Distal radius fractures are the most prevalent upper extremity fractures, posing a significant public health concern. Recent studies comparing regional and general anesthesia for postoperative pain management after these fractures have yielded conflicting results. This meta-analysis aimed to compare the effectiveness of regional and general anesthesia concerning postoperative pain management and opioid consumption following distal radius fracture surgery. A comprehensive search was conducted in PubMed, Cochrane Library, and EMBASE databases to identify relevant randomized controlled trials. Four randomized trials involving 248 participants were included in the analysis. A pooled analysis revealed that regional anesthesia led to significantly reduced postoperative pain scores at 2 h compared to general anesthesia . However, no significant differences in pain scores were observed between the two anesthesia types after 12 h post-surgery. Regional anesthesia was associated with lower total opioid consumption  and fewer occurrences of nausea and vomiting compared to the general anesthesia. Nonetheless, opioid consumption on the first day post-discharge was significantly higher in the regional anesthesia group . The analgesic superiority of regional anesthesia is confined to the early postoperative hours with overall lower opioid use but a notable increase in opioid consumption on the first day post-discharge, potentially attributable to rebound pain. Distal radius fractures are the most frequently encountered fractures in the upper extremities and pose a significant public health concern, especially among the elderly . NumerouSurgical fixation of distal radial fractures can be performed under general (GA) or regional anesthesia (RA). Regional anesthetic nerve blocks have a positive impact on various aspects of the surgical process, such as reduced acute postoperative pain, decreased opioid consumption, and improved patient satisfaction . HoweverRandomized controlled trials comparing RA with GA for postoperative pain management after distal radius fractures have reported conflicting findings. Two early randomized controlled trials ,13 reporAlthough some reviews have been published on this topic, the studies included mixed levels of evidence and lacked quantitative analysis ,16. TherThis meta-analysis was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement . We did Pubmed, Cochrane Central Register of Controlled Trials, and EMBASE database were searched for articles with language restricted to English. Initially, we did not restrict the research type or year of publication to avoid missing relevant articles. Search algorithms were developed for each database (without a set time limit). A combination of search terms was employed, encompassing the title, abstract, Medical Subject Headings (MeSH), Emtree, and keywords. The search terms included “wrist fracture[MeSH]”, “distal radius fracture[tiab]”, “anesthesia[MeSH]”, “regional anesthesia[tiab]”, “nerve block[tiab]”, “brachial plexus[tiab]” and “general anesthesia[tiab].Two authors  independently conducted the initial database search and screened the titles and abstracts for eligibility. The full manuscript was then reviewed for inclusion and exclusion criteria. Discrepancies were resolved by consensus among the reviewers. We also performed manual searches of the references in the relevant articles and previous systemic reviews to avoid missing eligible articles.We used the Population, Intervention, Comparator, Outcome and Study design (PICOS) framework to formulate eligibility criteria . StudiesThe methodological quality of the studies was evaluated using the Cochrane Collaboration’s Risk of Bias Tools . These cData extraction and outcome measurement were conducted independently by two authors (SGP and SHL). Any discrepancies that emerged were subject to discussion, and final decisions were reached through mutual agreement among the evaluators. We employed a pre-designed data spreadsheet for data extraction. It included key information such as author names, publication year, study design, sample size, patient demographics , anesthesia methods, primary outcomes, and complications.The following outcomes were investigated: postoperative pain levels, opioid consumption , and occurrences of nausea and vomiting.2 statistics. Values > 25%, >50%, and >70% were regarded as low, moderate, and high heterogeneity, respectively. Random effects models for meta-analysis were applied in the presence of moderate to high heterogeneity (I2 > 50%); otherwise, fixed effects models were used. The inverse variance weighting method was employed to derive pooled estimates of SMD or OR, along with their respective 95% CI. The results of the meta-analysis were considered statistically significant at p < 0.05. Subgroup analysis was only conducted for postoperative VAS pain at 24 h to explore potential explanations for the observed heterogeneity, given the limited number of articles available. A sensitivity analysis was conducted by omitting single eligible studies to evaluate the influence of each study in primary outcomes. A funnel plot was originally planned to detect publication bias but was excluded from the analysis owing to its limited interpretability caused by the small number of included studies. Statistical analyses were performed using the Comprehensive Meta-analysis Software version 3  and Review Manager .The primary outcomes of this meta-analysis included postoperative pain levels and opioid consumption, with the secondary outcome being the incidence of nausea and vomiting following distal radius fracture surgery. We conducted a pooled analysis to compare multiple clinical outcome measures between the groups depending on the availability of the data. For all comparisons, standardized mean differences (SMD) with 95% confidence intervals (CI) were used for continuous variables, while odds ratios (OR) with 95% CI were calculated for binary variables. When medians with interquartile ranges were reported without means with standard deviations (SD), SDs were calculated using the quantile estimation approach . BetweenThe initial search yielded 412 articles, 4 of which met the inclusion and exclusion criteria and underwent qualitative analysis . All fouThe postoperative pain score through visual analogue scale (VAS) at 2 h was assessed in the four studies, which involved 247 wrists. All four studies consistently showed that the RA group had lower pain scores than the GA group at 2 h. The meta-analysis demonstrated significantly lower VAS scores in the RA group than the GA group. The standardized mean difference (SMD) was calculated as −2.03, with a 95% confidence interval (CI) ranging from −2.88 to −1.17 A. The re2 = 94%).Two studies involving 108 wrists examined VAS pain scores at 12 h. One study demonstrated significantly higher pain VAS scores in the RA group than the GA group at 12 h, whereas another study found no significant difference in pain scores between the groups. A meta-analysis revealed that the pooled effect size was not significant (2 = 86%). The heterogeneity was resolved when the investigations were pooled within the subgroup on outpatient surgical settings . The sensitivity analysis revealed no change in the result of the original analysis.The pain score at 48 h was assessed in three studies with a total of 176 wrists. One study reported higher pain VAS scores in the GA group than in the RA group, whereas the other two investigations did not find any significant differences between the groups. The results of the meta-analysis showed no significant difference in the VAS pain scores between the two groups at 48 h (2 = 58%).The total amount of opioid consumption after distal radius fracture surgery was reported in three studies that included 132 wrists. Among these studies, two reported a higher total opioid consumption in the GA group than in the RA group, whereas the remaining study did not find a significant difference in opioid consumption between the two groups. The results of the meta-analysis demonstrated that the GA group had significantly greater total opioid consumption than the RA group (2 = 0%).Three studies consistently reported higher opioid consumption in the post-anesthesia care unit (PACU) or before discharge in the GA group than in the RA group. The meta-analysis indicated a significant increase in opioid consumption in the RA group compared to the GA group during this period (2 = 0%).Opioid consumption after postoperative discharge, specifically on the first day, was evaluated in two investigations focusing on ambulatory surgery. Both studies reported higher opioid use in the RA group than in the GA group. The results of the meta-analysis indicated that the patients in the RA group had significantly greater opioid use than those in the GA group (2 = 0%) and vomiting (2 = 0%) in patients who underwent RA compared to those who received GA.Postoperative nausea and vomiting were assessed in two studies involving 140 wrists. Both studies consistently revealed a higher incidence of postoperative nausea and vomiting in the GA group than in the RA group. The results of the meta-analysis indicated a lower risk of postoperative nausea (Prior investigations comparing RA and GA for postoperative pain management have yielded conflicting results, posing a significant challenge to clinicians in deciding which mode of anesthesia to employ in order to enhance post-operative recovery and reduce oral opioid use. In this meta-analysis, we identified four randomized controlled trials that directly compared RA and GA for postoperative pain management after distal radius fracture surgery. This analysis aimed to provide insights into the optimal choice of anesthesia for managing postoperative pain in this specific surgical context. Furthermore, it provides insight into rebound pain following RA, an aspect often overlooked in the context of distal radius fracture fixation. Our meta-analysis revealed significant differences in the early postoperative pain and opioid consumption based on the anesthesia method. Specifically, the GA group had significantly higher pain scores at 2 h compared to the RA group; however, opioid consumption after postoperative discharge on the first day was significantly increased in the RA group compared to in the GA group. The total opioid consumption was greater in the GA group than in the RA group. However, no significant differences were observed between the two groups in the VAS pain scores after 12 h.RA was associated with decreased postoperative pain scores at 2 h compared to GA. However, the association diminished after the early postoperative period, and no significant differences in pain scores were observed between the GA and RA group after 12 h. The early postoperative pain patterns were significantly influenced by the anesthesia method. Patients with RA consistently exhibited a rapid increase in pain scores on the first operative day once the effects of regional anesthesia wore off. Some patients experienced an abrupt increase in pain, necessitating more pain medications. In contrast, patients with GA showed a continuous decrease in pain during the early postoperative period. Patients who received RA for ambulatory wrist fracture surgery reported a higher rate of unplanned healthcare resource utilization caused by post-discharge pain than those undergoing GA . The hetOpioids continue to have a significant role for postoperative pain management, but their use in the postoperative period may elevate the risk of adverse effects, including nausea and vomiting, respiratory depression, sedation, pruritus, urinary retention, and sleep disturbances . Total oThe higher incidence of nausea and vomiting in the GA group could be attributed to the differences in total opioid consumption. Postoperative nausea and vomiting are known to be influenced by various factors associated with the patient, surgery, and anesthesia . PreviouThe main limitation of this meta-analysis is the small number of included studies. The inclusion criteria were limited to randomized controlled trials, resulting in a limited pool of studies eligible for the meta-analysis. However, it was chosen to ensure a high level of evidence and facilitate high-grade recommendations. Additionally, heterogeneity in outcome reporting was observed among the included studies. Not all of the included studies provided data on opioid consumption, and the timing of follow-up assessments varied across studies. Further research with larger sample sizes and diverse study settings is warranted to provide a more comprehensive understanding of this topic. In addition, treatment-related variables, including the time to surgery and initial closed reductions before surgery, and injury characteristics, such as open or closed fractures, could potentially influence postoperative pain level after distal radius fracture ,34, but The use of RA for distal radial fracture surgery was associated with reduced postoperative pain scores during the early postoperative period only. However, after 12 h, no significant differences in the VAS pain scores were observed between the GA and RA groups. Total opioid consumption was higher in the GA group than in the RA group. However, opioid consumption on the first day after discharge was significantly higher in the RA group, potentially because of rebound pain. These findings provide valuable insights for the selection of an appropriate anesthetic method based on patient characteristics and specific trauma surgeries.


Does patients revised for unexplained pain after mUKA present the same PROM and satisfaction scores 1–3 years after revision as patients revised for aseptic loosening?”.104 patients undergoing revision of mUKA's for the indications unexplained pain and aseptic loosening were included in the period January 1, 2018 to December 31, 2020.from the Danish Knee Arthroplasty Register. 52 patients were revised for unexplained pain and 52 for aseptic loosening. Patient demographics did not differ between the two groups. PROMs  and questions about satisfaction with the surgery were sent to digitally secured mailboxes. Pearson’s Chi-square test and Wilcoxon Rank Sum test were used to test for statistical differences between groups.p = 0.033. The median EQ-5D-5L Index after revision was 0.7 (IQR 0.6) for unexplained vs 0.8 (IQR 0.1) for aseptic loosening, p = 0.014. The median FJS after revision was 48 (IQR 10) for unexplained pain vs 52 (IQR 14) for aseptic loosening, p = 0.1. The mean satisfaction with the surgery on a 0–100 scale  was 55 (IQR 60) for unexplained pain vs 50 (IQR 67) for aseptic loosening, p = 0.087, and patients revised for unexplained pain were less likely to find their knee problem importantly improved (p = 0.032).The median OKS 1–3 years after revision was 26 (IQR 22) for unexplained pain vs 34 (IQR 12) for aseptic loosening, Patients undergoing revision of mUKAs for unexplained pain presented poor postoperative PROM scores, and PROM scores were worse compared to those of patients revised for aseptic loosening. Patients revised for unexplained pain were less likely to find their knee problem importantly improved. This study support the evidence against revisions for unexplained pain.Level III. Medial unicompartmental knee arthroplasty (mUKA) is increasingly used, but 3–6 times higher 5 year revision rates of mUKA vs total knee arthroplasty (TKA) have been reported . The surStudies investigating patient-reported outcome measures (PROMs) have found slightly better pain levels after UKA than TKA , 20, 28.Does patients revised for unexplained pain after mUKA present the same PROM and satisfaction scores 1–3 years after revision as patients revised for aseptic loosening?”.This retrospective cross-sectional nationwide study was conducted in accordance with the COSMIN reporting guideline for PROM studies .Data were collected on all revisions of mUKAs registered for the indications unexplained pain or aseptic loosening in the period January 1, 2018 to December 31, 2020 in the Danish Knee Arthroplasty Register (DKR). The DKR is a nationwide clinical database collecting data on primary and revision knee arthroplasties in Denmark since 1997 . All ort104 patients were included in the study, all of whom had a mUKA revised to a TKA , Odense, Denmark , 10.The questionnaires Oxford Knee Score (OKS), EQ-5D-5L, Forgotten Joint Score (FJS) and Copenhagen Knee ROM were used. The OKS score of 0–48 was calculated, with 48 being the best possible score . CalculaThe patients were asked about their level of pain and satisfaction after surgery Table . Table 4Permission from the Danish Data Protection Agency was achieved . Accept to contact the patients in this study was achieved from the Head of Departments of all included departments performing the revisions. The authors had no conflicts of interest to declare.Descriptive statistics were presented with means and standard deviations (SD) for normally distributed continuous variables and median and interquartile range (IQR) for non-normally distributed continuous variables. Distributions were inspected for normality via quartile–quartile-plots. Frequency counts and percentages were provided for categorical variables. Pearson’s Chi-square test was used to test for statistical differences between categorical measures. Wilcoxon Rank Sum test was used to test non-normally distributed continuous variables for statistical differences.Missing data were as recommended by the developers for each of the PROMs , 6, 21.Statistical significance was set at the 5% level. For all analyses, Stata Statistical Software were used: Release 17. College Station, TX: StataCorp LLC.p = 0.033, p = 0.014, and p = 0.013)  Table , and 3.T Table , There were no significant differences in FJS or Copenhagen Knee ROM scores between indication groups, P = n.s. Table .p = 0.043)  was low for both groups with a score of 55 (IQR 60) for unexplained pain vs 50 (IQR 67) for aseptic loosening, p = n.s. Table . Patient32 Table .The most important findings were, that patients revised for unexplained pain scored worse on OKS, EQ-5D-5L, and EQ VAS than patients revised for aseptic loosening. Further, the groups had similar low satisfaction rates with surgery, but a larger proportion of patients revised for unexplained pain did not consider the result of the surgery an important improvement.OKS after TKA has been investigated previously. A study investigating Patient Acceptable Symptom State (PASS) values of OKS after primary TKAs found OKS scores of 30 29–31) . Though 9–31 . ThA study of 578 patients undergoing aseptic revision of UKAs for all indications found a mean EQ-5D-5L Index score of 0.65 (SD 0.24) postoperatively , which iThis is an important study providing data on a sparsely investigated area. The DKR is a nationwide register with a high level of completeness, and patients for this study were identified from this register. Acknowledged validated questionnaires were used for the study to gather the most reliable results possible.There are limitations to this study. It was not possible to obtain a 100% response rate, and the missing responses might skew the results. However, a response rate of 73% was achieved, which was found adequate for a reliable analysis of data. PROMs prior to revision was not available for this study. It is a major limitation to the study, that the baseline status of the patients was unknown or if the groups differed initially on various PROMs. Furthermore, no information on the primary indications for the mUKAs were available, or if they were indicated according to good clinical practice.Patients undergoing revision of mUKAs for unexplained pain presented poor postoperative PROM scores, and PROM scores were worse compared to those of patients revised for aseptic loosening. Patients revised for unexplained pain were less likely to find their knee problem importantly improved. This study support the evidence against revisions for unexplained pain.


To construct a predictive model for pain in patients undergoing hepatic arterial chemoembolization (TACE) in interventional operating room.Through literature review and expert interviews, a questionnaire was prepared for the assessment of pain factors in patients with hepatic arterial chemoembolization. A prospective cohort study was used to select 228 patients with hepatic arterial chemoembolization in a tertiary and first-class hospital. The data of the patients in the pain group and the non-pain group were compared, and a rapid screening prediction model was constructed by univariate analysis and logistic regression analysis, and its prediction effect was tested.χ2 = 13.540, p = 0.095). The area under the receiver operating characteristic curve was 0.798, p < 0.001.Tumor size, liver cancer stage, and chemoembolization with drug-loaded microspheres and pirarubicin hydrochloride (THP) mixed with lipiodol were independent predictors of pain in patients after hepatic arterial chemoembolization. Finally, the pain prediction model after TACE was obtained. The results of Hosmer–Lemeshow test showed that the model fit was good (The rapid screening and prediction model of pain in patients undergoing hepatic arterial chemoembolization has certain efficacy, which is helpful for clinical screening of patients with high risk of pain, and can provide reference for predictive pain management decision-making. Transcatheter arterial chemoembolization (TACE) is the first-line treatment for primary liver cancer, but post-embolization pain is a common accompanying symptom . Pain isConsulting experts: This study selected 16 experts from 5 cities in Shandong Province. Selection criteria: (1) the research field is interventional therapy, (2) master degree or above, (3) deputy senior title or above, (4) at least 10 years of experience in the field of interventional therapy, and (5) participate in this research voluntarily.Evaluation objects: all consecutive patients with liver cancer TACE who were admitted to the interventional therapy department of a tertiary hospital in Yantai from May 2020 to September 2020 were screened. The diagnostic criteria for liver cancer were based on the “Guidelines for the diagnosis and treatment of primary liver cancer (2019 edition)” . The incThe questionnaire was designed to retrieve relevant literature at home and abroad in the past 5 years. The key words were liver cancer, hepatic arterial chemoembolization, pain, and influencing factors. A total of 57 target literatures were screened, and 10 causes of pain in TACE patients with the highest frequency were found in the literature, including age, gender, history of chronic liver disease, tumor location close to the liver capsule, tumor size, number of tumors, the dose of doxorubicin greater than 50% of the total theoretical dose, the amount of lipiodol embolism, the use of CalliSpheres® drug-loaded microspheres for TACE, and whether pirarubicin hydrochloride (THP) mixed with lipiodol is used. It is organized into three modules: basic information of patients, basic characteristics of tumors, and TACE treatment methods. Then, 16 experts are invited to conduct 2 rounds of consultation by referring to the Delphi method. When the experts are concentrated in the academic conference organized by the province, they are invited. The paper questionnaire was filled out, and experts who were not present used the form of questionnaire stars to summarize and organize expert opinions to determine the final draft of the questionnaire for the evaluation of pain factors in TACE patients. A total of 3 primary indicators were constructed, including basic information of patients, basic characteristics of tumors, and TACE treatment methods; 15 secondary indicators were included. The content validity index of 16 experts was 0.978.In the pre-trial stage of clinical application, 15 TACE patients who met the inclusion and exclusion criteria were selected, and the measured Cronbach’s coefficient was 0.887. In the clinical application evaluation stage, 228 TACE patients who were hospitalized in the interventional therapy department of the hospital from June 2020 to October 2020 were selected, and 228 cases were effectively evaluated.We determined the origin of the pain mainly based on nature type, symptoms, and timing of occurrence. When measuring the pain during surgery and within 24 h after surgery, a ruler about 10 cm in length and the visual analog scale (VAS)  was usedχ2 test was carried out; the age was described by the mean ± standard deviation; univariate analysis and multivariate logistic regression were used to analyze the risk factors affecting pain after TACE, with p < 0.05 as the statistically significant difference, and a rapid screening prediction model was constructed. The receiver operating characteristic (ROC) curve was used to analyze the screening value of the prediction model for pain in patients after TACE. The predictive value was determined according to the area under the curve, and the Hosmer–Lemeshow test was used to analyze the goodness of fit of the multivariate prediction to the model in this study. The calculation of sample size in this study was mainly based on the requirement of event per variable (EPV) of at least 10 in the logistic regression equation. It is estimated that if six variables are screened in the regression equation, the number of patients required to have an event is at least 60. According to our previous experience, the probability of pain after TACE is about 35%. Considering the probability of lost follow-up is 10%, the minimum sample size required in this study is 60 / (35% × 90%) = 191.SPSS 25.0 statistical software was used for data analysis. The enumeration data were described by frequency according to the characteristics of the evaluation index, and the n = 9), a history of long-term use of analgesics (n = 8), and prophylactic use of analgesics (n = 6). A total of 228 patients with hepatocellular carcinoma who underwent TACE treatment were collected in this study, ranging in age from 34 to 87 (60.64 ± 10.24) years old. Among them, 174 were male and 54 were female . There were statistically significant differences between the two groups in age, tumor location, tumor size, liver cancer stage, whether to use drug-loaded microspheres, whether to use THP mixed with lipiodol for embolization, and portal vein tumor thrombosis (p < 0.05).The mean VAS score was 3.73 ± 2.42; meanwhile, there were 100 (43.9%) and 128 (56.1%) patients with and without post-TACE pain, respectively. As shown in Table After entering significantly different variables in the univariate analysis, age, tumor size, liver cancer stage, use of drug-loaded microspheres, and THP mixed with lipiodol chemoembolization were independent predictors of pain in patients after TACE Table . Five inp < 0.001; see Fig. χ2 = 13.878, p = 0.085, indicating that the model has good calibration ability, indicating that the model can effectively predict the degree of pain after TACE, and it can be used for clinicians to assess the degree of pain after TACE and provide guidance for pain prediction and early intervention in patients after TACE.The ROC curve was used to test the fitting effect of the model and the pain occurrence of patients after TACE  had master’s degree or above and 93.7% (15/16) of experts have more than 10 years of work experience.Postoperative pain will increase the unpleasant experience of patients with TACE treatment, give patients a certain amount of negative reinforcement, and affect the next treatment. In this study, there were 100 patients 100/228) with pain after TACE, and the incidence rate was similar to the results of domestic and foreign studies 28 with p. So far,In this study, 228 TACE patients admitted to our hospital were analyzed and found that tumor size, liver cancer stage, use of drug-loaded microspheres, and THP mixed with lipiodol chemoembolization were independent predictors of pain in patients after TACE. In this study, the incidence of pain after embolization with drug-loaded microspheres is consistent with the related research results of some scholars at home and abroad –13. SomeLiver cancer stage (CNLC) is a risk factor for pain after TACE. The staging of liver cancer is very important for prognostic evaluation. There are many staging schemes abroad. In this study, the Chinese staging scheme for liver cancer (CNLC) was included as an influencing factor. The results of this study showed that patients with stage IIIa had the highest incidence of pain after TACE, which may be related to vascular invasion, chemotherapy, or tumor embolization in stage IIIa patients. In addition, when the tumor invades blood vessels, the interventional doctor is stricter in the degree of embolization. In clinical observation, it is found that the patients with adequate embolization have more significant pain than those with insufficient embolization  on the performance of the model for the prediction of TACE pain. There remains uncertainty regarding whether the length of pain and the degree of analgesics use contribute to post-TACE pain, which needs further studies to address these questions.In summary, this study analyzed 228 TACE patients admitted to our hospital and related literature published in the past 5 years. The analysis results showed that tumor size, liver cancer stage, drug-loaded microspheres, and THP combined with lipiodol chemoembolization were independent predictors of pain in patients after TACE. Although some predictors were reported in previous studies, we validated the association of these predictors with post-TACE pain in our Chinese population. In addition, we constructed a novel prediction model by combining these independent predictors, which is a simple and useful tool for clinical decision-making. The rapid screening prediction model for pain in patients after TACE based on these four factors has been verified to have certain predictive power. In addition, these four risk factors can be quickly extracted and evaluated through information sharing on the hospital intranet before surgery. Clinicians can use the rapid screening prediction model of this study to comprehensively evaluate the influencing factors of pain in patients at an early stage and can effectively predict the degree of pain of patients after surgery, relieve postoperative pain of patients, and provide effective guidance for clinical pain prediction and intervention after TACE.


To determine whether the preoperative inflammatory serum C-reactive protein (CRP) and leukocyte count (LEUK) are associated with postoperative pain and complaints after otolaryngological surgery.Retrospective evaluation of 680 patients  receiving otolaryngological surgery between November 2008 and March 2017 in a tertiary university hospital. Postoperative pain on the first postoperative day was assessed using the validated questionnaire of the German-wide project Quality Improvement in Postoperative Pain Treatment (QUIPS) including a numeric rating scale for assessment of postoperative pain . The influence of preoperative parameters including CRP and LEUK on patients' postoperative pain was estimated.p < 0.05). Higher postoperative pain was associated with LEUK values > 11.3 Gpt/l  and higher preoperative chronic pain . Multivariate analysis confirmed younger age, female gender, duration of surgery, preoperative chronic pain, type of surgery, and higher LEUK values > 11.3 as independent factors for postoperative pain. Perioperative antibiotics had no effect on the postoperative pain.Mean CRP value was 15.6 ± 34.6 mg/l and mean LEUK value 7.8 ± 3.2 Gpt/l. Patients with pharyngeal surgery had the highest CRP values (34.6 ± 52.9 mg/l), highest LEUK values (9.2 ± 4.2 Gpt/l) and the highest pain levels (3.1 ± 2.4 NRS) compared to all other surgical procedures (all Beyond known factors, preoperative LEUK as inflammation marker is an independent predictor for pain on the first postoperative day.The online version contains supplementary material available at 10.1007/s00405-023-07980-4. Most otorhinolaryngological inflammatory diseases as well as inflammation related to head and neck cancer are associated with acute or even chronic pain. Inflammation could be detected by local symptoms such as swelling, skin and mucosal redness, higher temperature or systemic symptoms like low blood pressure, high body temperature or high levels of inflammation parameters like C-reactive protein (CRP) or leukocytes (LEUK) in blood . PatientUse of perioperative antibiotics might be related with more postoperative pain as an indirect indication for a correlation between inflammation and postoperative pain . TherefoIn this retrospective study, 680 patients who underwent surgery as part of inpatient treatment between November 2008 and March 2017 in the Department of Department of Otorhinolaryngology, Jena University Hospital, Germany, were included. Data was collected by the QUIPS benchmarking project, which was used in previous prospective studies by the Department of Otorhinolaryngology, Jena University Hospital, Germany . In addiThe QUIPS questionnaires are presented in detail elsewhere . The QUIThe patients were divided into 6 surgical classes according to the type of surgery: pharynx surgery, larynx surgery, nasal/ sinus surgery, ear surgery, salivary gland surgery and neck surgery.p < 0.05.The statistical evaluation was performed with R  and IBM SPSS statistics software . Pearson Chi-Square test were used to compare categorical variables. The nonparametric Mann–Whitney-U test was used to examine the metric data of two independent groups. One-way analysis of variance (ANOVA) was used to compare more than two groups. To determine the relationship between two metric variables, the nonparametric Spearman correlation was performed. Multivariate linear regression analysis was performed to estimate predictors of postoperative pain including all significant factors from univariate analysis. The significance level was set at The patients were 47 ± 17 years old . The population consisted of two third male and one third female patients. The mean CRP level was 15.6 ± 34.6 mg/l . The mean LEUK count was 7.8 ± 3.2 Gpt/l .r = 0.12; p = 0.01). No significant correlation could be demonstrated for the number of LEUK .A correlation analysis between age and CRP showed a positive relationship (p = 0.03) and the LEUK (p = 0.02) compared to other patients (n = 553).About one third of patients had a benign or malignant tumor (n = 232). A pairwise multiple comparison showed that patients with peritonsillar abscess had significantly higher values of preoperative LEUK (13.8 ± 3.9 Gpt/l) and CRP concentration (93.0 ± 57.5 mg/l) than other diagnoses . The group of patients with a malignant tumor (n = 127) showed significantly higher values of CRP (p < 0.05).Patients with pharyngeal surgery had the highest CRP values 34.6 ± 52.9 mg/l) and LEUK concentrations (9.2 ± 4.2 Gpt/l) compared to the other surgical procedures Figs.  and 2. A.9 mg/l an = 373) received perioperative antibiotics. Patients in the nasal/ sinus surgery class received antibiotics (n = 163), followed by patients in the pharynx group . There was a significant correlation between the perioperative administration of antibiotics and increased preoperative CRP concentration (p = 0.01). No significant relationship between increased leukocyte concentrations and the antibiotic administration could be determined (p = 0.19).Over half of the patients (p < 0.05). Patients with neck surgery reported significantly more pain than patients with laryngeal surgery (p < 0.05). There was no correlation between postoperative pain and value of CRP , female gender , longer duration of surgery , and LEUK values > 11.3 Gpt/l  were independently associated with higher postoperative pain. Model 2 without the factor surgery class showed that younger age , higher preoperative pain , longer duration of surgery , and LEUK values > 11.3 Gpt/l  were independently associated with higher postoperative pain. There was also a trend to more postoperative pain in female patients .The average pain in activity on the first postoperative day was 3.1 ± 2.4 (NRS). The median NRS was 3.0 (range 0–10). Figure p = 0.0001), female gender , longer duration of surgery , and LEUK values > 11.3 Gpt/l  but also the surgical class  were independently associated with higher postoperative pain.Model 3 without the factor preoperative chronic pain level showed again that younger age  suffered from chronic pain before surgery. About 10% (n = 74) of the patients regularly took pain medication before surgery. Most of these were patients with malignant tumors (n = 32). The process parameters that were specified by QUIPS are listed in S1 Table. Patients who suffered from chronic pain before surgery reported higher postoperative pain intensity . Higher CRP value was significant correlated with breathing impairments (p = 0.01) and night pain (p = 0.02). Also, LEUK value was associated with breathing impairments . A Spearman correlation was performed for the total group and the individual surgical classes in order to demonstrate any connections between the preoperative chronic pain and the inflammation parameters. There was a weak positive correlation for the CRP value  as well as for the LEUK level  and more preoperative pain. The results for the individual surgical classes can be found in Table r = 0.49; p = 0.02) between CRP and the strength of preoperative chronic pain was shown for the diagnosis of chronic tonsillitis. The Wilcoxon-Mann–Whitney test was also able to show significant differences between the grouped inflammation parameters and the preoperative pain in the total group. Patients with CRP > 7.5 mg/l (p = 0.02) and patients with LEUK concentration > 11.3 Gpt/l (p = 0.001) had significantly more preoperative pain. Figure An ANOVA was performed to determine whether the individual surgical classes differ from each other according to preoperative chronic pain. No significant difference could be found p = 0.6. A SpeaThe basis for the data collection was the validated QUIPS questionnaire, which was filled out by the patients on the first postoperative day. In the past, QUIPS has proven to be a suitable tool for mapping postoperative pain intensity as well as functional effects and side effects caused by pain therapy , 7, 9–17In this study, a higher preoperative LEUK value was associated with higher postoperative pain. Because CRP and LEUK represent different responses to acute and chronic inflammation, this could be the reason why CRP was not and LEUK was associated with postoperative pain . In contBeyond LEUK, younger age, duration of surgery, and (as a trend) female gender were other independent predictors of postoperative pain. This confirms results from previous studies , 13.Patients with pharyngeal surgery had the highest CRP values, highest LEUK values and the highest pain in activity levels compared to all other surgical procedures. It is well known that pharyngeal surgery led to the highest pain in otolaryngological surgery –9. WhereWhen looking at the subgroup of patients who suffered from chronic pain preoperatively, a significant moderate positive relationship between CRP and the strength of preoperative chronic pain was shown for the diagnosis of recurrent acute tonsillitis. CRP can be regarded as potential biomarker for chronic pain .Perioperative antibiotics were not associated with postoperative pain in this study but other authors reported contradictory results. Studies performed within the QUIPS project also received different results. For example, Poller et al. were able to demonstrate a positive effect on postoperative pain and concluded that antibiotic administration prevents local inflammation by bacteria of the oral flora and consequently leads to less nociception . AnotherThe origin and processing of acute postoperative wound pain is a complex process that is influenced by pro- and anti-inflammatory cytokines . These aFor the first time it has been shown that the preoperative inflammation parameter LEUK but not CRP was associated with pain on the first postoperative day. Further studies are required to verify these results and develop standardized pain protocols for patients with high preoperative LEUK value.Supplementary file1 (DOCX 27 KB)Below is the link to the electronic supplementary material.


The association between hamstring tightness and knee osteoarthritis (KOA) is significant because tight hamstrings can put more strain on the knee joint, reduce its range of motion, and cause compensatory movements that worsen the KOA.To compare the effects of instrument-assisted soft tissue mobilization (IASTM) and proprioceptive neuromuscular (PNF) on hamstring flexibility in patients with KOA.n = 60 participants randomly divided into group A received IASTM and group B received PNF stretching. In group A, the therapist made 30 strokes gentle strokes with the tool from the origin to the insertion while holding the plane at a 45-degree angle over the treatment area. In group B, PNF stretching was done with three repetitions and 10 seconds rest between each, after isometric contraction of the hamstring muscle using approximately 50% of their maximum strength, holding it for 8 seconds, and then releasing it. A 30-minute session was given to each patient three times per week and was given for 6 weeks. Outcome measures were the visual analog scale (VAS) for pain intensity, the active knee extension test (AKET) for hamstring flexibility, and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) for the health status of KOA patients.Data for the randomized controlled trial (NCT05110326) was collected from p < 0.001) between interventions and time across several measurements. After 6 weeks, both interventions resulted in significant improvements (p < 0.001) across all dependent variables, with group A (IASTM) showing more significant improvement in hamstring flexibility, pain reduction, and health status (p < 0.001) compared to group B (PNF).The study found a significant interaction (Both the IASTM technique and PNF stretching resulted in increased hamstring flexibility, decreased pain, and enhanced general health. The IASTM technique, however, showed potential benefits over PNF stretching in terms of flexibility, pain relief, and public health enhancement. Physical therapists and manual therapists may prioritize the usage of the IASTM technique for patients who want to make significant changes in these areas. Knee osteoarthritis (KOA) is a painful musculoskeletal disease caused by degeneration and articular cartilage loss over time. KOA mostly affects the elderly population and commonly causes disability throughout the world . About 2Age, congenital and acquired deformity, trauma and female gender are all risk factors that have been linked to the development of KOA. The overweight population is more prone to develop osteoarthritis. Joint injury or overuse damages the articular cartilage leading to osteoarthritis . PersistKnee joint movements occur by the two primary muscles including the quadriceps and hamstrings and assist the smooth and accurate ambulatory growth factors in the knee joint . The assetc. , proprioceptive neuromuscular facilitation (PNF) stretching might be an effective technique to improve hamstring flexibility. This stretching method combines isometric contractions with passive stretching to increase joint range of motion and muscle flexibility . ResearcEnhancing hamstring flexibility through exercise and stretching can aid in symptom relief and lessen pressure on the knee joint, making it a crucial component of managing and treating KOA. IASTM and PNF stretching are two therapies that have been utilized to improve muscle flexibility and range of motion in joints. However, it is unclear how well they perform compared to one another when it comes to enhancing hamstring flexibility in knee osteoarthritis patients. It was hypothesized that IASTM techniques are more effective than PNF stretching in improving hamstring flexibility among KOA patients. Therefore, the study aimed to compare the effectiveness of IASTM and PNF stretching on hamstring flexibility in patients with KOA.It was a single-blinded, randomized clinical trial (NCT05110326) conducted at the RHS Rehabilitation Centre (RHS/EC/28-06-2021-03), Islamabad, Pakistan. The study was completed within 1 year from July 2021-June 2022 and approval was taken from the research and ethical committee (REC) of the Faculty of Rehabilitation and Allied Health Sciences (with Ref# Riphah/RCRS/REC-01055) Riphah International University.The 35–50 years patient having grade 1&2 knee osteoarthritis (KOA), according to the Kellegren and Lawrence criteria, hamstring tightness of more than 20° from the active knee extension test (AKET) , were inn = 60 sample size was calculated through G power, keeping the effect size small (0.24), α error margin at 0.05. To avoid β error probability, the power (1−β) was set at 0.95%. A total of n = 63 patients were assessed for eligibility and n = 60 participants fulfilled the inclusion criteria and were randomly allocated to group A (n = 30), which received IASTM technique, and group B (n = 30) which received PNF technique. A total of n = 57 participants were analyzed at the end of study due to loss of follow-up of n = 3 patients from Group A  was used to determine the severity of pain. The patient marked a point on a 100-mm horizontal line that indicated a continuum between “no pain” and “worst discomfort” . The VASThe hamstring flexibility was assessed by active knee extension test (AKET) using a goniometer . The AKEThe Western Ontario and McMaster Universities Arthritis Index (WOMAC) index was also used to assess the health status of individuals with knee osteoarthritis including three subscales of pain, stiffness, and physical function. It consisted of 24 questions with a total score ranging from 0–96 . All WOMηp2) as the effect size was used to examine the interaction between interventions and the level of assessment because parametric tests were determined to be appropriate for the data, the paired-sample t-tests were used to analyze changes over time for within-group comparisons, while independent t-tests used for between-group comparisons. As a measure for effect size, Cohen’s d was employed. The data examined using SPSS version 28 with a significance level of p < 0.05.The descriptive statistics, such as frequency (n), percentage (%), mean, standard deviation (SD), and mean differences (MD), used to summarize the study’s findings and subsequently presented in tables and graphs. A two-way mixed ANOVA with partial eta squared  of the n = 57 participants were men, and the remaining n = 43(75.4%) were women. The n = 30 participants were found to have grade 1 knee osteoarthritis (KOA) according to the Kellegren and Lawrence criteria, whereas the remaining n = 27 were determined to have grade 2 KOA. The mean age and BMI of the study participants were 45.14 ± 4.67 years and 28.53 ± 5.65 kg/mp < 0.001, ηp2 = 0.36}, pain on VAS {F =52.95, p < 0.001, ηp2 = 0.49} as well as pain {F =53.38, p < 0.001, ηp2 = 0.49}, stiffness {F =18.25, p < 0.001, ηp2 = 0.24}, physical function {F =78.26, p < 0.001, ηp2 = 0.58} and health status on WOMAC {F =96.15, p < 0.001, ηp2 = 0.63} as shown in Fig. 4To find the interaction effect between intervention and level of assessment, two-way mixed ANOVA was applied. As the sphericity was assumed, the results showed that there was a significant interaction effect between both interventions and time factor in all dependent variables with large effect size, including hamstring flexibility on AKET {F =32.13, t-test was applied to determine the main effect. It showed that significant improvement (p < 0.001) was observed in all the dependent variables with large effect size including hamstring flexibility (AKET), pain (VAS), and health status (WOMAC) including pain, stiffness, and physical functions after the 6th week of intervention  hamstring flexibility (AKET), pain (VAS), health status (WOMAC) with a large effect size than group B who received PNF technique  technique and PNF stretching in improving hamstring flexibility, pain, and health status in knee osteoarthritis. In the present study within group analysis showed that participants in both groups had significant improvement in pain, hamstring flexibility, and health status throughout the treatment duration. Between group analysis showed that IASTM technique showed more significant improvement in hamstring flexibility, pain, and health status on WOMAC scores  as compared to PNF stretching.A study comparing the effects of static stretching with PNF stretching in patients with knee osteoarthritis showed significant improvement in pain and hamstring flexibility in the PNF group . These rWithin-group analysis showed that PNF stretching had significant results in reducing pain and improving health status. A study had similar results showing that PNF stretching significantly reduced pain intensity and improved functional performance in patients with knee osteoarthritis and chronic non-specific low back pain . The incAn RCT showed that IASTM reduced pain and reduced functional disability in the patellofemoral pain syndrome . AnotherThe present study showed that IASTM had significantly improved hamstring flexibility compared to PNF stretching. This difference could be attributed to IASTM’s ability to directly target specific areas of tightness or adhesions, stimulate fibroblastic activity, induce tissue reattachment, and lead to greater improvements in hamstring flexibility . The staThe limitations of this study were that it was conducted in only one clinical setting. Another limitation that may affect the prognosis of the results, is the inclusion of both unilateral and bilateral knee osteoarthritis including different grades of knee osteoarthritis.This study indicated those with knee osteoarthritis benefited from both the IASTM technique and PNF stretching, resulting in increased hamstring flexibility, decreased pain, and enhanced general health. The IASTM technique, however, showed potential benefits over PNF stretching in terms of flexibility, pain relief, and general health enhancement. These benefits could be attributed to the IASTM technique’s improved hamstring flexibility. Multicentered future studies are recommended on the bases of BMI, gender differences as well as retention effects of the intervention.10.7717/peerj.16506/supp-1Supplemental Information 1Click here for additional data file.10.7717/peerj.16506/supp-2Supplemental Information 2Click here for additional data file.10.7717/peerj.16506/supp-3Supplemental Information 3SPSS or PSPP is required to view the datasetClick here for additional data file.


Older individuals are easily prone to chronic pain. Due to the complexity of chronic pain, most elderly often have difficulty expressing pain to others to seek assistance, especially those with Alzheimer’s disease (AD). The caregivers cannot instantly discover the patients’ pain condition and provide timely pain management. This project applies physiological signal sensing technology to help AD patients express the presence of pain non-verbally. We embed sensors on patients’ handkerchiefs to identify the patient’s abnormal physical activity when pain occurs. Next, we translate the physiological signal into qualitative light alert to send to caregivers and indicate the pain occurrence condition. Then, utilizing multi-sensory stimulation intervention, we create an electronic textile (e-textile) tool to help caregivers effectively support patients in pain. And thus to create a two-way pain communication between caregivers and the patients. Pain perception can be independent of subjective expressions and tangibly perceived by others through our textile prototype. The e-textile handkerchiefs also bring up a new guide to facilitate communication for caregivers when their patients. We contribute the design insights of building a bio-sensing and e-textile system with considering the pain communication needs, patients’ pain behaviors and preference of objects. Our e-textile system may contribute to pain communication bio-sensing tool design for special elderly groups, especially those with weakened cognition and communication abilities. We provide a new approach to dealing with the pain of AD patients for healthcare professionals. Alzheimer’s disease (AD) is a progressive neurodegenerative disease with insidious onset . It clinChronic pain is a degenerative disease. It is usually referred to as chronic pain if it occurs for over 3 months . The paiPain is invisible to others, and counting the AD patients’ deterioration of communication skills is even more challenging. AD patients often cannot report their pain, and caregivers also cannot notice their condition in a timely and accurate manner, especially for those patients in advanced stages of AD. This condition will leave the patient’s pain unassessed and untreated, affecting the diagnosis of pain-causing disorders , which wTo recognize the pain in AD patients, scales are widely adopted by caregivers and medical professionals, including self-reported scales and observation scales , e.g., VWearable technology embedded with different bio-sensors becomes an alternative pain evaluation solution for the scales . The tecExisting wearable sensor-based devices for pain recognition primarily allow patients to unilaterally report pain to caregivers, often by detecting pressure from hand movements to indicate pain levels . HoweverFor AD patients: What is patients’ need for pain information communication with their caregivers? How can we help them express pain non-verbally? How to sense patient pain non-verbally using wearable sensors?1) For caregivers: What is caregivers’ need for the access patient’ pain and provide feedback? How can we help to facilitate two-way communication between patients and caregivers with e-textile technology and MSS therapy effectively?2) Based on the states of diagnosis and treatment of chronic pain in AD patients mentioned above, this paper proposes the following research questions to help us rethink patient-caregiver relationships by applying tangible sensing e-textile technologies, and seek new approaches to help them break the barrier of verbal expression.• We identified the most pressing communication needs when pain occurs in AD patients through case-study interviews and observations. We also outlined the design criteria for designing a close-fitting computing device to detect AD patients’ pain by observing their preference for objects and behaviors in everyday life.• The e-textile system we proposed explored the possibility of a tangible interactive entity as a non-pharmacological intervention for pain in AD patients. Our system is not only a one-way message to the caregiver like other body data monitoring devices, and it could help the patient and the caregiver with two-way communication. Findings in our case study suggested that the patients seem calmer and more comfortable after enjoying the system with their close family when they are in pain, showing that it is important for caregivers to promptly react and accompany the patients in pain status. Moreover, the users advised us to improve our design, for example, by differing the level and complexity of interaction between the patient’s and caregiver’s sides to enhance the caregivers’ engagement.We conducted interviews with six families of AD patients and caregivers, and designed the e-textile system based on multi-sensory stimulation (MSS) intervention, the tangible interaction in our system, to assist communication about pain between patients and caregivers. We also presented a use case on evaluation and addressed the opportunities and challenges of the system. The main contributions of our work are as follows.In recent years, with the advent of wearable smart devices and physiological signal sensing technologies, implementing ubiquitous non-invasive systems for pain identification and monitoring has become possible. In this study, the wearable bio-data technology is considered to be the objective approach for caregivers to read the patients’ pain state and an alternative self-report of the patients. Therefore, it is necessary to identify each bio-sensor’s capability and limitation, so we could choose the appropriate sensor for discerning a patient’s pain state.Wearable devices are introduced to monitor patients’ pain long-term outside the hospital. An electrocardiogram (ECG) sensor can collect data on the surface of the chest or limbs. People usually infer whether the pain occurs by analyzing heart rate variability (HRV) . HoweverWhen individuals with AD experience pain, they often exhibit physical manifestations such as abnormal walking as a means to communicate their discomfort . ConsequFor people with AD, pain can provoke anxiety. If this painful emotional experience goes unnoticed or unrelieved, it will continue aggravating their pain and damage the body or mind. Therefore, numerous positive approaches to non-medicinal treatment were used to support daily pain management for AD.Multi-sensory stimulation therapy (MSS) therapy is most commonly used to help chronic patients relieve their negative sentiments. . DesigneCurrent wearable systems are not explicitly designed for AD patients with chronic pain and behavioral interventions. To better clarify the needs of the user and the contexts in which this wearable would be utilized, We invited six families to our online interview, including one late-stage and five middle-stage AD patients  and their caregivers to be our participants, as seen in According to the clinical consultation process of patients with chronic pain from physicians, pain information includes the location of pain, the degree of pain, the symptoms of pain (what conditions hurt), and the characteristics of the pain. The location of chronic pain is complex in many cases. Because chronic pain does not only cause pain at the injury but spreads to other parts of the body, causing holistic pain over time ; for exathe first goal of our interview was to investigate what information about patients’ pain most needed to be communicated with caregivers. This exploratory process first engaged all the caregivers due to the inconvenience in verbal communication for AD patients, which enabled us to gain background information on the typical pain type and basic pain information of the patients, together with how they assess the pain occurring.Therefore, The typical chronic pain suggested by caregivers in AD patients “belongs” to chronic musculoskeletal pain, according to the International Association for the Study of Pain classification . Except the second goal of our interview was to explore how to leverage the ability of bio-sensors in designing a system for detecting pain. Since most AD patients were cared for in a domestic environment, the abnormal physical activities of AD patients when they were in pain, decided how the design could take effect. Therefore, we adopted the patient journey approach in interviewing the caregivers to observe and record the regular physical activities of AD patients to investigate what is abnormal and what can be captured by the sensor when they are in pain. We asked the caregivers to record and report the daily activities to us, and then we could summarize a daily activities journey in the pain journey map 3 based on the reported pain level and timeline, which could help us recognize the most common abnormal activity when pain occurred to indicate the presence of pain by the bio-sensor.Since the functions of the bio-sensors and the signals they can collect about pain have been well clarified in According to all the caregivers, the patients get up in the morning and have lunch at noon. As they have chronic pain in their leg and the effect of AD, they are not interested in activities that need much effort so they sit somewhere in the house  for hours till night. However, when they are unwell some day, they may start to walk around the house after lunch. Furthermore, they cannot stay still and fall asleep at night. Instead, they will get up and go to the toilet repeatedly. F1, F3, F5, and F6 caregivers mentioned:” We did not know why my grandma/grandpa suddenly became an active walker at first, and she only walked back and forth in the room, till we asked her again and again and finally knew she is in pain.”In general, our interview showed that the abnormal physical activity was extra walking frequency, which could be a potential parameter to detect to represent the pain occurrence. We can use accelerometers to collect these bio-data. When there is abnormal physical activity, the physiological signal sensors could give us real-time feedback from the patient if there is any pain condition.the third goal of our interview was to probe what form of the wearable device would be acceptable for the patient to carry, and how to make the pain information perceived by caregivers since the wearable is on the patient. In addition, we realized that the communication process should be two-way, including transmitting information and receiving feedback. As F1, F3, F5 and F6 said, “When the patient was in pain, he/she would do some strange things, like screaming and blaming, in my opinion, they were trying to attract my attention to them … Sometimes I came along and did something or even just talked to him/her, he/she seemed better … ”. Thus, only informing the caregiver of the presence of pain is not a complete pain communication process for the patient; they also need to feel the feedback from the caregiver.The accelerometer needs to be carried around for real-time data collection, which means it needs to be embedded in a wearable device. Hence, Therefore, we wanted to record and analyze the patient’s daily living environment, their reliable daily objects and access to them, and the caregiver’s approach to pain relief when they find the patient is in pain. They all consented to tell their stories and allow the recording. However, due to the COVID-19 safety restrictions, we could not record at their home in person. Therefore, we asked the caregiver to record the above information in a diary, including images and text recordings of the environment and actions.DC1: The accelerometer sensor can be the potential bio-sensor for tracking the gait data, which will indicate the pain of patients.1) DC2: The tangible interaction interface should be portable and of a soft texture that can be easily held in hands. Almost all older adults show resistance to wearable products, but we found that the elderly prefer to hold some small objects . F3 told us, “We made my grandma a box containing some tissues and cloths, in case she can grab them and fold them beside her sometimes”, the others said, “A handkerchief is always in his pocket … he would take it out sometimes and just held it … ” From time to time, the patients will play with the objects in their hands. F1,2,3,4,6 indicated to us that the patients are resistant some wearable objects that closely attached to their bodies. “My aunt bought my grandma a lot of jewelry, but every time we let my grandma to try on something, she just took it off quickly” said by F1. “We once bought the patients a smart watch in case he/she got lost, because sometime he/she went out by himself/herself. But he/she did not like to put on the device, so the watch was left alone now.” mentioned by F5 and F6. These evidence help to exclude the bio-sensors that need to adhered on user’s skins, e.g., the ECG/GSR sensors.2) DC3: The tangible interaction needs to capture the attention of the older adults, presumably by using visually or auditorily salient features. It is difficult for caregivers to know from the patient’s abnormal physical activities whether the patient is in pain, unless the patient starts to make a loud noise to attract attention. F3 suggested, “My grandmother’s legs hurt for no reason … we always call her name loudly and talk to her when she is about to cry, she seems to forget that she is in pain.“, and F6 shared, “We will bring out my grandpa’s er’hu, a traditional Chinese instrument … As he sees the er’hu, he will stop being mad for his pain.” The comforting method caregivers use is to make some attractions like newfangled gadgets or talk about other things loudly to divert the patient’s attention so that the patient can be relieved.3) DC4: The tangible interaction can follow some existing therapy, which allows the caregivers to follow existing approaches in pain management. F2 mentioned, “It is difficult to summarize what method can make my grandmother becomes soothing. Sometimes gently patting her will be more useful, but sometimes it is more effective to talk to her.” F5 told us, “Because the patient does not particularly like anything, we can only try to meet her needs. For example, sometimes we will help her to find some food.” The facts suggest that it is often difficult for caregivers to have a general idea of communicating with and helping the patient, especially if the patient is impatient. Therefore, the rules of certified therapy, e.g., MSS therapy and music therapy, can be an effective mechanism for interaction for caregivers to engage in pain communication with the patients. For example, in MSS therapy, they shall provide a fidget tool to the patients to guide them to interact with sensory patterns in a certain order.4) From descriptions from caregivers and sharing of leisure records, we identified the following insights and design criteria that can define our design.Based on our interview insights, we constructed user personas for our design, representing both AD patients and their caregivers, as illustrated in As discussed in As shown in x, y, and z-axes. The data collected will be used for making a steps calculator and physical activities tracker. The calculation method is shown below:K is the time step, ax(K), ay(K), az(K) are the filtered accelerations of the x, y, and z-axes of the three-axis accelerometer.During the implementation, we employed the Adafruit Circuit Playground Bluefruit (CPB) to gather patient biofeedback data. The CPB is the main electronic board that processes and then presents the display data on both sides. We use the three-axis accelerometer lis3dh on the Adafruit CPB, which can collect the three components of the Alzheimer’s patient’s motion , corresponding to the acceleration in the As illustrated in When the patients were in pain, and the number of steps exceeded a threshold, the caregiver’s handkerchief received a signal to light up a red light indicating abnormal pain. At this time, the caregiver could come to the patient and control the handkerchief with interactive patterns to send guidance commands, implementing the MSS therapy. Thus, the caregiver could press the flower with the same color as the ones on the patient’s handkerchief, emitting the same color lights on the patient’s handkerchief or triggering the music and sounds. To complete the task, the patient did multi-sensory stimulation therapy by following the caregiver’s guidance to perform simple matching tasks using the handkerchiefs with interactive sensory components (such as pressing the red flower when the red light is on). We sew touch points connected to capacitive touchpads on the CPB on the tactile wool rope, which also light up the handkerchief when the patient strokes the rope. The procedure is shown in Due to the health concerns for the participants during COVID-19, we only invite one family (F6) to try out our prototype in person. F6 is also the most typical and important user case that matches our user persona and could provide valuable feedback for our design. After the presentation, we interviewed the caregivers. When the patient was in pain and the pain alert was triggered, the caregiver came by and triggered the multi-sensory stimulation therapy, leading the patient to calm down. The patient was a bit confused at first, but got calmer and learned how to use the system as feel accompanied by his family. The caregiver then taught the patient the way to interact. They tried a few times using the prototype, and when we asked the patient how he felt, he told us he was happy. For the caregiver’s handkerchief, she reported that the alert lights let them know the pain status quickly, and that the selection of flowers to control sensory interaction was easy to use. However, when patients used the handkerchiefs, they could correspond to the colors of the flowers to interact with and the blinking lights, but it took much work to know how the arrows and pockets interacted. Caregiver reported similarly that the arrows might no longer be recognizable to patients at this stage; they also suggested replacing them with small animals or flowers, as older adults are more attracted to these patterns. The task of finding and placing the flowers could be further simplified, similar to touching the flowers corresponding to the light. The caregivers also suggested that the existing interaction could be enriched. For example, sound could be added to the design since older people love to listen to old-school music or opera songs.According to the feedback from our participants, we first changed the pattern layout into a square arrangement as the patient loved to fold their handkerchiefs neatly, as shown in We engaged F6 and another caregiver (labeled as C1) from an Alzheimer’s Disease (AD) care center in Hong Kong, who also provided home care services, to assess our final design. With their consent, we observed and interviewed them in a domestic setting. A day prior to the interview, we met the caregivers and demonstrated the handkerchief’s usage, subsequently handing it over to record the patients’ physical activity. To validate the device’s effectiveness in pain detection, we juxtaposed the device’s pain alerts with the caregivers’ self-recorded observations of the patients’ painful behaviors. Our hypothesis was that a temporal correlation between the patient’s exhibited pain symptoms and the device’s alerts would attest to the system’s utility. We told the caregiver first to ask the patient if he/she would like to hold the handkerchief or put it in his/her pocket. The handkerchief would be placed in the patient’s pocket for the rest of the day with consent. We visited the patient in the late afternoon, the frequent pain period of the patients’ day, and introduced the caregivers to the method of providing instant feedback with the handkerchief. The patients followed their daily activities and interacted several times using the handkerchiefs when it suggested the presence of pain to the caregiver. After the patients were reassured and his status was stable, we conduct a semi-structured interview with the caregivers to learn about their experience interacting with our system. The interview framework drew inspiration from our research questions and the User Engagement Scale (UES) , addressA red light represents a warning in line with our common sense, and a sudden light can be noticeable to draw the caregiver’s attention. During the test, the caregiver F6 was cooking on the other side of the house and put the handkerchief somewhere noticeable. “When the lights are on, I know something is happening on the patient’s side. Previously, I had to keep yelling out to him to confirm his condition, sometimes without getting any answer.” The prompting using only lights still needs to be enhanced. The caregiver F6 told us, “I think it would be more effective if it vibrated like an alarm, because sometimes I might miss the reminder, just like I miss a message.” Alerting caregivers in multi-channel way and multi times may improve the ability of the pain communication of this system.When patients felt pain, they always squeezed the handkerchief, and their facial expressions became serious. However, when the caregiver interacted with them, they became visibly happy and even initiatively expressed to us that they were happy. We personalized a piece of the F6 patient’s favorite music in the sound effects, and the patient gradually relaxed and hummed along with the music after the sound was triggered, as seen in The data from the accelerometer, presented in The novelty of our design seemed very high to the caregiver. However, the entertaining feature of the MSS therapy was a bit low for adults with normal cognition, leading to low endurance and felt involvement for the caregiver. This directly affects the caregiver’s patience and trust in the design. As the caregiver F6 said, “The gameplay was too simple for me. It is great that I can use it to accompany the patient, but I gradually got bored. I would have been surprised if the gadgets were more varied.” This inspires us to make each fidget pattern changeable, turning-based handkerchief sewed with a processor into a blank board, on which we can constantly update and iterate the interactive components. For the patient, engagement comes from being constantly challenged and taught to do the task, and receiving some encouraging feedback after completing the task, which was previously difficult to get because the patient was usually not asked to do anything resulting in less interaction between the patient and caregiver.  The caregiver C1 shared another perspectives: “As I always conduct the simple tasks with simple tools in the MSS therapy, this system seemed is similar to those tools I used before. However, my engagement came from stories sharing of the patients. For example, I will ask the patients about their experience with the objects that we are interacting with, and the most of patients are very willing to share stories with me.” Inspired by this, designing the interactive attachments that are relate more on the daily life may help to enhance the engagement for both the patients and caregivers.To address the research question concerning differences in pain communication needs between patients and caregivers, we observed patients’ daily lives and their pain expression capabilities and conducted in-depth interviews with caregivers. Our findings indicated that the most pressing communication needs for both parties lies in different stages of communication. This challenges conventional understanding of the pain process, typically similar to a physician’s diagnostic approach. Past perceptions of pain communication have led to designs primarily focused on patients conveying pain to caregivers, overlooking the caregiver’s need for effective feedback communication. In our study, we indicated the two different needs of communication and propose a two-way pain communication framework.To discern and measure patients’ pain through non-verbal behavior, we tracked patients’ daily activities and abnormal behavior during pain episodes to match possible bio-sensor detection capabilities. Abnormal walking patterns among patients were particularly noticeable. Based on previous pain detection device research and clinical evidence linking AD patients’ pain with abnormal walking, we incorporated accelerometers to aid in non-verbal pain behavior detection. In testing, we found this method could provide insights into a patient’s overall daily pain condition. Align with Caregivers’ reports that patients’ adverse moods and behaviors typically presented after accumulated pain reached a certain threshold, which our device might potentially map this way of pain expression. However, such a detection method has significant limitations, like missing momentary pain spikes.To address the final research question on aiding caregivers in feedback and interaction, we introduced MSS therapy and e-textile devices resembling fidget blankets. On one hand, therapy procedures and toy interactions guide caregivers in leading patients into cognitive stimulation through play ; 2019). In the design process, the diversity and number of user population limit our designs and findings. F6 is the only family that got involved in the participatory design process in person. And we only got two groups ofparticipants in our analysis process. Though these use case is quite typical to our user portrait and has provided many valuable insights to our design, to validate the pain detection ability of the system, more AD patients with chronic pain and their caregivers from different backgrounds should join the design process to evaluate the prototype better and general to use. We may also recruit some families from the Western culture in case there may be different attitudes in pain communication. Moreover, we only discuss the design of the pain information display based on one usage scenario (working scenario) of the caregiver. More scenarios still need to be explored because different usage environments will affect the effectiveness of the way information is displayed. Different presentation modes can be selected through buttons by the caregivers. Thus, they can easily switch the notification form considering their condition, just like turning off the ringing mode on the smartphone in a meeting but turning it on when in need of an alarm to notice the message immediately.For the design of the handkerchief, wireless and smaller battery may help to improve user acceptance. The enrichment of the interavtive components will limit the interest and engaged level when people use it. More display modes can be prototyped to communicate more information about pain. For example, different lighting conditions  may represent different pain features. However, a single visual effect is less suggestive. Multimodal cues allow more effective pain communication in the future. Like the fidget blanket, the pain communication handkerchief can be personalized and iterated to make the MSS interactive parts relevant to each user’s preferences. Music is among the MSS interaction components that create more significant concerns for both caregivers and patients. In previous non-pharmacological pain management interventions, music has repeatedly been proven effective for pain-relief . DiffereFor pain recognition, only using one kind of bio-sensor is not precise enough. Multiple sensors in one system can improve accuracy. We need to consider wearing comfort and detection efficiency to adopt multiple sensors. With sufficient participants and data collecting duration, the accuracy of the sensors could have been better measured and compared longitudinally. Besides, adding the electronic component brought inconvenience and unnaturalness in use, such as increased weight and hardness, even if the interaction modality is enriched. Finally, the current premise is that if the number of steps by a patient exceeds a threshold (over 8k steps), that could be due to pain-related behavior. However, the step threshold represents the overall pain of the day, which may result in some lag in pain detection. For instance, if the patient starts walking due to pain in the morning or at night when the threshold is not hit, the system may delay telling the caregiver about the condition. In this circumstance, other compensating sensors like GSR should activate to detect the stress and pain condition for pain report. Machine learning techniques  may alsoFor the user study and analysis, the period of testing the prototype was not sufficient, so in the future, we could adopt the experience diary to help caregivers record the user experience for a more extended period to provide us with more valuable reflections on user behavior. We can also challenge the patients by repeating to play with the prototypes for times to test the relation between persistence ability and pain level to provide more insights into the design.Older adults suffering from AD and chronic pain have trouble expressing their pain, leading to issues like being untreated or mistreated by their caregivers and medical professionals. The bio-feedback and e-textile technology can help them to track and monitor their body condition and report to themselves and others in a user-friendly and comfortable interface. This e-textile handkerchief can be a potential alternative approach as two-way communication between non-patients and AD patients. For one thing, it reflects AD patients’ temporal pain condition, Sending out the pain message objectively without less bias and uncertainty, compared with the previous approached . For anoOur design enlightened caregivers about the potential of e-textile devices in aiding the understanding of a patient’s pain status, possibly fueling interest in a broader range of MSS tools and methodologies, as suggested by F6. However, during the design phase, it is evident that merely focusing on the patient-centric features and interactions is insufficient. Just as we account for the distinct pain communication needs of patients and caregivers, the requirements for interaction should be tailored based on cognitive levels to enhance the user experience.


To describe the long-term clinical results of arthroscopic fragment fixation for chronic primary osteochondral lesions of the talus (OLT), using the Lift-Drill-Fill-Fix (LDFF) technique.Eighteen patients (20 ankles) underwent fixation for a primary OLT with an osteochondral fragment using arthroscopic LDFF and were evaluated at a minimum of 5-year follow-up. Pre- and postoperative clinical assessment was prospectively performed by measuring the Numeric Rating Scale (NRS) of pain at rest, during walking and when running. Additionally, the change in Foot and Ankle Outcome Score (FAOS) and the procedure survival  at final follow-up was assessed.p =  < 0.001). This result was sustained from 1-year follow-up to final follow-up. The NRS during running significantly improved from 8 (IQR 6−10) to 2 (IQR 0–4.5) (p < 0.001) and the NRS in rest from 2.5 (IQR 1–3) to 0 (IQR 0–0) (p =  < 0.001). The median FAOS at final follow-up was 94 out of 100 for pain, 71 for other symptoms, 99 for activities of daily living, 80 for sport and 56 for quality of life. The FOAS remained significantly improved post-operatively on all subscales, except for the symptoms subscale. The procedure survival rate is 87% at final follow-up.At a mean follow-up of 7 years, the median NRS during walking significantly improved from 7 (IQR 5–8) pre-operatively to 0 (IQR 0–1.5) at final follow-up (Arthroscopic LDFF for fixable chronic primary OLTs results in excellent pain reduction and improved patient-reported outcomes, with sustained results at long-term follow-up. These results indicate that surgeons may consider arthroscopic LDFF as treatment of choice for fragmentous OLT.Level IV, prospective case series. Osteochondral lesions of the talus (OLT) affect the articular cartilage and its underlying subchondral bone. Treatment of these lesions is challenging as no superior treatment is available to date . TreatmeThe theoretical advantage of fixation over other surgical techniques is the preservation of native hyaline cartilage, immediate stabilization of the fragment and restoration of the talar dome congruency, as well as facilitating subchondral bone healing , 18. OneThe primary aim of the present study is therefore to evaluate the long-term patient-reported outcomes of arthroscopic LDFF. The hypothesis is that the results of arthroscopic LDFF results are maintained over time. The secondary aims of this study are to investigate the survival rate and complications.Approval for this study was obtained from the Medical Ethical Committee of Amsterdam UMC, Location AMC (reference number: MEC 08/326). The present study is in accordance with the Medical Research Involving Human Subjects Act (WMO) and the principles of the Declaration of Helsinki.The present study is a long-term follow-up of a cohort of consecutive patients who underwent arthroscopic fixation by means of LDFF for a primary chronic (> 6 weeks after trauma or start of symptoms) OLT and minimum of 6-month conservative treatment before surgery , 20. FraOutcomes were collected prospectively at the preoperative, one- and two-year follow-ups, and at a minimum of 5 years postoperatively at the cross-sectional final follow-up . At fina© electronic data capture system. The primary outcome measure for the present study was the Numeric Rating Scale (NRS) of pain during walking, which is a patient-reported pain scale from 0 (no pain) to 10 (most pain imaginable) [To obtain patient-reported outcome measures (PROMs), online questionnaires were distributed via the Castorginable) . The NRSginable) .By phone, and from the electronic patient records, any reoperation of the ankle was recorded. Revision surgery was defined as any reoperation of the OLT after the arthroscopic LDFF procedure. The survival rate was defined as the proportion of the number of ankles which did not undergo revision surgery from the total number of ankles included at final follow-up. Postoperative complications were extracted from the hospital electronic patient records.All patients received a preoperative and one-year postoperative radiological assessment of the OLT by means of a computed tomography (CT) scan. The aforementioned study by Lambers et al.  previousBaseline patient and treatment characteristics were extracted from the hospital electronic patient records. Patient characteristics included sex, laterality, age at surgery, body mass index (BMI), participation in sports and level of sports participation , injury circumstances , and concomitant injuries. Treatment characteristics collected were the follow-up time, screw type used for fixation , and any concomitant procedures at index surgery.α) of 0.05 . A minimally clinical important difference (MCID) of the NRS pain during walking 2.0 points between the preoperative and postoperative situation, with a standard deviation of 2.5 points and a power of 80% was chosen, as previous studies observed a much better improvement in pain [Before the start of the present study, a sample size calculation for the primary outcome was performed with a Wilcoxon signed-rank test, using a level of significance .Descriptive analysis was performed to summarize the baseline characteristic variables, which are presented with frequencies and percentages for categorical variables and means with standard deviations and ranges for continuous variables. Data were assessed visually for normality and with a Shapiro–Wilk test. Wilcoxon signed-rank test was used to compare clinical outcomes pre-operatively with postoperatively. Specifically for the primary outcome, a comparison of the NRS during walking between the final follow-up with 6-month follow-up, 1-year follow-up, and 2-year follow-up was made using the Wilcoxon signed-rank test. To test inter-rater reliability of the lesion size measurements and the lesion localization, 2-way mixed effects interclass correlation coefficient (ICC) model with absolute agreement and Cohen’s Kappa analysis were used, respectively. ICC analysis outcomes were interpreted according to Shrout et al.  with 0.4k > 0.81 . A two-sFrom the 25 eligible patients, 20 patients were included with a total of 23 ankles. 5 patients were excluded, as outlined in Fig. P =  < 0.01), as well as for the other NRS subdomains ) compared to pre-operatively (median: 7 out of 10 (IQR: 5–8), ns Table . The NRSns Table . An overA total of two patients underwent surgery to the ankle unrelated to the OLT after LDFF. From these two patients, one had an anterior ankle arthroscopy for anteromedial soft-tissue impingement debridement and one had a gastrocnemius release at another institution at 18 and 86 months after the LDFF procedure, respectively. Additionally, two patients underwent surgery of the ipsilateral lower extremity not involving the ankle .From the 20 patients with 23 ankles available in this study, two patients with a total of three ankles (13%) underwent revision surgery. This corresponds to a procedure survival rate of 87% national expert center for the diagnosis and treatment of ankle cartilage injuries. Patients were prospectively followed and data were collected by independent investigators not involved in patient care to limit observer bias. All radiological measurements were conducted by two independent raters with excellent inter-rater reliability.The present study is not without its limitations. First, 20% of eligible ankles were lost to follow-up. Lost to follow-up is a known problem in long-term follow-up studies . It coulThe present study addresses the paucity of literature concerning the long-term clinical outcomes as well as the clinical sustainability of the procedure. Fixation of fragmentous OLTs should always be considered by the treating physician and should be made in the context of an individualized treatment algorithm which includes patient and lesion characteristics . This stArthroscopic LDFF for fixable chronic primary OLTs results in a long-term procedure survival rate of 87%. Clinically, excellent and sustained pain reduction and patient-reported outcomes were observed. These results indicate that surgeons may consider arthroscopic fixation for a fragmentous OLT.