F = 4.29, <0.05, MSE = 46.00]. Similarly, one of the secondary pain measures, “lowest pain during wound care” was significantly lower in the VR group, No VR = 4.29 (SD = 3.75) vs. 1.68 (2.04) for the VR group, F(147) = 9.29, < 0.005, MSE = 83.52 for Study Day 1. The other secondary pain measures showed the predicted pattern on Study Day 1, but were non-significant. Regarding whether VR reduced pain beyond Study Day 1, absolute change in pain intensity  was significantly greater for the VR group, F(148) = 4.88, p < 0.05, MSE = 34.26, partial eta squared = 0.09, but contrary to predictions, absolute change scores were non-significant for all secondary measures.The objective of this study was to compare the effect of adjunctive virtual reality vs. standard analgesic pain medications during burn wound cleaning/debridement. Participants were predominantly Hispanic children aged 6–17 years of age, with large severe burn injuries (TBSA = 44%) reporting moderate or higher baseline pain during burn wound care. Using a randomized between-groups design, participants were randomly assigned to one of two groups, (a) the Control Group = pain medications only or (b) the VR Group = pain medications + virtual reality. A total of 50 children (88% Hispanic) with large severe burns (mean TBSA > 10%) received severe burn wound cleaning sessions. For the primary outcome measure of worst pain (intensity) on Study Day 1, using a between groups ANOVA, burn injured children in the group that received virtual reality during wound care showed significantly less pain intensity than the No VR control group, [mean worst pain ratings for the No VR group = 7.46 (SD = 2.93) vs. 5.54 (SD = 3.56),  Excessive acute pain during medical procedures is a common problem for a wide range of patient populations. As an extreme example, children recovering from large severe burn injuries frequently receive painful burn wound cleaning procedures several times a week, often daily, during hospitalization. Acute procedural pain during burn wound debridement is often difficult to control, despite pre-medicating patients with powerful traditional pharmacologic analgesics before wound care . Opioid Anxiety, fear, anticipation of pain , stimuluvia attention distraction  context. In their recent study, 48 pediatric patients with large burn injuries (40% TBSA) received VR vs. No VR during different portions of the same wound care session, in an ICU tank room setting. Patients reported significantly lower pain intensity during burn wound care when they were in VR (SnowWorld) vs. during No VR (pain medications only) and patients continued to report the predicted pattern of less pain and more fun during multiple wound care sessions .As the next step, using a randomized between-groups design, the current study compares pain during wound care with one group receiving adjunctive virtual reality and another group receiving No VR (standard of care pain medications).www.wma.net), with approval from the University of Texas Medical Branch Ethics Committee Internal Review Board, and all participants and their parents/legal guardians provided their written informed consent/assent in accordance with the Declaration of Helsinki.The current study was conducted between July 2015 and December 2017, in accordance with the Declaration of the World Medical Association  were transported to the burn center in Galveston Texas from Latin American countries and treated with support from humanitarian philanthropies in both the USA and Mexico. Such children received in house treatment in Galveston and returned to their home countries after discharge.Children were included in the current study if they were cooperative and able to answer the questionnaire, did not have a history of previous psychiatric (DSM-5 Axis I) disorder(s), did not have delirium, psychosis, or any form of organic brain disorder, were able to speak and understand English or Spanish, if they reported at least moderate worst pain intensity  during a No VR baseline wound care session, if they were admitted to the regional burn center in Texas and completed at least one baseline wound care session and one study day wound care session. Children were excluded from the study if the amount of skin burned was less than 10% TBSA, if they were unable to complete the study measures, if the patient did not require at least one study day wound cleaning session, if the patient had a previous history of psychiatric (DSM-5 Axis I) disorder(s), was currently showing evidence of delirium, psychosis, or an organic brain disorder, if the patient was not able to speak and understand English or Spanish, had a previous medical history of significant endocrine, cardiac, neurologic, respiratory, metabolic, genitourinary, or gastrointestinal impairment, if the patient was being treated for alcohol or drug withdrawal, was developmentally disabled, was less than 6 years old, over 17 years old, unable to use the VR equipment due to burns , or had a previous history of extreme sensitivity to severe motion sickness.NVISinc.com, with 90 degrees diagonal field of view, per eye , and 1,280 × 1,024 pixels resolution per eye. The VR goggles largely obscured the patients view of the wound care and substituted pleasant computer simulated imagery of SnowWorld viewed through the VR goggles. In SnowWorld, patients floated slowly through a 3D canyon, with an icy river flowing at the bottom of the canyon. They could see Snowmen, igloos, wooly mammoths, and flying fish in the virtual world. When interviewing patients and nursing staff when designing SnowWorld, some burn patients reported that wound care and the associated pain reminded them of the fire in which they were originally burned. SnowWorld was designed to be the antithesis of fire, to help patients avoid their pain during wound care, and to help patients avoid thinking about fire during wound care, in a simple environment that is easy to render, attention grabbing  but non-nauseogenic with passive navigation, and canyon walls that discourage wild changes in viewpoint , to help increase patients’ illusion of “being in a place” in the computer-generated world.Head and face burns are common for this patient population and can make it challenging or impossible for severe burn patients to wear a conventional VR helmet. Furthermore, conventional VR helmets are designed to be worn by a person that is either standing or sitting, whereas many burn patients are laying on their back on a shower table during wound care in the ICU. In the current study, a battery powered VR system was brought into the wound care room on an Anthro medical cart. Instead of wearing a head mounted display, a special robot-like arm goggle suspension system mounted to the cart allowed researchers to position the VR goggles near the patients head, without touching the patient, so the patient could look into the VR goggles without wearing a helmet. The goggles used were MX90 VR goggles, from iewpoint , p. 106.The VR system was approved for use in the ICU and was periodically inspected by clinical engineering and infection control. Cleanliness of the VR equipment was also periodically monitored by infection control at the treating hospital. In compliance with institutional infection control, clear disposable plastic was used to further reduce contact between the patient and the VR eyepieces and mouse, and the disposable plastic coverings were thrown away after each use. Chemical disinfectants were used to carefully clean the VR equipment after each use, and an ultraviolet radiation UV sterilization lamp was also sometimes used. For infection control, cotton swabs were periodically rubbed on the VR equipment  to detect if any pathogenic bacteria were present. The researchers sent culture samples to the microbiology testing laboratory at the treating institution. All post-cleaning tests were returned with no evidence of pathogens.The current study measures included “Time spent thinking about pain during burn wound care,” (a measure of the cognitive component of pain), pain unpleasantness , worst pain (a measure of the pain intensity), and lowest pain.Previous studies have shown that pain unpleasantness and worst pain are separate components of the pain experience that are sometimes differentially activated and can activate different parts of the brain . For exaUsing Graphic Rating Scales (GRS), shortly after the wound cleaning session, all patients retrospectively rated their worst pain during wound care during a “no VR” baseline wound care session. Similarly, patients retrospectively rated their worst pain shortly after their wound care session on each study day. The GRS is a horizontal line labeled with the numbers 0 to 10, with word descriptors under the numbers.Shortly after each wound cleaning session was completed , patients were given the following instructions prior to giving six separate ratings: “Please indicate how you felt during the wound cleaning session just completed by making a mark anywhere on the line. Your response doesn’t have to be a whole number.” A pictorial example of the labeled graphic rating scale was shown for each question. Rate your WORST pain during wound care. 0 = no pain at all, 1−4 = mild pain, 5−6 = moderate pain, 7−9 = severe pain, 10 = excruciating pain.Rate your WORST PAIN intensity during that wound care:How much TIME did you spend thinking about pain? 0 = none of the time, 1−4 = some of the time, 5 = half of the time, 6−9 = most of the time, 10 = all of the time. How UNPLEASANT was the most recent wound session? 0 = not unpleasant at all, 1−4 = mildly unpleasant, 5−6 = moderately unpleasant, 7−9 = severely unpleasant, and 10 = excruciatingly unpleasant. Rate your LOWEST pain during wound care. 0 = no pain at all, 1−4 = mild pain, 5−6 = moderate pain, 7−9 = severe pain, 10 = excruciating pain. How much FUN did you have during wound care? 0 = No fun at all, 1−4 = mildly fun, 5−6 = moderately fun, 7−9 = pretty fun, 10 = extremely fun. How much did you feel NAUSEA (sick to your stomach) during the most recent wound care session? 0 = no nausea, 1−4 = mild nausea, 5−6 = moderate nausea, 7−9 = severe nausea, 10 = vomit.On Study Day 1, patients in the VR Group were asked two extra questions  is one of the most reliable and valid subjective measures of pain . “The virandom.org and using blocked randomization  to help equalize the final group sizes.In the current between-groups study design, pediatric patients with large severe burn injuries were randomized to one of two groups, using random sequences generated at Each subject received standard pre-procedure pharmacologic analgesia, according to the published guidelines used at this hospital , p. 694;The wound care sessions began with a nurse cutting off, removing, and throwing away the gauze bandages, using warm water from a hand held medical shower hose, and wet washcloths to clean debris out of the patients wounds, and applying disinfectant and fresh bandages see . All patwww.vrpain.com), patients floated slowly through a snowy 3D virtual reality canyon they could see in the VR goggles. In the current study, the patient’s head and body remained still during wound care, and instead of moving their head to look around the virtual world (head tracking), patients used a wireless computer mouse to look around, aim and throw snowballs at snowmen, penguins, igloos, flying fish, and wooly mammoths. Subjects received converging sensory input from real time sound effects synchronized with the visual effects in VR . The sound effects were mixed with upbeat music in the background .Patients randomly assigned to the VR group interacted with a virtual environment named SnowWorld for Study Day 1 for up to 10 study days. The original version of SnowWorld , 2004a wShortly after each burn wound debridement/cleaning session, the pediatric patients briefly answered retrospective graphic rating scale questions to measure their subjective pain ratings. The patient received fresh bandages on their burns, and the patient was returned to their room. The VR system was cleaned/disinfected and was removed from the wound care room.This study was conducted between July 2015 and December 2017. Out of 62 patients initially screened, 50 pediatric patients met our apriori inclusion criterion of having a moderate or higher “worst pain” rating during the baseline wound care session with No VR . Eighty-four percent of the patients were male, and 16% were female. Most patients in the current study had burns covering nearly half of their bodies . In other words, the smallest burn wound was 14% of his/her body (TBSA), and the patient with the largest burn was burned on 86% of his/her body. Patients’ ages ranged from 6 to 17 years of age at the time of enrollment. Sixty-eight percent of the patients had hand burns, 76% had arm burns, 29% had foot burns, 59% had leg burns, 63% had head/neck burns, 76% had trunk/torso burns, and 12% had groin burns. The etiologies of the burns were as follows: Flame = 66%, electrical = 27%, scald = 7.3%, chemical = 2%, other = 4.9%. The mean duration of wound care on baseline was 23.81 min (SD = 6.87) for the control group vs. 23.40 min (SD = 8.28) for the VR group. The mean duration of wound care on Day 1 was 24.05 min (SD = 7.35) for the control group vs. 20.20 min (SD = 7.43) for the VR group.As in most or all of the previous studies by our team  = 4.29, p < 0.05, MS = 46.00, partial eta squared = 0.08, observed power = 0.53.Using a Between Groups One-Way ANOVA, for the primary outcome measure of worst pain intensity on Study Day 1, burn injured children in the group who received the custom articulated arm mounted water-friendly virtual reality treatment during wound care in the current study reported significantly less “worst pain intensity” than the No VR control group. On Study Day 1, on a 0 to 10 scale, the mean worst pain score for the No VR Control Group was 7.46 (SD = 2.93), and was 5.54 (SD = 3.56) for the Yes VR group, F = 4.88, p < 0.05, MSE = 34.26, partial eta squared = 0.09, , observed power = 0.58. In other words, overall, patients in the VR group continued to show small but significant reductions in worst pain ratings, beyond Study Day 1. On average, patients in the No VR group participated for 6 study days , and patients in the VR group also participated for an average of6 study days with VR .In addition, absolute difference scores were calculated  = 9.29 . In other words, least pain was significantly lower for the VR group. The results of the other secondary measures were non-significant but showed the predicted pattern on Study Day 1.Using a Between Groups One-Way ANOVA, for the secondary measure of patients ratings of “lowest pain during wound care,” (where lower is better), on Study Day 1, the No VR control group mean was 4.29 (SD = 3.75) as opposed to 1.68 during the Yes VR Group, F = 1.72, p = 0.20 NS.Time spent thinking about pain during wound care (24% lower for the VR Group), for the No VR control group mean was 6.33 (4.26) as opposed to 4.88 (3.54) during the Yes VR Group, F1,48), for the No VR control group mean was 5.29 (3.59) as opposed to 4.96 (3.66) during the Yes VR Group, F = 372, MS = 56.33, p = 0.06 NS, partial eta = 0.08, power = 0.47.Fun during wound care (44% higher fun for the VR group). Fun during the No VR control group mean was 2.97 (3.81) as opposed to 4.96 (3.97) during the Yes VR Group, VR nausea was very low , and subjects in the VR group reported a moderate illusion of “being there” in virtual reality and reported that the virtual objects looked moderately real.1 were non-significant for all secondary pain measures: Time spent thinking about pain, F < 1, NS, pain unpleasantness, F < 1, NS, Lowest pain, F = 2.67, p = 11 NS, MSE = 18.14, partial eta squared = 0.06, pain unpleasantness, F < 1, NS, and on a surrogate measure of positive emotional affect, Fun during wound care, F < 1, NS. One factor contributing to the finding that the primary measure was significant, and the secondary measures were not, is that there was more variance (noise) in the results of the secondary measures.Using Between Group ANOVA’s comparing the No VR group vs. the VR group, absolute difference scoresThe current study examined whether VR could help reduce pain during one of the most painful procedures in medicine. To our knowledge, this is the first randomized between-group study of children with large severe burn injuries to test whether virtual reality can reduce procedural pain. Despite the challenges of using VR in the ICU hydro tank to treat children with unusually large severe burn injuries, patients reported significant reductions in worst pain on Study Day 1 (25% less pain intensity/worst pain in the VR Group than the Control Group). In addition, the “lowest pain” the patient felt during wound care on Study Day 1 was significantly lower in the VR group (60% lower for the VR group than for the Control group). Patients in the VR group reported a moderate illusion of going inside the VR SnowWorld game, they rated the virtual objects as moderately real, and VR nausea was near zero, perhaps due in part to the lack of head movement. To summarize the secondary measure results on Study Day 1, as predicted, the secondary measure of patient’s “lowest pain” rating was significantly lower in the VR group on Study Day 1, and the results of all other secondary pain measures showed the predicted pattern of results but were non-significant on Study Day 1. The treatment duration of > 20 min for each group is an unusually long wound care duration compared to previous VR studies .In light of the current opioid overdose death epidemic , the medAt the time that this study began in 2015, the portable water-friendly VR system used in the current study had exceptionally large wide field of view military grade VR goggles . This extra peripheral vision of the MX90 VR goggles was designed to increase the patients illusion of presence , to makeThe current study had a number of limitations that should be taken into consideration when interpreting the results. All of the 50 pediatric patients in the current study were children, and most (88%) were from Latin America, and spoke Spanish, and the current study focused exclusively on severely burned children, which further limits generalizability of the current findings. The water friendly VR system used in the current study was custom designed for patients with head and face burns. Patients could not be blind to  the research demands within the VR condition. The children were likely able to directly connect study questions to the use of VR equipment. Future randomized controlled between group research studies are needed, ideally blinding patients to treatment conditions, to reduce bias . One posThe water-friendly VR system used in the current study was customized to minimize or ideally eliminate physical contact between the VR goggles and the burn patient. Patients used mouse tracking to look around and throw snowballs. However, the patients could not move their heads around to look around in virtual reality like they could with a conventional head tracked VR helmet. For this reason, one limitation of the current VR system is that, although having a wide field of view and being highly interactive, the water-friendly VR system was not fully immersive (no head tracking).Another important limitation is that the current study does not explore why VR reduces patients’ pain. The logic of why VR reduces pain often assumes an attentional mechanism . HoweverIn spite of these limitations, the current study makes several important contributions to the literature, with important implications for clinical practice. This is the first randomized between group study to measure VR pain reduction in the ICU, in predominantly Latino pediatric patients with unusually large severe burn injuries. The current study replicates our recent previous pilot findings that children with large severe burns were generally able to engage in a computer generated world during severely painful medical procedures, and results support our previous results showing that VR significantly reduced patients’ worst pain ratings during wound care . These rAlthough the VR group reported significantly less pain intensity (worst pain ratings) during wound care, the lack of significant results on most of the secondary measures indicate that a stronger dose of VR is needed. Additional research and development of more effective VR pain reduction systems is recommended. Improvements to the VR system to increase the illusion of presence could make the VR system more immersive, and we predict, can significantly further increase how much pain is reduced. More immersive VR systems with a wider field of view , increasBurn patients often become anxious before their wound care sessions. They ruminate about previous painful wound care sessions and anticipate that the wound care session they are about to receive is going to be painful. They may catastrophize or have exaggerated fears about how much pain they will experience during wound care. Future studies should explore the use of virtual reality during the 25 min before the patient’s wound care. VR may help reduce pre-procedure anxiety and common negative thoughts and emotions, so that patient enter the wound care session in a healthier psychological state of mind and may thus experience less pain during their wound care session.Due to the investment of large corporations into mass marketing of VR hardware for entertainment, this technology has recently become more immersive, more affordable, and there is an increasing demand for dissemination of effective treatments . VR has


Background: Research has shown that more than 50% of patients have insufficient postoperative pain relief despite the use of multiple pain management modalities. Insufficient pain relief leads to several pathophysiological effects. One of the barriers to optimal pain relief is patient’s lack of knowledge regarding the options available for pain management and their potential side effects. In this survey, we evaluated surgical patients’ knowledge about postoperative pain and its management in patients undergoing major upper abdominal surgeries at a tertiary care hospital.Methods and Material: This was a cross-sectional survey. A total of 155 patients (18-60 years of age) scheduled to undergo elective major upper abdominal surgery were included after ethical approval and informed consent. Preoperatively, patients were interviewed through a questionnaire regarding knowledge about postoperative pain and its management.Results: The average age of the patients was 42.97 ± 13.05 years. Excellent and good knowledge were observed in 11.61% and 21.94% patients, respectively, whereas fair and poor knowledge were seen in 42.58% and 23.87%, respectively. Inadequate knowledge was more marked regarding analgesic side effects and addiction risk. Education level, history of surgery, and adequate information provision about pain management plan by surgeons preoperatively were significantly associated with a higher level of knowledge about pain and its management .Conclusion: A considerable proportion of patients have inadequate knowledge about their postoperative pain and its management, particularly in areas of side effects and addiction risk. A lot of research has gone into the understanding and treatment of postoperative pain in recent times, and several advances have been made in the management of postoperative pain. However, ineffective postoperative pain relief still remains a common problem in health care, and it is estimated that approximately 50%-75% of patients have insufficient pain relief postoperatively -3. One oPostoperative pain management is a major concern for surgical patients. Ineffective pain relief leads to several pathophysiological and psychological issues that may hinder smooth postoperative recovery -14. BoziIt was a cross-sectional survey and was conducted at a tertiary care hospital of a developing country. Approval was obtained from the institutional Ethics Review Committee, and informed consent was taken from all patients. Sample size was calculated by using the WHO software for sample size calculation. Previous studies have shown that knowledge about postoperative pain is approximately 70%-75% ,10. UsinInclusion criteria to participate in the survey consisted of patients aged between 18 and 60 years scheduled to undergo elective upper abdominal surgery (incisions extending above the umbilicus). Patients who had a history of neurological or psychiatric diseases, had difficulty in communication, those unwilling to participate, and those undergoing emergency procedures were excluded. Patients coming for preoperative evaluation before major upper abdominal surgery and met our inclusion criteria were recruited. One of the authors interviewed all patients in the preoperative clinic before preoperative assessment and filled out a questionnaire. Patient’s confidentiality was ensured by assigning code numbers, and data were kept under lock and key by the primary investigator.QuestionnaireThe questionnaire for this survey was modified from the Patient Pain Knowledge Tool drafted by Borneman et al. for their work on cancer pain (with permission) and the American Pain Society Patient Outcome Questionnaire, which is permitted to be used by the Society ,9,17. BoStatistical analysisAll statistical analyses were performed using Statistical Package for Social Sciences version 19 . Frequency and percentages were computed for categorical observations like gender, education level, and knowledge of pain and its management. Mean and standard deviation were estimated for age. The chi-square test was applied to observe significant difference in knowledge with respect to gender, education status, and previous surgery. P-value of ≤ 0.05 was considered as significant.A total of 155 patients were included in this survey. Overall knowledge about postoperative pain and its management was found to be excellent in 11.61% (18/155) of the study population, good in 21.94% (34/155) patients, and fair and poor knowledge were observed in 42.58% (66/155) and 23.87% of patients (37/155), respectively. Knowledge about postoperative pain and its management with respect to patients’ demographics is provided in Table Age group and gender were not associated significantly with level of knowledge about postoperative pain management as shown in Table Analysis of individual questions was also performed, and it was observed that most of the questions had below 50% correct response rate as shown in Table This survey was conducted to assess the knowledge about postoperative pain management in patients undergoing major upper abdominal surgery at a tertiary care hospital. These surgeries were selected for the study because they cause moderate-to-severe postoperative pain that requires focused strategies including careful counseling of the patient for effective pain relief. The results revealed deficiencies in knowledge, especially pertaining to the nature of postoperative pain and the methods available to manage it. Scott and Hodson have reported similar results in their study . They coThe results of our survey showed that only 33.55% of patients had excellent to good knowledge, whereas 66.45% had inadequate (fair to poor) knowledge regarding postoperative pain and its management following major upper abdominal surgeries. These finding are not consistent with the study conducted by Borneman et al. on patients with cancer pain ,9. They Our results did not reveal a significant difference in the level of knowledge in context to age and gender. A similar finding was established by the Norwegian study done by Valeberg . However, there was a higher percentage of female patients (68.39%) in our study compared to almost equal gender distribution in Valeberg’s study sample .A significant correlation was found between educational level and the total score of knowledge about pain in our study population. The enrolled population who had graduate level education and above demonstrated better knowledge regarding pain management options than those who had received lower levels of education or were illiterate. Baker et al. found in their research that individuals with higher education actively seeked information regarding their treatment and discussed that information with their physicians, while lower education was found by them to be one of the barriers to receiving and understanding information regarding pain management . ResultsIn our survey, patients who received adequate information about their pain management plan in the surgical clinic during the preoperative visits were more knowledgeable as compared to those who did not receive adequate information (p = 0.0005). Similar findings were observed by Stomberg et al., who concluded that inadequate knowledge about pain management was due to a lack of preoperative information and inadequate preoperative discussions about pain management . They alMore than 50% of our patients were of the belief that the need to increase the dose of their pain medicine was a sign of addiction. Borneman et al. had similar findings in their study and discovered that the belief that ‘use of opioids for pain relief leads to addiction’ was the knowledge item which had persistently low scores among their questionnaire items . They foIn our findings, the question with the highest knowledge score was related to treatments other than medicines  to help relieve pain. Patients are aware of these options through various sources, such as magazine articles, family, and friends. Despite having knowledge about these strategies, patients often do not make use of them . Becker Assessment of pain is an essential part of effective pain management. The health care provider must assess patients’ pain at regular intervals to ensure that the patient is pain free or ascertain whether action needs to be taken to improve pain management. Patients’ understanding and cooperation is required for adequate pain assessment. Only 31.6% of our patients knew that pain scales are used to assess the severity of pain. Pain is a complex phenomenon that involves physical, psychological, and social variables . Level oBozimowski concluded that lack of knowledge about pain and its management is an important barrier to optimal pain relief . MiaskowThe results of our survey demonstrate that patients have limited knowledge with respect to their postoperative pain management, particularly in areas of drugs, addiction risk, and pain scoring. Future research in this area should capture a larger surgical population including patients having different surgical procedures. Moreover, the impact of preoperative patient education regarding pain management practices on improvement in postoperative pain management needs to be studied.


Today immersive environments such as Virtual Reality (VR) offer new opportunities for serious gaming in exercise therapy and psychoeducation. Chronic back pain (CBP) patients could benefit from exergames in VR. The requirements in older CBP patients for a VR pain therapy have not yet been determined in studies. The aim of the study was to perform a requirements analysis for the user group of geriatric patients with CBP for a VR exergame. The objective was to find out the expectations, desires, preferences and barriers in order to collect them as requirements for this vulnerable group and to determine frameworks of therapy by physiotherapists and psychotherapists.We conducted a requirements analysis through semi-structured interviews with 10 elderly participants with CBP. Furthermore, two focus groups were conducted with three physiotherapists and two psychotherapists to determine frameworks of therapy programs for the target group. The qualitative data were transcribed and examined through a structuring content analysis. Subsequently, the results of the analysis were prioritized by all participants of the study.The results of the requirements analysis indicate mandatory requirements for the overall system, hardware, software and gamification elements. The key requirements were target-group-specific applications of the VR exergame through e.g. individual briefing, user-friendly handling, inclusion of movement limitations, presentation of everyday scenarios in combination with biofeedback, age-appropriate feedback through praise and awards and a maximum exercise duration of 30 min and 15 min of relaxation.It should be possible to use the determined requirements productively to create user-friendly VR exergames that motivate elderly chronic back pain patients to perform exercises regularly.DRKS00015294 12.10.2018).The study is registered in the German Clinical Trials Register (DRKS-ID:  Back pain is the most common musculoskeletal condition and a major health problem. Back pain can be acute, when it lasts for less than 4 weeks, or subacute, when the pain lasts between 4 weeks and 3 months. If the pain persists for more than 12 to 24 weeks, a chronic course is assumed  So they [peers] wouldn’t be able to do it alone” (CBP patient). This underlines the importance of the user-centered design, which is applied in the project through usability evaluations with the purpose of creating the most appealing and functional operation possible for the age group; if this is not possible, then use of the system under personal supervision must be considered.On the level of The system should offer breaks between exercises to be the most important requirement in the level duration of use. Especially during home exercises, patients showed inconsistency in taking breaks. “No, it then automatically follows that one stops or does not stop” (CBP patient). Mostly the seniors in the groups performed the exercises all at once and without a break as a matter of course. Newcomers may be prone to overestimating themselves; especially in cases of chronic pain, over-ambitiousness can lead to severe pain. The patients should learn for their everyday life what individual dose of exercise is right for them and therefore they should have the opportunity to take a break. Another requirement the participants stated, was: The exercises should last a maximum of 30 min. Further a very important requirement was: The system should offer 15 min of relaxation. Psychoeducation plays an important role in multimodal pain therapy. The requirements analysis showed that relaxation therapy in VR can be offered in addition to movement training, but it should take less time in the game.The physiotherapists considered the requirement: safety: The system should be used in a safe place with sufficient space. Due to the lack of perception of the real space, many older adults can be exposed to the risk of falling. “Of course, you must do such things [...] in a safe environment where there’s just enough room that you can’t knock anything over or put yourself in danger” (CBP patient). This implies that a concept for safe use of the exergame is needed. The system should allow you to sit down. This approach also involves the risk of falling, which can result from overexertion, for example. A possibility of sitting or even executing the exercises in seated position would minimize the danger of falling. The following requirement was also given: The system must contain a help button.The physiotherapists considered the following requirement to be important in the level of The system should be offered for rent was preferred. “Renting would be a good solution.” (CBP patient). This proposal would allow multiple users to share the system and make it available to a larger number of potential users.In the level of financing the requirement: This dimension did not consist of various levels. Due to the small number of requirements and semantically similar requirements, code groups were not created in the content analysis and were not presented in the prioritization as levels for this dimension. For this reason, this dimension consists of only one level. In the dimension hardware, the participants also identified the physiotherapists as the most important stakeholder. The psychotherapists were ranked 2nd and the CBP patients 3rd.The patients should be able to put on the googles by themselves. This requirement is associated with another important requirement: The goggles should be easy to put on and take off. The ability to put the goggles on and take them off independently was perceived as important in order to enable the system to be used independently at home by older CBP patients. Here the hardware design must be adapted to the requirements of the seniors.The physiotherapists determined the most important requirement to be the following: in-game environment, application of game and exercises. In the dimension software, the participants identified the physiotherapists as the most important stakeholder. The psychotherapists were ranked 2nd and the CBP patients 3rd.The software dimension consists of the following levels: in-game environment was: The system should perform an individual calibration (e.g. to detect movement limitations). The desire for calibration was mainly expressed by the physiotherapists. With an individually adapted environment, limitations of the patients could be integrated into the game. Patients are thus not forced by the game environment to make movements that they cannot functionally perform, e.g. due to a limited range of motion in a joint. “Yes, but I could imagine, for example, that [...] the environment knows how big the patient is. Or how high he can stretch to get it calibrated” (Physiotherapist). The physiotherapists stated that they could imagine, for example, a movement assessment in the VR to be carried out by the patient before the start of the game.The decisive requirement in the level application of game the requirement: The system should enable the therapist to intervene on patients  was prioritized in first place. This requirement of course depends on the setting in which the exergame is performed. If the exergame is performed in a setting in which the therapist stands next to the patient, immediate intervention is possible. In a setting where the patient performs exercises independently at home, a concept must be considered for the therapist’s intervention (e.g. though a help button/emergency-supporting system). “Well, definitely intervene when there’s fear, when there’s irritation [...] can be a technical problem. [...] And of course even if I feel like someone can’t handle it, or do something completely different than (laughing) actually the model” (Physiotherapist). The physiotherapists could consider an intervention, e.g. by assisting or stopping the game, if the patient experiences severe pain during the game, is afraid while playing, or performs the exercises incorrectly, which can lead to danger or increased back pain. During the task-based part, the phenomenon of cybersickness in a subject was detected once, but disappeared after a short break (approx. 5 min).In the semantic level exercise the requirement: The patients should perform everyday exercises was preferred. The physiotherapists see the VR as a chance to try out tasks that are close to everyday life in a realistic way. “In the training program one could use environments / tasks that are attractive for many older people or are close to everyday life – such as the garden ... planting something, harvesting or maybe shopping” (physiotherapist).In the level of This dimension consists of the following levels: display of feedback, biofeedback, progress, and storytelling. In the dimension: gamification / game integration, the participants identified the psychotherapists as the most important stakeholder. The physiotherapists were ranked 2nd and the CBP patients 3rd.display of feedback the following requirement was perceived as the most important: The feedback in the system should always reinforce positively, never negatively. In the interviews, the physiotherapists also named this as an important method for giving feedback. This is particularly important in order to stabilize a long-term intrinsic motivation of CBP patients during the exercises in the exergame in order to support long-term training adherence.At semantic level biofeedback the participants considered the requirement: The exergame is intended to provide the user with behavioral recommendations (e.g. advice on how to relax) to be the most important requirement in the level of biofeedback. During the interviews the psychotherapists always expressed their views on psychoeducation in the exergame: “Well education, I think, is of course very, very important in terms of stability of the spine for example, if there are fears, like: ‘that breaks everywhere and [...]’” (Psychotherapists). In classical multimodal pain therapy, behavioral therapeutic aspects play an important role. These aspects should also find their place in an exergame for CBP patients. Particularly in forming habits, patients must be aware of why they perform the exercises and what can cause them harm. It is precisely through misconceptions that many patients develop fear avoidance beliefs or poor stress management. In order to avoid and counteract these negative strategies, the system can be supported by e.g. stress sensors that measure the pulse during training and to give positive feedback of vital parameters. By using quantitative measurable methods, behavioral recommendations can be made usable, comprehensible for the user, which contribute to therapy adherence . The seniors often stated during the interviews that rewards after completing a task in the game would please them. “Well, all right. A reward if you do the task or something. Like I said, I’m not the person who wants to win while playing. The thing itself has to be fun and it has to have something to do with creativity” (CBP patient). Figure On the level of storytelling the most prioritized requirement was: The system should not tell a continuous story. The psychotherapists said that longer-term success would be possible through an appropriate individual division of work and recovery phases. This speaks against a strict story, as it is difficult to divide it up individually. Also some subjects said that a continuous story is not imaginable for them. “I think that would kind of distract me. Then I would listen to the story and become inactive when I listen to it” (CBP patients). On the other hand, five of the 10 test persons said that they could imagine a continuous story and would like to experience it in the VR.On the level of Within the ViRST requirements analysis, we gathered mandatory requirements for the conception of a VR HMD-based active exergame for older users with chronic back pain.The key requirements of the overall system showed a desire for an individual briefing for the system. In addition, a sufficient instruction is considered necessary not only by the CBP patients, but also by the therapists. These requirements call for a differentiated consideration of the target group of older people. Especially due to a strong divergence in the acceptance of technology, it is necessary to take a closer look at the existing skills and abilities of the target group. Wright’s study  showed tThe therapists recommended that the exercises should last a maximum of 30 min. This also matches the health and safety warning of the oculus [We determined in the requirements analysis also that a user-friendly handling of the system and hardware is important and can also contribute to an easier access for the peer group. In addition, older persons need expert training and instruction in the use of the system, especially with regard to immersion in VR and the risk of falls, which can be plausible with a wired VR HMD. For the user group, a wireless HMD would be the preferred option. The focus group with the physiotherapists confirmed, that the system should be used in a safe place with sufficient space and with appropriate safety regulations such as to allow the patient to sit down in VR or to use a help button. If the older users do not get along with the operation of the system, an instructor may be considered to be present during the exergame. Palazzo et al.  came to Considering the use of augmented reality and its applications in comparison to VR systems, it is obvious that the handling AR involves a lower risk of falls , 33 but With regard to the financing of the system, a concept should also be considered for how the system could be affordable for the target group. In our requirement analysis the stakeholder preferred, that the system should be offered for rent. In view of the increasing poverty among the elderly in Germany  it is neOn the other hand, the physiotherapists stated, that virtual reality offers the opportunity to safely test everyday scenarios. The multimodal pain therapy experts suggest that exercises should be transferable to the everyday life of seniors. The requirement “the exergame is intended to provide the user with behavioral recommendations” was also raised in the requirement analysis for exergames by Paulino et al. . BehavioThe physiotherapist emphasized that the system should perform an individual calibration in order to detect movement limitations. From a technical point of view, it would be possible to use tracker, inertial measurement units (IMUs) or cameras for human pose estimation to detect the range of motion of the relevant joints of the patients and to adapt the objects in the VR. Stănică et al. also suggested to use movement tracking equipment and biosensors for training session configuration in VR systems in neurorehabilitation .In psychoeducation a combination with biofeedback would be possible e.g. by a measurement of heart rate variability (HRV). This would be an easy way to measure stress and react appropriately in game situations to show seniors their stress level and to teach them how to change their behavior. As further biofeedback the controllers can be used and additionally trackers could be attached to the back of the patients to enable posture correction. Barmpoutis showed a way give haptic-based guidance in tele-therapy by using wearables with vibrator motors . The bioNevertheless, the study had some limitations. An external limiting factor was the small number of participants. Due to a small and imbalanced number of experts, the results cannot be generalized easily. Furthermore, within the older participants, who all had no previous experience with VR, there was a lack of technical skills and a low understanding of the applied technology. However, an initial saturation of the results could be achieved. Furthermore, this study was a first step, as the current application was an exergame user experience prototype whereas a more specified application with a proven therapeutic benefit is expected to be developed in the course of the project. In this respect, the requirements must be tested and specified with older users in a VR back pain exergame with implemented gamification aspects.Within the scope of the requirements analysis 104 requirements could be identified, which represent the basis for the conception of an exergame and the use cases in the ongoing ViRST project to create a user-friendly VR exergame that motivates older chronic back pain patients to perform exercises regularly. If the exergame is a user-centred VR back pain training program, it is quite conceivable in the future to adapt it for other target groups and to transfer the system from the inpatient area to the domestic environment of the patients. Therefore, it should be ensured that the safety and motivational elements correspond to the expectations of the target group. A more effective multimodal pain therapy could be achieved by a higher adherence of the home-based exercises, which could reduce the long-term cost of the health system.Additional file 1.


Musculoskeletal disorders are common in the general population and a leading cause for care seeking. Despite the large number of patients with musculoskeletal disorders seeking care, little is known of the clinical course, pathways and predictors of healthcare utilization among these patients. The purposes of the study were to 1) describe the clinical course and related healthcare utilization in primary care physiotherapy and secondary healthcare among patients with neck, shoulder and low-back pain treated in physiotherapy practice, and 2) identify independent clinical, socio-demographic, psychological and general health predictors of healthcare utilization.The study was a prospective cohort study of patients seeking physiotherapy treatment for neck, shoulder, or low-back pain in physiotherapy practices across Denmark. A total of 759 physiotherapy patients completed questionnaires containing information on clinical course and potential predictors of healthcare utilization. Healthcare utilization was obtained from the Danish National Health Service Register and National Patient Register. Associations between potential predictors and low/high primary care physiotherapy utilization and hospital contacts in relation to specific neck, shoulder or low-back disorders were analysed using binomial regression analyses and adjusted for age, sex, duration of pain and comorbidity.During 6 months follow-up, patients experienced clinically relevant improvements in pain, fear avoidance and psychological wellbeing. Patients with higher baseline pain and disability and who were on sickness leave were more likely to have high primary care physiotherapy utilization. Hospital contacts were predicted by higher levels of pain, disability and low psychological wellbeing.Clinical factors and sickness leave seems to be the main predictors of primary care physiotherapy utilization, whereas for secondary care contacts, psychological factors may also be of importance. The study contributes to the on-going research into clinical pathways and may identify future target areas to reduce healthcare utilization in patients with musculoskeletal disorders. Musculoskeletal pain and disability are common in the general population and it has been estimated that over 1.2 billion people worldwide are affected by musculoskeletal disorders , and in According to clinical practice guidelines the majority of the patients with non-specific musculoskeletal disorders should be managed and treated in primary care. In Denmark, most people with musculoskeletal disorders seeking care is referred to physiotherapy by their general practitioner (GP) and physiotherapy treatment is often a central part of the clinical pathway , 6. The With limited healthcare resources an increasing interest on healthcare utilization and subsequently healthcare costs has naturally emerged. Thus, identifying predictors of healthcare utilization in both primary and secondary care could help allocate limited healthcare resources towards patients who are most in need. In the general population musculoskeletal pain and disability, as well as psychological factors, have shown to be predictive of both primary and secondary healthcare utilization –15. Nevewww.praksis.dk) and a total of 26 practises applied for participation, of which three practises declined after further information about the project . A total of 577 patients (72%) had an individual first consultation and 553 of these patients also had one or more individual treatment sessions . A total of 65 patients (8.6%) also received group exercise with the highest prevalence among patients with low back pain (11%) and the lowest prevalence among patients with neck pain (5%). The median number of group exercise was 6 [IQR 4 to 10]. For a period of 12 months from baseline, 112 patients (15%) had a contact related to ICD-10 chapter XIII: Diseases of the musculoskeletal system and connective tissue. A total of 84 patients (11%) had one or more hospital contacts related to specific low back, neck or shoulder disorders during the follow-up period. No difference in healthcare utilization was detected between responders and non-responders (data not shown).Figure Diseases of the musculoskeletal system and connective tissue did not influence the already identified associations, but a further two associations were identified; fear avoidance and general health. See Three predictors of high primary care physiotherapy utilization were identified Table . PatientThis study evaluated the clinical course, healthcare utilization and predictors of healthcare utilization among patients with neck, shoulder or low back pain treated in Danish physiotherapy practice. During 6 months follow-up, patients experienced clinically relevant improvements in pain, fear avoidance and psychological wellbeing. However, only 56% of the patients rated their symptoms as acceptable at 6 months. On average, patients with few contacts had significantly greater improvements in fear avoidance and psychological wellbeing than patients with many contacts. During 6 months from baseline the median number of treatments in primary care physiotherapy was 5 [IQR 3 to 9] and during 12 months 11% of the patients had a secondary healthcare contact related to specific neck, shoulder or low back disorders. Three predictors were identified for primary care physiotherapy utilization: Higher levels of pain and disability and sickness leave and three predictors emerged for secondary care contacts: Higher levels of pain and disability and psychological wellbeing.fear avoidance was measured using two questions from ÖMPSQ [A limitation in the study was the modest follow-up rates at 3 and 6 months in questionnaire data and as differences between responders and non-responders were identified we cannot exclude differential attrition bias with respect to the results of the clinical course. However, the estimated differences in pain and psychological wellbeing were small and no subsequent difference in healthcare utilization was detected between responders and non-responders, thus the risk of bias of the estimated clinical course is considered limited. As healthcare utilization was based on national health registries with 100% follow-up attrition bias in these analyses are not present. Still, when using registry data there is a risk of bias due to misclassification. Such misclassification would not be associated with any specific exposure group and therefore most likely to be non-differential thereby risking bias towards no association . Clinicaom ÖMPSQ , 35, 37.om ÖMPSQ , 42–44. om ÖMPSQ , since iThe results were naturally influenced by cut-off values in healthcare utilization. Nevertheless, changing cut-off values of low/high primary care physiotherapy had little impact on the estimated associations. Grouping according to more specific ICD-10 diagnose codes of neck, shoulder or low back conditions resulted in a very small group of patients (cases). This lead to limited statistical power and although the estimated association on e.g. general health was strong , the association did not reach statistical significance. Moreover, when the outcome was changed to contacts of overall diseases of the musculoskeletal system and connective tissue, thereby increasing the number of cases, associations with general health was statically significant . This underpins the importance of general health perceptions, when predicting secondary healthcare utilization. Larger studies could advantageously explore this association further.The observed improvements in pain were similar to those reported among Danish musculoskeletal physiotherapy patients  and low Three independent predictors of high primary care physiotherapy utilization were identified: higher levels of pain and disability and sickness leave. These results add to the on-going research into predictive factors of healthcare utilization and to our knowledge no other studies have investigated independent clinical, socio-demographic, psychological and general health predictors of high primary care physiotherapy utilization among physiotherapy patients. However, these results are in line with large population-based cohorts examining predictive factors of healthcare utilization , 10, 12,As patients were recruited consecutively in 23 physiotherapy practices across Denmark, we believe the cohort to be representative of patients with neck, shoulder or low back disorders seen in primary physiotherapy practice. A limitation of the study was the participation rate at baseline (63%) which could affect the generalizability of our findings. Such non-participation rates are however common in large population studies and evidence from other Danish studies suggest the estimated associations may not necessarily be biased by non-participation , 59.When predicting future health care utilization among patients with musculoskeletal disorders it seems that the clinical factors and sickness leave is of importance to the utilization of primary care physiotherapy. This contrasts to secondary care utilization which seems to be predicted not only by clinical but also by psychological factors. The study contributes to the on-going research into clinical pathways and may identify future target areas to reduce healthcare utilization in patients with musculoskeletal disorders.


ObjectiveDysmenorrhea is the most important cause of chronic pelvic pain in women. Sometimes, dysmenorrhea can be severe enough, leading women to present to emergency departments. The aim of this study was to investigate factors affecting dysmenorrhea in female patients who presented to the emergency department of our hospital.MethodsFemale patients who presented to our emergency department with dysmenorrhea between January 2012 and January 2014 were included in the study. Patients’ demographic and clinical data were filled in the Dysmenorrhea Data Form, which was designed by the researcher by screening the relevant literature. Patients’ age, educational status, smoking status, age and regularity of menarche, sexual activity, and age of dysmenorrhea onset were recorded and analyzed.ResultsThe mean age of the patients was 21.80 ± 3.75 years. There was a significant correlation between the type of dysmenorrhea and sexual activity (p=0.001). There was a statistically significant difference between age at menarche and age of dysmenorrhea onset (p<0.001). Absenteeism was less common in patients with an age of dysmenorrhea onset of <12 years compared with the other age groups (p<0.05).ConclusionsThere was a significant correlation between age at menarche and age of dysmenorrhea onset. Data obtained in this study could be used in developing educational programs on dysmenorrhea for adolescents at the age of menarche. Dysmenorrhea, one of the most common causes of pelvic pain and menstrual disorders, is defined as uterine-induced painful cramps. Dysmenorrhea is a severe pain localized primarily in the lower abdominal quadrant, resembling labor pain. This pain can be defined as a cramp-like severe or blunt pain, suggesting compression in the pelvic region . The majDysmenorrhea can be divided into two categories: primary (spasmodic) and secondary (congestive). Primary dysmenorrhea is defined as menstrual pain without macroscopic pelvic pathology involved. Normally, it occurs within the first several weeks after menarche. In primary dysmenorrhea, pain is usually localized in the suprapubic region in the form of cramps or spasm. Pain begins with menstruation and ends within 48-72 hours. Secondary dysmenorrhea is defined as menstrual pain resulting from anatomical or macroscopic pelvic pathologies. Pain may begin before menstruation and last a few days after menstruation [Several studies have defined the risk factors of severe dysmenorrhea episodes. These may include smoking, an earlier age at menarche, positive family history, prolonged menstrual periods, obesity, and alcohol consumption ,9. DepreVarious pharmacological and nonpharmacological methods are used in the management of dysmenorrhea, including non-steroidal anti-inflammatory drugs (NSAIDs), herbal remedies, diet therapies, yoga, meditation, and acupuncture .Sometimes, dysmenorrhea can be severe enough to result in women presenting to emergency departments. It is important to determine the factors affecting dysmenorrhea, which is an important public health problem. In this study, we aimed to investigate the effects of various biological and sociodemographic factors on dysmenorrhea in female patients who presented to the emergency department of our hospital due to dysmenorrhea.Female patients who presented to our emergency department with concerns of dysmenorrhea and completed a data form between January 2012 and January 2014 were included in the study. Patients who presented to the emergency department with concerns of abdominal pain due to other reasons, those who had entered menopause and had pain, those who presented with dysmenorrhea-like complaints but were diagnosed with different abdominal pain, and those who did not agree to complete a data form were excluded from the study. Patients’ demographic and clinical data were filled in the Dysmenorrhea Data Form, which was designed by the researcher by screening the relevant literature. Patients’ age, educational status, height, weight, marital status, smoking status, age and regularity of menarche, sexual activity, age of dysmenorrhea onset, time and duration of dysmenorrhea onset, additional symptoms , and absenteeism were recorded in the Dysmenorrhea Data Form. In addition, patients' analgesic use, analgesics used , hormonal therapy, history of systemic diseases, and previous operations were also recorded in the forms. Based on the responses given by the patients, those with underlying disease were categorized as secondary dysmenorrhea, and patients without underlying disease were categorized as primary dysmenorrhea. Pain severity of the patients was measured using a descriptive category scale. Accordingly, patients were asked to score their pain severity between 1 and 10 points. Based on the responses, the cases were grouped as mild if <4, moderate if 5-8, and severe if 9-10 points.Ethics statementPrior to beginning, the study protocol was approved by the Local Ethics Committee of our hospital. All patients were informed about the objectives of the studies, and they provided their consent. The study was conducted in line with the ethical principles of the Declaration of Helsinki.Statistical analysisData obtained from the study were statistically analyzed using SPSS Statistics for Windows, Version 17.0 . Descriptive statistics were expressed as number and percentage. Numerical variables were expressed as mean ± standard deviation and as minimum and maximum values. Normality of the variables was tested with the Kolmogorov-Smirnov test. Mann-Whitney U and Kruskal-Wallis tests were used to analyze continuous variables. Categorical variables were analyzed using chi-square and Fisher’s exact tests, and p < 0.05 values were considered statistically significant.A total of 215 female patients who presented to the emergency department of our hospital with the concern of dysmenorrhea between January 2012 and January 2014 were included in the study. The mean age of the patients was 21.80 ± 3.75 years (minimum-maximum: 16-45 years). Of all patients, 84.7% (n=182) were college graduates. When patients were evaluated according to body mass index (BMI) values, 20.9% (n=45) were weak, 69.8% (n=150) were normal, 7% (n=15) were overweight, and 2.3% (n=5) were obese. Of the patients, 94% (n=202) were single and 30.2% (n=65) were smokers. Menstruation was regular in 66.5% (n=143) and irregular in 33.5% (n=72) of patients. Of the patients, 12.6% (n=27) were receiving hormonal therapy. While 17.3% (n=37) of the patients had a history of previous surgery, 6.5% (n=14) had systemic diseases.When patients were evaluated according to the time of pain onset, pain began before menstruation in 50.2% (n=108) and during menstruation in 49.8% (n=107). Of all patients, 9.8% (n=21) reported that they were sexually active. Among all dysmenorrhea cases, pain onset was more commonly before menstruation in the presence of sexual activity (81%) and during menstruation in the absence of sexual activity (53.1%), and the difference was statistically significant (p<0.05). In addition, there was a statistically significant correlation between the time of pain onset and educational status (p=0.029).Primary dysmenorrhea was found in 80% (n=172) and secondary dysmenorrhea in 20% (n=43) of the patients. There was a significant correlation between the type of dysmenorrhea and sexual activity (p=0.001).The mean age at menarche was 13.37 ± 1.38 years. The mean age of dysmenorrhea onset was 14.68 ± 3.47 years. Of all patients, 3.7% (n=8) reported that dysmenorrhea began before 12 years of age, 77.2% (n=166) between 12 and 16 years of age, and 19.1% (n=41) after 16 years of age , it did not cause absenteeism in 25.1% (n=54). It was found that absenteeism was less common in patients with an age of pain onset of <12 years compared with the other age groups , and the difference was statistically significant (p<0.05).Patients were asked to score their pain from 1 to 10 points. Accordingly, pain severity was grouped as severe in 45.6% (n=98), moderate in 51.6% (n=111), and mild in 2.8% (n=6). There was a significant correlation between pain severity and sexual activity  were found in 79.1% (n=170). A statistically significant correlation was found between the presence of additional symptoms accompanying dysmenorrhea and smoking (p=0.049).Of all patients, 81.4% (n=175) reported that they used analgesics. Among these patients, 74.2% (n=130) reported that they were receiving NSAIDs, 14.9% (n=26) were receiving paracetamol, and 10.9% (n=19) were receiving smooth muscle relaxants. There was a statistically significant correlation between the use of analgesics and educational status (p=0.012).Of the 202 patients who responded to the question “Did you benefit from pain killers?”, 57.9% (n=117) stated that they benefited, whereas 42.1% (n=85) reported no benefit. There was a statistically significant correlation between the status of benefiting from drugs and educational status (p<0.001).In our study, no statistically significant correlation was found between BMI, marital status, smoking, menstruation regularity, and absenteeism, and the other examined parameters.In this investigating the effects of several biological and sociodemographic factors on dysmenorrhea in patients who presented to the emergency department with concerns of dysmenorrhea, in addition to other factors, we studied the effects of smoking status, sexual activity, educational status, menstrual regularity, age at menarche, and accompanying symptoms. Smoking has been shown to be among the primary risk factors of dysmenorrhea in the literature ,9. In a In addition, studies have also examined the effect of smoking on the severity of dysmenorrhea symptoms. In a study by Burnett et al. from Canada, female smokers were found to have more severe dysmenorrhea symptoms . In our In this study, the mean age at menarche was determined to be 13.37 ± 1.38 years, and the mean age of dysmenorrhea onset was 14.68 ± 3.47 years. There was a statistically significant correlation between age at menarche and age of dysmenorrhea onset (p<0.001). In a study by Muluneh et al. in North-West Ethiopia in 2018, early age at menarche was associated with an increase in the prevalence of dysmenorrhea . AkbarzaIn a study by Chen and Chen from the United States, adolescents were observed to largely have moderate-to-severe menstrual cramps . In our In a study by Latthe et al. investigating the factors causing chronic pelvic pain in women, BMI < 20 kg/m2 was reported as a risk factor for primary dysmenorrhea . Harlow Similarly, in a study by Unsal et al. investigating the prevalence of dysmenorrhea and its effects on quality of life, no significant correlation was found between obesity and dysmenorrhea among college students . Again, Study limitationsThis study has some limitations. Because our hospital was located near a college, the majority of cases presenting due to dysmenorrhea consisted of students. College students more commonly have primary dysmenorrhea. This resulted in a small number of cases with secondary dysmenorrhea. Furthermore, the number of patients with mild pain was low. These patients might have determined a therapy method by themselves without presenting to the emergency department.In this study, there was a significant correlation between age at menarche and age of dysmenorrhea onset. Severe pain was found in patients with an age of dysmenorrhea onset of <12 years. Significant correlations were found between pain severity and sexual activity and between the type of dysmenorrhea and sexual activity. No significant correlation was found between BMI values, smoking, and dysmenorrhea. The obtained data could be used in developing educational programs on dysmenorrhea for adolescents at the age of menarche.


Background: Over the last 12 years, the fundamentals of automated pain recognition using artificial intelligence (AI) algorithms have been investigated and optimized. The main target groups are patients with limited communicative abilities. To date, the extent to which anesthetists and nurses in intensive care units would benefit from an automated pain recognition system has not been investigated.Methods:N = 102 clinical employees were interviewed. To this end, they were shown a video in which the visionary technology of automated pain recognition, its basis and goals are outlined. Subsequently, questions were asked about: (1) the potential benefit of an automated pain recognition in clinical context, (2) preferences with regard to the modality used , (3) the maximum willingness to invest, (4) preferences concerning the required pain recognition rate and finally (5) willingness to use automated pain recognition.Results: The respondents expect the greatest benefit from an automated pain recognition system to be “to avoid over- or undersupply of analgesics in patients with limited communicative abilities,” a total of 50% of respondents indicated that they would use automated pain recognition technology, 32.4% replied with “perhaps” and 17.4% would not use it.Conclusion: Automated pain recognition is, in principle, accepted by anesthetists and nursing staff as a possible new method, with expected benefits for patients with limited communicative skills. However, studies on automated pain recognition in a clinical environment and proof of its acceptance and practicability are absolutely necessary before such systems can be implemented. To date, the recognition of pain in patients with reduced verbal communication skills has been realized by external observation only. However, all known external observation methods require professional expertise. Even if trained medical personnel could, in principle, record the intensity of pain several times a day or night using common observation instruments, continuous documentation is not possible. Automated pain recognition is a visionary means of utilizing valid and robust pain reaction patterns that can be recorded in a multimodal manner for a dynamic, high-resolution automated pain recognition system.The development of automated pain recognition (APR) was driven primarily by the finding that patients with limited communicative abilities are at a significant risk of being exposed to over- or undersupply of analgesics. In addition, external observation scales, which use a pain score based on sound expression, facial expression, body language, and physiological indicators, are only effective to a limited extent. In Germany, the BESD scale  is most Nevertheless, the extent to which the detection of pain intensity can be differentiated from other states of non-pain-related stress in a specific context  is also of high relevance. This requires further intensive and fundamental research through laboratory experiments. A further objective is the development of an APR system for the recognition of pain quality  and pain localization , 4.The present study is intended to answer the following questions for the first time:Do physicians and nurses see a benefit in the clinical use of APR?Which modality   would thHow much would they be willing to invest financially in APR technology?What pain detection rate would they consider clinically sufficient?Would physicians and nurses actually use APR in everyday hospital life?The Clinic of Anesthesiology at University Hospital Ulm was chosen for the monocentric survey.N = 102 (56.9% response rate) employees were willing to participate in the survey . In detail, 89 physicians (senior physicians and assistants) of the Clinic of Anesthesiology in Ulm were contacted by e-mail and asked to participate in the study. A total of 43 physicians (48.3% response rate) participated in the survey. In addition, 90 nurses working in the intensive care units CGI and CF1 (https://www.uniklinik-ulm.de/anaesthesiologie/interdisziplinaere-operative-intensivmedizin-ioi.html) were personally visited by an assistant and asked to complete the survey using a tablet. A total of 59 nurses (65.6% response rate) were willing to answer the questions.In total, 179 employees of the Department of Anesthesiology at University Hospital Ulm were asked to take part in the survey. Of these, https://youtu.be/kKwEGa-oV5s), which showed the vision of APR using AI algorithms AI   . ParticiFor questions 1–8, mean values were calculated in each case and shown in histograms. The results are not normally distributed. In addition, a Friedman test (with a corresponding pair comparison test) was performed with regard to the clinical benefit (Q1–Q4) to identify any significant differences in the questions concerning the benefits of the system. A Friedman test was also performed with regard to the preferred modality  (Q5–Q8). Relative frequencies were determined for Q10–Q15 (except for Q12). Q12 was only answered by 10 subjects and was not qualitatively evaluated in the present study.The SPSS 25 statistical software was used to calculate all statistical analyses.The results are shown in X2 = 14.15; p ≤ 0.001; N = 102. The greatest benefit expected is that “Automated pain recognition provides a benefit in terms of preventing over- or undersupply of analgesics for patients with limited communicative abilities” (Q3) with M = 4.60, SD = 1.5. In a post-hoc (Wilcoxon) comparison, Q3 receives significantly more positive answers than:For the questions on the benefits of APR (Q1–Q4), the differentiation shows a significant preference among the benefits expected Automated pain recognition generally provides a benefit in acute medical settings  for clinical staff and patients” ,Q1 “Automated pain recognition provides a benefit as a diagnostic tool in the detection of complications for clinical staff and patients”  andQ2 “Automated pain detection provides benefits for clinical staff and patients during inpatient stays at night” .Q4 “X2 = 68.89, p ≤ 0.001, N = 102. The results showed that multimodality (Q8) M = 4.09; SD = 1.87, similarly to the physiological modality (Q5) M = 4.06; SD = 1.43, was favored by the majority of respondents. The post-hoc (Wilcoxon) tests for the physiological modality (Q5) vs.:With regard to the questions on the preferred modality of APR system (Q5–Q8), a clear preference was apparent Z = −5.16, p = 0.001) andthe paralinguistic modality (Q6) the video-based modality  (Q7) (are significant.post-hoc (Wilcoxon) tests for multimodality (Q8) vs.:Likewise, the Z = −4.35, p = 0.001) andthe paralinguistic modality (Q6) the video-based modality  (Q7) , age (Q14), profession (Q15) and decision use APR (Q11) regarding Q1–Q8 see :There was no significant difference between men and women. For questions Q1, Q3, Q4, Q7, Q8, higher values are reported significant for the “younger” respondents. Physicians have rated Q8 significantly higher. Q1–Q8 were rated lower for respondents who would decide against APR .In terms of willingness to use the device, What else would you like to see from the device?”):The following answers were given regarding Q12 , easy to cleansimple visualizationsmall & compact design, wireless or max. one cableout of reach of patient, should not restrict patientsreliable (measurement)if pain detected then recommendation for action or adapted administration of medication(modular) design for integration into existing monitoring systemspossibility to print measured parameters, integration in electronic medical recordinput/consideration of possible error sources such as hyperactive delirium etc.“Reliability” and “usability” were mentioned most frequently.The development of an APR methodology has advanced in an experimental setting; uni- and multimodal pain intensity recognition rates of >80% have already been achieved with machine learning procedures . TheUltimately, the acceptance of APR in everyday clinical practice depends on factors such as data protection, user-friendliness, miniaturization of hardware, etc. Another important factor is how patients – with and without limited communicative skills — will tolerate and accept pain detection using a camera, microphone and multiple contact sensors, and also the extent to which they would consent to the continuous collection and processing of their data, as required for this method.The fact that ultimately 50% of respondents have a positive attitude toward APR, 30.4% would “perhaps” and 17.6% would not use this technology, indicates that APR research and development should continue constructively and critically. It is important to bear in mind that there is an age effect. At 29.8%, older participants (>40 years) are rather critical to APR. It can also be seen that participants who would not use APR (Q11), in principle have less affinity for the area of application (Q1–Q4) and modality preferences (Q5–Q8). Further studies should help to clarify the reasons why a small group of physicians and nurses reject APR and why they are rather critical to the different areas of applications (Q1–Q4) and modalities (Q5–Q8). However, there is a tendency to assume that the aspects of quality criteria  and user-friendliness will be important, as these were mentioned most frequently in the expectations (Q12). The aspect of user friendliness in particular could play a greater role for the “older” group.The authors are not aware of any other studies on the acceptance of APR in the clinical setting.A recent study from China  indicateIn particular, the present survey shows that physicians and nursing staff in an anesthesiological intensive care unit would see the benefit of APR in the prevention of over- or undersupply of analgesics in patients with impaired communication skills. Thus, the potential of APR is clearly seen to lie in improving the therapeutic care of these patients in intensive care units in terms of pain management and to reduce suffering and side effects. This confirms the appropriateness of the adopted focus of the development of APR on patients with impaired communicative skills, which should therefore be pursued and not reconsidered.It is not surprising that, with regard to APR, physicians and nurses in an anesthesiological intensive care unit would give the highest priority to a unimodal method with a physiological modality, as they are traditionally familiar with this modality. On the other hand, a multimodal APR would also be given clear priority, so the complex multimodal approach should also be tested in a clinical setting. Facial and gestural reactions could possibly be recorded entirely by means of EMG surface sensors . Nevertheless, the differentiation of pain from the behaviors in states such as of delirium, panic or breathing difficulties is only possible to a very limited extent using “purely” physiological means.The majority of respondents would consider a sum of at least €10,000 appropriate to invest in APR technology. From the authors' point of view, it seems realistic that an APR device could be purchased for this amount of money once the development of the method has been completed. There is an indication that the mass production of APR devices would make it possible to further reduce costs. In other words, a larger intensive care unit (20–40 patients) would have to invest about €200,000 to €400,000 in order to equip all of its beds with this technology. However, it would also be conceivable to equip a small number of beds especially for patients with limited communicative abilities.The respondents indicate that they would accept recognition rates of about 80% or higher, which is comparable to recognition rates in other areas of affective computing .Limitation: Forty-three and one tenths percentage of the staff were not willing to participate in the survey, the reasons being exclusively, a workload in the intensive care unit.The authors are planning to pilot APR prototype in an intensive care unit as part of a future study. Furthermore, they plan to conduct an international multicentric acceptance survey on automated pain recognition.In the future, multimodal data sets should also be collected in clinical acute medicine settings in order to test and further develop APR and AI algorithms.steffen.walter@uni-ulm.de.The datasets presented in this article are not readily available due to German data protection regulations. Requests to access the datasets should be directed to Steffen Walter, The studies involving human participants were reviewed and approved by Ethics Committee Ulm. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.SW: literature search, data analysis, and writing. SG: study design and writing. SF: critical revision and writing. JL: data collection. LJ-B and BZ: critical revision. EB: critical revision and data interpretation. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Several psychological interventions have been implemented to manage chronic pain. In this study, in addition to the patients, his/her spouses have participated in the program. Besides, this innovative therapy integrates several practical approaches into one comprehensive protocol.This study aimed to analyze the effectiveness of couple therapy (patient/caregiver-oriented) on improving the quality of life and reducing pain among patients with chronic pain.The present study is a quasi-experimental and clinical trial with a control group with pretest and posttest. The authors conducted this study at LABAFINEJAD Hospital in Tehran on 30 patients with chronic pain and their spouses by having a short form of a questionnaire for quality of life and chronic pain score questionnaire to measure the effectiveness of the treatment.The results indicated that this treatment increased two aspects of quality of life remarkably, social function and strength for continuing the performance; that help boosts interpersonal relationships as well. Regarding the results, although the couple-based treatment could improve all aspects of pain, the two primary subscales, physical health and mental health, both enhanced. Besides, the treatment reduced the intensity of pain.Couple-based intervention through increasing social support, improving the quality of sex, decentralizing of pain, and paying attention to the neglected needs of caregivers and patients with chronic pain can improve quality of life and reduce pain in patients. Continu2This study aimed to examine the effectiveness of a new therapeutic approach, to improve the quality of life, and to reduce the pain intensity of patients with chronic pain.3The present study is a quasi-experimental and clinical trial with a control group with pre-test and post-test. This study has been conducted by researchers at LABAFINEJAD Hospital in Tehran on 30 patients with chronic pain and their spouses. The sampling method was convenience; at first, people who met the criteria of the study were selected from the list of patients. In the second stage, researchers have randomly divided patients into intervention and waiting lists. The inclusion criteria included the diagnosis of chronic pain, being married, and having a minimum secondary education for both couples. Exclusion criteria included having a dramatic personality disorder (categorized in cluster B) such as borderline or histrionic personality disorder, receiving other psychological synchronous treatments. Before the intervention, the patients were informed of therapeutic targets. Their satisfaction was driven to participate in the research. However, almost all patients did not give up attending the treatment sessions. On average, they have participated in six sessions; as required, depending on the circumstance, the number of courses could be in the range of five to seven. The intervention was carried out for both couples simultaneously in each session .3.13.1.1First session: The therapist initiates rapport and obtains information about the relationship, the history of pain, through a semi-structured interview. The familiarity of each of the couples with the logic of intervention- Introducing mindfulness and action based on values. Second session: introducing additional mindfulness skills: bring their focus into their body scan meditation and be in the present moment. They learn how to concentrate on each part of their body organs; it started from toes. Identify potential benefits from anniversary exercise- Form the benefits and assess the extent to which each person lives with his or her values- Introducing psychological flexibility and its meaning. Third session: Determine specific behaviours and goals in line with values- Definition of mindfulness skills by practicing being in the moment- and be conscious. Fourth session: couple based practice of mindfulness-awareness identification and problem solving based on the values and objectives of Behavior-Adaptation of psychological flexibility skills for interpersonal interaction that includes mindful listening and response along with the transfer of positive emotions to the spouse. Fifth session: Detecting and solving problems based on the values and objectives of behaviour-psychological flexibility skills for interpersonal relationships and practising psychological flexibility skills. Sixth session: Combining the skills learned during the intervention – identifying psychological and interpersonal flexibility skills to continue practicing after the treatment has finished – problem-solving challenges that may patients encounter.3.1.2Ware and Sherburne  preparedMoreover, at the same time, it has excellent reliability. Three separate studies confirmed the validity and reliability of this test. The Cronbach’s alpha scale ranged from 0.73 to 0.93, and the internal consistency coefficient for the eight sub-scales was reported to be 0.76 to 0.95. In Iranian society, this test was performed on 404 students. The ratio of test re-test was 0.79, and Cronbach’s alpha was 0.85 .3.1.3et al. for measuring the severity of chronic pain. On this scale, three axes are evaluated, including the severity of pain, the stability or duration of pain, and the degree of pain disability. The respondents respond to each of the seven questions, on a scale with 11 points (0-10), marks the most suitable answer upon their circumstances. The score is estimated in three sub-scales, including pain intensity, the count of disability, and degrees or levels of disability. This questionnaire includes seven questions. Patients provided information on the severity of the pain and the amount of perturbation they experienced during the past six months in their daily activities. Cronbach’s alpha of disability and pain intensity was 0.87 and 0.68, respectively [The questionnaire was developed in 1992 by Von-Korff ectively . In this3.1.4 The questionnaire provides seven questions about the severity of the pain and the degree of disorder that the patients have been engaged in their daily activities during the past six months. The Cronbach’s alpha was 0.87 and 0.68 for disability and severity of pain, respectively . In this41 presents the demographic characteristics of patients with chronic pain based on gender, age, and education. The mean age of the subjects in the experimental group was 52.38 and in the control group was 54.86Table 1, out of a total of 16 test groups, six had less than a diploma, 6 were associated degrees, and 4 were bachelor’s degrees. Also, a total of 16 controls among participants, which underwent the intervention  were men, and 50% of those were women_ Considering gender proportion. Among patients in the waiting list, 36.4%  were women, and 73.5%  were men.As shown in Table 2 the mean and standard deviation of the factors contributing to the quality of life of patients have reported.Table 2, the most significant change among the subscales of quality of life scale was the social function score. After participating in the treatment, participants indicated the enormous leap from 34.37 in the pre-test to 118.75 in the post-test. At the same time, in the control group, the grades were steady with trivial changes (in pre-test it was 41.28 and in post-test was 57.14).As shown in Table 3). Table 3 shows that there was a significant difference between the experimental and control groups in terms of physical health  and psychological well-being .To determine the changes in the quality of life dimensions, in the two groups, MANCOVA was used 1) shows changes in the quality of life scores in both physical and psychological dimensions.Chart (The results of MANCOVA on the mean scores of the posttest show the amount of pain in the studied groups with pretest control.P= 0.71).Based on the results, the severity of pain after the intervention was significantly decreased (5The present study showed that couple therapy (focused on chronic pain) improved the quality of life of patients with chronic pain and reduced the amount of perceived pain.et al. [et al. [et al. [et al. [et al. [Hoffman et al. , in a me [et al. , in anot [et al. . In the  [et al.  compared [et al.  showed t [et al.  showed t [et al. . In a coThirdly, changes in the attitude of couples about pain as the uncontrollable issues can be useful, and they try to restrain it. As a consequence, they are, instead of blaming each other, or being angry resulting from the pain, looking for an efficient solution to manage it. They can throw away a vain attempt to stop the pain. It seems that the key to effectiveness and excellence in this therapeutic approach is to increase mutual social support. In this method, the focus has shifted from the patient individually to the patient and caregiver's needs, which fade into oblivion. The limitation of this research is the absence of a follow-up period and a modest number of participants.The results showed that social function and energy for the continuation of the performance had improved the most. According to the results, although the couple-based therapy could improve all aspects of physical and psychological subscales of pain, the physical health of patients was principally affected. This finding indicates that dealing with deep-rooted psychological problems requires more sessions; indeed, more than six-session treatment have had a positive impact on physical function. It is beneficial to carry out future research with the follow-up period and more participants. For future studies, it is suggested to emphasize cultural aspects that enhance couples' interpersonal relationships. Each culture has special features to enhance couples' ability to struggle with chronic pain. Researchers also suggest that therapeutic techniques should adjust to the elderly, who are more likely to be associated with comorbid illnesses and pain experience.