The precise etiology of knee osteoarthritis (KOA) pain remains highly controversial and there is no known effective treatment. Due to the known and suggested effects of neuropeptide Y (NPY) on pain, we have sought to investigate the relationship between the concentration of NPY in synovial fluid of knee, pain of KOA, and structural severity of KOA.One hundred KOA patients and twenty healthy participants (control group) were recruited. The pain and the radiographic grade of KOA were assessed separately by Hideo Watanabe’s pain score and Tomihisa Koshino’s scoring system. Synovial fluid of knee from all participants was collected with arthrocentesis. Radioimmunoassay was used to examine the concentration of NPY in synovial fluid of knee.p = 0.0297). According to Hideo Watanabe’s pain score, 100 KOA patients were divided into 5 subgroups: no pain (n = 12), mild pain (n = 25), moderate pain (n = 37), strong pain (n = 19) and severe pain (n = 7). Within the KOA group, significantly higher concentrations of NPY were found in each subgroup as pain intensified . Meanwhile, according to Tomihisa Koshino’s scoring system, 100 KOA patients were divided into 3 subgroups: early stage (n = 30), middle stage (n = 53), advanced stage (n = 17). Concentrations of NPY in middle and advanced stage groups of KOA patients were significant higher than early stage group of KOA patients  . Concentrations of NPY in advanced stage group of KOA patients has no significant difference compare with middle stage group of KOA patients (p = 0. 2175).Concentrations of NPY in synovial fluid were significantly higher in KOA patients (124.7 ± 33.4 pg/mL) compared with controls (64.8 ± 26.3 pg/mL)  contains supplementary material, which is available to authorized users. Knee osteoarthritis (KOA) is a chronic degenerative joint disorder that affects a large proportion of the population, particularly in elderly people –6. EpideNeuropeptide Y (NPY), a 36 amino acid peptide, is one of the most widely distributed neuropeptides in the nervous system , 14. It This study is in accordance with the ethical principles of the Declaration of Helsinki and was approved by the Local Research Ethics Committee , and the trial number 023–01 from Research Ethics Committee of People’s Hospital of Hangzhou, Nanjing Medical University.All participants provided informed, written consent.This one year study was conducted in People’s Hospital of Hangzhou, Nanjing Medical University from January 2009 to January 2010.One hundred KOA patients were recruited from the department of orthopedic surgery in People’s Hospital of Hangzhou, fulfilling the American College of Rheumatology clinical criteria for the diagnosis of KOA . In caseTwenty healthy participants between 35 and 65 years of age without any diseases judged by the physician were recruited from the People’s Hospital of Hangzhou as the control groups.Pain was assessed by the physician based on the patient’s medical history according to Hideo Watanabe’s knee scoring system-related pain score . PatientFull-extension posterior-anterior radiographs (X-ray) of the knees were obtained and assessed by the physician. The degree of radiographic KOA in individual joints was graded (0 to 5) by the study investigator using the Tomihisa Koshino’s scoring system . Grade 1All participants were in a supine position on a stretcher. The same entry site was demarcated with a skin-marking pen. The skin was prepared with povidone-iodine. A sterile drape was placed around the site. Then the region was anesthetized by placing a wheal of lidocaine, using a small (25-gauge) needle. Intermittently the plunger was pulled back during the injection of the anesthetic to exclude intravascular placement.An 18-gauge needle was used directly behind the patella into the synovial cavity with the lateral approach. Upon insertion into the articular cavity, 3 mL of 0.9% saline was injected slowly into the joint and after 20s 3mL of turbid-appearing fluid was aspirated and immediately centrifuged  at 4°C and stored at -70°C until analyzed. Synovial fluid from healthy individuals were collected, frozen, and stored in the same way as the KOA patients.125I] Neuropeptide Radioimmunoassay kit, Institute of RIA, Chinese PLA General Hospital, China) in accordance with the standard protocols included in the kits. The sensitivity of the radio-immunoassay kit was < 33 pg/mL.Radio-immunoassay was performed to determine concentrations of NPY in KOA synovial fluid. Concentrations of NPY in joint fluid was determined by commercially available radioimmunoassay kits  test was used to compare the mean of concentrations of NPY in synovial fluid of each KOA subgroup. A linear regression was used to assess the relationship between concentrations of NPY in synovial fluid and the pain of KOA patients. A p value less than 0.05 was considered to be statistically significant.All analyses were performed using SPSS version 13.0. Data presented as mean ± SD. Bartlett’s method was performed first to identify the homogeneity of variances. Group p = 0.347). The gender distribution between the two groups was similar with 39% of the KOA patients and 50% of healthy controls being male (p = 0.3609).In total, 100 KOA patients and 20 healthy controls participated in this study. The mean age of the KOA patients was 56 ± 6.9 years and 48 ± 8.1 years for the healthy controls, which was not significantly different (As previously stated the KOA patients n = 100) were divided into 5 groups according to Hideo Watanabe’s pain score: no pain group n = 12), mild pain group (n = 25), moderate pain group (n = 37), strong pain group (n = 19) and severe pain group (n = 7) . Within KOA subgroups, significantly higher concentrations of NPY were found in each subgroup as pain increased .In all tested KOA groups, there was a positive correlation between concentrations of NPY and the level of pain. Concentrations of NPY were significantly higher in KOA patients (124.7 ± 33.4 pg/mL) than in healthy participants (64.8 ± 26.3 pg/mL) , middle (n = 53) and advanced (n = 17) . Concentrations of NPY in the middle and advanced staged patients  were significantly higher compared to the early staged patients (96.4 ± 27.1 pg/mL) . Concentrations of NPY in the advanced staged patients were not significantly different compared to the middle staged patients (p = 0. 2175).Concentrations of NPY were significantly higher in the KOA patients (124.7 ± 33.4 pg/mL) compared to the healthy controls (64.8 ± 26.3 pg/mL) , compared to control patients with non-inflammatory joint disorders , admitted for arthroscopy , 41.With an increase in pain based on each KOA subgroups we found significantly higher concentrations of NPY. This result was similar to literatures that found that pain gradually developed from the initial mild pain into a long period of severe pain during the pathological process of KOA –12. ThisConcentrations of NPY in synovial fluid of middle and advanced KOA stages were significantly higher than early KOA stage. But concentrations of NPY in synovial fluid of advanced stage of KOA patients have no significant difference to compare with middle stage of KOA patients. These results contradict the notion that NPY has significant relevance to joint pain in patients with KOA, and significantly higher concentrations of NPY may lead to a significant increase in pain. It suggests a lack of agreement between X-rays evidence of KOA and patients’ report of pain at that site base on the result of our studies, which are the first study specifically designed to evaluate the relationship between NPY and KOA pain. Meanwhile, the orthopedic community has been plagued for years by this discordance. Many researchers –46 have 2+ conductance in dorsal root ganglion neurons and inhibits substance P released from the central terminals of the primary afferent fibers [2-agonists through stimulation of its Y2 receptor subtype [Studies have shown that during arthritis, pro-inflammatory mediators are released into the joint  which set fibers , 53, 54.t fibers . Noradret fibers  and NPY t fibers , 56, 57. subtype .This study is limited by a small sample size and the different sub-scales of classifications for pain and grade of KOA. In addition, the underlying molecular and cellular mechanisms of NPY in KOA pain remain poorly understood. Hopefully, future studies will provide answers to these questions.This study demonstrated the concentrations of NPY between KOA patients and healthy controls. These results suggest a role for NPY as a putative regulator of pain transmission and perception of KOA pain. In addition, concentrations of NPY may reflect the pathological progressing and severity of KOA. The precise roles of NPY in the pathogenesis of KOA pain require further investigation. However, our results have contributed to a better understanding of the molecular processes underlying KOA pain and, in addition, foster the option of local therapeutic intervention targeting NPY. The understanding of the role of NPY in KOA pain is a prerequisite to developing such novel therapeutic options for the treatment of KOA pain and restoration of tissue function.


The study aimed to analyze the role of axial view in different phases of treatment and demonstrate whether axial view is still useful in evaluating the calcaneal fractures.156 patients with suspected unilateral calcaneal fractures were enrolled in the study, axial and lateral view of the affected foot and single axial view of the unaffected foot were gained. 16 were excluded due to unsatisfying axial radiograph. The remain 140 patients were eventually included into the study. Two separate assessments were conducted on two occasions with a three weeks interval to diagnose fractures. Lateral views were assessed firstly, and lateral combined with axial views were assessed three weeks later. Each of the 140 sets was evaluated by one of 6 surgeons randomly. Sensitivity and specificity value were compared between the two assessments. A new value Z which can directly reflect the degree of bulge on the calcaneal lateral wall on the axial view were introduced into the study. Z value of the 140 unaffected feet were measured. Data of another group of 31 patients who confirmed their lateral hindfoot pain caused by widening of calcaneus was reviewed. Liner regression was employed to analyze the relationship between angle Z and the severity of lateral pain.p = 0.024) and sensitivity value will be significantly lower in distinguishing intra-articular fractures (p < 0.001). The normal threshold of angle Z was estimated from 98.06° to 100.64° (p <0.001). Liner regression shows that the lateral hindfoot pain will obviously aggravate along with the increasing of angle Z value (p <0.001).According to the two assessments, without axial view, specificity value will be significantly lower in diagnosing calcaneal fractures  contains supplementary material, which is available to authorized users. Calcaneal fractures are the most commonly foot injury encountered by orthopedic surgeon, which comprise 1%-2% of all fractures . LateralRetrospective review was performed on a, previously identified, cohort of 156 patients with suspected calcaneal fractures, all patients had a unilateral foot injury, were older than 18 years, without polytraumatic injuries of the ipsilateral lower limbs or severe medical ailments. All patients underwent calcaneal lateral and axial X-rays of the injured foot and single axial X-ray radiograph of the unaffected foot. Among the 156 patients, 16 were excluded due to unsatisfying axial radiograph before assessment. The remaining 140 patients, including 122 males and 18 females with a mean age 39.2 years , were included for evaluation and analysis. At the first stage, the calcaneal lateral radiographs of the 140 sets were assessed by a group of 6 senior orthopedic surgeons. Six surgeons gain a number from 1 to 6, and each of the 140 sets were evaluated by one of the 6 randomly. During the examine process, a form with two questions should be filled out. Q1: Is there a calcaneal fracture? Q2: extra- or intra-articular fracture? In all patients, CT scan were subsequently obtained to confirm the diagnosis. At the second stage, the radiographs were rearranged three weeks later, and assessed by the same group of surgeons with both lateral and axial view.In this study, angle Z was served as a critical index to assess axial radiographs. As Figure Another 31 patients who suffered from sustained isolate lateral hindfoot pain caused by malunion of calcaneal fractures after conservative treatment were included in the study. The source of pain was confirmed by injecting anesthetic into subtalar joint. Anesthetic technique with a minimal amount of local anesthetic was performed to the skin around injection point. The patients were then asked to perform activities which may elicit their pain, those who underwent immediate relief of pain after injection were excluded. Then patients were processed to anesthetic technique into peroneal tendon sheath to further identify the painful source. NPRS  was employed to evaluate the lateral hindfoot pain of the 31 patients, with other sources of pain were blocked by anesthetic. The severity of lateral pain slight pain (NPRS 0-3), moderate pain(NPRS 4-6) and severe pain (NPRS 7-10) were assigned a value of 1, 2 and 3 respectively and recorded for further analysis, Angle Z of the 31 patients were measured and recorded as well on axial view.The study was approved by the Institutional Review Board of the Third Hospital of Hebei Medical University . All patients included in the study signed the informed consents.p < 0.05.The data was analyzed with SPSS 13.0 for Windows . Categorical data was statistically analyzed by means of chi-square test or Fischer’s exact test (n < 40 or T < 1). Liner regression was employed to analyze the relationship between angle Z value and the values of Numerical Pain Rate Scale. Differences were regarded as statistically significant when p > 0.05) for diagnosing fractures but significantly lower in distinguishing intra/extra articular fractures (p < 0.001). In contrast, the specificity of the combined lateral and axial view group is significantly higher for diagnosing fractures (p = 0.024) but is similar to single lateral view group when distinguishing intra/extra articular fractures (p > 0.05).According to CT scan, 97 of the 140 patients had a confirmed calcaneal fracture. Among the 97 patients with calcaneal fracture, 79 were intra-articular and the other 18 were either calcaneal tuberosity fractures or fractures involve calcaneocuboid joint. Table p <0.001).The average angle Z value of the 140 unaffected feet is 99.35 ± 7.73°range from 83.0°to 119.7°. The 95% confidence interval of the overall average value is estimated from 98.06° to 100.64° . The angle Z values were found to be associated with severity of lateral hindfoot pain (P < 0.001). The severity of lateral hindfoot pain has an obviously increasing tendency along with the adding of angle Z value  than combined lateral and axial view group, which means intact calcaneuses sometimes are difficult to rule out. The inefficiency of excluding intact calcaneus may lead to an increasing use of computed tomography scan which will not only increase unnecessary radiation dosage but also waste manpower and financial resources. In addition, the results also point out that sensitivity value of single lateral view group is significantly lower than combined lateral and axial view group (p < 0.05) for distinguishing intra/extra-articular fractures. It indicates that intra-articular fractures may be ignored if only lateral calcaneal view can be referenced [Additional files Below we analyze the clinical value of axial view in terms of three respective aspects, diagnosing process, intra-operative and post-operative process. At the very beginning of diagnosing suspected calcaneal fracture, plain radiograph can efficiently distinguish real fracture from others as a quick means of method. As it showned in Table During operative process, the axial view used to be widely accepted as an essential method to evaluate the reduction quality of calcaneal fractures . The widDuring post-operative inpatient and outpatient follow up process, axial view can be employed to assess the loss of reduction combined with lateral calcaneus view. Böhler angle can be gained through lateral view and angle Z can be gained from axial view respectively. Synthetically analyze the two indexes (Böhler and Z angle) can predict the long-term outcomes more effectually than merely lateral view .There are still some limitations in the current study. First, standard axial views are painful to obtain especially in diagnosing and post-operative procedure. Therefore, some datas in our study excluded due to a satisfying preoperative axial view can not be obtained. More standardized, convenient and painless procedure for axial view should be introduced in future studies to minimize the bias among different axial views. In addition, Numerical Pain Rate Scale (NPRS) which is an subjective evaluate system may compromise the reliability of results, even though we divided the NPRS values into three levels  to minimize the variability. Peroneal tenography suppose to be more objective in reflecting the severity of compression on peroneal tendon sheath than NPRS scale, however, it is hard to persuade all the patients to accept the invasive technique. Furthermore, more exquisitely designed prospective studies are needed to further confirm the relationship between ankle Z and long-term lateral pain after calcaneal fractures.Axial view is useful in diagnosing a patient with suspected calcaneal fracture especially for distinguishing intra-articular fractures and selection for CT scan. With the introduction of angle Z, axial view can get excellent performance in both intra-operative assessment and post-operative follow-up evaluation. Axial view can still play an irreplaceable role in assessing and evaluating calcaneal fractures, and can be employed as an essential reference during surgical procedure.


Fabry-associated pain may be the first symptom of Fabry disease (FD) and presents with a unique phenotype including mostly acral burning triggerable pain attacks, evoked pain, pain crises, and permanent pain. We recently developed and validated the first Fabry Pain Questionnaire (FPQ) for adult patients. Here we report on the validation of the self-administered version of the FPQ that no longer requires a face-to-face interview but can be filled in by the patients themselves allowing more flexible data collection.n = 56) were first interviewed face-to-face. Two weeks later patients’ self-reported questionnaire results were collected by mail (n = 55). We validated the self-administered version of the FPQ by assessing the inter-rater reliability agreement of scores obtained by supervised administration and self-administration of the FPQ.At our Würzburg Fabry Center for Interdisciplinary Treatment, Germany, we have developed the self-administered version of the FPQ by adapting the questionnaire to a self-report version. To do this, consecutive Fabry patients with current or past pain history  contains supplementary material, which is available to authorized users. The X-linked lysosomal storage disorder Fabry disease (FD) is caused by mutations in the encoding gene of the α-galactosidase A (α-GAL), which lead to reduction or complete loss of enzyme activity. The consequence is the accumulation of the sphingolipid globotriaosylceramide-3 (Gb3) particularly in kidneys, heart, and the nervous system . The onlPatients with FD frequently suffer from pain that mostly starts in early childhood , 3. OfteOur study was approved by the Ethics Committee of the Medical Faculty of the University of Würzburg (#25/13), and written informed consent was obtained before inclusion from every study participant. On the basis of the recently validated face-to-face version of the FPQ  we firstFrom July 2014 to February 2015 study participants were first interviewed face-to-face with the saFPQ by a trained interviewer (BM) during their visit at our Fabry Center for Interdisciplinary Treatment (FAZIT) or were visited at their homes. The questions were read out to the patient, and the individual answers and the time necessary to complete the questionnaire were noted. Patients were then asked to individually fill in the questionnaire again two weeks later at their homes and to send back the questionnaire by mail. Patients also noted the time needed to complete the questionnaire.The following inclusion criteria were applied for the study cohort: ≥18 year old men or women with genetically proven FD; current and/or past pain history. Patients were recruited at FAZIT in Germany, which is a tertiary referral center. Patients had previously not taken part in the evaluation of the FPQ .a priori defined that analyses would be restricted to patients who reported identical current pain intensities at both sessions, defined as a deviation of ≤1 point on a numeric rating scale (NRS) for question 6 of the FPQ. For a detailed description of the statistical analysis performed see Additional file All analyses were performed using IBM SPSS Version 22  and SAS, version 9.3 . According to previous studies  and withTable All saFPQ items were answered completely by all study participants. The overall acceptance by the patients was high and patients gave a very positive feedback about the content and the format of the questions. The median time necessary to fill in the saFPQ during the face-to-face interview was 15 min (range 10–20 min), and during the self-filling-in period 15 min (range 10–30 min).Agreement between the self-administered and the face-to-face version was very high for nominal-scaled items with a mean of all AC1-statistics of 0.857 (range 0.580-1.000). With the exception of evoked pain by contact (4a), all items of questions 1–5 (referring to the four major pain phenotypes and sensitivity impairment) showed good agreement with AC1-statistics . However, in its original version with a face-to-face interview design the FPQ was unpractical and time-consuming for the treating physicians. To overcome this drawback we have now designed and validated the self-administered version of the FPQ that allows the assessment of Fabry patients in a self-reporting manner and even if they cannot personally come to the referral Fabry Center.http://www.fda.gov/downloads/Drugs/DrugSafety/DrugShortages/UCM187056.pdf). During this period not only ERT dosage but also the compound  was changed in some patients. It may have been difficult for these patients to judge if any changes in their pain during this phase were due to changes in ERT dosage or compound, or whether this was part of the natural course of their disease. Another aspect that needs to be taken into account are the known alterations in cognitive function of Fabry patients [One limitation of our study is the relatively low number of subjects, however, the statistical analysis of the saFPQ showed that the majority of questions have a good to very good test-retest-reliability. Few questions were obviously difficult to answer in the study setting with two time points and potential events in between like question 7: “How did your pain (with or without treatment) develop since last visit ?” Some patient referred to the last visit two weeks ago  and some patients referred to their last regular visit at the FAZIT one year ago. This, however, is due to the special study situation with two consecutive interviews, which is not clinical routine and therefore without practical relevance. One reason why some patients may have given inconsistent answers to some of the questions at the two sessions may be that particularly patients with low-frequent episodic pain do not see this (manageable) pain as a major problem and therefore judge changes less consistently when asked at two different time points. Another reason for the inconsistent answers particularly with regard to the analgesic effect of ERT may be based on the experiences patients made during ERT supply shortage  can even be obtained in remote areas where only few or no Fabry Centers are present. Thus, saFPQ brings further flexibility to the assessment of Fabry-associated pain. The next step will be to validate the English version of the saFPQ to make the questionnaire available for even more Fabry patients.Fabry-associated pain is distinct in phenotype and needs special tools for standardized assessment during clinical practice and in trials. The saFPQ is the first self-administered pain questionnaire designed for Fabry patients and will substantially improve pain management and data acquisition in patients suffering from Fabry-associated pain.


Prolonged mechanical ventilation for acute medical conditions increases the risk of chronic critical illness (CCI). Close family members are confronted with the life-threatening condition of the CCI patients and are prone to develop posttraumatic stress disorder affecting their health-related quality of life (HRQL). Main aim of the present study was to investigate patient- and family-related risk factors for posttraumatic stress and decreased HRQL in family members of CCI patients.n = 83, aged between 18 and 72 years) up to 6 months after transfer from ICU at acute care hospital to post-acute rehabilitation. Patients admitted a large rehabilitation hospital for ventilator weaning. The Posttraumatic Stress Scale-10 and the Euro-Quality of life-5D-3L were applied in both patients and their family members via telephone interview.In a cross-sectional design nested within a prospective longitudinal cohort study, posttraumatic stress symptoms and quality of life were assessed in family members of CCI patients  and the patients’ diagnosis of PTSD . Perceived satisfaction with the relationship turned out to be a protective factor for posttraumatic stress in family members of CCI patients . Regarding HRQL in family members, patients’ acute posttraumatic stress at ICU  and their own posttraumatic stress 3 to 6 months post-transfer  turned out to be significant predictors.A significant proportion of CCI patients and their family members  showed clinically relevant scores of posttraumatic stress. Both CCI patients and family members reported poorer HRQL than a normative sample. Factors independently associated with posttraumatic stress in family members were the time following ICU discharge  contains supplementary material, which is available to authorized users. Treatment on intensive care unit (ICU) for acute medical, surgical, neurologic or cardiac critical illness can go along with secondary medical complications such as severe sepsis with multiorgan failure. Elective placement of tracheotomy and prolonged mechanical ventilation for at least 21 consecutive days put these patients at risk for the development of chronic critical illness (CCI). About 5–10 % of patients requiring prolonged ventilator weaning show an unspecific clinical syndrome of additional key characteristics, e.g., neuromuscular weakness, myopathy, neuropathy, protracted coma, delirium, malnutrition, anasarca, endocrinopathy, inflammatory impairment and intense psychophysiological distress   and the acute posttraumatic stress at ICU as assessed with the ASDS in CCI patients  could be identified as significant predictors of HRQL in close family members. The model explained an adjusted total variance of 47.4 %   putting those patients at increased risk of persistent or delayed PTSD in the follow-up . FollowiWe could not find a significant effect of the severity of illness, the length of ICU stay, family member’s age and gender. This is in line with existing findings e.g., , 47 but For the present study, some methodological shortcomings should be addressed. First, for the assessment of posttraumatic stress disorder a self-report measure (PTSS-10) instead of a clinician administered structured diagnostic interview was applied. The PTSS-10 is based on subjectively reported symptom intensities. Thus, a potential overestimation of the frequency of posttraumatic stress might have occurred. Above, the PTSS-10 has some limitations since it is based on DSM-III criteria, items on numbing or flashbacks are missing and only one item assesses avoidance. Future study should rather use the PTSS-14  as extenThere is a considerable rate of clinically relevant posttraumatic stress symptoms and significantly diminished HRQL in close family members of CCI patients following ICU stay. Close family members of CCI patients display second-order patients which also suffer from impaired mental and physical long-term sequelae following CCI and intensive care. We suggest a routine assessment of patient- and family-related risk factors while the chronically critically ill patient is in the ICU and up to 6 months following discharge from ICU at acute care hospital. Posttraumatic stress and quality of life should be ascertained at regular intervals starting at ICU admission and being followed up at least 6 months post-ICU.


An academic, community medicine partnership was established to build a phenotype-to-outcome model targeting chronic pain. This model will be used to drive clinical decision support for pain medicine in the community setting. The first step in this effort is an examination of the electronic health records (EHR) from clinics that treat chronic pain. The biopsychosocial components provided by both patients and care providers must be of sufficient scope to populate the spectrum of patient types, treatment modalities, and possible outcomes.The patient health records from a large Midwest pain medicine practice  contains physician notes, administrative codes, and patient-reported outcomes (PRO) on over 30,000 patients during the study period spanning 2010 to mid-2014. The PRO consists of a regularly administered Pain Health Assessment (PHA), a biopsychosocial, demographic, and symptomology questionnaire containing 163 items, which is completed approximately every six months with a compliance rate of over 95 %. The biopsychosocial items  were examined by exploratory factor analysis and descriptive statistics to determine the number of independent constructs available for phenotypes and outcomes. Pain outcomes were examined both in the aggregate and the mean of longitudinal changes in each patient.Exploratory factor analysis of the intake PHA revealed 15 orthogonal factors representing pain levels; physical, social, and emotional functions; the effects of pain on these functions; vitality and health; and measures of outcomes and satisfaction. Seven items were independent of the factors, offering unique information. As an exemplar of outcomes from the follow-up PHAs, patients reported approximately 60 % relief in their pain. When examined in the aggregate, patients showed both a decrease in pain levels and an increase in coping skills with an increased number of visits. When examined individually, 80-85 % of patients presenting with the highest pain levels reported improvement by approximately two points on an 11-point pain scale.We conclude that the data available in a community practice can be a rich source of biopsychosocial information relevant to the phenotypes of chronic pain. It is anticipated that phenotype linkages to best treatments and outcomes can be constructed from this set of records. With the high prevalence of chronic pain in America, plus the corresponding personal, social, and economic burdens from pain –3, it isPragmatic approaches to comparative effectiveness must be built on the knowledge of the patients and their environment. Considering that the number of patient visits in the US per year for all conditions is approximately 190 million , patientTM). This was designed to give each patient a consistent voice in their medical record, reflecting the complexities and multidimensional nature of pain and its effects on the whole person. Supplementing this is the physician perspective recorded as text in detailed progress notes following an enhanced SOAP note format and rendered in correspondence form. With these components available, an opportunity now exists to utilize this community-based patient data to improve outcomes ).The types and characteristics of the data stored in the EHR at MPC are shown in Table TM Pain Health Assessment (PHATM), developed by ProCare Systems, Inc., which is a patient self-assessment instrument that provides demographic, medical and social history, as well as patient-reported outcomes (PRO). It contains core outcome domains that evaluate the efficacy of treatments, consistent with the recommendations of the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) [As part of MPC’s initial assessment, patients are asked to complete an initial pain health assessment (iPHA). MPC utilizes the PRISMIMMPACT) , 24. TheThe development of the PHA was motivated by the needs of community based physicians in the emerging field of pain medicine to demonstrate the quality and effectiveness of the care being provided. ProCare began working with the American Academy of Pain Medicine in the mid 1990’s as a beta test site for the Digimed project. Although that system failed to produce the sensitivity needed for the task, the project set the stage for the evolution of other measurement systems.In 2004, the TOPS  survey wIn 2007 substantial evolutionary changes to the survey and its administration were undertaken. The goal was to develop a PRO tool that would not interfere with clinic flow or add significantly to the cost of care. The tool was composed of quality-of-life indicators, as well as additional questions assessing functional impairment, psychosocial health, and patient satisfaction. Response scales were universally formatted to an 11-point Likert scale to be sensitive enough to map incremental changes. In 2009, technology allowed for a fully functional web-based system that could be accessed from any computer or tablet device. In 2011 an assessment of narcotic risk was incorporated.TM portal. Information from the PHA is instantly analyzed and transferred to a Patient Summary Page dashboard for the physician and care team to inform clinical decision making in real-time during the patient visit.Currently, the PHA is self-administered by patients using iPads provided in the clinic at check-in or through the PRISMTwo versions of the questionnaire are used in the practice: an initial assessment version  for new patients and a version for follow-up visits containing repeated measures for most iPHA questions plus the addition of specific outcome questions. (This is referred to as the cumulative PHA or cPHA.). The cPHA is also used for patients that did not complete an iPHA because their initial visit preceded its rollout. The full questionnaire covers 39 categories with a total of 163 items designed to assess pain characteristics, social and demographic characteristics, health behaviors, habits, symptoms, narcotic risk, and self-reported syndromes and symptoms. A breakdown of categories is shown in Table Michigan State University (MSU) through its Biomedical Research Informatics Core (BRIC), a division of the MSU Clinical and Translational Sciences Institute (CTSI) has entered into a Business Associates agreement with Michigan Pain Consultants (MPC) and ProCare Systems, Inc. MSU BRIC houses de-identified copies of their Pain Health Assessment questionnaire, their de-identified practice management data, and their dictated clinical progress notes on a secure workstation isolated from the internet, in compliance with HIPAA regulations and IRB requirements. The Michigan State University IRB has declared this project to have a category 4 exempt status under 45 CFR 46.101(b)(4). Questionnaires from April 1, 2010 to September, 2014 were used in this analysis because the PHA question slate remained unchanged during this span, except for the addition of the Opioid Risk Tool  questionDuring the study period, approximately 30,400 patients completed one or more PHA surveys. Of this number, ~22,700 were new patients who completed the iPHA. A total of ~61,000 cPHAs were completed, which included patients who had completed the iPHA during this span and patients who had completed previous versions of the iPHA or none at all due to their much longer history with the MPC clinics. Approximately 12,600 patients had completed both an iPHA and one or more subsequent cPHAs during this span. The remainder of patients with an iPHA had no cPHA primarily because they either chose not to return or their return date was outside the study period. Furthermore, there are occasional workflow issues in the clinic that have hindered completion of cPHAs and some patients’ health prevents them from complying. Those patients with both iPHA and cPHA during this period had completed approximately 31,600 cPHAs over varying numbers of subsequent visits.Preliminary exploratory factor analysis (EFA) of the PHA battery of questions (as implemented by the principle factor methodology in Stata™ v12) examined both the iPHA and cPHA repository. Cronbach’s alpha  and inteQues.1. Overall, how much relief have you received from pain treatments and medications? Please fill in the percentage that shows how much relief you have received. (0–10) 0 % - 100 %;On a scale of 0–10, please rate your average pain in the past 4 weeks”;Ques.2. “Fill in the number that best describes your average daily pain at this point in treatment at the pain management center. Please rate (0–10) No pain – worst pain”;Ques.3. ““On a scale of 0 to 10… Your control over your pain. (0–10) Complete – None”Ques.4. To provide preliminary evidence for the utility of the PHA in pain outcomes, we focused on a small subset of questions. The PHA questions of interest for this analysis are:Ques.1 and Ques. 3 appear only in the cPHA.  In each of these questions, the responses are on an 11-point Likert scale ranging from 0–10. For question Ques.1, this scale was presented to patients as percent relief (0 – 100 %).The PHA was assembled to evaluate multiple patient dimensions by deploying several question items that potentially consolidate into factors and therefore may be combined into scale scores useful as representations of constructs in models and decision support engines. While the items in the PHA were inspired by existing pain questionnaires, the reliability, validity, and construct mapping of item sets deployed in the PHA were not determined a priori in pilot studies. Rather, the decision was made by ProCare to collect large quantities of responses within the environment of a community-based. multi-site medical practice to allow the data to drive the organization of constructs from identifiable factors. Once in place, reliability and validity estimates can be made. Therefore, we begin with an unbiased examination of these items using exploratory factor analysis to identify groups of items that have high inter-item correlation, strong factor loadings, and high Cronbach alpha values. The goal is to determine which questions can be combined into relatively homogenous scales and which questions provide unique information and should stand alone. In contrast to efforts to design question batteries that can be combined into scales representing conceptual constructs , this wAs shown in Table Choosing 15 factors for the analysis yielded 15 identifiable clusters with two or more questions per factor Table . Seven oIn Table The communality values in Table To examine the degree of independence among the 15 identified factors from the iPHA analysis Table , scales In the follow-up questionnaire, the 21 questions unique to the cPHA (Q23 – Q27) formed two factors plus three questions that did not have strong loadings. Two of those outcome questions  are analyzed below (Ques.1 and Ques.3). With regard to the two identified factors, one is composed of 11 questions related to patient satisfaction with the clinical experience (Q27). The other contains seven questions regarding biopsychosocial health improvements after treatments (Q26). These question batteries have alpha values of 0.96 and 0.94, respectively, and in a cPHA factor analysis they consolidate into factors with mean loadings of 0.85 and 0.78, respectively. In order to fully examine the factors for the cPHA, the cases must be sorted into groups denoted by which cPHA in a patient’s treatment it is. Currently, patients range from having only one cPHA on file  to ten on file (42). Full factor analyses for these groups are outside the scope of this report.In the previous section, a portion of the PHA was shown to contain identifiable structure that would help populate components of a person-in-pain phenotype model. To be a comprehensive dataset, it must also contain viable outcomes information to allow the full phenotype-treatment-outcome model to be constructed. A sample of outcome measures is explored in this section.Responses to question Ques.1 (see Methods section) strongly indicated that patients experienced benefit from the care received. This is shown in Fig. While aggregate results are enlightening, longitudinal intra-patient responses offer a more robust examination of treatment responses. Therefore, within-patient pain outcomes were examined in the patient population that had both iPHA and cPHA responses on file from the April 2010 to September 2014 time period. This was approximately 12,600 patients. From this group two subpopulations were identified: one that had initial responses to Ques.2 within the range 1–9 ; and one that had initial responses only in the range 7–9 (approximately 4600 patients). Question #2 requests a patient’s pain level within the previous four weeks. We used the responses to this question in the iPHA as an indicator of starting pain levels. Outcomes from treatment were examined by calculating the numeric change in responses to Ques.2 in the subsequent visits when the cPHA was filled out, and by examining the responses to Ques.3, which is specifically worded as an outcome question and exists only in the cPHA.To obtain an appreciation for the range of responses rather than simple averages, the distributions of patient outcomes were calculated. The distributions of the changes in patient pain levels with time are shown in Fig. The distributions within Fig. Health records from a community-based pain medicine practice have been described and a preliminary evaluation of patient-reported status and outcomes has been performed for patients seen between April, 2010 and September, 2014. The patient population is constrained by the demographics, socio-economic profile, and local referral patterns of the region. In this case, the 7 community clinics of Michigan Pain Consultants represent an upper Midwest USA region serving 6 counties in West Michigan containing medium-sized urban, suburban and rural environments. The patients seen by this practice are those with commercial or government medical insurance or have the means for private pay. As such, the findings, while broad, cannot be generalized to large urban centers or to the poor without further work to show that the resulting phenotypes cross these boundaries.This work is part of a larger study designed to construct a phenotype – treatment – outcome model for pain medicine. Our working hypothesis is that knowing phenotype profiles for pain patients will help predict appropriate treatments associated with better outcomes and that this type of data can be extracted from community clinical practice, where most chronic pain is treated. A university-community partnership was established to provide a foundation for this study. The first goal was to determine if the pain clinic medical record database (EHR) contained sufficient information to construct a model. The MPC EHR is composed of practice management data, patient questionnaires, and physician progress notes with a longitudinal component available for many patients.In this study, we show that the biopsychosocial component of the patient questionnaire contains identifiable factors that will allow combining question items into measures of interest for a phenotype model. It should be noted that no inferential statistical methods are available for exploratory factor analysis, thus there is a subjective element to the choice of the number of eigenvalues and acceptance/rejection criteria for correlations, loadings, and Cronbach alpha values. Nevertheless, from exploratory factor analysis, preliminary models can be constructed and confirmatory factor analysis can provide the statistical tests to evaluate these models. We will use the data acquired after September, 2014 for this type of work.It will also be important to identify the factors (latent variables) in the practice management data, the progress notes, and in the remainder of the PHA data. Larger models can then be constructed, initially tested with CFA and then comprehensively tested with structural equation modeling (SEM) . It is dThe preliminary examination of pain outcomes showed that pain indicators can be followed with time. In the analysis of the patient outcomes it is useful to note that the mean improvement of pain levels across repeated visits was approximately one to two units on an eleven-point scale. This degree of improvement was consistent with previous validation studies on small patient numbers utilizing other pain scale tools –36. ThisTM care management clinical outcomes tool helps to assess the efficacy of interventional treatments and helps guide physicians in the use of opiates and other medicationsThis approach is important for the field of pain medicine and for the patients receiving therapy. The use of systems like the PRISMFinally, it must also be noted that many patients stop returning after varying numbers of visits. This leads to many patients with only the iPHA on file and/or only a few cPHAs on file. The reasons for patients not returning are probably many. After an initially scheduled follow-up visit, a patient may not return because their pain is adequately under control, or they did not receive any relief, or they left the area, changed insurance plans or have other financial barriers, or they are deceased. It is important that we determine the size and characteristics of these sub-populations to make meaningful longitudinal predictions of outcomes. These patient decisions will also need to be part of the chronic pain phenotype profile. This will be one focus of future work based on sampling surveys.In conclusion, early results are presented that lay the groundwork for extracting patient and physician perspectives in a community pain medicine specialist practice. We have demonstrated that multiple biopsychosocial variables and pain level outcomes are being captured by the various tools used by the practice.. We believe that these data can be used to begin building phenotypes for persons in chronic pain and the linkages to treatments and outcomes that, in turn, can be used to facilitate evidence-based, personalized treatment of pain in community settings.


Concerns about pain control in patients with cerebral palsy (CP) are especially anxiety provoking for parents, given the fact that spasticity, communication issues, and postoperative muscle spasms are significant problems that make pain control difficult in these patients. A better understanding of the magnitude and quality of the pain these patients experience after our surgical procedures would better prepare the patients and their families. The purpose of this study is to quantify the amount of postoperative pain in children with CP undergoing hip reconstruction and spinal fusion. Specifically, the study will compare pain scores and the amount of narcotics used between the two groups.t-tests were utilized to statistically compare differences between the groups, with significance determined at p < 0.05.This is a retrospective chart review of a consecutive series of children with CP (GMFCS levels IV and V) over a 5-year period undergoing hip reconstruction  and posterior spinal fusion (PSF) at a tertiary-care pediatric hospital. The primary end point was the total opioid used by the patient during the hospitalization, by converting all forms of narcotics to morphine equivalents. The secondary end point was the documentation of pain with standard pain scores at standard time points postoperatively. Adverse effects related to pain management were documented for both groups. Student’s p = 0.014). The mean pain score for the hip group was 1.52, compared to 0.72 for the spine group (p = 0.013). There were no significant differences in the occurrence of adverse effects related to pain management between the two groups.Forty-two patients with CP who underwent hip reconstruction (mean age 8.8 years) were compared to 26 patients who underwent PSF (mean age 15.4 years). The total opioid used, normalized by body weight and by days length of stay (DLOS), in the hip group was 0.49 mg morphine/kg/DLOS, compared to 0.24 for the spine group . The assessment, impact, and treatment of pain in patients with cerebral palsy (CP), especially those with cognitive impairment and developmental delay, can be difficult, and is an important concern for the practitioner, the family, and the patient . ConcernMore attention in the literature is being focused on the presence of pain in patients with CP , 6. HowePatients with CP often need a variety of orthopedic surgical interventions to improve their function, provide pain relief, or prevent deterioration of the musculoskeletal system that could negatively impact their future quality of life (QoL) –13. FreqThe concept of an interactive, mutual informed consent process is now the mainstay in our relationships with our patients. Part of the informed consent process is a description of the risks, benefits, and alternatives of the proposed surgical procedure . A discuThe purpose of this study is to quantify the amount of postoperative pain in children with CP undergoing hip reconstruction and PSF. Specifically, the study will compare pain scores and the amount of narcotics (opioid) used between the two groups. The goal of the study is to provide better objective information on postoperative pain in children with CP, so that providers can better prepare their patients and families.This is a retrospective chart review of a consecutive series of children with CP over a 5-year period at a tertiary-care pediatric hospital. Inclusion criteria included patients with diagnosis (ICD-9) codes for CP, with a GMFCS level IV or V, who underwent procedures for hip dysplasia with reconstruction  and PSF identified by CPT codes for those procedures. An additional inclusion criterion was that the medical records of all patients had to have documented complete pain assessment scores during the first 3 days postoperatively. Exclusion criteria were any child with CP who did not undergo those specific procedures, or those patients who underwent the procedures without a specific diagnosis of CP. Also, any patients who had an anterior spinal release and/or fusion as part of their spine treatment were also excluded from the study. The study was reviewed and approved by the hospital’s Institutional Review Board (IRB).All of the patients in the hip group underwent soft tissue lengthening with adductor longus and gracilis tenotomy with a fractional lengthening of adductor brevis, and varus derotational osteotomies (VDRO). The VDROs were performed through a standard lateral approach with a supine position and all had a 2-cm femoral shortening performed as a standard portion of the hip reconstruction to decrease soft-tissue tension. Patients older than 7 years of age underwent concomitant pelvic osteotomies with the VDRO if there were any signs of acetabular dysplasia. All pelvic osteotomies were performed with an anterior approach, elevating the gluteal muscles off the outer table of the pelvis; the inner table was not violated. The osteotomies were lateral-based San Diego-type procedures, with the graft being taken from the femoral shortening.4) equivalents. A normalized opioid value was then obtained by dividing the total opioid used by the weight of the child (in kg) and the number of days of hospitalization (nTOU) (units of mg MSO4/kg-days). All of these patients remained on the inpatient unit for at least 3 days postoperatively. The data from these two groups were then analyzed to determine differences in TOU.The primary end point was the total opioid used by the patient during the hospitalization, by converting all forms of narcotics  to morphine . For non-verbal children, the revised face, legs, activity, cry, and consolability (FLACC) behavioral tool was used , 25.All patients received standard pain control postoperatively through on-demand intravenous narcotics and/or a patient-controlled analgesia (PCA) pump. The standard on-demand intravenous morphine dose at our institution is 0.05 mg/kg every 1 h; the standard morphine PCA dose is 0.02 mg/kg every 10 min, with a 1-h maximum of 0.1 mg/kg. However, occasionally, a substitute opioid with equivalent dosing was used. All of the patients in the hip group also received indwelling epidural catheters  for the first 48 h postoperatively.In addition, all patients in both groups also received scheduled intravenous and oral diazepam (0.1 mg/kg every 6 h) and scheduled intravenous ketorolac  to assist with adjunctive pain control. These adjunctive pain control modalities were used in both groups, with standardized dosing regiments. In these cohorts of patients, none of the spine group had any additional adjunctive pain control methods, such as intrathecal injections or submuscular pain pumps.The postoperative protocols for each group were similar, with mobilization out of bed to their wheelchairs either as soon as possible, typically on postoperative days 1 or 2. Postoperative immobilization for the hip group was either with spica casts or with full-time hip abduction pillows and knee immobilizers . There were no differences in the GMFCS level between the groups. The patients in the hip group had a mean Reimer’s index of 68 % (range 40–100 %). The patients in the spine group had a mean preoperative Cobb angle of 78° (range 50–120). The overall demographics of each group are detailed in Table Forty-two patients with CP who underwent hip reconstruction at a mean age of 8.8 years range 4–21) were compared to 26 patients who underwent PSF at a mean age of 15.4 years (range 10–22). The differences in age were statistically significant ( were comp = 0.014) , compared to 0.24 for the spine group (range 0.06–0.62) p = 0.04  , compared to 0.72 (range 0.0–2.29) for the spine group  than hip reconstruction. Because of that, many families delay the spine fusion significantly. We designed this study to evaluate the pain that patients experience with spine fusion, relative to the amount of pain experienced with hip reconstruction.In this retrospective series, patients with CP undergoing hip reconstruction surgery had significantly more pain, as exhibited by requiring more narcotics and having higher pain scores, than those patients undergoing PSF. These findings confirm the subjective opinions of many providers that care for these patients, as well as the observations of many patients and their families who have undergone both procedures. The results of this study are not surprising; immobilization generally leads to better pain control, and the immobilization from the spine fusion may be one significant cause in the difference in pain generation when compared to the mobility of a hip that has undergone osteotomy and reconstruction.While recent reports have focused on the difficulty in assessing pain in patients with CP, we feel that the comparisons made in this study are valid , 26. WhiThe focus on family-centered care is shifting our treatment priorities away from isolated clinical outcomes, such as postoperative radiograph findings, and focusing more on patient-centric outcomes. Certainly, the ability to provide adequate postoperative pain control is central to many patients’ and families’ concerns when considering a surgical procedure , 20. A bIn addition to better patient and parent education, we feel that another very real, practical benefit may come from the findings in these studies. Most hip reconstructions for patients with CP are typically done at an earlier age when compared to the age for PSF, as is shown in our mean age data for each group. A common complaint we hear from our families is how difficult the postoperative period after hip reconstruction can be. For those patients who originally need hip surgery, the authors have observed hesitancy for those families to agree to undergo PSF in a timely fashion. These families often point to the severe postoperative pain after the hip surgery for their delay in seeking treatment for the scoliosis, thinking the spine surgery must be “at least as painful” as the hip surgery. In our experience, this delay has caused some children’s scoliosis to progress severely, thus making the ultimate surgical treatment more difficult, with a concordant higher risk of postoperative complications.Our study has several limitations. The retrospective nature of the review lends the study to be subject to a variety of bias-related errors. Secondly, the previously mentioned difficulty in assessing and treating postoperative pain in patients with CP could be a significant confounding variable . ThirdlyIn conclusion, patients with CP undergoing hip reconstruction surgery had significantly more pain, as exhibited by requiring more narcotics and having higher pain scores, than those patients undergoing PSF. The knowledge that hip reconstruction is more painful than PSF for patients with CP will better prepare families about what to expect in the postoperative period and will alert providers to provide better postoperative pain control in these patients.


Advanced osteoarthritis and total joint replacement (TJR) recovery are painful experiences and often prompt opioid use in developed countries. Physicians participating in the philanthropic medical mission Operation Walk Boston  to the Dominican Republic have observed that Dominican patients require substantially less opioid medication following TJR than US patients. We conducted a qualitative study to investigate approaches to pain management and expectations for postoperative recovery in patients with advanced arthritis undergoing TJR in the Dominican Republic.We interviewed 20 patients before TJR about their pain coping mechanisms and expectations for postoperative pain management and recovery. Interviews were conducted in Spanish, translated, and analyzed in English using content analysis.Patients reported modest use of pain medications and limited knowledge of opioids, and many relied on non-pharmacologic therapies and family support to cope with pain. They held strong religious beliefs that offered them strength to cope with chronic arthritis pain and prepare for acute pain following surgery. Patients exhibited a great deal of trust in powerful others, expecting God and doctors to cure their pain through surgery.We note the importance of understanding a patient’s individual pain coping mechanisms and identifying strategies to support these coping behaviors in pain management. Such an approach has the potential to reduce the burden of chronic arthritis pain while limiting reliance on opioids, particularly for patients who do not traditionally utilize powerful analgesics. Arthritis is a leading cause of long-term pain worldwide . OsteoarIn developed countries, pain management for arthritis is often multimodal, involving a combination of both pharmacologic and non-pharmacologic therapies –8. PatieThe global prevalence of arthritis has prompted proliferation of philanthropic programs that aim to alleviate the burden of arthritis and associated pain. Operation Walk Boston  is one such program, which has offered TJR to economically disadvantaged patients in the Dominican Republic since 2008. Prior studies have indicated that OpWalk patients experienced substantial preoperative pain as measured by the Western Ontario McMaster Universities Osteoarthritis Index . NeverthThe Dominican Republic occupies the eastern two-thirds of the Caribbean island of Hispaniola. Of its 10.3 million citizens, approximately 41.1 % live below the poverty line. The per capita gross domestic product is $12,800, of which health care expenditures account for 5.4 % . AlthougParticipants for this study were chosen from the 40 patients in OpWalk Boston 2015. These individuals learned of the program through advertisement, word of mouth, or physician referral. All patients were low-income and unable to pay for the procedure. The criteria for selection into OpWalk included symptomatic, radiographically advanced knee and/or hip arthritis, stable medical status, and willingness to stay in the Santo Domingo area for 2 weeks after surgery for postoperative visits. Patients for this study were sampled pre-operatively because their perceptions of arthritis pain management and surgery may be altered in the post-operative state. All patients recruited understood that participation in the study was optional and would not impact their upcoming surgery. Due to timing constraints, not all patients enrolled in OpWalk were approached for interviews. For each of the four consecutive days that the study was conducted, participants were selected randomly, to minimize selection bias, from those who had not yet completed surgery. Interviewers met at the end of each day to discuss common preliminary themes observed during the interviews and to determine if data saturation was met. We limited the sample to 20 patients because we reached a point of saturation at which completed interviews revealed commonalities and no longer produced new themes and insights. Consent for participation and publication was obtained from all patients. All study activities were approved by the institutional review board at Brigham and Women’s Hospital.Three trained interview teams, each comprised of one US student and one medical student from Universidad Iberoamericana, performed 20 preoperative interviews over 4 days during OpWalk Boston 2015. Interviews were conducted in Spanish and followed a moderator’s guide to ensure consistency of content  coded five randomly selected transcripts using the final coding scheme. The inter-rater agreement among the two reviewers (AY and CAD) in the assignment of specific themes to particular quotations was assessed using Cohen’s Kappa coefficient. The Kappa was 0.86 (95 % CI = 0.80–0.92), reflecting excellent agreement . The invOf the 40 patients participating in OpWalk 2015, 20 were approached for preoperative interviews and all consented. Of the interviewees, 16 (80 %) were women and the median age was 62.5 years (range 20–79). Seven received total hip replacements , and 13 received total knee replacements . Ten participants were unemployed, seven were self-defined housekeepers, two were retired, and one was employed as a teacher. The sex and age distributions of those who participated were similar to those who did not participate .Patients discussed a range of pharmacologic and non-pharmacologic approaches to pain management, from traditional Western medications to prayer and relaxation. For many, strong religious convictions greatly influenced their ability to cope with painful experiences. Patients spoke powerfully of strength and endurance as means of overcoming pain. Although most patients expected surgical pain, they were prepared to cope with it and were confident that the union of doctors and God would yield a successful surgery. In the following sections, representative quotations for each theme are presented throughout the text and in Table Most patients reported experience with pain medications, yet personal preferences varied from regular self-administration to sparse use only when absolutely necessary. Those who reported taking medications tended to rely on non-steroidal anti-inflammatory drugs (NSAIDs) including diclofenac and ibuprofen. A few patients described using steroid injections or topical menthol creams to alleviate pain. When asked about specific analgesia terminology, only two of 20 preoperative interviewees were familiar with the term “opioid.” One recognized it as a derivative of opium: “it’s a plant, a legume” . The other described using tramadol for a short period of time, during which she experienced side effects including “intense euphoria” and sleeplessness. Half of the interviewees recognized the term “morphine,” of which one recalled using the drug following a prior orthopedic surgery. Most who recognized the drug name understood its role as an analgesic, but none knew of others who had used it previously. One patient remembered reading about morphine: “It’s in novels, books from that time period… in the Old West” . Patients were further asked if they would take morphine if available. Many expressed limited knowledge of the drug, but stated they would follow a doctor’s order if morphine was prescribed. On the other hand, one patient stated: “I don’t want to go to such an extreme that I have to use [morphine]” .In discussing the frequency and timing of preferred medication use, few patients described routine administration of painkillers. For the majority of patients, fear of side effects was a major concern that caused them to use medications sparingly. One patient shared: “I can’t take them, or use them, because I get side effects. Painkillers help my problem but I run the risk [of side effects]” . Another patient discussed the desire to prolong the interval between each dose of medication: “Sometimes I take a painkiller. Sometimes. Not every time, but maybe every 15 days or so. Because when I take a medication, it makes my stomach hurt” . Patients often credited their knowledge of side effects to conversations with family and friends: “People told me that [diclofenac] was a little harmful for the kidneys… So I decided to cut it in half to limit its effect on my body” . Some also cited fear of addiction as a reason to limit medications: “I didn’t want to take much medication because when you start taking them every time something hurts, you get addicted… I didn’t want to do that to myself” .Almost all patients described using therapies other than painkillers to reduce pain. Some discussed relaxation and distraction as a means to forget about their pain: “When it hurts a lot, I lie down for a while” . Another patient shared: “When I am in a lot of pain, I always try not to focus on the pain, I look for some way to distract my mind” . Four patients found exercise or physical therapy to be valuable complements to medication. For them, moving their joints relieved pain rather than instigating it: “I have to stand up and move around, because when I’m moving, the pain goes away” . Seven individuals rubbed ointments and creams on their joints, and three discussed using cold compresses or ice to alleviate acute pain.Among the most common approaches to pain management were religion and prayer. Many who held strong religious beliefs understood pain as a part of life and an experience to endure: “Pain is a reaction that you have to live with, because if God sent it, you have to endure” . Fifteen patients discussed the role of faith in overcoming pain. Patients formed partnerships with God through prayer, and God rewarded them with strength to bear the pain: “I say: ‘Lord, if you think I deserve more, send it to me. Just give me the strength to continue to endure it.’ And I stand up like nothing happened. When I pray to the Lord, the peace I feel inside is so strong, it makes me forget about the physical pain” . One patient depicted her conversations with God: “I put myself in God’s hands and I pray. I stay strong, because God says: ‘You must be strong.’ If God is with me, who can be against me?” . Another shared: “Often when I’m in pain, I pray to God. God is number one, because He is the one who directs our lives. He knows when someone may be in pain, when it can be taken it away” . For some individuals, God not only provided strength to endure pain, but also granted power to use medicine: “God takes away the pain. God takes your hand, and you put menthol or something on it, and then it calms down” .Although religion afforded many the strength to endure, patients also found strength within themselves. One individual described her experience with pain as a battle: “I keep fighting, I fight, fight, fight. Because the pain won’t defeat me, I am going to defeat the pain” . Another patient cited the power of positivity to provide strength: “I always try to smile. Because for me, it’s one of the things that helps me endure it, to overcome the pain” . Patients described the desire to live as normally as possible, in spite of their pain. A retired physical therapist stated: “I never stopped doing things, never, never, never skipped a case in the middle of the day” . When speaking of pain management, many believed endurance to be a primary means of coping, and used medication as a last resort.Patients also emphasized the importance of social support in coping with pain. Family members are often primary points of contact when they experience pain. Patients cited various examples of emotional and physical support from family, such as consoling, aiding in doctor visits, performing day-to-day tasks, and providing therapies. One described: “You go to family when you have something, and the family tries to take you to the doctor, give you painkillers” . Moreover, family traditions often dictated how pain was managed. Referring to pain medications she uses, one patient stated: “We use things [medications] from the past. You always carry those things your grandparents told you” . Finally, patients often mentioned family members as the ones who helped them enroll in OpWalk.When asked about postoperative pain and recovery, the majority of patients interviewed understood that surgery itself could cause pain, but they were not afraid of the possibility. Patients reported being so accustomed to arthritis pain that surgical pain would not bring new challenges: “Since I’ve had so much pain, that kind of [surgical] pain doesn’t scare me. I can get over that easily. They open it, sew it, and that will get better, because skin heals. I think my leg pain was worse” . Patients were asked about long-term pain relief; many expressed hope that surgery would diminish their arthritis pain, if not completely relieve it: “I know it’s to help with the pain, to get rid of the pain” . In anticipating postsurgical pain management, all patients expected to take less pain medication each day, and most expressed the desire to end pharmacologic therapy as soon as possible.For many patients, their commitment to God provided reassurance and confidence that surgery would be successful: “I believe in God, because with God first, I believe I will be okay. I trust in Him that everything will turn out well” . Some discussed how divine intervention played a role in their acceptance into OpWalk, suggesting that surgery was God’s gift: “I have been asking God to give me an opportunity, and He gave it to me… We are poor, we don’t have any resources. Just God. What God provides” . When asked about coping with pain during surgical recovery, many patients conveyed confidence that God would cure their pain. One stated: “This pain I have now, I won’t have it tomorrow, because God is going to heal me” .Patients also expressed a great deal of trust in doctors, with many discussing both God and doctors as key players in their journey through surgery: “I hope that with the Lord’s strength and the doctors, I will get well” . Another shared: “I trust in you and God. You will help me to be able to walk” . For one patient, God and physicians are closely intertwined, as God empowers surgeons to perform operations for the betterment of humankind: “You all are doctors, His instruments, because He [God] is the one that does it. He uses you as instruments to do things” .This is the first qualitative study, to our knowledge, that investigates pain management among patients with advanced osteoarthritis in a developing nation. We interviewed 20 patients before TJR to understand their approaches to pain management and expectations for postoperative recovery. Patients reported modest use of medications, possessed limited knowledge of opioids, and employed a range of non-pharmacologic coping strategies including prayer, distraction, and relaxation. Many patients turned to religion as an explanatory model of and coping mechanism for pain. They understood pain as God’s will and an experience to be endured, equipping them to expect surgical pain and persevere through postoperative recovery. Our interviews revealed that many patients with chronic pain exhibited a great deal of trust in powerful others, expecting God and doctors to eventually cure their pain through surgery.Prior research has illuminated ways in which individuals respond to setbacks and stressors. Lazarus and Cohen described stressors as internal or external environmental demands which upset balance, requiring action to restore equilibrium . In the Pain coping strategies have been researched extensively in rheumatologic conditions in developed countries. These strategies are often classified as active coping such as physical activity, or passive coping involving rest and withdrawal from activities . StudiesWe also suggest core socio-cultural differences between the US and Dominican Republic may help to explain our observations. In the US, the emphasis on pharmacological accessibility, direct-to-consumer advertising, and patient activation yields a health care model that empowers patients to request powerful pain medications, including opioids . In contFurthermore, our findings elucidate the significant role religion can play in each aspect of the pain experience. Our subjects’ comments suggest that religion and pain are closely intertwined, as individuals learn approaches for pain management and expectations for surgical recovery from partnerships with God. Furthermore, reliance on medications was often minimized due to fear of harmful side effects. In particular, we note that patients had little knowledge of the existence and purpose of opioids. The fear of side effects and limited understanding of opioids may have prevented these patients from pursuing pharmacologic pain management, potentially resulting in under-treatment. We note that these same factors may have enabled patients to develop stronger coping methods and mechanisms of resilience when faced with painful experiences. These findings suggest that individuals’ values, beliefs, and past experiences contribute greatly to their management of pain. During clinical care, health care providers should be encouraged to gain a thorough understanding of a patient’s pain coping behaviors and identify strategies to support those coping mechanisms when appropriate. This approach is especially important for clinicians working with patients in the developing world as well as minority patients in the developed world. Achieving adequate pain relief may be challenging or ineffective, if not introduced in the context of patients’ individual coping mechanisms and resources. While Dominican patients’ experiences may not represent the pain experience of patients of other diverse backgrounds, we emphasize the value of the patient-physician partnership in achieving appropriate pain relief. For certain populations, such a partnership may limit the use of opioids while ensuring that patients bring adequate resources to bear against disease stressors including pain. This strategy may also help minimize the risk of side effects, addiction, and diversion from opioid use , 9.Several limitations of our study should be noted. Our sample size was comprised of OpWalk Boston patients, who represent a small sample of the individuals with arthritis pain in the Dominican Republic. We acknowledge they may not be typical of the larger population of persons with arthritis pain, as they actively sought pain relief through TJR. Furthermore, due to timing constraints, interviews were performed within a span of four days, limiting our capacity to incorporate accumulating knowledge to our interview protocol as data were collected. Finally, our analysis may have misinterpreted subtle aspects of language. To minimize this, we worked verbatim from interview text and involved Dominican clinicians during the analysis process in order to ensure objective and culturally appropriate interpretations of transcripts.In conclusion, many patients reported modest use of pharmacologic therapies, and the majority employed non-pharmacologic therapies, including religion, to manage arthritis pain. Patients felt equipped to cope with postsurgical pain and persevere through recovery. Understanding patients’ individual coping approaches and resources in developing countries will enable health care professionals to better determine optimal pain management interventions for patients of diverse backgrounds. In particular, physicians should identify pain management plans that are congruent with patients’ cultural beliefs and coping mechanisms. Consideration of these coping strategies could be employed in reducing the burden of chronic arthritis. The approach could result in less reliance on powerful analgesics including opioids, particularly for patients of diverse backgrounds who employ alternative pain coping mechanisms and do not traditionally use strong medications to manage pain. We also suggest that lessons from Dominican patients’ conceptions of pain could be applied to the development of pain management pathways in developed countries and international mission programs such as OpWalk. Management of chronic arthritis pain could be improved if tailored to a patient’s preferred coping strategies.Consent for participation was obtained from all patients. All study activities were approved by the institutional review board at Brigham and Women’s Hospital.Consent for publication was obtained from all patients.The data supporting the conclusions of this article are included within the manuscript and in Table


Patients' limited literacy and language fluency of different kinds cause them problems in navigating the medical interview. However, it is not known how physicians' native language skills affect the reported intensity of pain among Finnish emergency patients. Data were collected with two consecutive questionnaires in 16 healthcare centres and outpatient departments along the Finnish coast. Swedish and Finnish speaking 18–65-year-old emergency patients were eligible for this study. Our patients were predominantly Finnish speakers. Patient-rated poor language skills in Finnish among the physicians in ED setting increased statistically significantly pain reported by the Finnish speaking patients and their dissatisfaction with the health service. These patients were also less motivated to adhere to the instructions given by their physician. Patients speaking various languages reported less degree of pain. Foreign physicians' poor language proficiency in Finnish was expected to explain only some of the patients' pain experience. Physicians' good native language skills may help to reduce pain experience. Despite concordant language communication, other unknown barriers in the interaction might reduce the magnitude of pain reported. Healthcare is ideally delivered in language concordance which means that both the patient and the physician speak the same preferred language. Mutual language and understanding are critical in generating good functional relationships between health staff and patients. Language barriers cause communication difficulties which may hamper the treatment of a disease . PatientMeasuring the pain intensity in a clinical situation is challenging and as a rule healthcare personnel underestimate the severity of pain , 11. In By tradition Finland is an ethnically broadly homologous but bilingual country where patients have the right to get health service either in Finnish or in Swedish. The great amount of language contacts had exposed the minority of Swedish speakers to increasing Finnicization (“language transition”) . This liOur study was approved by the Ethics Committee of the Hospital District of Helsinki and Uusimaa (Reference number 5/13/03/00/2008). Data were collected in 2008-2009 in 15 healthcare centres and outpatient departments along the south coast and in one healthcare centre in South Ostrobothnia. Only Swedish and Finnish speaking 18–65-year-old emergency patients were eligible for this study. Patients with major mental disturbances as well as life threatening symptoms were excluded by the personnel.Everyone visiting healthcare in Finland is registered electronically. The personal data in the registration for population are automatically transferred into everyone's electronic case record. These data contain also information about the patients' native language. The arriving emergency patient was informed by a receptionist or a nurse about the possibility to voluntarily participate in the study. Interested and applicable patients were provided with language concordant information about the study and an agreement-form plus a questionnaire. All corresponding data-collection material was also accessible on a table in the waiting-room for entering patients in order to facilitate participation by oneself. The patients completed the questionnaire before the physician's appointment and were advised to drop the sealed questionnaire into a locked box in the waiting-room. The questionnaire included 43 closed questions, of which 15 were standardised questions about socioeconomic and health conditions used in periodical population surveys in Finland; 23 questions about native and nonnative language proficiency, the relatives' native language, language spoken at home and stated in registration for population, Finnish or Swedish schooling, and preferred communication language with the general practitioner (GP); and 5 questions about the frequency and quality of health centre visits and the reason for the visit.Two weeks after the emergency visit, the patients who agreed to a follow-up were sent a second questionnaire including detailed filling instructions by mail. The language in the second questionnaire was specified according to the patient-reported native language during the visit. This structured questionnaire included 30 closed questions about the GP's language proficiency in the patient's native language and patient-preferred communication language, the patient's feeling of confidence and satisfaction on a 1–5 graded scale, pain experience on standardized VAS scale, frequency of laboratory tests and X-rays during the visit, medication prescriptions, pain medication, written and verbal instructions in the patient-preferred language, and length of sick leave. To quantify the language discordance between the patients and the GPs, the patients were asked to assess the GP's language proficiency in Finnish or Swedish according to a numerical, well-established Finnish school grade of 4–10. The patients' numeric ratings of the GP's language proficiency in the patient-preferred language were pooled into good, average, and poor by means of a data reduction technique for statistical analysis . A measup < 0.05. Adjustment was used for age, income, education, and gender.Data were statistically analysed with SPSS system. Correlations between variables were calculated using linear regression. Statistical significance was set at n = 466), predominantly Finnish speaking female patients, replied to the second questionnaire. All respondents did not reply on every question in the questionnaire. Tables include only individuals with available data.875 patients in total filled in the first questionnaire during their emergency visit on the healthcare centres. 53% of them  and Finnish speakers (n = 407) revealed that the Swedish speakers were significantly less confident about the GP's professional qualification (p < 0.001) and the care quality (p < 0.001) during the visit. They also reported significantly less motivation to adhere to the GP's instructions (p < 0.001) (Comparison between Swedish speakers (< 0.001) . The Swe< 0.001) .p < 0.01)  . The pat < 0.01) . One-thip < 0.001) given by the GP  has been noted to increase the patient-reported pain compared to normal-weight and underweight patients [2 indicating that obesity was not the exclusive explanation for pain. Furthermore, pain is the most prominent symptom in musculoskeletal diseases and therefore is likely to be noted by the GP in the medical interview, but we assume that urological, gynaecological, obstetrical, and abdominal symptoms including pain might embarrass many patients minimizing their information especially if the communication with the GPs is poor. Unquoted and unexplained pain can increase the patients' worries for the situation which in turn intensify the symptoms. Being disbelieved by healthcare providers or reassured that nothing is physically wrong has also been noted to worsen symptoms [The patients reported more pain when the GP's language proficiency was poor in all other reasons for the visit other than musculoskeletal diseases. Obesity (body mass index, BMI, > 30 kg/mpatients . Our ressymptoms . Many syThe GPs' deficient native language proficiency affects negatively patients' experience of the emergency visit which might affect also pain communication. Our study could thus verify that although language concordant communication is a prerequisite for mutual understanding, pain revealing requires additionally good language skills.Previous studies have consistently confirmed that language minority patients are in general at risk for communication problems in healthcare mainly caused by their unfavourable socioeconomic conditions as well as cultural and lingual disparities. We could, however, demonstrate that language discordance alone in a sociocultural homogenous population is sufficient to increase both minority and majority patients' insecurity and fear and can also intensify patient-reported pain.The strengths of this study were that the respondents represented typical acutely ill native patients making out-of-hour visits to healthcare centres in Finland. The coastal region of Finland is an ethnically and culturally relatively homogenous but bilingual part of the country providing exceptionally favourable opportunities to study how linguistic factors impact pain measuring in EDs.A considerable proportion of our Swedish speaking minority patients reported impediments during the medical interview performed in a nonpreferred language. Our sample was, however, too small to reach the level of significance due to minority patients' reported pain. Further studies are required to reveal how often pain other than that caused by musculoskeletal diseases remains unobserved by the GPs.


Numbness and pain are currently evaluated using subjective methods such as the visual analog scale (VAS). However, because assessment of pain can vary greatly depending on the mood and physical state of the patient at the time of assessment, it is best to evaluate pain objectively. pain vision PS-2100 (PV) is an analytical instrument that was designed to quantitatively and objectively assess sense perception and nociception in patients. The present study examined the correlation of subjective and objective assessment of oxaliplatin-induced peripheral neuropathy (PN) using VAS and PV, respectively. The mean VAS and PV scores of PN were 20.5 (range 0–100) and 27.9 (range 0–416), respectively. The partial correlation coefficient was 0.274 (p = 0.0003). No strong correlation was observed between the results and a weak correlation was observed between VAS and PV. Oxaliplatin-induced peripheral neuropathy (PN), for which there is no firmly established treatment till date, is a critical factor that makes maintenance of chemotherapy difficult , numerical rating (NRS), or verbal rating (VRS) scales. VAS is one of the oldest, easiest and best validated measures to assess pain  was developed and introduced in clinical practice  and was performed between April 2014 and August 2014.Patients with histologically proven metastatic and unresectable colorectal adenocarcinomas who had not undergone chemotherapy or who had completed adjuvant chemotherapy during the last 6 months were enrolled in the study. Patients were excluded if they had a mental disorder or poor mental health that made it impossible to understand the concepts of VAS and PV. Patients were also excluded if they had any peripheral sensory neuropathy or musculoskeletal pain before chemotherapy that may disrupt the measurement of quantitative pain. All patients provided written informed consent.2 oxaliplatin on day 1 and 2000 mg/m2 capecitabine on days 1–14, every 3 weeks) or XELOX therapy   who received XELOX+bevacizumab therapy ’’ on the left edge and ‘‘100 (worst imaginable pain)’’ on the right edge.The PV system was developed as a medical device to evaluate pain intensity as a numerical value. The principle of measurement of this system is to compare a unique electrical stimulation with the pain that the patient is experiencing. An electrical stimulation without pain, whose intensity is equivalent to that of the pain experienced by the patient, is applied, and the current value of this electrical stimulation is defined as the “pain-equivalent current.” The sensitivity (threshold) of the patient for the electrical stimulation is defined as the “minimum perceived current,” which is intended to eliminate variations between individuals. Using these two values, pain intensity is defined by the following formula:Pain intensity = /minimum perceived current × 100.An electrode is attached to the medial side of the upper arm. An electrical current is applied , and the stimulation is increased. The patient is instructed to press a button when she/he perceives this stimulation for the first time; the current at this point is defined as the “minimum perceived current” value. As the stimulation current is increased, the patient is instructed to press the switch when she/he feels that the intensity of the stimulation current is equivalent to that of the pain she/he is experiencing. The current at this point is defined as the “pain-equivalent current” value. Using the values obtained, “pain intensity” is calculated using the aforementioned formula. When there is no pain, the value is 0, and it increases according to the degree of pain, with no upper limit. Each measurement is simple and can be completed within a few minutes.Data were collected and analyzed using SAS Version 9.3 . To investigate the reliability of the device in terms of internal consistency, we assessed the QPD score twice. Data are reported as mean ± standard deviation (SD), median (interquartile range 25–75 %), or number of participants (percentages). Partial correlation analysis was performed to estimate the relationship between PV and VAS after adjusting for sex and subject. Namely, the correlation coefficient between PV and VAS was computed using residual values of the mixed-effects model including sex as a fixed effect and subject as a random effect. P values of 0.05 or less were considered statistically significant.Between April and August 2014, a total of 64 patients received chemotherapy for metastatic CRC. Six patients were excluded according to the selection criteria . A half of patients had any neuropathic pain therapy . The final cohort included 40 men and 18 women ranging in age from 43 to 80 years . The patient characteristics are presented in Table Among the included patients, 81.0 % had ECOG PS 0 at baseline, with the liver being the most common site of metastasis. The median cumulative amount of oxaliplatin was 1751 mg/body (345–5903), and the number of cycles was 10.Grade 3 or higher hemotoxicity and grade 3 or higher non-hematological toxicity were noted in 12.5 and 17.4 % of patients, respectively.PN was assessed using both VAS and PV a total of 173 times. The mean VAS and PV scores of PN were 20.5 (range 0–100) and 27.9 (range 0–416), respectively. The partial correlation coefficient after adjusting for sex and subject was 0.274 (p = 0.0003) (Fig. VAS is one of the most common methods used for the evaluation of pain (McCormack et al. A newly developed device, PV, has recently been used for the quantitative analysis of pain perception and sensation, measuring pain intensity as the “degree of pain.” In clinical practice, this method has been used for evaluating not only chronic pain, such as fibromyalgia (Osada et al. To the best of our knowledge, no previous study has investigated oxaliplatin-induced PN quantitatively using electrical stimulation. The limitation of this study include only VAS as a subjective evaluation that did not allow adequate assessment of PN. Accordingly, neuropathic pain questionnaire, leeds assessment of neuropathic symptoms and signs scale and Douleur Neuropathique en four Questions needs to be performed using well-matched groups of patients to confirm our findings. We believe that the effect of the drug for oxaliplatin-induced PN should be evaluated objectively.Although both assessments evaluated the same events, no strong correlation was observed between the results and a weak correlation was observed between VAS and PV. These results suggest that because VAS and PV each measure different factors, both are needed to evaluate oxaliplatin-induced PN with the aim of aiding treatment. These findings are expected to help in the amelioration of PN through the use of objective assessment and to support future clinical trials associated with oxaliplatin-induced PN.