Background: Spinal infections represent a therapeutic challenge. The often protracted course of the disease is accompanied by pain, which can lead to a chronic pain experience even after the infectious disease has been treated successfully. The aim of this study was to investigate possible risk factors of pain chronification. Methods: In a prospective study, 14 patients with spinal infections were examined at admission (T1), at discharge from inpatient therapy (T2), and three to eight months postoperatively (T3) byquestionnaires on risk factors for pain chronification and by quantitative sensory testing (QST). Results: In-patient treatment lasted on average 45.3 days (±33.13). The patients complained of pain for 3.43 months (±2.77) prior to inpatient treatment. The visual analogue scale (VAS) for pain (0–10) and the Oswestry Disability Index detected significant improvement in the course of the study. However, patients also reported catastrophic thinking, as well as fear of movement and (re)-injury. Conclusion: In summary, our results demonstrate that patients with spinal infections did not suffer from pain chronification, but might benefit from an interdisciplinary therapeutic approach, which emphasizes promoting active pain-coping strategies, as well as addressing fear of movement and catastrophic thinking. Infections of the musculoskeletal system are difficult to treat and frequently require a protracted and rigorous therapy . Spinal Staphylococcus aureus has been traditionally described to be the most common causative agent, however, recently also coagulase-negative Staphylococci and faecal bacteria have been described in association with spinal infections [fections . Furtherfections . Once bafections ,7.Bone infections, or osteomyelitis, of the vertebral body (spondylitis) and the intervertebral disc space (spondylodiscitis) are the third most common location of osteomyelitis, after the tibia and the femoral bone. Yet, they have a rather low incidence of approximately 1:250,000 inhabitants per year . FrequenFurthermore, it has been demonstrated that psychological, social and also iatrogenic factors significantly contribute to chronic pain, which require an interdisciplinary therapeutic approach . The impTherefore, we were interested in evaluating the pain sensation of patients suffering from spinal infections during the course of the disease. We hypothesized that these patients are at high risk of developing a chronic pain syndrome, which should be addressed in an interdisciplinary way early on. In order to evaluate risk factors for pain chronification, as well as coping strategies, patients who suffered from spinal infections were examined by various questionnaires. Furthermore, quantitative sensory testing (QST) was performed on all patients. This method represents a subjective psychophysical examination to quantify functions of the somatosensory system. By means of thermal and mechanical stimuli, not merely loss of function, but also gain of sensory functions can be evaluated, along with hyperalgesia, allodynia und hyperpathia ,15,16,17n = 12) or spinal implant-associated infections (n = 2) of the thoracic or lumbar spine by evaluating C-reactive protein (CRP) concentration, plain X-rays, magnetic resonance imaging (MRI) and computed tomography (CT) analysis. Twelve patients received a surgical intervention. Ten patients underwent debridement, dorsal spondylodesis with disc replacement due to instability; additionally one patient had an evacuation of an epidural abscess, and two patients received a debridement with implant-exchange. Two patients underwent non-surgical treatment, but received a CT-guided biopsy of the spine. All patients were examined at admission , at discharge from inpatient therapy  and three to eight months postoperatively . Exclusion criteria were chronic inflammatory disease of the musculoskeletal system, severe mental disorders, epilepsy, known dysfunction of the afferent nervous system , dementia, other factors affecting cooperation and/or consent of the test persons and lack of written informed consent to participate in the study. Patients under the age of 18 were excluded from this study. The present study refers to data collected from March 2019 until May 2020.A total of 14 persons were recruited for this study (prospective cohort study). The study was approved by the local ethics committee of Heidelberg University (S-466/2014). The patients were recruited using the internal patient management system of the Heidelberg University Hospital. Written and informed consent was obtained from all participants. All patients were diagnosed with spondylodiscitis , Pain Catastrophising Scale (PCS), Relationship Questionnaire (RQ), Coping Strategies-Questionnaire (CSQ-D), Oswestry Disability Index (ODI), Rosenberg Self-Esteem Scale (RSES) and the Tampa Scale (TS). The PHQ explores underlying psychological tendencies, such as a somatoform component, depression, panic or anxiety. Catastrophizing level whilst in pain is measured with the PCS. The RQ determines the kind of attachment style and the general application to the patient’s personal life. Here, the secure, the dismissive-avoidant, the anxious-preoccupied and the fearful-avoidant style of attachment are evaluated. With the CSQ-D, the different kinds of coping strategies when experiencing pain are explored. There are active coping strategies like Reinterpreting pain sensations, diversion, self-instruction, ignoring pain and passive strategies like catastrophizing, praying and hoping, and self-efficacy methods like overall reduction and control of pain. To test daily life restrictions, the ODI was used . The RSES detects with ten questions a tendency of reduced self-esteem. Lastly, the TS was used to determine fear of movement and (re)injury. Additionally, pain levels were evaluated by visual analogue scale (VAS), ranging from 1–10.All questionnaires were completed in one session. Each session took about 45 min and the questionnaires were always completed in the same order as seen above. The patients did not criticize the length of the examinations.2 and the baseline temperature was 32 °C. Temperature was raised or lowered by 1 °C/s until thermal detection was indicated by the test person. The mean value of five consecutive measurements was calculated. Cut-off values for thermal pain were 0 °C and 50 °C, respectively.Thermal detection thresholds , thermal pain thresholds , mechanical detection threshold (MDT) and pressure pain threshold (PPT) were tested according to a standardized protocol published by Rolke, et al. . These pAdditionally, the mechanical detection threshold was measured using Von-Frey-Filaments with optical glass fibres . Furthermore, mechanical pain sensitivity data to blunt pressure was collected with a pressure algometer . Contact area was 1 cm2 and stimuli were gradually increased by 50 kPa/s. Mean pressure pain thresholds were calculated using three consecutive measurements.All tests were performed by one trained examiner only. Each session was about 45 min long and the tests were always performed in the same order. First, thermal detection thresholds, followed by thermal pain thresholds were evaluated. Lastly, mechanical detection and pressure pain thresholds were measured. Room temperature was constantly between 20 °C and 24 °C and the test persons were seated comfortably on a chair or lying down.n = 20), as previously described [Quantitative sensory testing was performed at hospital admission, before hospital discharge and repeated after three to eight months. During this time, patients underwent conservative therapy or surgical therapy of a spinal infection. Results of QST were compared to a healthy control group (escribed . These it-test) and the course of questionnaire-sessions (two-sample t-test). Connections between QST values and questionnaire results were evaluated with Spearman’s rank correlation coefficient. Values measured for the mean detection threshold (MDT) were logarithmic transformed, so a statistical calculation with a parametric test (one-sample t-test) was possible. The significance level was determined as p < 0.05.Test results were evaluated using SPSS 27.0. Data  were evaluated using descriptive statistics like mean and standard deviation. Differences among groups in QST as well as differences between the first, second and third QST sessions were calculated by non-parametric tests , because previous histograms revealed no statistical normal distribution among the collected values. Parametric statistical tests were used for the questionnaires . On the VAS pain scale (0–10), significant improvement of pain levels could be detected over the course of time between T1 and T3 (p = 0.005)  .In the PHQ, three patients (18.75%) at T1, three patients (18.75%) at T2 and one patient (6.25%) at T3 were above the cutoff for a depressive mood, whereas three patients (18.75%) at T1, one patient (6.25%) at T2 and none at T3 showed signs of anxiety. Six patients (37.5%) with spinal infections reported catastrophic thinking (PCS) at T1 and T2.By means of the RQ, 2 patients (12.5%) related to statements consistent with a dismissive-avoidant and two patients (12.5%) with a fearful-avoidant attachment style at T1. At T2, only one patient (6.25%) related to a dismissive attachment style, while at T3 four patients (25%) related to this kind of attachment style.p = 0.001; p = 0.003; p = 0.001) and turned more to praying and hoping . Furthermore, they used strategies like reinterpreting pain sensations (T1 and T3: p < 0.05) and diversion (T2: p = 0.004 and T3: p = 0.015). Also, the feeling of control over their pain was decreased at T1 and T2 (T1: p = 0.037 and T2: p = 0.045)  A–D.p < 0.001, T2: p < 0.001, T3: p = 0.015). Still, they showed a significant improvement between T1 and T3 (p = 0.024). , 38% (T2) and 25% (T3) disability were determined, which all were significantly higher than a healthy individual (T1:  0.024). .p = 0.001, T2: p = 0.029, T3: p = 0.038).Patients with spinal infections showed significantly low self-esteem in the Rosenberg Self-esteem Scale , 39.7 (T2) and 43.2 (T3), which all are very near the typical value of chronic back pain patients (43.2) .p = 0.014, T2: p = 0.001). Likewise, a significant association between the PCS and the ODI .In T1 and T2, there was a significant correlation between the test results of the PCS and Catastrophizing of the Coping Strategies Questionnaire  were decreased and detection thresholds for warm temperatures (T1-3: p < 0.001) were increased at the control region (hand) . Additionally, in T2 patients with spinal infections were found to have significantly higher thresholds on their back for the detection of warm temperatures  and mechanical contact  in comparison to the control region (hand).Compared to healthy individuals, the detection thresholds for cold temperatures (T1: n (hand) . The colp = 0.023, T2: p < 0.001, T3: p = 0.046)  was significantly lower over the course of time (T1: = 0.046) .Spinal infections are particularly detrimental due to the fact that considerable destruction to the profile of the spine might cause neurological deficits and removal of an implant might lead to loss of correction, as well as stability of the spine . BecauseThe aim of this study was to evaluate clinical data, risk factors for pain chronification, as well as coping strategies in patients suffering from infections of the spine.n = 2) and patients suffering from spondylodiscitis (n = 12). It could be of interest, if these two infectious groups show significant differences during the course of the disease. Furthermore, 12 patients received surgical treatment, predominately due to instability, and two patients underwent conservative treatment. It would be of further interest to evaluate these two groups separately, because there might be differences among patients regarding the risk of pain chronification and pain coping strategies. Another limitation of this study was that the time point T3 varied among patients (3–8 months) according to the individual course of the disease. Also, QST results were compared to healthy individuals. Patients of the control group were significantly younger than patients with spinal infections. It has been proposed that younger age might be associated with higher sensitivity to thermal stimuli [The limitations of this study were that the number of patients included was not sufficient to further differentiate between test results of patients suffering from implant-associated infections of the spine  is used to detect fear of movement and (re-)injury. The measured values of the TS in patients suffering from spinal infections were all similar to typical values measured in patients suffering from chronic back pain , even afFurthermore, quantitative sensory testing was performed on all patients. Nociception is the perception of stimuli that potentially or actually harm the body. Nociceptors register these stimuli and they are then transmitted to the brain via afferent ascending pathways mainly in the spinothalamic tract, where they are located in parallel to the ascending pathways for thermal stimuli . In therOur results are in line with this data. We also detected modified thermal thresholds at the control region (hand) and the test region (lower back), which indicates that patients suffering from spinal infections also possibly demonstrate a changed perception of pain.Peripheral sensitization  indicates that nociceptors become more sensitive to stimuli. The excitation threshold of the nociceptors can be lowered to such an extent that non-noxic or non-painful stimuli are able to trigger action potentials. Moreover, sensitized nociceptors are characterised by a stronger response to supra-threshold stimuli. Central or spinal sensitization  is characterized by a stronger response of neurons to stimuli from the diseased area and even to stimuli from adjacent, non-diseased areas . This deIn summary, patients with spinal infections showed significant improvement of pain levels and less limitation in everyday life over the course of the disease. Therefore, pain chronification did not occur in these patients. Furthermore, questionnaire results show distinctive features, such as the use of passive coping strategies, catastrophic thinking and fear of movement and injury. Therefore, patients might benefit from an interdisciplinary therapeutic approach, such as multidisciplinary pain therapy, which should be included in the treatment of spinal infections early on. Multidisciplinary pain therapy consists of somatic and psychotherapeutic procedures in combination with physical and psychological training programs, which can be adapted according to individual needs ,37,38. I


The anatomical mechanisms of cervicogenic headache caused by upper cervical lesions have been reported. However, the pathomechanisms of headache caused by lower cervical spine disorders remain unknown. The purpose of the current study was to clarify the prevalence and pathogenesis of headaches in patients with cervical spondylotic myelopathy (CSM). post hoc tests were used for comparisons.  In this retrospective study, a questionnaire regarding preoperative and postoperative symptoms was sent to 147 patients with CSM who were surgically treated in our hospital during the previous 10 years. All of the surgical procedures were decompression surgeries between the C3 and C7 levels. Data from 74 patients (50.3%) were available for analysis. Subjects were divided into four groups according to the presence or absence of preoperative and postoperative headache. The severity of pain, severity of neuropathic pain symptoms, depression, severity of myelopathy, and quality of life (QOL) were also evaluated using questionnaires. The scores of these questionnaires were then compared between the four groups. Kruskal–Wallis tests with Dunn–Bonferroni  Of the patients with CSM, 31% had headaches preoperatively, and 43% of these headaches disappeared postoperatively. Type 4 (preoperative headache-positive/postoperative headache-positive) patients had more severe pain and neuropathic pain symptoms and lower QOL scores compared with type 1 (preoperative headache-negative/postoperative headache-negative) patients.  Approximately one-third of all patients with CSM had headaches preoperatively. Headache in patients with CSM may be neuropathic pain. A proportion of headaches in patients with CSM can be treated by decompression surgery. The concept of cervicogenic headache was introduced by Sjaasatd in 1983 . In 2004The purpose of the current study was to clarify the prevalence and pathogenesis of headache in patients with cervical spondylotic myelopathy (CSM). CSM is a disease with various symptoms, such as numbness of the upper and lower extremities, disturbed fine motor skills, and gait disturbance. These symptoms are caused by spinal cord compression as a result of degenerative changes in the intervertebral discs, vertebrae, and ligamentum flavum.This retrospective study was approved by the ethical committee of Fukushima Medical University (no. 1015). We sent questionnaires regarding preoperative and postoperative symptoms to 147 patients with CSM who had been surgically treated in our hospital during the previous 10 years (2001–2010). This survey was performed from September 2011 to January 2012. All of the surgical procedures were decompression surgeries between the C3 and C7 levels  . Data frThe patients with CSM had numbness and/or pain in the upper and lower extremities. They also complained of disturbed fine motor skills and gait disturbance. The severity of pain in upper and lower extremities, severity of neuropathic pain symptoms in upper and lower extremities, depression, severity of myelopathy, and quality of life (QOL) were evaluated between the groups using the following questionnaires.A short form of the McGill Pain Questionnaire (SF-MPQ) was used for the evaluation of pain. The main component of the SF-MPQ consists of 15 descriptors (11 sensory and 4 affective) which are rated on an intensity scale as 0 = none, 1 = mild, 2 = moderate, or 3 = severe. Three pain scores are derived from the sum of the intensity rank values of the words chosen for sensory, affective, and total descriptors. The questionnaire's interpretation is relatively basic: a higher score means a higher pain level , 11. TheNeuropathic pain symptoms were evaluated using the Neuropathic Pain Symptom Inventory (NPSI). The NPSI is a self-administered questionnaire that is specifically designed to evaluate the different symptoms of neuropathic pain. Each of the items was quantified on a numerical scale (0–10). The NPSI includes 10 descriptors  that allow the discrimination and quantification of five distinct clinically relevant dimensions of neuropathic pain syndromes , 13. Thehttp://www.saccess55.co.jp/, http://www.chibatc.co.jp, and http://www.nichibun.co.jp/.The Beck Depression Index (BDI) was used to evaluate depression. This questionnaire measures the self-reported presence and severity of depression symptoms. A higher score indicates greater depression, and the scores can be classified as follows: minimal range = 0–9, mild depression = 10–16, moderate depression = 17–29, and severe depression = 30–63 , 15. Thehttps://ssl.jssr.gr.jp/member/) and used without a license.The Japanese Orthopaedic Association Cervical Myelopathy Evaluating Questionnaire (JOACMEQ) was used for this evaluation. The JOACMEQ is a self-reported questionnaire that is completed by the patient. The major characteristic of this questionnaire is that the evaluation is performed based on patient-oriented outcomes. The JOACMEQ is not a single scoring system, but it consists of the evaluation of five different scores: cervical spine function, upper extremity function, lower extremity function, bladder function, and QOL , 17. TheT scores for each scale (with a mean of 50 and standard deviation (SD) of 10) [https://www.sf-36.jp/index.html).QOL was evaluated using the MOS Short-Form 36-Item Health Survey (SF-36). This questionnaire is a multi-item, generic, health-related QOL survey intended to measure “general health concepts not specific to any age, disease, or treatment group.” The SF-36 measures eight health domains: physical function (PF), role physical (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role emotional (RE), and mental health (MH). The SF-36 can also be used to evaluate the physical component summary (PCS) and mental component summary (MCS) in the summary scores. The scale scores are calculated by summing responses across the scale items, and these raw scores are then transformed to a 0–100 scale. Computerized scoring algorithms are available and can produce norm-based ) of 10) . The SF-post hoc test. A p value less than 0.05 was considered statistically significant. All analyses were performed using IBM SPSS statistical software .A normality test of the data was performed using the Shapiro–Wilk normality test. Differences in age between the three patient types were analyzed using one-way analysis of variance (ANOVA). Gender bias was analyzed using Pearson's chi-squared test. The questionnaire scores were compared between the three patient types using the Kruskal–Wallis test with the Dunn–Bonferroni p=0.208; mean age in years (SD): type 1: 72.0 (12.6), type 3: 65.1 (6.9), and type 4: 68.5 (12.3)). However, there were significant differences in sex between the three types (p < 0.05) (The patients were divided into four types . In tota < 0.05) .The MPQ scores were significantly higher in type 3 and type 4 patients than in type 1 patients .The NPSI scores in type 4 patients were significantly higher than in type 1 patients .There were no significant differences in BDI scores between the three patient types .In the JOACMEQ, there were no significant differences in cervical spine function, upper extremity function, lower extremity function, bladder function, or QOL between the three patient types .The BP, VT, and MCS scores in type 4 patients were significantly lower than those in type 1 patients .The CSM patients with preoperative headache had higher pain levels compared with the CSM patients without preoperative and postoperative headache, regardless of whether they also had postoperative headache. In addition, the CSM patients with preoperative and postoperative headache had higher neuropathic pain symptom and lower QOL scores compared with the CSM patients without preoperative and postoperative headache.CSM is a disease with various symptoms, such as numbness of the upper and lower extremities, disturbed fine motor skills, and gait disturbance, caused by spinal cord compression. It has been reported that approximately 40% of patients with cervical myelopathy have severe allodynia or hyperalgesia in the upper and lower extremities , 20. AltThe International Spinal Cord Injury Classification mentions pain subtypes in neuropathic pain: at-level SCI pain and below-level SCI pain. Headache is classified as nociceptive pain , 22. HowIn the present study, 31% of patients with CSM had headache preoperatively, and these patients had more severe neuropathic pain symptoms than the other patients. Furthermore, 43% of these patients reported that headache disappeared after decompression surgery. These findings suggest that headache in patients with CSM may be associated with spinal cord compression. That is, headache in patients with CSM may be a kind of neuropathic pain caused by spinal cord compression. It is therefore important to pay attention to headache in patients with CSM and to clarify which patients can be treated surgically for headache.There are several limitations to the current study. First, this study was retrospective. The preoperative characteristics of headache and the course of postoperative changes of headache were therefore unable to be clarified. Second, the rate of analyzed patients was low (50.3%). The prevalence of headache and the improvement rate of headache after surgery in our study might therefore differ from the total patient population. Finally, we were unable to investigate the diagnostic procedures for evaluating headache originating from facet joints or soft tissue. However, the current study did present the possibility that the mechanism of headache in patients with CSM might be neuropathic pain and suggest that some headache in patients with CSM can be treated surgically.Headache existed in 31% of the patients with CSM in the present study, and these headaches might be associated with a neuropathic pain mechanism. Furthermore, 43% of patients with CSM reported that headache disappeared following decompression surgery.


To compare custom-made insoles to sham insoles and general practice (GP)-led usual care in terms of pain at rest and during activity at 12 weeks follow-up in individuals with plantar heel pain.In this randomised clinical trial 185 patients aged 18 to 65 years, with a clinical diagnosis of plantar heel pain for at least 2 weeks, but no longer than 2 years were recruited. Patients were randomly allocated into three groups: (1) GP-led treatment, plus an information booklet with exercises , (2) referral to a podiatrist for treatment with a custom-made insole plus an information booklet with exercises  and (3) referral to a podiatrist and treatment with a sham insole plus an information booklet with exercises . As well as the primary outcome of pain severity  we used the Foot Function Index (0 to 100) as a secondary outcome.Of 185 randomised participants, 176 completed the 12-week follow-up. There was no difference in pain or function between the insole and the sham groups at 12 weeks. Participants in the GP-led usual care group reported less pain during activity at 12 weeks, (mean difference (MD) 0.94, 95% CI 0.23 to 1.65), less first step pain , better function  and higher recovery rates  compared with participants in the custom insole group.Referral to a podiatrist for a custom-made insole does not lead to a better outcome compared to sham insoles or compared to GP-led usual care.NTR5346. Plantar heel pain, also known as plantar fasciitis or fasciopathy, is a common cause of foot pain. Plantar heel pain accounts for an estimated 8% to 15% of all foot complaints requiring medical care in adults.et al found a small, but statistically significant, beneficial effect of insoles on heel pain at 7 to 12 weeks when compared with sham.Plantar heel pain can be managed by a range of different treatments in clinical practice and orthoses, such as in-shoe foot insoles are commonly applied by clinicians.We conducted a randomised clinical trial with a pragmatic design that compared custom-made insoles with sham insoles, as well as general practice (GP)-led usual care. The hypothesis was that custom-made insoles would be better than sham insoles and GP-led usual care at 12 weeks follow-up in terms of pain at rest and during activity.The study was performed according to the published protocol.A total of 175 GPs and 6 sports physicians were engaged in the study and invited patients with plantar heel pain to participate in the study. Inclusion criteria for study participation were: age between 18 to 65 years, minimal pain duration of 2 weeks and presentation with plantar heel pain, characterised as pain at the medial hind foot. Exclusion criteria were: recurrent complaints of plantar heel pain for more than 2 years, complaints caused by trauma, earlier treatment for plantar heel pain by a podiatrist or with insoles, suspected (by the GP or sports physician) osteoarthritis in the subtalar or talonavicular joint, suspected tarsal tunnel syndrome, suspected stress fractures, infections or tumours in the painful foot, presence of systemic diseases  and insufficient understanding of the Dutch language. Patients who were regarded eligible by the GP or sports physician and were interested in the study were double screened on eligibility by the research assistant by telephone.Participants were randomised with the use of a computer-generated randomisation list using block randomisation with random block sizes between 3 and 10 with a 2:3:3 allocation randomisation ratio, to receive the following interventions:Referral to podiatrist for custom-made insole (custom-made insole).Referral to podiatrist for sham insole (sham).GP-led usual care .The randomisation list was created by an independent person (data manager) and the sequence was hidden from all involved researchers. Randomisation was stratified for type of referral (GP or sports physician). Patients were blinded to the type of insole they received. Podiatrists were blinded during the first consultation, but received information necessary to fabricate the insole after the first consultation and were no longer blinded afterwards. Podiatrists were instructed to not inform the patients about the allocation during the course of the study. GPs remained blinded as well as they did not receive any information on group allocation.Participants allocated to the usual care group received usual care by their GP or sports physician. This included a non-surgical approach and any intervention the physician considered to be necessary for each particular patient, except a referral to a podiatrist.Participants allocated to the custom-made insole group and the sham insole group, were referred to one of the 50 participating podiatrists. In the Netherlands, a podiatrist is a certified paramedical specialist providing podiatric care. Participants referred to a podiatrist received a standardised assessment, including the making of a 3D  imprint of the feet of the patient. After this intake, the podiatrist contacted the research team to receive the allocation of the patient. Consequently, participants randomised to the custom-made insole group received a custom-made insole, which was manufactured at the discretion of the individual podiatrist. Therefore, multiple approaches were used. The common goal was to influence the biomechanical process to reduce traction on the plantar aponeurosis and to reduce ground reaction force below the calcaneal tuberosity. To achieve this, most applied full-length insoles with shock absorbing material (PPT/Poron of 15 Shore A) at the calcaneus, with or without a shell shape under the attachment of the medial portion of the plantar aponeurosis. A corrective element for the calcaneus aimed to correct range of motion of the tarsus in frontal plane and often an additional arch support was applied. The material used for the insoles was of 30 to 60 Shore A. Participants randomised to the sham insole group received a sham insole that was designed for each participant (based on the 3D imprint) and designed to have the visual effect of a podiatric insole, but providing as little mechanical effect as possible. All sham insoles were produced by the same podiatrist after receiving the 3D imprint from the different podiatrists. The sham insoles were sent back to the different podiatrists to give to the patients. The detailed procedure for making the sham insole is described elsewhere.et al and Rathleff et alParticipants in all three groups received an information booklet with general information on plantar heel pain, as well as information on stretching and strengthening exercises, based on those described by Digiovanni Podiatrists were instructed to provide patients with the allocated insole and to provide exercises and shoe advice when needed and to withhold other interventions available to them. Physicians were instructed not to refer patients in the usual care group to a podiatrist during the study period. Other interventions, including the prescription of paracetamol or non-steroidal anti-inflammatory drugs, as well as all other co-interventions, were left to the physician’s decision.Participants completed online questionnaires at baseline, 2, 4, 6, 12 and 26 weeks of follow-up. At baseline, information on demographics including the activity score (in tertiles) based on the SQUASH questionnaire  was gathered.et al) on a scale of 0 to 100 between patients with a sham insole and custom-made insole at the 12-week follow-up.Sample size was based on the ability to detect a clinically relevant effect size of 0.5, translated to a difference in pain score of 10.5  and an increase in pain when wearing the insole .Predefined subgroup analyses were performed on participants with a duration of complaints <12 months at baseline (n=160), participants in which the podiatrist agreed with the referral (n=180) and patients with a high or intermediate activity (in tertiles) based on the SQUASH (n=124). These results are presented in 10.1136/bjsports-2019-101409.supp1Supplementary dataNo patients were involved in the planning and development of this study. The results will be disseminated directly to all participants via email.This study found no differences between a custom-made insole and a sham insole on pain, function, recovery or quality of life in patients with plantar heel pain. Patients with plantar heel pain treated with GP-led usual care experienced less pain, better function and greater improvement compared with patients allocated to the custom-made insole intervention. However, the differences found were small and did not reach clinical importance except for foot function.To our knowledge, this is the first randomised trial that compares the effectiveness between two commonly used treatment approaches: GP-led usual care versus referral to a podiatrist for custom-made insoles. Our results show no superiority of a custom-made insole over a sham insole and over usual care. Two systematic reviews found conflicting evidence for the effectiveness of custom-made insoles.This study adds to literature, since it provides a comparison of custom-made insoles and usual care of the GP in patients with plantar heel pain. Usual care in our study consisted of the care that the GP would normally provide for these patients and all participants additionally received an information booklet with exercises. Participants in the usual care group reported more visits to the GP and more use of freely available biomechanical interventions and corticosteroid injection as co-interventions at 12 weeks. Biomechanical interventions such as heel cups, and corticosteroid injections are common interventions by GPs.Information on adherence to the podiatry-led interventions was only collected at 26 weeks of follow-up and may be influenced by recall bias.The sham insoles may have mechanical effects on the foot, and blinding might be an issue.No patients were included by participating sports physicians. The study results might therefore not be generalisable to a population with a high activity level. Moreover, the inclusion of patients was based on the clinical diagnosis by the GP and we did not include the specific criteria of pain at palpation of the medial tubercle of the calcaneus, as in prior RCTs of plantar heel pain.One of our primary outcomes was pain at rest. We did not find any differences between the groups for this outcome at any time point, in contrast to pain during activity and first step pain. Scores for pain at rest were relatively low at baseline, which might reflect that walking after a period of inactivity is most burdensome for patients with plantar heel pain. Pain at rest may not be an appropriate outcome for patients with plantar heel pain.Since this is the first RCT in patients with plantar heel pain using usual care by the GP as a treatment arm, more studies on plantar heel pain including a comparison of usual care (GP-led or other) or watchful waiting are needed. When communicating to patients and clinicians about usual care, it is important to explain that this is not the same as doing nothing. Exercise-therapy and general advice should be included in these approaches. Taking the results of this study into account, GPs can apply a usual care approach, including different types of interventions, when treating plantar heel pain. Since custom-made insoles do not have an additional beneficial effect over sham insoles and GP-led usual care, healthcare providers should be reserved in prescribing custom-made insoles to patients with plantar heel pain.In patients with plantar heel pain in general practice, treatment with custom-made insoles does not have additional value compared with the usual care provided by the general practitioner.No differences were found between custom-made insole and sham insole treated patients with plantar heel pain.Healthcare providers such as GP’s and podiatrists should be reserved in prescribing custom-made insoles to patients with plantar heel pain.


Previous studies demonstrate routine overprescription of pain medications after total joint arthroplasty (TJA). A standardized reduced opioid prescription protocol for TJA was initiated at our institution, which we hypothesized would lead to a reduction in opioid consumption compared with patients who had surgery before initiation of the new protocol.We evaluated 97 consecutive opioid-naive patients undergoing primary total knee arthroplasty (TKA) and total hip arthroplasty (THA) using a standardized opioid prescription protocol (standardized group). A control subject group consisted of 99 patients undergoing TKA and THA just before the adaptation of the standardized prescribing protocol (historic group). Postoperatively, patients brought their remaining pain medication to their 1-month follow-up visit. The number of pills consumed was counted and converted into oral morphine equivalents (OME). Current pain level and the need for pain medication refill was assessed.P < 0.01). Refills were required in 50% of the standardized group and 29% of the historic group (P = 0.038). Average pain scores for the standardized and historic groups were 2.3 and 3.2, respectively (P = 0.057). Among THA patients, mean opioid consumption in the standardized group  was markedly less than the historic group  (both P < 0.01). Refills were required in 16% of the standardized group and 8% of the historic group (P = 0.263). Average pain scores for the standardized and historic groups were 1.7 and 1.8, respectively (P = 0.608).Among TKA patients, mean opioid consumption in the standardized group  was markedly less than the historic group  (both Initiation of a standardized opioid prescribing protocol after TJA for opioid-naive patients led to a reduction in opioid consumption, but resulted in an increased need for refills. We found that narcotic pain medications were overprescribed after both total knee arthroplasty (TKA) and total hip arthroplasty (THA) by 34% and 140%, respectively.Although previous studies evaluating reduced opioid protocols have demonstrated success in reducing OME prescribed to patients, no study to date has determined whether reduced standardized prescriptions lead to less opioid consumption or the amount of pills remaining in the patient's possession in the early postoperative period.The purpose of this observational follow-up study was to determine whether a standardized protocol for opioid prescriptions reduced pills remaining and opioid consumption. We hypothesized that patients would consume less OME and have less pills remaining with a standardized prescribing pattern.12A total of 97 patients undergoing primary THA and TKA from a single surgeon from July 2018 to January 2019 were prospectively selected to receive a standardized postoperative opioid prescription and compared with a historical cohort of 99 patients who underwent THA and TKA from July 2017 to January 2018. We included patients treated by a single surgeon to control for variability in surgical technique and perioperative pain management regimens. Patients were excluded if they underwent a revision surgery, had bilateral procedures, deviated from standard inpatient pain protocol outlined below, had incomplete data, or were discharged to a skilled nursing facility. Patients were also excluded if they had a history of opiate dependency or narcotic abuse, which was verified through the use of a government registry . We defined opioid dependency as use greater than 3 months before the patient's surgical procedure, which has been used as criteria in previous opioid-related research.In all patients, TKA was done through a standard medial parapatellar approach and THA through a standard posterolateral approach. Patients were mobilized on postoperative day 0 and were discharged once pain was adequately controlled, and they met physical therapy criteria. The mean length of stay was 1.3 days . All patients in both cohorts received a standard inpatient postoperative pain protocol including intravenous opioids for breakthrough pain in addition to oral narcotic pain medications. Patients received 5 or 10 mg of oxycodone for moderate or severe pain, respectively, with scheduled acetaminophen. Patients received celecoxib 200 mg twice daily while in the hospital. A short course of oral steroids was prescribed, in the form of dexamethasone 4 mg taper while in the hospital.Patients in the historic prescribing practice cohort were given a postoperative pain medication prescription at the inpatient provider's discretion. THA and TKA in the standardized prescription cohort were given 30 and 40 pills, respectively, with dose dependent on the patient's pain medication requirements while in the hospital.13 Pain scores were assessed using the Numeric Rating Scale. Refills of pain medication were retrieved through a government database and verified. The average number of refills per patient was defined as the total number of refills requested within the cohort (as some patients requested a refill more than once) divided by the total number of patients.Patient characteristics  and narcotic prescription information  were extracted from medical records and verified with the use of a government database . All patients were called before their 1-month follow-up visit and asked to bring their remaining prescription pain medication to their appointment. At the 1-month follow-up visit, the number of pain pills remaining in each patient's prescription bottle was manually counted and recorded. To account for the differences in types of opioids consumed, dosages were converted into OME using a common conversion formula.Descriptive statistics were used to summarize patient characteristics. Frequencies and ranges were used to summarize categorical variables, and mean values and SDs were calculated to summarize continuous variables. Differences in opioid consumption between historic and standardized prescribing practices were compared with regard to total number of pills prescribed, pills remaining, OME consumed, and average refills per patient. Statistical significance was set at α < 0.05. All tests were two-tailed.Ninety-seven patients (51 THA and 46 TKA) met the inclusion criteria and were included in the study. Patient demographics between the standardized prescription and historic group were comparable with regard to sex, age, body mass index, and duration of follow-up (Table P < 0.001) and THA . Patients had less pills remaining at their first follow-up for both TKA  and THA . Patients consumed significantly less pill quantities after TKA  and THA  with a standardized protocol along with less OME consumed in both TKA  and THA .Findings for both cohorts are summarized in Table P = 0.002) and THA  with a standardized protocol. The total number of refills per patient within the first month ranged from one to four times for TKA and one to three times for THA. The refill rate was higher in the standardized prescribing cohort with both TKA  and THA . There were more average refills per patient in the standardized prescribing group with both TKA  and THA .When comparing patients in each cohort who did not request a refill, OME consumed was also decreased in both TKA  and TKA  cohorts, although in both cases, differences were less than the minimum clinically important difference of that has been reported, and not statistically significant.14Pain scores were lower with standardized prescribing practices versus historic for both THA (1.8 versus 1.7, 13 Other previous studies have evaluated the number of prescriptions given to patients and the associated OME prescribed, but no study to the best of our knowledge has evaluated the actual amount of opioids consumed in the postdischarge period after TJA when a standardized protocol was implemented.16 This is the first study to demonstrate that with a reduced opioid prescription, the quantity of pills and OME consumed is also reduced after TJA.A previous study has suggested that similar to spine and upper extremity surgery, opioids are typically overprescribed for TJA, but there have been little data to suggest what an appropriate amount may be.Although it would be reasonable to expect that the OME consumed may be unchanged between cohorts with a reduced number of pills remaining. We found that the OME consumption also decreased by greater than 50% in both THA and TKA when standardizing the quantity of the initial postoperative prescription.This was not only found to apply to all patients but also in patients who did not request a refill. Patients who did not request a refill still consumed less OME with a standardized prescription. In the case of THA, this averaged to 37 fewer oxycodone 5 mg pills and in the case of TKA, 63 fewer oxycodone 5 mg pills in the first month when compared with our traditional prescribing practice.There have been concerns that with reduced amounts of opioids that patient perceived pain would be increased, although this does not seem to be the case with pain scores being comparable between both THA and TKA cohorts.16 Increased refills may also decrease opioid consumption. Patients who need a refill are typically advised to reduce their dosing or given lower strength prescriptions when compared with their initial postoperative prescription. They are also encouraged to use non-narcotic measures for pain control. Although there may be some benefit from the perspective of narcotic consumption when restricting postoperative pill quantities, this does have to be weighed against the time of office staff and providers to provide refills and counsel patients. An average refill rate per patient has not been reported previously and may be a useful metric in determining the extra resources that need to be dedicated to pursuing a standardized opioid protocol. Assuming a minimum of 10 minutes of staff time per refill to include counseling a patient, checking the government registry for abuse which is now required by law, and contacting a provider to approve a refill, at least an extra 5 minutes of staff and provider time for every TKA and 1 minute of time for every THA would need to be accounted for with our protocol.Previous studies have demonstrated that refill rates were not markedly changed when restricting postoperative opioid prescriptions, but we found an increase in the average number of refills per patient.15 We also found that this threshold may be reduced in the setting of THA.The strengths of this study include strict exclusion criteria and use of a sample of patients treated by a single surgeon to control for confounding variables with similar demographics. We physically counted the number of pills remaining for each patient as opposed to determining the number of prescriptions administered as has been done in previous studies to determine true consumption. We were also able to account for patients who requested multiple refills because this also has a magnified influence on provider time and resources when contrasted with determining percentage of patients who request a refill. We converted all medications to OME to account for different types of opioids prescribed. We believe these methods ensured that we were able to effectively capture all oral narcotics consumed. The use of a government registry also minimized concerns regarding recall bias or chart documentation as any narcotic prescriptions that were filled in the state by any provider postoperatively were accounted for. Our findings of the average OME consumption at 1 month are consistent with a previously cited study where the maximum prescription was 400 OME after TJA.There are some weaknesses associated with our study. Our sample size from a single institution is limited. For patients who received refills, we were unable to standardize what medications they had refilled. Given the nature of how patients experience pain, there was wide variation in how many pills patients consumed even in the setting of a standardized protocol. Given the wide variation in the number of pills consumed, future work will focus both on which group of patients it may be possible to further reduce or forego narcotic pain medication altogether and which groups in the opioid-naive patient cohort undergoing TJA may be at risk of requiring high doses of narcotics or have the potential for dependence.


Thoracic epidural analgesia is the standard postoperative pain management strategy in esophageal cancer surgery. However, paravertebral block analgesia may achieve comparable pain control while inducing less side effects, which may be beneficial for postoperative recovery. This study primarily aims to compare the postoperative quality of recovery between paravertebral catheter versus thoracic epidural analgesia in patients undergoing minimally invasive esophagectomy.This study represents a randomized controlled superiority trial. A total of 192 patients will be randomized in 4 Dutch high-volume centers for esophageal cancer surgery. Patients are eligible for inclusion if they are at least 18 years old, able to provide written informed consent and complete questionnaires in Dutch, scheduled to undergo minimally invasive esophagectomy with two-field lymphadenectomy and an intrathoracic anastomosis, and have no contra-indications to either epidural or paravertebral analgesia. The primary outcome is the quality of postoperative recovery, as measured by the Quality of Recovery-40 (QoR-40) questionnaire on the morning of postoperative day 3. Secondary outcomes include the QoR-40 questionnaire score Area Under the Curve on postoperative days 1–3, the integrated pain and systemic opioid score and patient satisfaction and pain experience according to the International Pain Outcomes (IPO) questionnaire, and cost-effectiveness. Furthermore, the groups will be compared regarding the need for additional rescue medication on postoperative days 0–3, technical failure of the pain treatment, duration of anesthesia, duration of surgery, total postoperative fluid administration day 0–3, postoperative vasopressor and inotrope use, length of urinary catheter use, length of hospital stay, postoperative complications, chronic pain at six months after surgery, and other adverse effects.In this study, it is hypothesized that paravertebral analgesia achieves comparable pain control while causing less side-effects such as hypotension when compared to epidural analgesia, leading to shorter postoperative length of stay on a monitored ward and superior quality of recovery. If this hypothesis is confirmed, the results of this study can be used to update the relevant guidelines on postoperative pain management for patients undergoing minimally invasive esophagectomy.NL8037. Registered 19 September 2019.Netherlands Trial Registry,  Esophageal cancer is the 9th most common cancer worldwide and is increasingly diagnosed in the Western world, mainly due to the growing incidence of adenocarcinoma . EsophagIn previous systematic reviews that included patients undergoing a variety of thoracotomy or thoracoscopy procedures (mostly lung surgery), paravertebral analgesia was found to achieve comparable pain relief while inducing less postoperative hypotension, urinary retention, and nausea when compared to epidural analgesia , 18. WhiMost available studies on the efficacy of paravertebral analgesia after esophagectomy are retrospective in nature and included patients who underwent resection by an open approach, implying a substantial risk of bias and the possibility that these results cannot be generalized to the setting of MIE. Therefore, the primary aim of the current study is to compare the postoperative quality of recovery between paravertebral and epidural analgesia in patients undergoing MIE. Secondary objectives are to compare the efficacy, side-effects, and cost-effectiveness between these analgesic modalities. The hypothesis of this study is that paravertebral analgesia achieves comparable pain control while causing less side-effects, leading to shorter length of stay on a monitored ward and superior postoperative quality of recovery compared to epidural analgesia.This study represents a multicenter randomized superiority controlled trial that is conducted in 4 Dutch high-volume centers for esophageal cancer surgery: (1) University Medical Center Utrecht, (2) Amsterdam UMC (3), Catharina Hospital Eindhoven, and (4) Hospital Group Twente Almelo. The current version of the study protocol (V1.2) was approved by the Medical Ethical Committee of the University Medical Center Utrecht (reference number 19–588) and was prospectively registered in the Netherlands Trial Registry . Amendments to the protocol will first be presented to the ethics board and the approved adjustments are then also processed in the Netherlands Trial Registry. As this study is considered to carry negligible risks for participating patients, a data monitoring committee (DMC) was judged to be redundant.Patients who are scheduled to undergo elective minimally invasive esophagectomy with two-field lymphadenectomy, gastric conduit reconstruction, and intrathoracic anastomosis (i.e. Ivor Lewis procedure) are eligible for participation and will be included according to the flowchart in Fig. The coordinating investigators and involved trial nurses will screen patients for eligibility and obtain informed consent during patients’ visits to the preoperative outpatient clinic. After inclusion and ultimately the day before surgery, one of the coordinating investigators or trial nurses will enter the patient in Castor EDC, which is the primary data capturing platform for this study and allows digital randomization. Randomization will be performed in a 1:1 ratio and stratified per including center to minimize the risk of center bias. The coordinating investigators of the study will ensure that patients receive the allocated analgesic modality at the time of esophagectomy. As a sham epidural catheterization would need to be performed prior to the induction of general anesthesia in the paravertebral group, which is considered unethical, patients will not be blinded. Health care providers will also not be blinded, since blinding would likely increase the risk of errors in pain management to an unacceptable extent.All patients will undergo MIE with two-field lymphadenectomy, gastric conduit reconstruction, and an intrathoracic anastomosis. The operation may be performed by conventional or robot-assisted thoracolaparoscopic surgery. The procedure starts with an abdominal laparoscopic phase, which involves mobilization of the stomach, abdominal lymphadenectomy and gastric conduit construction. Then, the patient will be placed in (semi) prone position for thoracoscopy to mobilize the esophagus and perform a mediastinal lymphadenectomy. One of the trocar ports is widened to a mini-thoracotomy for specimen extraction and when indicated, for the creation of the anastomosis. Gastrointestinal continuity is finally restored by a stapled or hand-sewn intrathoracic esophagogastric anastomosis. A maximum of one thoracic drain is placed on each side.At the start of the thoracic phase of MIE, the surgeon places a paravertebral catheter at level T4–5 under thoracoscopic vision. After administering an initial bolus of 20 mL of bupivacaine 0.125%, continuous infusion of bupivacaine 0.125% is started and postoperatively continued at an infusion rate of 8–12 mL/hour, depending on the patient’s weight and comfort. Patient-controlled intravenous opioid analgesia is additionally provided according to the local protocol in each center.An epidural catheter is placed by the anesthesiologist at an intervertebral level between T5 and T8 prior to the induction of general anesthesia. After induction, a bolus of 5–10 mL of bupivacaine 0.25% is administered and traditional continuous epidural analgesia is initiated (bupivacaine 0.125% + sufentanil 0.5 mcg/ml) in a dose of 6–14 mL/hour, depending on the patient’s weight and comfort. Patient-controlled intravenous opioid analgesia is provided as escape medication according to the local protocol in each center.The primary outcome measure is the total score on the Quality of Recovery 40 (QoR-40 ) questiohttps://www.castoredc.com) and the coordinating investigators will oversee the overall data collection process. Castor EDC generates a subject number for each patient and securely stores all entered research data in a pseudonymized fashion. A code file that links subjects numbers to individual patients will be securely stored in each center, and will only be accessible to authorized study staff. Collected baseline data , treatment details , and data regarding blood pressure  will be prospectively entered in a case report form with built-in validation checks. Patient-reported outcome measures (PROMs) will be collected during the postoperative hospitalization by asking patients to complete the QoR-40 and IPO questionnaires on postoperative days 1, 2, and 3. Furthermore, Quality of life questionnaires (EORTC QLQ-C30 and QLQ-OG25) will be sent to patients before surgery, at 3 months follow-up, and at 6 months follow-up after esophagectomy. Pain scores (VAS) at 3 and 6 months after esophagectomy will be collected and registered during the patients’ regular outpatient follow-up visits. The timeline of the study procedures is summarized in Fig. All data will be collected and stored in Castor EDC  QoR-40 measurement, age, and comorbidities will be included as potential confounders. Validity of the model  will be assessed by means of residue analysis. A per-protocol analysis will additionally be performed in the same manner. Analyses of the secondary outcomes are performed depending on data type and distribution. Chi-square tests will be performed for categorical data. The t-test or Mann-Whitney U test will be used to compare continuous outcomes with a normal or non-normal distribution, respectively.The study has started on December 3rd 2019. The first 24 months will be used for patient inclusion. After finishing patient inclusion, there will be 6 months of follow-up and an additional 6 months of data analysis.Thoracic epidural analgesia has long been the gold standard for pain management following esophagectomy. However, paravertebral analgesia is increasingly suggested as a good alternative for patients undergoing MIE, as the catheter can be placed under direct thoracoscopic vision possibly reduces the incidence of hypotensive events. Furthermore, by avoiding epidural catheterization and its potentially severe neurological complications, paravertebral analgesia may be safer. However, the currently available studies mainly included patients undergoing other thoracic surgical procedures and high-quality prospective studies investigating paravertebral analgesia for esophageal cancer surgery are lacking. Therefore, the PEPMEN study aims to compare paravertebral analgesia versus epidural analgesia in patients undergoing MIE by means of a prospective multicenter randomized controlled trial.Adequate analgesia is one of the key parts of enhanced recovery after surgery (ERAS) protocols for major surgical procedures, aiming to achieve effective pain control whilst avoiding the side-effects of high doses of systemic opioids. These aims were also described in the recently developed ERAS Society guidelines for esophagectomy, which state that regional analgesia should be the backbone of pain management in enhanced recovery after esophagectomy protocols . In abseIn contrast to epidural analgesia, paravertebral analgesia can only induce a unilateral sensory block of thoracic dermatomes. Nonetheless, this unilateral thoracic block is expected to achieve adequate control of chest pain after MIE, especially when combined with patient-controlled intravenous opioid analgesia as an escape for breakthrough discomfort . If paraOne might argue that the current randomized study design could be replaced by a prospective cohort study with sequential measurement of a control group followed by an intervention group which might be acceptable regarding the risk of selection bias, as the demographics of esophageal cancer patients are not expected to change within a period of a few years. However, it should be noted that the intraoperative techniques and perioperative facets of enhanced recovery protocols are continuously subjected to alterations based on new developments in the field of MIE. In case of a non-randomized sequential prospective design, changes in parts of the perioperative protocol during the study (e.g. the postoperative mobilization program) would not be possible without potentially inflicting a bias that significantly impacts the interpretability of the results. By choosing a randomized study design with stratification per center, the participating centers can still implement perioperative developments in other areas than the pain management regimen without compromising the reliability of the comparison between analgesic techniques.In summary, the PEPMEN study is a randomized controlled multicenter trial comparing paravertebral versus epidural analgesia in patients undergoing MIE in 4 high-volume centers for esophageal cancer surgery in the Netherlands. The primary endpoint will be the quality of recovery, as measured by the QoR-40 questionnaire on postoperative day 3. By improving the quality of recovery and shortening the length of stay on the ICU, paravertebral analgesia is expected to reduce the costs of perioperative care for patients undergoing MIE. A total sample size of 192 patients is required and the duration of the study will be 3 years.


Adductor canal block has become a popular mode of pain management after total knee arthroplasty. This study compared a single-injection adductor canal block (SACB) with continuous adductor canal block (CACB). The hypothesis was that the 2 groups would have equivalent analgesia at 48 hours post-neural blockade.This is a double-blinded, randomized, controlled, equivalency trial that is conducted at a single university hospital in China. A total of 60 patients who meet inclusion criteria are randomized in a ratio of 1:1 to either CACB (0.5% ropivacaine 20 mL followed by continuous infusion of 0.2% ropivacaine at 5 mL/h for 48 hours) or SACB (0.5% ropivacaine 20 mL) group. The primary outcome is pain scores at 48 hours utilizing the visual analog scale, whereas the secondary outcomes include opioid consumption, Timed Up & Go test, ambulation distances at discharge, length of stay, and maximal flexion at discharge. All pain scores are assessed by an independent observer who is blinded to the allocation of groups.This study has limited inclusion and exclusion criteria and a well-controlled intervention. This clinical trial is expected to provide evidence of better therapy for the pain management after total knee arthroplasty.This study protocol was registered in Research Registry (researchregistry5431). Previous study has shown that 23% of patients cite at home pain as “severe/extreme” after surgery, whereas 54% of the patients indicate “severe pain at least some of the time.” In addition, it has been suggested that severe pain can also interfere with the recovery process, which increases the risk of postoperative complications, including infection, joint loosening, and reflex sympathetic dystrophy.Currently, total knee arthroplasty (TKA) has been widely used in treatment for the elderly patients with end-stage osteoarthritis.,7 Recently, ACB has emerged as an alternative to femoral nerve block, with the advantage of sparing the motor nerve supply to most of the quadriceps muscle and may lead to a reduction in falls after surgery.,9 However, the optimal duration to maintain ACB is unknown. Some hospitals use a single shot adductor canal block (SACB), while others use a continuous catheter to maintain the infusion for 24 hours or 48 hours after surgery. The advantages of continuous infusion over a single injection are debatable. Critics argue that similar analgesia can be achieved with SACB, especially as the duration of the single-shot block can be extended over 12 hours in some patients, while the insertion and maintenance of continuous catheters is resource- and labor-intensive. Another argument against continuous infusion is that longer blocks may adversely affect physiotherapy and delay patient rehabilitation after surgery.,10At present, various techniques can be used to relieve postoperative pain, including epidural anesthesia, femoral nerve block, adductor canal block (ACB), and local infiltration analgesia. While femoral nerve block has traditionally been the gold standard for analgesia following TKA, it significantly impairs quadriceps motor function, which may interfere with rehabilitation and delay discharge.However, limited randomized clinical trials have been conducted to compare the efficacy of SACB with continuous adductor canal block (CACB) in patients undergoing TKA. The aim of the current study was to compare SACB and CACB techniques with regard to early period pain levels, need for additional opioids, and ambulation and functional scores in patients who had undergone primary TKA. We hypothesized that there was a significant difference between the CACB group and the SACB group in terms of postoperative analgesia, opioids consumption, ambulation ability, and early functional recovery after TKA.2This study was a prospective randomized blinded study, with a parallel design and an allocation ratio of 1:1 for the treatment groups. The study was approved by the Institutional Review Board in our hospital (PS2020037) and was registered in the Research Registry (researchregistry5431). Written informed consent was obtained from all subjects prior to enrolment. This study was performed and reported in accordance with the principles of the Declaration of Helsinki (2000).2.12 and allergy to local anesthetics, systemic opioids , or any of the drugs included in the multimodal perioperative pain protocol. We also excluded patients undergoing revision knee arthroplasty, those with impaired kidney function or a coagulopathy, and those with chronic pain syndromes or chronic opioid use. Chronic pain was defined as use of regular daily doses of systemic opioids in the 6 months prior to the surgery.The inclusion criteria were set as follows: osteoarthritis of the knee requiring primary TKA during hospitalization; patients that were over 18 years old and could cooperate with us for treatment and postoperative observation; American Society of Anesthesiologists status of I to III. Exclusion criteria included patients with a body mass index of ≥40 kg/m2.2A computer-generated randomization table was used for patient allocation to one of the 2 study groups: the SACB group or the CACB group. Each time a patient is included in the trial, the generated randomized number is assigned accordingly. The patients assigned an even number are allocated to the CACB group and those with an odd number are allocated to the SACB group. Patients’ assignments were written in a sealed envelope, which was only opened after the patient had consented to the study Fig. .2.32.3.1The ACB was performed while the patient remained under spinal anesthesia. A 13 to 6 MHz linear transducer on a SonoSite Edge ultrasound machine  was used to perform an anatomical survey of the medial thigh with identification of the femoral artery, sartorius and vastus medialis muscles. A 22G × 80 mm SonoPlex STIM needle  was introduced in plane lateral to medial and 20 mL of 0.5% ropivacaine was deposited at the midportion of the adductor canal with peri-arterial spread around the femoral artery as the end point.2.3.2Under ultrasound guidance as above, a 17G Tuohy needle  was introduced into the adductor canal. Following dilation of the adductor canal with normal saline, a 19G nerve catheter was threaded up to 3 to 5 cm beyond the needle tip. The guidewire was removed upon the catheter exiting the needle tip while threading to avoid inadvertent advancement of the catheter out of the space. The catheter was then manipulated and normal saline injected to confirm the catheter tip location within the adductor canal on ultrasound visualization, with peri-arterial spread as the endpoint. Up to 5 to 10 mL of normal saline was used in total per catheter placement. Twenty milliliter of 0.5% ropivacaine was then injected via the catheter, following which a continuous infusion of 0.2% ropivacaine commenced at 5 mL/h for 48 hours and then removed. On the ward, the infusion could be temporarily stopped to facilitate physiotherapy or mobilization with prompt resumption post activity. If the catheter failed, was replaced, or fell out after surgery, patients were withdrawn from the study.2.4Postoperative drainage lasted 1 to 2 days until flow volume was <30 mL. All patients received the same standardized postoperative multimodal pain protocol, with 4 doses of 1 g of acetaminophen, 2 doses of celecoxib 200 mg, and morphine (first 48 hours) or tramadol (after 48 hours) for pain exacerbations. All patients underwent the same postoperative rehabilitation program, with partial weight bearing with the use of crutches for the first postoperative day and active range of movement exercises.2.5At the time of admission, patients were explained about the visual analog scale, pain scale, and mobilization ability assessment. Patients were assessed for pain at 4, 8, 12, and 24 hours postoperatively, pain at rest, pain after mobilization on POD1 and POD2, opioid consumption, side effects if any. Ambulation ability was assessed 24 hours after the block, in form of Timed Up & Go (TUG) test, 10 m walk test, and 30 seconds chair stand test. Furthermore, ambulation distances at discharge, maximal flexion at discharge, and length of hospital stay were evaluated. Pain was evaluated on a VAS with 0 = no pain, and 100 = worst imaginable pain. The TUG test measures the time it takes a person to stand up from a chair, walk a distance of 3 m, and return to the chair. The 10-m walk test measures the time it takes to walk a distance of 10 m as quickly as possible. The 30-second Chair Stand test assesses how many times a person is able to rise from a chair and sit down again in 30 seconds, with the arms kept crossed over the chest. During the assessment of ambulation ability, use of gait aids was not allowed. The tests were only performed if the subject felt that it was possible without the risk of falling.2.6t test was used for comparison of continuous variables and Pearson chi-square test was used for comparison of categorical variables. Results were evaluated in a confidence interval of 95% and at a significance level of P < .05.Statistical analyses were conducted using SPSS v22.0 software . Conformity of the data to normal distribution was tested with the Kolmogorove–Smirnov test. Independent 2 samples 2.7The trial was designed to test equivalency between groups. Using an 11-point numerical pain scale (0–10), the study was powered to find that the 2 approaches to nerve blockade do not differ by >2-points on the pain scale . We used an alpha value of 0.05 and a power of 90%. Preliminary data from 50 subjects with a CACB following TKA at our institution showed a mean movement pain score at 36 hours of 5.08 and a standard deviation of 1.94. Power analysis determined that 26 patients in each group would be needed. Allowing for 10% dropout, 30 patients per group  were enrolled in the study.3–6 Moreover, few studies had demonstrated the superiority of ACB in preserving quadriceps muscle strength and thereby early mobilization compared with Femoral nerve block (FNB).–8 In addition, the administration of ACB may be accomplished either as a single shot injection or as a continuous block using epidural catheter and infusion. Furthermore, few studies in literature has studied the differences in efficacy of a SACB or CACB post-TKA.–13 Hence, an ideal regimen for adductor canal blockade to provide optimum pain relief and concomitantly promote early patient mobilization following TKA needs to be defined.ACB, an alternative form of peripheral nerve block, is almost a pure sensory nerve block. Several studies, in recent past, had reported the efficacy of ACB in management of analgesia following TKA.This trial has some limitations. First, the subjects may be exclusively Chinese. Therefore, the data from this clinical trial cannot be applied to other ethnic groups. Second, owing to the small sample size, the results of this study cannot be generalized. Despite these limitations, this trial is expected to provide evidence of better therapy for the pain management after total knee arthroplasty.Yulin Tao planned the study design and wrote the study protocol. Yulin Tao, Qingjun Mao, and Jixiang Wang reviewed the study protocol. Yulin Tao and Qingjun Mao will recruit participants and collect data. Yulin Tao wrote the manuscript. All of the authors have read, commented on, and contributed to the submitted manuscript.Jixiang Wang orcid: 0000-0002-8201-4515.


To assess knowledge and practice trends in managing acute pain in patients infected with human immunodeficiency virus (HIV+) or having acquired immunodeficiency syndrome (AIDS) among emergency physicians of four tertiary care hospitals. Acute pain management in such patients is complex because of multiple concomitant painful conditions related to their disease. After obtaining ethical approval and written informed consent, emergency physicians were requested to fill out a questionnaire.Out of 84 physicians who participated, 49 had managed HIV+/AIDS patients during the preceding year. Out of the 49, 30 (61.2%) physicians stated that they used a combination of analgesics for acute pain in these patients. Forty-two (50%) out of the 84 participants believed that routine doses of opioids were adequate for pain relief, while 42 (50%) agreed that pain management was more complex in these patients mainly due to presence of multiple coexisting problems and psychological issues. Only 26 (31%) respondents considered that pain was under-reported and under-treated in these patients, mainly because physicians were more focused on patients’ other disease related complications and issues. Formulation of guidelines are recommended for effective acute pain management in these patients encompassing associated issues, including concomitant painful conditions, opioid dependence, psychiatric problems, etc. Despite considerable research on pain management in recent decades, inadequate acute pain control is still a sizable problem, even more so in low- and middle-income countries . Some paAcute pain management in HIV+/AIDS patients is a complex task because of multiple concomitant painful conditions, for instance cellulitis, septic arthritis, abscesses, HIV+/AIDS related neuropathies, etc. , 3. A nuAccording to an estimate by The Joint United Nations Programme on HIV/AIDS (UNAIDS), there are approximately 130,000 people living with HIV in Pakistan . SeveralA cross-sectional survey was conducted at four tertiary care hospitals of a major city of a developing country after approval from Ethics Review Committees and individual written informed consent from participants. Two of the hospitals were 300 bedded and 500-bedded private hospitals, while two were large government hospitals with 1500-beds each. Emergency physicians, consultants and trainees with an experience of more than 1 year were included.A questionnaire was developed by the authors comprising of anaesthesiologists and emergency physicians. The questions pertained to physicians’ knowledge and practice about managing moderate to severe acute pain in HIV+/AIDS patients. In view of the research findings that HIV still carries a stigma in the authors’ country  and thatThe questionnaire was shared with two senior consultants of anaesthesiology and emergency medicine for feedback and suggestions. Following this five pilot sessions were conducted with senior emergency medicine trainees. Based on the feedback and finding of these sessions, survey questions were reviewed and modified. The questionnaire was administered by a research assistant trained by the primary investigator, who visited the study sites during each duty shift, obtained informed consent, distributed the questionnaires and collected filled out questionnaires after 1–2 h. The identity of participants was kept confidential by assigning a code number to each participant and each hospital. The filled out questionnaires were kept under lock and key and data were entered in a password-protected computer. Data were entered and analyzed using statistical packages for social science version 19 . All categorical variables were summarized as frequencies and percentages.Eighty-four physicians participated in the survey, 25 (29.8%) consultants and 59 (70.2%) trainees with more than 1-year experience. Questions were divided into two categories: practice-related and knowledge-related. Only two physicians had managed more than 80 HIV+/AIDS patients during the preceding year, while 35 had not managed any such patient. Thirty (61.2%) physicians, out of the 49 who had treated HIV+/AIDS patients in the preceding year, stated that they use a combination of analgesics for relieving acute pain in HIV+/AIDS patients, while the rest use single analgesic therapy. More responses to practice-related questions are provided in Table Regarding knowledge-related questions, 42 (50%) out of the 84 participants claimed that the usual routine doses of opioids are adequate for effective pain relief in HIV+/AIDS patients presenting with acute pain. Responses to knowledge-related questions are provided in Table Pain relief is a basic human right. Pain in HIV+/AIDS patients has been recognized as a major global healthcare problem . When thOnly two emergency physicians in our study had managed more than 80 HIV+/AIDS patients in the last 1-year, while majority of the respondents had managed less than 20 such patients (Table Around 61% of the respondents stated that they use a combination of analgesics for relieving moderate to severe acute pain in HIV+/AIDS patients. This is an encouraging response as multimodal analgesia is the recommended method for managing moderate to severe acute pain , using mFifty percent of the participants claimed that the routine doses of opioids are adequate for HIV+/AIDS patients presenting with moderate to severe acute pain. This is a misconception because chronic pain is commonly present in these patients , for whiThirteen participants stated that the reason for complexity in pain management in HIV+/AIDS patients was the multiple health problems that co-existed in these patients. This is a correct perception as these patients often suffer with peripheral neuropathy, painful dermatitis, infections, and other pain syndromes, thus having pain of varying severity in their daily lives , 12. FivOnly 31% respondents agreed that pain is under-reported and under-treated in HIV+/AIDS patients. Parker et al. have reported marked under-treatment of pain in HIV+/AIDS patients . They haEffective acute pain management depends upon multiple factors including the available resources. When using multi-modal analgesia involving strong analgesics, physicians in emergency department need to be aware of the side effects and complications involved and be prepared to diagnose and treat them. Optimal pain relief in these patients may require a multidisciplinary approach , 22. In We discovered considerable gaps in emergency physicians’ knowledge regarding acute pain management in HIV+/AIDS patients. Best approach is to use a multimodal analgesic regime modified according to the available resources. The authors strongly recommend formulation of guidelines for effective acute pain management in these patients, encompassing associated issues, such as concomitant chronic pain conditions, opioid dependence, psychiatric problems, etc.A limitation of our survey is that, in addition to consultants, we have included trainee emergency physicians with more than 1-year experience. The reason for this was that trainees are usually the first respondents when patients present in the emergency room following acute trauma and other acute conditions and therefore manage the patients at the time of maximum pain intensity. They should therefore be knowledgeable about the specific concerns regarding acute pain management in this patient population.


Study findings reveal continued opioid reduction and enduring pain stability for a substantial fraction of patients, 2 to 3 years after a patient-centered voluntary opioid tapering program. We previously reported promising results for a 4-month patient-centered voluntary opioid tapering study. Key questions remain about the durability of effects and possible risks after opioid reduction. We provide the longest follow-up data to date for prospective opioid tapering: 2- to 3-year follow-up for pain intensity and daily opioid use in a subset of patients from our original 4-month opioid tapering study.Twenty-three patients  responded to contact attempts through telephone and reported their average pain intensity and current opioid use. Opioid doses were converted to morphine equivalent daily dose (MEDD). Data were analyzed within a repeated-measures model where time  was the within-subject factor.Among reachable patients, the effect of time on change in MEDD from baseline to 4 months to 2 to 3 years was significant. Since baseline, 20 (95%) of the current sample reduced MEDD, and 15 (71%) further reduced MEDD at 2- to 3-year follow-up. There was no effect of time on change in pain intensity from baseline to 4 months to 2 to 3 years. Since baseline, 11 (52%) of the current sample reported pain reduction, and 12 (57%) reported reduced pain from the 4-month follow-up to the 2- to 3-year follow-up. Five (24%) reported increased pain intensity.Study findings reveal continued MEDD reduction and enduring pain stability 2 to 3 years after a patient-centered voluntary opioid tapering program for a substantial fraction of patients. Notably, we were not able to verify current opioid use through medical records and were limited by self-report. Recent work also indicates increased risks of opioid overdose and suicide for veterans after opioid tapering.10 More recently, a study by Nicholas et al.9 showed that after cognitive-behavioral therapy-based interdisciplinary treatment for chronic pain, the use of opioids was significantly reduced, and these gains were maintained over the 12-month follow-up.Research on prescription opioid tapering is scant, low in quality, and minimal data exist for tapering outcomes exceeding 1 year.3 Patients with noncancer chronic pain taking long-term opioids at community suburban and rural pain clinics were provided education about the benefits of opioid reduction  by their prescribing physician. Physicians offered to partner with patients to slowly reduce their opioids and arrive at their lowest comfortable dose at 4 months. Patients were able to control the pace of their taper, pause their taper, and stop their taper if they wished; importantly, the taper progam was not unidirectional, thereby allowing physicians to address the needs of the individual patient. Patients reported average morphine equivalent daily dose (MEDD) decreases of roughly 50% at 4 months with stable pain intensity. Although promising, questions remain about the durability of these effects. Furthermore, detailed data are lacking for individual long-term taper outcomes. The current study aimed to report long-term outcomes on pain intensity and daily opioid use for the subset of voluntarily tapered patients we were able to contact.Better data are needed to understand how tapering methodology—including voluntary vs involuntary patient participation—impacts safety and outcomes. We previously reported results for a 4-month voluntary patient-centered opioid tapering study in 51 patients from Colorado.Using email and telephone outreach up to 3 years later, we made contact with 44% of our original sample  and 1 additional patient who was not reached at the initial follow-up. Brief telephone interviews were used to collect average pain intensity and current opioid use. Average pain intensity was assessed by asking patients, “In the past 7 days, how intense was your average pain?” on a scale from 0 (no pain) to 10 (the worst pain imaginable). Current opioid use was assessed by initially asking patients a binary (yes/no) question, “Are you currently taking opioid medication?” followed by a drop-down menu of opioid medication options, including the respective dose options, frequency, and total milligrams taken per day.All patients had new prescribers at the time of this survey, and medical records were unavailable. There were no Colorado death records for the unreachable 29 patients. Study procedures were approved by the Stanford University Institutional Review Board.We converted opioid doses to MEDD using the conversion guidelines provided by the Centers for Medicare and Medicaid Services. Change in MEDD from baseline was the primary outcome, and pain intensity was secondary. Data were analyzed within a repeated-measures model where time  was the within-subject factor. We hypothesized continued reduction in MEDD over time with stable pain report.Among reachable patients (n = 23), average age (SD) was 51 (13) years, and 11 (48%) were women. Twenty-nine of 52 enrolled patients (56%) did not respond to contact attempts and therefore are not included in this follow-up report. However, 2 of the patients were on suboxone and were therefore excluded from follow-up analyses involving change in MEDD and pain intensity. Table P < 0.0001); the reduction in MEDD from 4 months  to 2 to 3 years  was significant (P = 0.012). Similarly, the reduction in MEDD from baseline to 2- to 3-year follow-up was significant (P < 0.0001) . Age inversely predicted change in pain intensity from baseline to 2- to 3-year follow-up and was included as a covariate in the final model.P = 0.15); the reduction in average pain intensity from 4 months  to 2 to 3 years  was also not significant (P = 0.63). Similarly, the reduction in average pain intensity from baseline to 2- to 3-year follow-up was not significant (P = 0.16)  had poor long-term outcome in terms of increased pain. Future research should focus on meeting the needs of patients who report increased pain with opioid reduction, and we recognize that opioids may be an essential part of their care plan.Fourth, because of changes in medical care, we were not able to verify current opioid use through medical records, and study data are limited by self-report. A fifth and final consideration is the brief patient assessment, which was a strategic effort to increase patient engagement and data collection. However, our ultrabrief survey precluded our ability to determine whether other pain management or nonpharmacological interventions were trialed by patients in the intervening timeframe.Despite the aforementioned limitations, our brief report provides evidence for continued opioid reduction and enduring pain stability for some patients. Our low-cost, scalable, and patient-centered voluntary opioid tapering methods seem to have long-term efficacy for a substantial fraction of patients, a point that may offer hope and reassurance to many patients who may wish to reduce prescriptions but are ambivalent because of a lack of long-term outcomes data. Finally, we strongly underscore the need to better characterize and treat patients who do poorly with voluntary opioid tapering and for whom opioid reduction may be contraindicated and/or other pain management strategies are required.The authors have no conflicts of interest to declare.


Pain ratings reported by patients with cancer continue to increase, and numerous computer and phone apps for managing cancer-related pain have been developed recently; however, whether these apps effectively alleviate patients’ pain remains unknown.This study aimed to comprehensively evaluate the role of mobile apps in the management of cancer pain.Literature on the use of apps for cancer pain management and interventions, published before August 2019, was retrieved from the following databases: MEDLINE, Embase, Cochrane, CINAHL, Scopus, and PsycINFO. The effects of apps on cancer pain were evaluated using RevMan5.3 software, and the rates of adverse drug reactions were analyzed using the R Statistical Software Package 3.5.3.2=62%, P=.02). We then used apps that have an instant messaging module for subgroup analysis; these apps significantly reduced patients’ pain scores . Patients using apps without an instant messaging module did not see a reduction in the pain score . Overall, patients were highly satisfied with using apps. Other outcomes, such as pain catastrophizing or quality of life, demonstrated greater improvement in patients using apps with instant messaging modules compared with patients not using an app.A total of 13 studies were selected for the analysis: 5 randomized controlled trials (RCTs), 4 before-after studies, 2 single-arm trials, 1 prospective cohort study, and 1 prospective descriptive study. The 5 RCTs reported data for 487 patients (240 patients in the intervention group and 247 patients in the control group), and the remaining studies reported data for 428 patients. We conducted a meta-analysis of the RCTs. According to the meta-analysis, apps can significantly reduce pain scores (mean difference [MD]=–0.50, 95% CI –0.94 to –0.07, IThe use of apps with instant messaging modules is associated with reduced pain scores in patients with cancer-related pain, and patient acceptance of these apps is high. Apps without instant messaging modules are associated with relatively higher pain scores. The presence of an instant messaging module may be a key factor affecting the effect of an app on cancer pain. According to the 2018 global cancer statistics, there were approximately 18.19 million new cases of cancer . AccordiDue to differences in treatment levels, cancer pain that is not adequately controlled is still widespread in developing countries . AccordiWith the development of the Internet, the number of health-related apps is growing rapidly, including apps for monitoring and managing diseases ,7-9. AppIt is not clear whether using an app to manage cancer pain can improve pain relief rating or which module type is the most effective in terms of app usability and pain management. Therefore, we conducted a systematic review and meta-analysis of studies of apps intended to manage cancer-related pain to explore whether these apps can improve pain relief ratings for patients with cancer and identify which modules increase the app’s effectiveness for managing pain.Eligible studies were identified by searching Medline, Embase, Cochrane, CINAHL, psycINFO, and other relevant databases, and the results were combined using the literature traceability method. Searches were conducted on August 1, 2019. Search keywords included “cancer pain+,” “cancer pain management+,” “mobile phone,” “+,“ ”Mobile Devices,“ ”Mobile Apps,“ and ”mHealth.“ Search strategies are detailed in Studies were included when they (1) focused on patients with cancer pain, (2) involved an intervention using apps downloaded and registered on either a mobile phone or computer for the management of cancer pain, (3) used the numeric rating scale to assess pain, (4) included patients that were followed up for more than a week, and (5) reported the results in English.Studies were excluded when (1) the study type was a review, model study, literature review, or conference summary; (2) the results of the study used scales other than the numeric rating scale or did not report the pain score; (3) the study intervention was a telephone conversation; or (4) the study was a duplicate report.All reference titles and abstracts were initially screened for relevance by two reviewers. Afterward, full-text analysis for eligibility was independently performed by Caiyun Zheng and Lizhu Weng. Disagreements were resolved by discussion and consensus or third-party arbitration.The required data were extracted by a researcher using a literature data extraction table, and another researcher confirmed the accuracy and authenticity of the data. The extracted content included study information , baseline characteristics of the study subjects , specific details of the app intervention, pain scores for up to 12 months of intervention, and other outcome indicators .Risk assessment of the included RCTs was performed using the Cochrane risk of bias tool based on the Cochrane Systematic Review Manual's literature evaluation criteria.2. Values of P≥.05 and I2 ≤50% were considered to represent no heterogeneity, and a fixed-effect model was used. If P<.05 and I2>50%, a random-effects model was used, followed by subgroup analysis to identify the cause of heterogeneity [Meta-analysis of RCTs was performed using RevMan5.3 software. Heterogeneity was assessed using the chi-squared test, and quantitative analysis was performed using Iogeneity .A total of 11,217 articles were retrieved from the systematic literature search, and 4 articles were retrieved by other means, totaling 11,221 articles. After removing duplicate studies, the remaining 8640 were screened. After reading 40 eligible full-text articles, 27 were excluded, and 13 were selected -28. The The 5 RCTs included a total of 487 patients: 240 patients in the intervention group and 247 patients in the control group. The remaining studies reported data for 428 patients. General information from the studies is shown in 2=62%, P=.02). Subgroup analysis was performed for apps with instant messaging modules. Instant messaging modules are a channel for real-time communication between patients and medical staff. Patients who used apps with instant messaging modules had lower pain scores  than patients who used apps without an instant messaging module  showed similar results to the studies included in our analysis. Schatz et al  used smaThis study found that patients with cancer might benefit from the use of apps for cancer pain management, especially those with instant messaging modules, which can reduce pain scores in cancer patients. Patient acceptance of these apps is high. At the same time, the app has a palliative effect on patients’ cancer pain and other cancer-related symptoms. Pain management apps with instant messaging modules provide the ability to connect patients and medical professionals with a convenient learning channel, especially in outpatient clinics and for patients living in remote areas with less access to doctors and medical support. Therefore, the findings of this study can guide the development of cancer pain apps, help optimize app modules, and narrow the gap between doctors and patients to achieve better control of cancer-related pain.