communication barriers of various sorts hindered a patient’s ability to provide staff with information on their pain experience. These included: issues related to language and cognitive impairment, the impact of patterns of work on a patient’s ability to communicate, and issues of trust and familiarity. We describe and discuss each of these aspects below.somebody might have no concept of what moderate means, for example .Patients with severe dementia showed significant communication difficulties. Interviewees explained that questions about pain should be rephrased to account for this. For example, when questions were asked for the purpose of gathering and recording a pain score in a form structured with the three options ‘mild, moderate and severe’, these were to be translated into words patients could understand, taking into account the ability of each individual:‘we need to get staff to think differently’ .Patients appeared to be using various gestures, postures, bodily movements, behavioural prompts, metaphorical expressions and a combination of these in what was interpreted as an expression and communication of pain. Data from interviews suggested that nurses and clinicians also looked at physical and behavioural signs to understand patients’ pain. One interviewee commented that the identification of these non-verbal communication cues depended largely on staff skills, experience, knowledge and perceptions and added that It’s murder, it’s awful. For quite a while it’s alright and then suddenly is murder”  and another patient expressed headache as “red hot” . An interviewee suggested that ‘it is not always what is said, but how it is said’  that gives a cue of a patient’s pain.Some patients made use of metaphorical expressions to communicate their experience of pain. For example a patient explained the pain in her knee as “they are always dashing’ , or in the words of a carer, ‘it’s just a fleeting glance, they talk to them and off they go’ .as an FY1 [Foundation Year 1 doctor], I’m only seeing the patients for a few minutes at a time then the rest of the time looking at their investigations or trying to organise things, I don’t usually, I wouldn’t say that I actually get to know the patient as a person […] The challenges raised by cognitive impairment in patients were compounded by the organisational context and time frames of staff interactions with patients. Organisational routines and staffing numbers meant that the majority of patients’ encounters with staff during their hospital stay were brief, sometime extremely brief and less frequent when with more senior staff members. One patient said, ‘there’s not enough of us, and we just haven’t that time patients shouldn’t go a long period of time without their pain being reassessed […] certainly you’ve got to go back, it does recommend half an hour, but as I said, it’s quite difficult to get back within that period of time Furthermore, given the organisation of staff work over rotas and shifts, a patient’s communication about their pain was not always with the same member of staff but may have involved several different HCAs, nurses and doctors. There was awareness among staff that patients with dementia would need more time than usual to communicate pain. For example a local Pain Dementia Care Plan guidance (H1) did include instructions for nurses and HCAs to give enough time to the patient to communicate, but in practice this was a matter of minutes. Indeed in interviews the lack of time was often voiced by the nurses as a concern.These brief encounters required the patient to be ready to answer questions and to recall their pain experience with little or no forewarning. Moreover, these opportunities at times occurred while patients were otherwise engaged in eating or sleeping, or when they were not prepared to discuss pain.Patients were directed to use a call button at bedside (a ‘buzzer’) to request assistance. Patients with more severe dementia appeared not to recognise the purpose of the buzzer or forgot it was there, thus severely limiting their ability to communicate pain. Also calls for help, including those using a buzzer could not always be answered immediately, leading to distress and confusion for the patients concerned. Some patients seemed to have no memory of having used the buzzer when a staff member arrived. In other cases patients expressed a disinclination to use the buzzer and disturb busy staff, or they did not know what the buzzer was ‘for’, thus rendering it unhelpful to the person with dementia. Cases were also recorded where patients verbally reported pain, but at a time when there were no staff members present. During bedside observations it became apparent that it was necessary to be in close proximity to the patient in order to communicate, and in the same bay or at bedside, as patients rarely left their bed or chair. At times patients’ needs surfaced out of background noise or while the staff were in the room with other patients and patients were able to attract their attention through verbal communication or behaviour. However, this was not always the case and some patients were alone and without interaction for relatively long periods. Many of the ward routines such as note keeping and handovers took place away from the bedside, thus minimising a clinician’s opportunity to communicate with the patient during periods of alertness, or to detect subtle changes in expression and engagement.if you feel that somebody cares about you then I’m sure it makes it easier to express it if you’ve got pain” , and a student nurse of HCA’s background stated, “if you are connected with your patient, if you, they know you and they trust you, if you build that rapport, that itself will allow you better access to how their pain is” . However it seemed to the researchers that establishing these relationships was not facilitated by the brief time frames available for communication and patterns of interaction.Clinicians were aware that relationships of trust and familiarity were important for a patient to communicate their pain. One Elderly Medicine Consultant explained: “[carers] would know the patient much better than we would and they would be able to assess whether [the patients with dementia] they’re in pain or how they’re feeling, and communicate with us. So yes we often ask for input from the carers or the family members to guide us in how we’re managing the patientsRelatives, visitors and carers represented an important information source in the recognition, assessment and management of pain. These individuals have been described as ‘a hidden workforce’ (as suggested in ). One wamy mum has a terrible habit, even though we know as a family, when she needs to go to the bathroom she starts shaking her leg and she was doing that in hospital and she was getting in a panic, she actually was crying, she went in with a really bad urine infection which was causing a lot of pain at the time […] Carers were observed as acting as messengers on behalf of the patient, and helped recognise and interpret pain cues. An example of this process is described in a quote from a carer interview:“the needs of how [patients] are and how we can help them here” . This observation is strengthened by the lack of documented communication with carers found in patient records. In part this was also due to unavailability of family members in a number of cases . Several carers perceived staff to be occupied, and therefore were reluctant to initiate a conversation, while others expressed that they did not perceive themselves as experts in the knowledge of the person they care about. Some were elderly, and had dementia themselves. Family conflicts, domestic violence, poverty and deprivation seemed also to be complicating factors in some cases.However, the observations conducted in this study showed that the majority of staff communications with relatives were concerning medico-legal reasons of consent or about discharge arrangements, and less about I hear a conversation at the nurses’ station between nurses about another patient. A nurse spoke with the niece, says the patient is okay at home. The other nurse says the niece may not know, may only see her once a week, to talk with , that they may have a completely different picture. the skill that the juniors need to have is in digging out, ferreting out the information that is relevant to a person […] in order for us to make an informed decision […] it’s not just, it’s not just asking the question, “How was your relative before they came into hospital?” It’s really understanding the nitty-gritty of the details, […] of course I don’t have the time, unfortunately, to do all of that for every patient, so […] Staff expressed the belief that there is a need for clinicians to improve communication skills with carers. They explained this as having the ability to elicit the right information from the right relative/carer and assess the trustworthiness of these information sources.The most common pain treatment used in the study sites was analgesic medication. Indeed pain management and pharmacological management of pain often appeared to be one and the same. A limited number of non-pharmacological pain management strategies were used, such as patient re-positioning. Clinicians considered potential side effects of medications, including confusion when making treatment decisions.pain relief already regularly on their charts for their surgical procedures” and this prescription was administered “every six hours” even if patients did not report pain . This standard acute pain medication prescription followed an established protocol. The prescription was provided by the anaesthetists at the time of surgery. More difficult cases, or when pain was clearly not under control, required escalating out of the routine prescription through contact with a specialist pain team and trialling combinations of different analgesic drugs. In other sites pain medication was administered on an ad hoc basis, depending on the patient’s medical condition. In these cases pain management was commonly approached in a trial and error mode, titrating the dose gradually and assessing the patient’s response.In certain wards, depending on the ‘type of patients’, pain medications were prescribed routinely to all patients. For example in a ward in case site H4, an orthopaedic surgery ward, patients received “obviously a knowledge of the reason why they’re in hospital and if they’d had a particular surgery, of knowledge of what is happening within the body. […] And how much pain relief somebody would need for that Importantly, the process of (re)assessment for the purpose of establishing the most appropriate medication encountered similar communication challenges as described above as not all patients were effectively communicating changes in their pain. Judging the level of titration, or the appropriate step in the analgesic ladder, relied on clinicians’ knowledge or ‘sense’ of what the expected pain medication for a given medical condition would be:Pain relief medication prescribed to be administered as and when needed (PRN) was usually considered part of this process of titration but could not be used effectively with patients with dementia who would not request additional pain relief.“we’re trying to build a picture” - staff nurse, H1). This process required time and availability of information from various sources, including carers, the multidisciplinary team assessment, administration of medication and the patient’s response.Overall, understanding a person’s pain in these acute hospital wards involved investigative work and ‘putting a picture together’ of an individual’s pain Importantly however, paper-based documentation was fragmented, not easily accessible or poorly organized. The various documents retained and used by different health care professionals were kept ‘in silos’.The nurse completes the patient’s chart for 15:00. He is still trying to sit up, but the nurse does not help. After the nurse moves away, I [researcher] check the record, which is recorded as confused and alert, despite the patient being asleep since I arrived at 14:53. Comparison of audit data and observations raised a question regarding the quality of data recorded, as suggested in the field notes below.when we fill in care plans, we’ve got the specialist assessment [forms] and they say the same things as your care plans In one ward the intentional rounding forms were filled in every two hours, in what appeared to become an administrative, rather than investigative exercise. Staff respondents in the study raised concerns over the large amount of paperwork, some of which they considered redundant.if there’s nothing written, I suppose I would assume the question hasn’t… has the question been asked? I don’t know, I probably from a personal point of view […], I would have asked it but probably not documented that there was no pain. If I don’t see anything written I would assume that the patient hasn’t complained of pain but I suppose what I can’t say is that they’ve been asked if they’ve got any pain. We also identified ambiguity in documenting the absence of pain. The interviewees reported the tendency to assume that the patient is not in pain if patients’ pain is not recorded in the documents.No use of decision support tools was observed in any of the settings studied for pain assessment or management. In one site (H1) the Abbey Pain Scale  was reconot well used on the ward”, that the criteria for using it were unclear and that it ended up been used as a ‘tick box exercise’ . Wards in case site H2 had recently implemented a generic pain assessment (GPA) form, developed locally, to be used alongside the PACSLAC tool (Pain Assessment Checklist for Seniors with Limited Ability to Communicate) [nurses have so many assessments now to do that [...], they’ve kind of lost their credibility a bit, [the GPA form] it’s just seen as a form and a tick box exercise […] it’s another thing to do and yet they have a hugely frantic day One site utilized electronic documentation and at the time of the study it was in the early stages of implementing the Abbey Pain Scale in electronic form. However, no data could be collected regarding this and no staff were observed using it. A manager reported how the tool had been trialed, but “unicate) . In the This study explored how pain is currently recognised, assessed and managed in patients with dementia from a decision making perspective. Recognition, assessment and management of pain in patients with dementia in hospital wards involved a number of information sources and individuals at different times and in different places.The main information source was claimed to be the patient, as the sole individual with insight into their pain. However, cognitive impairment, communication difficulties, the organisation and context of the ward, all contributed to hinder access to this source of knowledge. As also shown in other contexts of care , the comThe social context of the ward environment also critically shaped health professionals ability to recognise and respond appropriately to a patient’s communication of pain. The time frames for patient interaction, the number of patients on each ward and the expectations set up by the ward routines, all influenced HCPs and HCAs’ ability to perceive, recognise and manage a patient’s pain. Observational studies have revealed the challenges of pain management in acute settings and the barriers to optimal pain relief, such as staffs’ attentiveness to pain cues, interruptions when assessing pain and reconciling varying interpretations of pain from multiple sources , 51. TheHypothetico-deductive reasoning  posits tAnalysis of data also revealed organisational routines with an almost exclusive reliance on medication for managing pain. This type of approach is reliant on patients being able to communicate the presence of pain and changes in their pain after administration of medication. However, the communication difficulties in dementia drastically alter the effectiveness of this process. Other pain management interventions, such as repositioning, physiotherapy or physical activity, or patient engagement in meaningful activities, may offer the patients more opportunities to express and communicate their experience of pain and are included in best practice guidelines . AdditioThe key elements of our findings are shown in Fig. The creation and development of an overall picture of pain, specific for the patient, is both a prerequisite for planning and undertaking a trial of therapy and a result of this trial. In the sites we studied there was a disconnect in documentation between the information about decisions to act , the feedback from the action  and the re-assessment that informs following decisions/actions. This disconnect represented a considerable challenge to the understanding of the patient pain and effectiveness of therapy. It involved on the part of staff, a cognitive process of re-assembling the pieces requiring memory, ‘mental computation’ and time.Given a ward’s division of labour and organisation of work over shifts, effective documentation is essential for composing this ‘overall picture’ over time, each information item acquiring value when aggregated with and compared to others. Decision tools would need to assist in the integration of the distributed pain information, allowing a central point where the picture of a patient’s pain is created, over time and across individuals. Furthermore, it would have to assist with action and decision taking in a dynamic fashion that supports the trial and error nature of pain management and options for intervention.The paper based information systems currently in use in the majority of wards in our study for the distributed work processes involved in pain assessment and management do not facilitate the perception of such a holistic ‘picture of pain’. Pain assessment tools are often designed to support and record single instances of assessment, rather than the multiple (re)assessments of a patient’s pain. However, a patient’s pain may change and fluctuate in time and this information on changes and patterns is needed to gain a ‘full picture’ of the patient’s pain. Single pain assessments at one point in time, even if they were done with the aid of one of the many pain assessment tools available, do not provide sufficient information about a patient’s pain; even when repeated they risk remaining as isolated information points because they are not connected in a common, accumulated picture of a patient’s pain, integrating the effectiveness of any pain mitigating care given. Much of the literature concerned with the assessment and management of pain for people with cognitive impairment has focused on the development and validation of observational instruments designed for the purpose of assessment . A numbeA significant part of the information gathering and sense-making process (that would be documented in a ‘pain picture’) is in capturing the pain experiences of the patients themselves. People with dementia who are able to communicate verbally may use a range of metaphors and analogies drawn from their life experience to communicate their pain. Where these vulnerable patients are unable to communicate verbally, effort is required to understand cues unique to each person that may indicate the presence of pain.When ‘pain pictures’ are informed by the person with dementia’s sense-making of their own situation, these new practices and charts are a potential means of enabling the person with dementia to make their pain understood and documented from a person-centred perspective. To achieve this, it is important to build a relationship with the person with dementia, their carer and other support networks as necessary, in order to elicit self-reports and/or maximise understanding of individuals’ idiosyncratic methods of communication - what is normal for them, and what drugs or other interventions are known to work or not work for them. This process is in line with the gold standard of person-centred care, which is established as a critical element in any dementia care , 58. SucThere is a perennial difficulty of interpreting behaviours which indicate some kind of distress. Information cues  are often not recognized by staff as indicating the presence or absence of pain, or are misinterpreted as “behavioural problems”. Distress may be due to pain, but it may also have other causes which the patient may be unable to communicate. Familiarity with the patient should enable ward staff to untangle possible causes of distressed behaviours, and to attempt analgesic trials where pain is a likely cause .Finally, the involvement of carers can help clinicians and patients in overcoming communication barriers. At present information provided by carers, when available, is not well integrated in the information system in use or not documented. Increasingly in the UK paper forms are being introduced in hospitals where family members are asked to describe the person’s usual behaviour, likes and dislikes  but these do not seem to be integrated with a patient medical record. It should be acknowledged that challenges are often encountered in clinicians-carers relationships, and staff perceived need “to manage the family”  . BehaviThe vast majority of the research concerned with managing pain in people with dementia has taken place in care homes, with most being undertaken in the US, Europe and Australia. Very little research has considered issues encountered in busy acute hospital settings. Furthermore, most research in the field has focussed on the development and validation of observational pain instruments, with less attention paid to the contextual factors influencing their use. Not only should suitable assessment tools be used, but also the relative contributions of factors such as improved use of time, improved multidisciplinary communication and a more varied range of resources for managing pain need to be understood. Realist studies of clinical practice where decision support tools have been implemented could explore the relevance of contextual contributory factors. This should be followed by clinical trials of the effectiveness of the interventions likely to have the most positive impact. There is also a need for research to evaluate integrated approaches to pain management, considering behavioural symptoms, prescription patterns and institutionalisation, in order to embed pain management within the overall treatment and care a person receives throughout their journey with the condition.There are few in-depth qualitative studies about pain assessment and management in patients with dementia in hospital settings e.g. , 3), and, and3]),Similarly, we have only limited data on clinicians’ views and reasons for not using structured pain assessment tools and further research could be done on this. However, when asked, clinicians may have difficulties making their rationales explicit, and there may be a tendency to blame a general lack of time as the culprit. As suggested in this study, some of the reasons may lie instead in a lack of fit between design of the tool, staff information needs and work practice in the different contexts of care.Pain assessment and management are activities that embrace patients’ physiological, emotional, cognitive, and social dimensions. Pain is often described as a private experience but in reality it regularly requires public expression in order to obtain relief. When caring for people with dementia, communication between patients and staff about pain is made more difficult due to the challenges that the progressive cognitive and functional decline present, with non-verbal communication  becoming more essential and yet more ambiguous. Furthermore, communication occurs within hospital contexts and routines organised mainly around the needs of the organisation rather than those of individual patients. Information about a patient’s pain for the purpose of pain management is generated and constructed through the activity of multiple people at different times; knowledge about patients’ medical condition and expectations about probable pain, inform the times and patterns of interaction, and these affect the way pain is identified and documented, and what is expected and done about pain. The pain assessment and management process is distributed and complex, with mechanisms that are multiple and recursive rather than linear. This complexity may, at least in part, explain why simple tools available to assess pain in patients with dementia are not well used in practice. Future decision support interventions need to take this complexity into account during their development, re-organising frames and quality of time for communication with patients, making a more varied range of pain management interventions routine, and devising tools that bring together information to provide a ‘picture of a patient’s pain’ accessible to all involved, within an overall framework of person-centred care.


No adverse event was reported during the treatment. In addition, the decreased pain level and improved function continued for over one year. Although we did not find definitive evidence, the study results suggest that KM combination therapy may be beneficial for decreasing pain and improving function in LSS patients and may produce comparatively few adverse events.This is a retrospective case series exploring the therapeutic benefits and harm of nonoperative Korean medicine combination therapy for lumbar spinal stenosis (LSS). The medical records of a total of 33 LSS patients, who were treated as inpatients at Mokhuri Neck and Back Hospital, Republic of Korea, from November 2010 to January 2012, were reviewed first and telephone survey on these patients was conducted after one year. Body acupuncture, pharmacoacupuncture, Chuna, and oral administration of herbal medicines were offered to all patients. A Visual analogue scale (VAS) of pain and the walking duration without pain were used to assess the patients during the approximately 1-month treatment period. The average VAS score of pain and the walking duration improved significantly; the VAS score decreased from 9  to 2.75 (2.22) ( Lumbar spinal stenosis (LSS) refers to a narrowed spinal canal that commonly arises from degenerative changes in the bony structures or ligaments of the lumbar vertebrae. The characteristic symptoms of LSS include low back and leg pain in one or both sides and neurological claudication, which deteriorates in a lumbar extension posture . SurgeryAlthough a current Cochrane review on the effect of nonoperative treatment modalities for LSS only suggests a low quality of evidence , many prThis was a retrospective case-series study. The study consisted of two parts; the medical records during the admission treatment period from all of the eligible patients were reviewed to assess the short-term effect of KM treatment for LSS first, and then a telephone follow-up survey of the available patients was conducted after one year to assess the midterm effects. The medical records of all patients who were diagnosed with LSS and treated as inpatients at the Mokhuri Neck and Back Hospital in the Republic of Korea from November 2010 to January 2012 were reviewed. Criteria for eligibility included patients less than 80 years of age diagnosed with LSS with at least a 3-month history of LSS symptoms and neurological claudication. All patients were required to meet the radiological diagnostic criteria, including an anterior-posterior (AP) diameter of the spinal canal less than 12-mm in MRI axial images . Th. Th Coptt-test or Wilcoxon signed-rank test based on the normality of data with PASW Statistics 18 software (Polar Engineering and Consulting). The patients were evaluated for adverse events at every treatment. All of the study personnel complied with the ethical guidelines of the Mokhuri Neck and Back Hospital regarding all treatment procedures and patient medical record assessments.A 0 (no pain) to 10 (worst possible pain) visual analogue scale (VAS) for the daily average of low back pain and the walking duration without pain were used to assess patients before and after admission treatment. The telephone survey of each patient was conducted one year after treatment by the same KM doctor who assessed the VAS score and walking duration without pain. Statistical analyses were conducted with a A total of 39 patients were admitted for treatment of symptoms related to LSS, and 4 patients were excluded from the study because they did not meet the diagnostic criteria for LSS; that is, the AP diameter of the spinal canal was over 12 mm on an L-spine MRI. In addition, 2 patients were excluded from the study during the treatment course; 1 refused admission for treatment, and the other developed an elevated serum aspartate aminotransferase (AST) level. As a result, the medical records of 33 patients were reviewed. Among the 33 LSS patients, 24 were contacted by telephone and finished the secondary interviews.A total of 5 male and 28 female patients received the treatments. The median age was 66 years old , and the average disease duration was 9 (SD: 9.42) months. The average admission period was 28.75 (4.11) days. Seven patients were advised to undergo decompression surgery, and 13 had previously undergone a nerve block treatment. The L4 to L5 intervertebral space was the most frequent location where stenosis occurred (26 patients) followed by the L3 to L4 space (10 patients), the L2 to L3 space (8 patients), and the L5 to S1 space (4 patients); 13 patients had multilevel lesions. According to the radiological diagnostic criteria, absolute LSS  was observed in 14 patients, and the remaining patients showed relative LSS (an AP diameter 10 to 12 mm). Four patients were diagnosed with spondylolysis, and 9 were diagnosed with spondylolisthesis.p < 0.01, p < 0.01, Not all of the outcome data were normally distributed according to the Shapiro-Wilk test for normality. Therefore, the Wilcoxon signed-rank test was used for the statistical analysis on the difference between before and after treatments. The average VAS score for pain was significantly decreased from 9 (1.15) to 2.75 (2.22)  to 2.33 , and it continued to improve over the one-year follow-up period (2.10 (1.98), p < 0.001, p < 0.001, To assess the midterm effects of KM treatment for LSS, data from the 24 patients who finished the one-year follow-up telephone interview were used for analysis. Among the 24 patients, no patient underwent spinal surgery during the follow-up period. Statistical analyses were conducted with a The results of this study demonstrate that approximately one month of nonoperative KM combination therapy may result in decreased pain and improved function with a comparatively low adverse event rate for LSS patients. The patients had extremely severe pain (average VAS: 9) at the beginning of the study, but only mild pain remained shortly after the treatment (average VAS: 2.75). Considering that the minimum clinically important difference in low back pain after spinal fusion surgery is approximately 2.2 points based on the recent literature , a 6.25-The possible mechanism of KM combination interventions for the treatment of LSS has not been previously well established. However, a mechanism can be hypothesized based on the effects of separate individual interventions, which have been assessed in previous studies. Evidence of the effectiveness of acupuncture for low back pain has been shown, and practitioners generally agree with its clinical efficacy . A previThis study has several limitations. First, as we mentioned earlier, conclusive evidence for the use of combination therapy to treat LSS cannot be established from this study because case series have only limited value and occupy a low grade in the hierarchy of levels of evidence. Second, only short-term effects were evaluated, and well-validated, standardized, LSS-specific outcome assessment tools were not used. In particular, walking capacity was needed to be evaluated using condition-specific tools or questionnaires with ensured validity and credibility to support the clinical evidence . The evaDespite these limitations, this study is, to our knowledge, the first English language report of KM treatment for LSS. We hope the clinical efficacy and effectiveness of KM combination treatment for LSS will be established through future rigorous RCTs with larger sample sizes. A standardized treatment protocol for KM treatment using the appropriate assessment tools will be necessary for future studies.


Patients with PTPS described discomfort as pain only (15.1%), neuropathic symptoms only (30.2%) or pain and neuropathic symptoms (54.7%). Scores differed between patients with and without PTPS for symptom distress (p < .001), anxiety and depression (p < .001), and QOL (p = .009), with higher distress associated with PTPS. Despite new surgical techniques, PTPS remains common and results in considerable distress. A focused assessment is needed to identify all experiencing this condition, with referral to pain management specialists if symptoms persist.Postthoracotomy pain syndrome (PTPS) is a common complication following thoracic surgery. Most studies examining the influence of PTPS on patient-reported symptoms include few patients managed using a minimally invasive approach. Associated sensory changes, potentially neuropathic in origin, are not well described. We therefore examined the symptoms and quality of life (QOL) of patients with and without PTPS who underwent a standard thoracotomy (n = 43) or minimally invasive surgery (n = 54). Patients in this prospective, cross-sectional study completed questionnaires to assess pain (McGill Pain Questionnaire), neuropathic symptoms (Neuropathic Symptom Questionnaire), symptom distress , anxiety and depression , and QOL . Excepting younger age ( Postthoracotomy pain syndrome (PTPS) is defined as pain that develops after a surgical intervention, lasts longer than 2 months, and cannot be attributed to any other cause or condition . FollowiNotably, not all patients who undergo thoracic surgery for lung cancer develop PTPS. The pathology of PTPS has been attributed to rib , nerve , or muscAlthough it has been suggested that minimally invasive thoracoscopic procedures may result in less injury and therefore, less risk for PTPS, most prior studies included few  or no paDesign and SampleParticipants for this prospective, cross-sectional study were recruited during visits to clinics affiliated with a university-based cancer center. Inclusion criteria were as follows: (1) managed surgically for stage I, II, or IIIa lung cancer without evidence of metastasis; (2) between 2 and 12 months postsurgery (conforms to definition of PTPS); and (3) greater than 40 years of age . Exclusion criteria were as follows: (1) any other cancer diagnosis or metastatic disease (to avoid confounding symptoms); (2) inability to speak, read, or understand English (questionnaires were in English); and (3) presence of comorbidities such as dementia or memory loss (limited ability to participate as informant). A power analysis revealed that 42 participants per group should result in a power slightly over 0.8, with alpha at 0.05. Therefore, a sample of 84 subjects or more was judged to be statistically appropriate. The study was approved by the Institutional Review Board, and all participants provided written informed consent.A total of 112 potentially eligible subjects were recruited between August 2010 and December 2012. Two patients were not enrolled due to refusal. Of the 110 patients who provided informed consent, 13 did not complete the study for the following reasons: 5 did not return instruments, 5 died, and 3 were no longer eligible due to new metastatic disease. Thus, the final sample consisted of 97 of 110 (88.1%) participants.All patients were recruited from one surgical service, and practice was similar with regard to operative management and protocols for pain management. Choice of surgical procedure was at the discretion of the operating surgeon. Reasons for performing a thoracotomy vs. a thorascopic procedure included tumor grade, location, lymphovascular invasion, histology type, pleural involvement, size, and surgical margins . A complMeasuresParticipants were given six self-report measures that took an average of 30 minutes for them to finish, with the option to complete the instruments in clinic or at home and return them in a preaddressed mailing envelope. Study participants provided informed consent before any completing study instruments.Health History Survey (HHS): A researcher-designed self-report instrument was used to identify personal, social, and medical variations among patients. Personal information was provided by the participant and included age, gender, race, ethnicity, and smoking history. Social information included marital and employment status. Information provided by medical record included comorbidities, tumor type, cancer stage, surgical approach, and surgical procedure.Charlson Comorbidity Index (CCI): The CCI was designed to assess the presence and type of 19 comorbid conditions (nditions . Each conditions .McGill Pain Questionnaire (MPQ): This self-report questionnaire was the primary tool used to identify pain resulting from PTPS. It was chosen because it assessed pain intensity , included descriptors that characterized the sensation, and included a figure used to identify specific body locations (ocations . Of the ocations .Neuropathic Symptom Questionnaire (NSQ): Because the MPQ was deemed inadequate to appropriately identify symptom descriptors associated with PTPS, the NSQ was added after 51 subjects were recruited. Descriptors included in the NSQ were chosen based on the terminology used by patients during follow-up clinic visits and a literature review (p = .016), there were no significant differences in personal, social, or medical characteristics in patients who did or did not complete the NSQ.e review . When coSymptom Distress Scale (SDS): The SDS was a 13-item, self-report scale designed to assess the subjective distress associated with 11 cancer-related symptoms using a Likert-type scale (1 = least distress to 5 = most distress), with a total score ranging from 13 to 65 : This instrument was a 14-item questionnaire designed to screen for mood disorders : The FACT-L is a self-report, 44-item questionnaire designed to measure quality of life for lung cancer patients . There were no other statistically significant differences.The sample included 97 patients  who ranged in age from 45 to 84 years (mean 67.3 ± 9.7 years); see Impact of PTPSPatients with PTPS reported a relatively low rating of pain on the MPQ  more distress. Notably, both groups included patients who reported moderate distress (SDS score 25–32). These individuals included 4 (4.1%) patients who reported no symptoms associated with PTPS and 12 (12.4%) patients who reported symptoms associated with PTPS. Ten (10.3%) patients reported scores ≥ 33 (severe distress). All were diagnosed with PTPS and were offered treatment for this condition.Total SDS scores differed between patients with (25.9 ± 8.1) and without PTPS (18.3 ± 3.7), with patients with PTPS reporting significantly (p = .001) and higher subscores for anxiety (p = .013) and depression (p <. 001). Within the total group, 6 (6.2%) subjects reported at least one subscore > 11 for anxiety or depression, which is a reportable level of distress. All were currently under treatment for their symptoms and all were in the group that reported PTPS.Total HADS scores differed between patients with (10.1 ± 7.6) and without PTPS (5.4 ± 5.4); patients with PTPS reported higher total distress scores (p = .009) for quality of life. Scores for two of the five subscales were significantly different between groups. Patients with PTPS assigned lower ratings to subscores for physical (p = .001) and functional (p = .006) but not for social, emotional, or lung-related symptoms.FACT-L total scores differed between patients with  and without PTPS . Patients with PTPS reported lower ratings  reported pain only, 16 (30.2%) neuropathic symptoms only, and the remaining 29 (54.7%) both pain and neuropathic symptoms. With the exception of smoking pack-years, there were no significant differences between groups for any variable examined .Type of SurgeryAn approximately equal number of patients with PTPS underwent either a thoracotomy (54.7%) or thoracoscopic (45.3%) procedure . PTPS paLocation of DiscomfortPatients were instructed to mark all location(s) of discomfort on the McGill figure. The eight patients reporting pain only, cited three locations: incision and chest tube, incision and drain, and incision only . There wSubgroup Ratings of Anxiety, Depressive Symptoms, and QOLBecause psychosocial experiences can influence PTPS, we also explored the impact of anxiety and depression as determined by the HADS total score and subgroup scores in patients reporting pain only, neuropathic symptoms only, and pain and neuropathic symptoms . There wp = .027) compared to those with pain only or both pain and neuropathic symptoms.Impact on QOL was measured by the FACT-L . There wMajor FindingsThere were four major findings in this study: (1) patients who underwent a thoracotomy or thoracoscopic procedure using current surgical techniques did not differ in reports of symptoms consistent with PTPS; (2) patients who experienced PTPS had discomfort at varied locations ; (3) PTPS discomfort manifested as pain only, neuropathic symptoms only, or as a combination of both; and (4) symptom distress and QOL differed significantly in patients with and without PTPS.Prevalence of PTPSp = .382) or time since surgery (p = .380).In the present study, which excluded patients with lung cancer metastasis, approximately half (54.6%) of the patients reported symptoms consistent with PTPS when the definition was expanded to include pain, neuropathic symptoms, or both. There was no significant difference in report of symptoms related to the type of surgery  identified a combination of symptoms. However, 8 (15.1%) identified pain only and 16 (30.2%) identified neuropathic symptoms only. Prior studies have reported a varying prevalence of neuropathic symptoms. Steegers et al.  used a vSeveral validated questionnaires are available for use in detecting the prevalence of neuropathic symptoms and describing related characteristics, including the DN4 and PainDETECT  and, becSymptom Distress and Impact on QOLAlthough pain was a frequent complaint, the majority of patients identified pain as mild with mean ratings in the range of 3.3 ± 3.3. However, a substantial minority reported moderate (22.6%) or severe (17.0%) pain, consistent with findings from prior studies . Using sOur study used a cross-sectional design that limited assessment of symptoms to a single time point. It is possible that symptoms may have differed over time. However, we found no difference in the number of patients reporting symptoms of PTPS based on time since surgery. The sample was recruited from a high-volume academic service specializing in thoracic surgery. Results may not be generalizable to other practice settings. Approximately half of the subjects did not complete the NSQ, as it was added midstudy. MPQ descriptors ("numb" and "tingling") were used prior to adding the NSQ. Patients with PTPS or subgroups may have been over or underestimated using this approach. Finally, we did not distinguish between muscle sparing and open thoracotomy nor did we distinguish between video-assisted and robotic thoracoscopic surgeries.Despite new innovations in surgical technique, PTPS remains common. Advanced practitioners managing the care of these patients need to be aware of the various ways symptoms can manifest, i.e., pain only, neuropathic symptoms only or a combination of these factors in various body locations, and question patients specifically regarding their presence. Referral to specialists in pain management should be considered if initial interventions prove ineffective in achieving symptom relief . A targePatients may not share their symptom profile unless directly questioned and often attribute all symptoms to a return of cancer. Serial assessment of physical and psychological sequelae insures comprehensive evaluation of symptoms and concerns and provides objective data that can be used to guide management. Future studies should focus on identifying best treatment approaches to manage the complex and varying symptoms seen in this patient population.


The Oxford Shoulder Score (OSS) is a reliable and valid construct measuring non-specific shoulder pain, which are widely used to evaluate shoulder related quality of life. This study was to cross-culturally adapt and psychometrically validate a simplified Chinese version of the OSS (SC-OSS).Cross-cultural adaptation was performed according to the international recognized guidelines. Consecutive patients with nonspecific shoulder pain were recruited to test the psychometric properties of SC-OSS. Item response trend and item-total correlation were evaluated to measure homogeneity. Principal component analysis (PCA) was used to evaluate the factorial structure. Cronbach's α and intra-class correlations were used to determine the reliability. Construct validity was analyzed by evaluating the correlations between SC-OSS and the Constant-Murley shoulder outcome score (CMSOS), the short form (36) health survey (SF-36) containing eight domains, and pain visual analogue scale (VAS).r = -0.70, -0.65, -0.53, and -0.66, respectively). SC-OSS moderately correlated with role-physical (RP), social functioning (SF), general health perception (GH) and vitality (VT) , but had a low correlation with role-emotional (RE) and mental health (MH) domains of SF-36 .Overall, 121 patients were recruited. Each of the 12 items was properly responded and correlated with the total items. PCA extracted one factor for SC-OSS. SC-OSS had excellent reliability, with a Cronbach's α of 0.92 and intra-class correlation coefficient of 0.97 (95 % CI: 0.94-0.98). SC-OSS had a high correlation with CMSOS, physical functioning (PF) and bodily pain (BP) domains of SF-36 and VAS (SC-OSS demonstrated excellent acceptability, internal consistency, reliability and construct validity, which can be recommended for application in mainland China. Shoulder pain is a common disabling orthopedic condition experienced by many patients worldwide, just following low back pain and neck pain as the third most common disease in orthopedic visits . The lifRecently, more and more healthcare providers are concerned about the quality of life of patients with shoulder pain , 37. IntCross-cultural adaptation of an existing measure may render the adapted measure as an objective uniform criterion for international or multi-center clinical trials , 17. DueThe Oxford Shoulder Score (OSS), first described by Dawson et al. in 1996, is a shoulder pain specific questionnaire for the evaluation of pain perception and daily function in patients suffering from shoulder pain, with excellent internal consistency, reliability and validity . It has Therefore, the aim of this study was to cross-culturally adapt and psychometrically evaluate the simplified Chinese version of OSS (SC-OSS) in patients with shoulder pain in mainland China.The English version of OSS was translated and cross-culturally adapted according to international guidelines for the process of cross-cultural adaptation of self-report measures , 17. OwiEthnical Han Chinese outpatients over 18 years of age with a confirmed diagnosis of non-specific shoulder pain for over 4 weeks due to rotator cuff pathology or inflammatory arthritis were eligible for recruitment in the Orthopedic Department at the Changhai Hospital between November 2013 and May 2014. Approximately 50 % of the eligible patients were randomly selected to take “test and retest” with an interval of 3 to 5 days. Patients who had shoulder pain with specified causes, such as shoulder instability, acute traumatic shoulder injury, tuberculosis or tumor, and who were unwilling to complete the questionnaires were excluded from the study. Demographic and clinical data and medical history were obtained, and a physical examination was performed at admission. Radiological images such as X-ray, computerized tomography, or magnetic resonance imaging were performed if they were required to evaluate the disease or confirm the diagnosis. The study was approved by the Human Research Ethics Committee of the Changhai Hospital, and written informed consent was obtained from every participant.OSS contains 12 items, each of which scores from 0 (worst) to 4 (best), according to a modified version , with thCMSOS is widely used for assessing the outcomes of the treatment of shoulder disorders, especially with surgeries, including pain perception scoring, functional assessment, range of motion and strength measures . CMSOS cSF-36 is widely applied to assess the health status of patients . It contPain VAS allows patients to rate their pain intensity on a 100 mm line anchored with two endpoints labeled 0 (No Pain) and 100 (Worst Possible Pain). It is highly accepted and widely used as a psychometric tool for its simplicity and good reliability, validity, and responsiveness .The scores obtained for each of the items among the patients should be normally distributed, such that the mean score obtained on an item is close to the center of the possible response range of scores available for that item. Items with a mean score near the extreme of a possible range have low variance, whereas items that vary over a narrow range have poor correlations with other items .Therefore, the standardized values of skewness (Z-skewness) were computed for each item. Any items with a skewness value within 1.96 were defined to have a response trend of normal distribution .Ceiling and floor effects were also analyzed, with such effects being present if over 15 % of participants achieved the highest or lowest score, respectively.A measure should be homogeneous; items should assess different facets of the same construct and correlate moderately with each other, and more importantly, each item should correlate with the total items. Therefore, internal consistency and item-total correlations were determined as functions of homogeneity. Internal consistency was calculated as Cronbach’s α, which was considered acceptable if the value was over 0.70 . An itemThe structure of SC-OSS was explored. Principal Component Analysis (PCA) with both varimax and oblimin rotations were adapted. The Kaiser-Meyer-Olkin measure and Bartlett's test of sphericity were conducted. The factorial structure was determined by the scree plot of the eigenvalues against the component numbers.To assess the reproducibility of SC-OSS, the intra-class correlation coefficient (ICC) was tested between the scores obtained at the first test and the second test. An ICC value was interpreted as good (>0.60) and excellent (> 0.80) reliability . Also, aConstruct validity was analyzed by Pearson’s correlation coefficients for the correlations between SC-OSS and other shoulder pain related measures . Correlation was interpreted as poor, fair, moderate, very good and excellent when r = |0.00-0.20|, r = |0.21-0.40|, r = |0.41-0.60|, r = |0.61-0.80| and r = |0.80-1.00|, respectively .P value of less than 0.05 was considered statistically significant for all analyses.It has been advised that at least 100 patients are necessary for internal consistency analysis and 50 for appropriate analyses of reliability and construct validity . TherefoThere were no major linguistic problems in the translation. Some discrepancies were encountered due to cultural differences. Specifically, the third item “car” was replaced by “private automobile,” as car has many meanings in Chinese such as small cars, sport-utility vehicle or jeep. “Chopsticks and spoons” were substituted for the fourth item “knife and fork” because Chinese usually do not use a knife and fork. Some male participants reported that they did not do household work so the fifth item was amended as “if you are doing the household shopping, could you do it on your own”. In addition, “bowl” was used to replace the sixth item “tray” since most Chinese people commonly use a bowl to hold food.Overall, 121 eligible patients were recruited in the study. Of the eligible patients, 55 were selected and participated in the test-retest. The mean completion time was 2.1 (±1.2) minutes. Nearly all of the participants filled out the questionnaire properly. Only 1 or 2 items were left blank in 18 participants with a responding rate was 95.9 % (1426/1452) for total items. The clinical and demographic characteristics of the patients are summarized in Table Z-skewness showed that none of the items were distributed outside 1.96. The item-total correlation analysis revealed that each item had a moderate to good item-total correlation, and none had a Pearson coefficient of less than 0.30. Detailed results are demonstrated in Table P < 0.001). Both the eigenvalues and the scree plot  for SC-OSS. The Bland-Altman plot demonstrated the differences between scores from the two test sessions for the individual patients and the overall means of the two sessions . SC-OSS correlated moderately with domains of SF-36 relating to function loss due to chronic pain, including RP, SF, GH and VT . Finally, SC-OSS had low correlation with domains of SF-36 unrelated to shoulder pain, including RE and MH in SF-36 (r = -0.28 and -0.23) , whereas our study observed a high correlation (r = 0.70). This discrepancy is probably due to the difference in patient demographic characteristics . However, since no other studies reported a correlation between OSS and VAS, this assumption should be further tested and other factors contributing to the discrepancy should also be explored. SF-36 has been applied worldwide for evaluating patient quality of life, especially in chronic pain patients [The construct validity of SC-OSS was tested against CMSOS, VAS and SF-36, as these constructs are commonly used in China. As expected, SC-OSS highly correlated with CMSOS, similar to the English, Dutch, German, Italian and Korean studies. However, regarding the correlation with VAS, the Korean study  verifiedpatients . It has patients , indicatpatients , Italianpatients , Dutch [patients  versionspatients  and presThere are some limitations in this study. First, the patients in this study are from a single center, which may not fully represent the whole country. Multi-center large sample study is favored. Second, responsiveness  of SC-OSS was not determined, so as the German, Korean, Turkish and Italian studies.SC-OSS was successfully cross-culturally adapted and psychometrically validated in Chinese patients with non-specific shoulder pain. SC-OSS demonstrates high acceptance, excellent internal consistency, reliability, and solid construct validity. These findings provide Chinese surgeons and investigators with a tool to evaluate patients with non-specific shoulder pain.


Sixty-eight patients were enrolled from July 2003 to May 2005. The median follow-up period was 1925 days. The OPRT/DPD ratio cut-off values for 5-year DFS and OS were 0.015 and 0.013, respectively. During the 5-year DFS and OS periods, patients with higher cut-off values had a better prognosis than those with lower ratios . In conclusion, our results suggest that the OPRT/DPD ratio could be a predictive factor for response to 5-FU/LV adjuvant chemotherapy.Although 5-fluorouracil (5-FU) is an important drug for colorectal cancer (CRC) treatment, no useful biomarker is currently available to predict treatment response. Since 5-FU is converted into active or inactive forms by orotate phosphoribosyltransferase (OPRT) or dihydropyrimidine dehydrogenase (DPD), a correlation between these enzymes and response to 5-FU has been suggested. However, such a correlation has not been investigated prospectively. Therefore, in the present study, we aimed to prospectively evaluate whether OPRT and DPD were predictive factors of the response to 5-FU treatment in patients with resectable CRC. The present investigation was designed as a multicenter prospective cohort study. OPRT and DPD activities were assessed in biopsy samples, obtained surgically from patients with resectable CRC. The OPRT/DPD ratio was calculated and the cut-off values for this ratio were determined for 5-year disease-free survival (DFS) and overall survival (OS). Patients were treated with 5-FU/leucovorin (LV) regimens and oral 5-FU. The endpoint of this study was the correlation between the OPRT/DPD ratio and 5-year DFS and OS. The cut-off value for the OPRT/DPD ratio was determined by using the maximum χ Various useful biomarkers for molecular targeted drugs have recently been identified in advanced gastrointestinal cancer chemotherapy. For example, human epidermal growth factor receptor 2 (HER2) is involved in the pathogenesis and poor outcomes of several cancer types, including advanced gastric cancer. Molecular targeted drugs, such as trastuzumab, have been shown to prolong overall survival and progression-free survival in HER2-positive gastric cancer . In colo5-Fluorouracil (5-FU) is commonly used worldwide for the treatment of various tumors and is a key drug in CRC treatment. However, no useful biomarker is available to predict tumor response to 5-FU treatment. Consequently, individualized therapy with 5-FU is not available, despite extensive investigation on the correlation between 5-FU metabolic enzymes and antitumor effects to predict drug efficacy. Orotate phosphoribosyltransferase (OPRT) mostly converts 5-FU into its active form in the first metabolizing step, whereas dihydropyrimidine dehydrogenase (DPD) is the initial enzyme of 5-FU catabolism. Additionally, these enzymes also convert 5-FU pro-drugs such as S-1 and capecitabine into their active or inactive forms. Therefore, it is important to evaluate the activities of these enzymes to better understand the antitumor effects of 5-FU. Although there are several reports on the correlation between these enzymes and response to 5-FU –23, suchIn the present study, we aimed to prospectively evaluate whether OPRT and DPD are predictive factors of 5-FU response in patients with resectable CRC.Patients were enrolled in the present study based on the following eligibility criteria: age of 18–75 years, histologically confirmed colon adenocarcinoma after curative surgery, Dukes’ clinical staging of B or C, Eastern Cooperative Oncology Group performance status of 0–1, no prior chemotherapy or radiotherapy, sufficient oral intake capability, and adequate major organ function. Other exclusion criteria were the presence of continuous double cancers and asynchronous multiple cancers.2) and a 2-h infusion of LV (167 mg/m2) on day 1 weekly for 6 consecutive weeks postoperatively. Thereafter, the patients were treated with oral 5-FU tablets (200 mg/day) for 2 years. This treatment was changed to other chemotherapy regimens when cancer recurrence was confirmed.The present investigation was designed as a multicenter prospective cohort study, involving collaborative efforts from 13 centers. All patients provided written informed consent. The institutional review board or independent ethics committees approved the study protocol at each center. The endpoint of this study was the correlation between OPRT/DPD activity ratio and 5-year disease-free survival (DFS) and overall survival (OS). All patients underwent complete CRC resection without preoperative chemotherapy. They subsequently received adjuvant chemotherapy with 5-FU/leucovorin (LV) regimens as follows: bolus 5-FU  for Windows version 21 . A P-value <0.05 was regarded as statistically significant.The cut-off values for the OPRT/DPD ratio against recurrence and death were calculated by using the maximal χc method ,28. SubsSixty-eight patients were enrolled from July 2003 to May 2005. Patient characteristics are summarized in The enzyme activities and OPRT/DPD ratio are shown in 2 statistics were 0.01467  and 0.01254 , respectively.The cut-off values for the OPRT/DPD ratio against DFS and OS obtained by maximal χPatients were divided into high and low OPRT/DPD ratio cohorts using a cut-off value of 0.01467. No significant differences in patient characteristics were observed between the two cohorts . The DFSPatients were divided into high and low OPRT/DPD ratio cohorts using a cut-off value of 0.01254. No significant differences in patient characteristics were observed between the two cohorts . The OS OPRT is involved in the conversion of 5-FU to the active nucleotide and is considered to be a key enzyme in the first metabolizing step, leading to DNA synthesis inhibition and RNA dysfunction. DPD is the initial enzyme of 5-FU catabolism. Thus, OPRT and DPD are believed to be essentially associated with the antitumor effect of 5-FU –23. In tWe found that patients in the high OPRT/DPD ratio cohort had significantly better DFS and OS than those in the low ratio cohort. These results were consistent with the findings that 5-FU could be more easily metabolized to fluorodeoxyuridine monophosphate in the high OPRT/DPD ratio cohort, thus resulting in the induction of higher antitumor effects by 5-FU.The nodal status and tumor OPRT/DPD ratio were identified as significant predictive factors for DFS by multivariate analysis in the present prospective study. The identification of nodal status as a predictive factor was quite logical. However, only the OPRT/DPD ratio was identified as a significant independent predictive factor for OS by multivariate analysis. The reason for this finding may be due to the influence of treatment with multiple drug combinations  in addition to 5-FU after disease recurrence.For all cancer types, the primary purpose of adjuvant chemotherapy is to eliminate traces of residual disease, which are likely to exist in high-risk patients. This prospective study revealed that the tumor OPRT/DPD ratio could be a useful independent factor to select high-risk patients for adjuvant chemotherapy. Thus, the OPRT/DPD ratio could be a predictive factor for 5-FU-based adjuvant chemotherapy. Patients in the low OPRT/DPD ratio cohort had significantly worse DFS and OS. A low OPRT/DPD ratio could be due to low OPRT activity or high DPD activity. In patients with low OPRT activity, the antitumor effects of 5-FU were not expected. Therefore, adjuvant chemotherapy with multiple drug combination  was recommended for low OPRT activity patient. In high DPD activity patient, on the other hand, 5-FU involving a DPD inhibitor was recommended . S-1 involves gimeracil to inhibit DPD, therefore, the serum 5-FU level is kept high. Recently, the safety profile of S-1 and SOX was disclosed with adjuvant chemotherapy trials for colorectal cancer . In advaet al reported that the DPD mRNA level in cancer stromal tissues was significantly higher than that in cancer cells (There were several limitations to this prospective study. First, the sample size was small. A larger sample size would have improved the quality of the data. Second, in the present study, 5-FU metabolic enzymes were evaluated in tumor tissue instead of cancer cells. Although 5-FU metabolic enzymes in cancer cells have been previously investigated using the microdissection method, cancerous tissue includes not only cancer cells but also stromal cells such as cancer-associated fibroblasts, tumor endothelial cells, tumor associated macrophages, and many other cells present in the tumor microenvironment. Recently, the tumor microenvironment has been reported to play an extremely important role in the progression of cancer, which suggests that cancer stromal cells contribute to cancer progression –38. Nagaer cells . Since tIn conclusion, our results suggest that patients with a high OPRT/DPD ratio had significantly better DFS and OS than those with a low OPRT/DPD ratio. Moreover, the tumor OPRT/DPD ratio was identified as a significant predictive factor for DFS and OS by multivariate analysis. These results suggest that the tumor OPRT/DPD ratio may be a predictive factor of 5-FU response in patients with resectable CRC. In addition, the tumor OPRT/DPD ratio may contribute to the individualization of 5-FU-based chemotherapy in the clinical setting.


Background: Postendodontic pain (PEP) has always been a major problem for patients and dentists and NSAIDs are being used to relieve PEP and it is supposed that some benzodiazepines may potentiate facilitate the analgesic effects of the NSAIDs. This study was conducted to evaluate the effect of alprazolam on the analgesic effect of ibuprofen in PEP treatment.Methods: This randomized double-blind clinical trial was conducted on 45 patients aged 20-45 years who were subjected of root canal treatment. A written informed consent was obtained from each patient. The subjects were randomly divided into three groups; placebo, ibuprofen (400 mg) and alprazolam (0.5) mg + ibuprofen (400 mg). The intensity of pain was recorded using visual analog scale (VAS) at 4, 6, 12, 24, 48 and 72 hours after drug administration.Results: Of the participants, twenty six (57.8%) were males and 19 patients (42.2%) were females. Four hours after starting treatment, the VAS scores in the placebo and ibuprofen -treated groups were significantly higher than ibuprofen and alprazolam+ibuprofen groups . The VAS scores in alprazolam + ibuprofen group (2.33±1.05) were significantly lower at 6 hours after treatment when compared to the other groups . This decrease in VAS score sustained to 12 hours after the start of alprazolam + ibuprofen treatment when compared to ibuprofen or placebo receiving group alone (p<0.003). The average pain score in female patients who received alprazolam + ibuprofen was significantly lower than males at 12 hours  and 24 hours after treatment . Conclusion: According to the results, it can conclude that alprazolam may enhance the analgesic efficacy of ibuprofen in postendodontic pain. Although, endodontic therapy is done without pain in the entire duration of the work, but still the pain may be experienced after treatment. Based on the patient’s variability, postendodontic pain (PEP) could vary from mild to severe . PEP mayUsually the easiest way to treating and relieving the pain of dental procedures is through the use of non-steroidal anti-inflammatory drugs (NSAIDs) which act by inhibition of the cyclooxygenase pathway, the synthesis of prostaglandins and thromboxane is reduced and among NSAIDs is ibuprofen, which is more commonly used (-). The first generation drugs in this category are non-selective inhibitors of the cyclooxygenase . The enzyme COX I is found throughout the body and plays an important role in protecting the gastrointestinal mucosa, normal kidney function and platelets . COX II is involved in the production of prostaglandins that are pain mediators and the inhibition of this enzyme could prevent the production of these types of prostaglandins . IbuprofThe combined analgesics with the different mechanisms of action may exert synergistic effect and can improve the management of postoperative pain in dental procedures . After tSome NSAIDs like ibuprofen have advantages as compared to others, including the lower incidence of gastrointestinal ulcers , less daA receptors in the CNS (-). Benzodiazepines are among the other drugs that can be used as adjuvant drugs in times of pain that may enhance the analgesic effects of NSAIDs , 18. VarGABA receptor agonists showed significant analgesic properties in the animal models of pain studies. Thus, by targeting these receptors involved in the regulation of pain threshold, some new drugs may be introduced for pain controlling goals , 23. TheHowever, successful pain control is still one of the most important issues in dentistry and nowadays, several medical analgesic protocols are proposed for PEP treatment . The synIbuprofen has been commonly used in dental pain and benzodiazepines may be used for sedation during and after dental painful procedures. Based on the mentioned above, the present study has been designed and implemented to determine the possibly analgesia - enhancing effect of alprazolam on ibuprofen in postendodontic pain.IRCT201312219271N4.This randomized double-blind clinical trial was conducted on 45 patients 20-45 (30.4±6.9) years old who referred to the Department of Endodontics, the Dental School of Babol University of Medical Sciences . The proposal was approved by the University Committee of Medical Ethics and all patients signed a written informed consent after explaining to them about the investigation and type of drugs. This project was registered in IRCT  data bank with registration number: The inclusion criteria were: no systemic diseases, no drug allergy to NSAIDs and benzodiazepines, not receiving any other sedatives and analgesics, no gastrointestinal problems, and no pregnancy or breast feeding during the study. Three participants were excluded from the investigation due to failure to provide pain relief. The participants should not receive analgesics at least 4 hours before starting the investigation. The initial pain score reported by patients was in a range of moderate to severe. The pain should only be reported in the molar tooth. This means that the person had irreversible pulpitis . The subjects were randomly divided into three groups (n=15 in each group). Lidocaine 2%+1/80000 epinephrine , gutta percha , AH26 sealer , gelatin capsules , sucrose (Merck Germany), ibuprofen 400 mg , alprazolam 0.5 mg  and acetaminophen 325 mg  were purchased.The endodontic treatment was done for the patients in two sessions. In the first session of treatment, access cavity was prepared using master apical file (MAF). During this step, the prepared canals were washed with saline solution and cleaned and dried using sterile cotton. All the canals were dressed in this step. For local anesthesia, lidocaine 2% containing epinephrine 1:80000 was used. At the end of the first session of treatment, the patients in each group have randomly received one of the three treatments; placebo, ibuprofen 400 mg and alprazolam 0.5 mg with ibuprofen 400 mg. All drugs were encapsulated encoded and administered as single dose. The patients were called, completed the data sheet including the personal information and pain score assessment. They were asked to record their pain scores at 4, 6, 12, 24, 48 and 72 hours after receiving drugs based on a visual analog scale (VAS) method . Meanwhile, a package containing two tablets of acetaminophen 325 mg as rescue dose was given to each participant to take if the pain persists. The patients were asked to record the rescue dose in the form once used. In the second session of treatment, the canals were filled with gutta percha and AH26 sealer and after dressing the tooth, the patient was referred for a crown restoration.Data were extracted from the patient’s data sheets and were presented as mean±standard deviation (SD) and analyzed using One-Way ANOVA post hoc Tukey and repeated measures tests. Any difference between data was considered statistically significant at p-value less than 0.05.All 45 patients completed the study. Twenty-six (57.8%) of the participants were males and 19 (42.2%) were females. The mean and standard deviation of age of patients in placebo, ibuprofen and ibuprofen+alprazolam groups were 30.66±7.26, 31.4±64.4 and 29.13±7.18 years, respectively. There was no significant difference between the gender of the patients in the 3 groups (P=0.54).vs 3.00±1.36, P=0.018) and placebo group obviously (P=0.018). Twelve hours after the treatment, the average VAS score in ibuprofen + alprazolam group was significantly lower than the placebo group . The female patients in the ibuprofen + alprazolam group reported an average VAS score less than the male patients 12 hours after treatment . The comparison of VAS score at 24, 48 and 72 hours between ibuprofen and ibuprofen + alprazolam groups showed no significant differences (p>0.5). Twenty-four hours after the treatment of females in ibuprofen + alprazolam group, showed a VAS score lower than the males . The time dependent variation in VAS scores showed an intra-group significant differences in three treatment groups (p<0.0001).A receptors in dorsal horn of spinal cord and this mechanism may enhance the analgesic effects of NSAIDs (A receptors in spinal nociceptive pathways is well established (A receptors. Many studies have shown PEP during the first 24 to 48 hours after treatment (The results show that alprazolam can increase the effect of ibuprofen on alleviating PEP compared to ibuprofen alone. This result is inconsistent with previously reported investigations , 28. Somf NSAIDs . The GABf NSAIDs , 36. Theablished . Enhancireatment , 39. Prereatment . But somreatment  that is reatment , 42. In reatment . In the present investigation, the patients receiving ibuprofen and ibuprofen + alprazolam have significantly lower pain score than the placebo and ibuprofen receiving subjects at 4, 6, and 12 hours after the treatment, But in one study, no significant difference has been reported between placebo and ibuprofen in PEP 12 hours after treatment , that isIn conclusion, although the exact mechanism of action of alprazolam effect in enhancing analgesia induced by NSAIDs remains to be elucidated, it can be concluded that alprazolam can enhance the analgesic effect of ibuprofen in postendodontic pain and also can reduce the side effects of ibuprofen. Authors’ contributions MB: research coordinator, study design; MRH: clinical part supervision, study design and patients management; MRM: patient handling, data collection and executive affairs; MA: references double checking and reviewing the text of the manuscript; SK: registering study in IRCT, preparing reference library and writing coordination, literature searching; AAM: data handling and statistical interpretation, manuscript correction. All authors read and approved the final manuscript.


Pain after total knee arthroplasty is severe and impacts functional recovery.We performed a retrospective study, comparing conventional patient control analgesia (PCA) modalities versus continuous femoral nerve blockade (CFNB) for 1582 post-TKA  patients.Using our electronic acute pain service (APS) database, we reviewed the data of 579 patients who had received CFNBs compared with 1003 patients with intravenous PCA over 4 years.Our results show that the incidence of a severe pain episode was higher in the PCA compared with the CFNB group. Lower pain scores were observed in the CFNB group compared with the PCA group from postoperative day (POD) 1 to 3, primarily due to lower rest pain scores in the CFNB group.Our study shows that there is improvement in pain scores, at rest and on movement, as well as a reduction in incidence of severe pain, in patients who receive CFNB versus those who receive intravenous PCA. Severe postoperative pain is a major complaint in patients who have undergone total knee arthroplasty (TKA). In addition, post-TKA pain directly impacts postoperative physiotherapy and mobilization, which can result in stiffness and poor joint function -3. Post-Effective postoperative pain control is important, especially with the initiation of physiotherapy and early ambulation, which hastens recovery and reduces hospital length of stay . The risPain control modalities for post-TKA include intravenous patient-controlled analgesia (PCA), peripheral nerve blockade, and continuous epidural analgesic techniques. All methods have been shown to be efficacious in relieving postoperative pain. However, conventional techniques that use intravenous PCA with morphine and fentanyl are associated with side effects, such as respiratory depression, sedation, pruritus, nausea and vomiting, hypotension, constipation, and urinary retention ; epiduraWe performed a retrospective study, comparing conventional PCA modalities versus continuous femoral nerve blockade (CFNB) for 1582 post-TKA patients.We reviewed the electronic acute pain service (e-APS) records of patients who underwent total knee arthroplasty between May 2006 and December 2010. Patients were included if they had received a CFNB via catheter or intravenous PCA with opioids. Intravenous opioid was not used in the postoperative period in the CFNB group.Both groups were provided with adjunct analgesics, such as paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDS) namely, etoricoxib, celecoxib, and ibuprofen depending on the patient’s clinical condition. Oral opioids, such as tramadol and oxycodone, were given for breakthrough pain in the CFNB group. Data on catheter placement methods , sensory stimulation parameters, and volume of initial LA bolus were not available in the electronic database.The main outcome measures were:Incidence of severe pain [defined as visual analog scale (VAS) ≥ 6]VAS  for rest and dynamic pain on POD 1 to 3. The use of adjunct analgesics, such as oral paracetamol and NSAIDS, as well as significant adverse reactions (respiratory depression and hypotension) from PCA or CFNB, was also compared.t-test, for which equal variances were assumed only when P > 0.05 by Levene’s test for equality of variances. The categorical baseline data and incidence of side effects were compared by chi-square test.Sample means and standard deviations (SD) were applied to continuous baseline characteristics data. Frequency counts were used to summarize categorical data. The normal distribution of samples was tested by the degree of skewness and kurtosis for all baseline characteristics and measured parameters and was subsequently compared by independent P ≤ 0.05.Due to the multiple daily pain scores that were compared, multivariate testing using the general linear model was performed for VAS at rest and during movement from Days 1 to 3 for the PCA versus CFNB group. Post hoc analysis (Tukey’s HSD) was applied to interactions that were statistically significant. All analyses were performed using the SPSS for Windows (version 16.0). The significance level was set to The 1582 patients who underwent TKA from May 2006 to December 2010 received PCA (n = 1003) or CFNB (n = 579) exclusively. The PCA and CFNB groups were similar with regard to age, gender, and usage of adjunct analgesics, such as paracetamol and NSAIDs .P = 0.003). Individual effects of time  and VAS  were significant between the PCA and CFNB groups. The following interactions were significant: time-group ; VAS-group , and time-VAS . The time-VAS-group interaction was not significant (P > 0.05) (The incidence of severe pain (VAS ≥ 6) from post operative day (POD) 1-3 was higher in the PCA group compared with the CFNB group  .For the time-group interaction, the post hoc analysis revealed:P = 0.048).Lower pain scores in the CFNB group compared with the PCA group on POD 2 compared with POD 1 (P < 0.001).Lower pain scores in the CFNB group compared with the PCA group on POD 3 versus 2 (P < 0.001).For the VAS-group interaction, the post hoc analysis showed lower rest pain scores compared with dynamic pain scores in the CFNB versus PCA group (In summary, the incidence of a severe pain episode was higher in the PCA group compared with the CFNB group. By multivariate testing, pain scores in both groups were lower on POD 2 versus POD 1 and on POD 3 compared with POD 2. This change was significantly lower in the CFNB group versus the PCA group from POD 1 to 3. Overall, lower rest pain scores were observed significantly lower in the CFNB group versus the PCA group. There was 1 incident of hypotension and 1 incident of respiratory depression in the PCA group but no documented adverse events in the CFNB group.Our study shows that there is improvement in pain scores, at rest and on movement, as well as a reduction in the incidence of severe pain in patients who receive CFNB versus those who receive intravenous PCA. There were no documented adverse events in the CFNB group, whereas an incident of hypotension and respiratory depression was noted in the PCA group. We did not record common side effects, such as pruritus, nausea, and vomiting. To our knowledge, this is the largest single-center retrospective study of CFNB alone versus PCA.Severe pain after total knee arthroplasty has been shown to impact functional recovery . Variouset al. (Similarly, a recent meta-analysis by Paul et al.  found thet al. , 22, howBecause our report was a retrospective case review, there are inherent limitations. The data were obtained from an electronic database; thus, details, such as the method of insertion of the femoral nerve catheter, mode of anesthesia, and surgical technique, were unavailable. For future studies, it might be useful to perform continuous FNB, which allows one to control the concentration of the local anesthetic dose, type of local anesthetic, and infusion regimen, which preserves the quadriceps function better, resulting in earlier mobilization .In total knee arthroplasty, postoperative pain control is imperative in facilitating physical therapy and rehabilitation. Our study demonstrated a significant reduction in the incidence of severe pain with CFNB versus PCA, with lower pain scores to Day 3 post-TKA. In addition, we did not observe any adverse effects from CFNB, such as hypotension and respiratory depression. Thus, CFNB is a safe alternative for post-TKA pain control.


Background. For a long time it has been accepted that the main problem in the anterior knee pain (AKP) patient is in the patella. Currently, literature supports the link between abnormal hip function and AKP. Objective. Our objective is to investigate if Cam femoroacetabular impingement (FAI) resolution is related to the outcome in pain and disability in patients with chronic AKP recalcitrant to conservative treatment associated with Cam FAI. Material and Methods. A retrospective study on 7 patients with chronic AKP associated with FAI type Cam was performed. Knee and hip pain were measured with the visual analogue scale (VAS), knee disability with the Kujala scale, and hip disability with the Nonarthritic Hip Score (NAHS). Results. The VAS knee pain score and VAS hip pain score had a significant improvement postoperatively. At final follow-up, there was significant improvement in all functional scores . Conclusion. Our finding supports the link between Cam FAI and AKP in some young patients. Assessment of Cam FAI should be considered as a part of the physical examination of patients with AKP, mainly in cases with pain recalcitrant to conservative treatment. Anterior knee pain (AKP)  is one of the most frequent reasons for consultation within knee conditions in adolescents and young adults . HoweverFor a long time, it has been accepted that the main problem in the AKP patient is in the patella. However, currently, literature supports the link between abnormal hip function and AKP –7. We haA computer-assisted search of our surgical database was performed to find patients who had AKP associated with Cam FAI. Seven consecutive patients  were identified from May 2011 to April 2013. All of them were available for follow-up. All patients gave their informed consent to participate in the study. This study was approved by our Institutional Review Board. Patient characteristics are presented in Inclusion criteria included the following: (1) pain on the anterior aspect of the knee following exclusion of other objective causes of pain, (2) knee Visual Analogic Scale (VAS) of 5 or higher, (3) normal image studies of the knee, and (4) presence of disabling pain and disability which had not responded to a previous physical therapy treatment for at least 3 months. Normal image studies included torsional computed tomography or magnetic resonance image with femoral torsion of 5° to 20°, tibial torsion of 20° to 35°, TT-TG distance < 20 mm, patellar tilt < 20°, lateral radiograph with Caton Deschamps index of 0.8 to 1.2, and telemetric radiograph with mechanical axis of lower limb of 5° to −5°  and limb length discrepancy less than 1.5 cm. Cam FAI was confirmed by groin pain, positive impingement test, positive decompression test, and radiograph with alpha angle at Dunn view greater than 50°.Patients were studied with VAS for AKP and groin pain, Kujala knee score and Nonarthritic Hip Score (NAHS). Pain VAS was used to evaluate pain intensity preoperatively and at the time of final follow-up. VAS scales have been used in several studies to measure subjects' level of pain and it has demonstrated good reliability and concurrent validity when compared with other methods of pain measurement , 9. The Statistical Analysis. Descriptive statistics for each of the measures evaluated was calculated. Quantitative variables were described with means and standard deviations. Mean preoperative and postoperative hip VAS, knee VAS, Kujala scale, and NAHS values were compared using the Wilcoxon test in the Statistical Package for Social Sciences (SPSS), version 16.0 , with statistical significance for p values defined as p < 0.05.p = 0.014). The VAS hip pain score had a significant improvement from 4.35 ± 2.13 preoperatively to 0.85 ± 0.89 postoperatively (p = 0.018). At final follow-up, there was significant improvement in all functional scores  (p = 0.018). The Kujala score improved from 44.85 ± 11.99 preoperatively to 93 ± 2.51 postoperatively. The NAHS improved from 60.53 ± 15.37 preoperatively to 90.67 ± 3.74 postoperatively. There were no perioperative complications. The alpha angle decreased from 67.42 ± 4.57 preoperatively to 42.71 ± 6.29 postoperatively (p = 0.018).Detailed results are presented in The most important finding of this study was the link between abnormal hip function, in our case Cam FAI, and AKP in young patients. In our experience, all of our patients went to the orthopedic surgeon for the first time due to AKP that was recalcitrant to a correct conservative treatment. The hip pain appeared always later.A clear understanding of the cause of AKP is crucial to perform the treatment. Our findings are in agreement with a growing body of literature linking abnormal hip function with AKP –7. Clinin = 7). The great strength of our study is that it is the first one that analyzes the link between AKP pain and Cam FAI.The major limitation of our study was the small number of included patients (In spite of the limitations of this study, our findings could have meaningful potential implications for clinicians in the evaluation and treatment of AKP and for researchers in future studies on etiopathogenesis of AKP. The results of our study support the link between abnormal hip function, in our case Cam FAI, and AKP in young patients. Patellofemoral joint is very sensitive to this specific hip condition. That is, in some patients the underlying cause of AKP cannot be in the patellofemoral joint. From a clinical point of view, our data suggest that assessment of Cam FAI should be considered as a part of the physical examination of patients with AKP, mainly in cases with pain recalcitrant to conservative treatment. Cam FAI surgery is a safe and efficacious treatment . TherefoHowever, more studies on larger patient series would be required to draw definitive conclusion. In addition, long-term follow-up is mandatory to further confirm our results.