Neuropathic pain is characterized by spontaneous painful symptoms. Medical therapies include the use of a capsaicin 8% patch , and patients may experience a sharp burning sensation at application and removal of the patch. This study aimed to evaluate the impact of playing a standardized hypnosis recording during application, on the pain and anxiety induced by capsaicin treatment.In a randomized, controlled trial, we assessed the benefits of the intervention firstly on pain and secondly on anxiety, as measured using numerical rating scales. All patients had application of the capsaicin patch, including the possibility for the patient to apply a cold patch. Participants were randomly assigned to one of 3 groups, namely the “Standard group” (no intervention), “Hypnosis group”, in which a standardized hypnotic message was played during application, or the “Music group” in which relaxing music was played during application of the patch.p = 0.355). Compared to standard application, anxiety was significantly lower in the hypnosis group after application (p = 0.007), with no significant difference between the standard and music arms (p = 0.271), or between the hypnosis and music arms (p = 0.423).Sixty-nine patients were included. Overall, there was no significant difference in pain scores between groups (Listening to a standardized hypnotic message during application of a capsaicin patch was found to significantly lower anxiety. These findings indicate that the use of a hypnotic message can reduce discomfort and warrant its evaluation in other indications of pain or anxiety during treatment procedures.NCT02822625. The International Association for the Study of Pain (IASP) defines neuropathic pain (NP) as “pain that arises as a direct consequence of a lesion or disease affecting the somatosensory system”. The world prevalence of NP in the general population varies from 6.9 to 10% . NP is cImprovements in our understanding of the pathophysiology of NP have led to the emergence of medical and non-medical therapies, which are generally proposed in a pluridisciplinary context. Medical therapies include the use of local topical applications such as 5% lidocaine, plasters or an 8% capsaicin patch  . CapsaicDespite the agonistic activity, exposure to capsaicin applied topically at high doses leads to initial activation of nociceptive nerve fibers expressing TRPV1, causing a burning sensation and erythema. Then, after exposure to capsaicin, TRPV1-containing sensory axons are desensitized, with down-regulation of TRPV1 expression. Consequently, cutaneous nociceptors become less sensitive, leading to pain relief. The changes induced in cutaneous nociceptors by capsaicin are reversible and their normal function can be restored within a few weeks . The mosThe difficulty of controlling these AEs prompted us to envisage the use of therapeutic hypnosis as a complementary strategy on top of standard treatment, which generally associates the use of painkillers with application of cold. According to the American Psychological Association, therapeutic hypnosis can be defined as a state of consciousness involving focused attention and reduced peripheral awareness characterized by an enhanced capacity for response to suggestion. Since the end of the 1990s, the field of neurosciences has confirmed the existence of a unique neurological functioning occurring during hypnosis, notably by demonstrating how suggestions of pain relief can modify the sensory and affective components of the pain process , in partWe therefore sought to propose a hypnotic approach that would be able to relieve the burning sensations felt by patients receiving treatment with a capsaicin patch in the framework of follow-up for chronic neuropathic pain in relation to active cancer or its treatment . The aim of the study was to evaluate the impact of playing a standardized hypnosis recording during application of an 8% capsaicin patch, firstly on the pain induced by capsaicin treatment, and secondly, on the anxiety felt during application of the patch.We performed a randomized, single-centre, prospective pilot study in three parallel groups at the Institut de Cancérologie de Lorraine . Participants were randomly assigned between the following groups in a 1:1:1 ratio: (1) application of the capsaicin patch according to standard procedure, which includes the possibility for the patient to apply a cold patch on the affected zone (Standard group); (2) application of the capsaicin patch according to the standard procedure, while at the same time playing a recording of a standardized hypnotic message (Hypnosis group); and (3) application of the capsaicin patch according to the standard procedure, accompanied by relaxing music (Music group). Randomization was centralized by computer-generated random numbers in blocks of six. The study was not blinded owing to the practical barriers to masking. The study design is illustrated in Fig. All patients were attending the Interdisciplinary Unit for Supportive Care for Oncology Patients at ICL. Patients were eligible if they had neuropathic pain, as diagnosed with the Douleur Neuropathique 4 Questions (DN4) questionnaire, and had previously had at least one application of a capsaicin patch, and had a new indication for capsaicin patch application. We excluded patients with psychotic disorders, patients with hearing disorders, patients unable to understand French, patients < 18 years old, persons under judicial protection or legal guardianship, patients requiring premedication with painkillers before capsaicin patch application, and patients with a history of hypersensitivity to capsaicin or to any of the patch excipients.Patient screening was performed by the lead nurse from the pain management clinic (ML). After obtaining written informed consent, inclusion was performed on the day of the patch application in the outpatient unit. Then, patient randomization was performed. Study procedures were carried out in the same conditions for all patients, namely in the room located furthest away from the workstation in the unit, in order to minimize background noise, and to facilitate patient comfort and high-quality listening. In addition, a “Do not disturb” sign was placed on the door of the room to deter anyone from disturbing the patient during the time the patch was in place. The duration of capsaicin patch application was one hour. After patch removal, the patient was free to go home. A study nurse called the patient by phone at 72 h after the patch application for the final evaluation of pain.The hypnotic message was created and recorded by a nurse hypnotist (RE) at our institution who is qualified to train other hypnosis practitioners. The full script was read and amended by a renowned scientific expert in the field of medical hypnosis (AB). The text of the script included the different elements that characterize a hypnosis session, taking account of the rhythm of suggestions and the tone of voice, adapted to the progress of the study procedures and accommodating the constraints related to the monitoring of the patient. The therapeutic metaphor used in the recording was a walk in the mountains, with a dip in a lake of cool water. The story was aligned with the different stages of application of the capsaicin patch . Numerous hypnosis techniques are proposed in the script in addition to the metaphors . The hypnotic message was recorded in a professional recording studio in order to minimize background noise and optimize the quality.The relaxing music was chosen by the study investigators based on the advice of a music therapist who works with patients suffering from pain. Three musical atmospheres were chosen , in order to allow the patients to choose whichever type of music best corresponded to their expectations and personal tastes.All recordings  were transferred to an MP3 player to make listening easier for the patient and played through a high-definition audio headset .Assessments were conducted at 4 different times see Fig. . Data reQuantitative variables are described as mean ± standard deviation (SD) if normally distributed, or median [interquartiles] if non-normally distributed, and were compared using ANOVA or the Kruskal-Wallis test. The normality of the distribution was investigated by the Shapiro-Wilks test. Qualitative variables are described as number (percentage) and were compared using the Chi square or Fisher’s exact test as appropriate.The primary endpoint was pain as assessed by the NRS  at the time of patch removal. Comparisons of pain and anxiety immediately after patch application and removal were performed by analysis of covariance (ANCOVA) in order to adjust for values prior to application. In case of differences across the three groups, Bonferroni correction was applied to account for multiple comparisons.p-value < 0.05 was considered statistically significant.All analyses were performed using SAS version 9.4 . All tests were two-sided and a The average pain score after application of a capsaicin patch is estimated at 6 ± 2 . A diffeFrom August 2016 to July 2019, a total of 69 patients were included; 23 were randomized to each arm .In the music group, 14 patients (60.9%) chose easy-listening music, 5 (21.7%) chose classical music, and 3 (13%) chose relaxing music. Twenty patients (90.9%) listened the hypnotic message in its entirety. A cold pack was applied by 18 patients (78.3%) in the standard group, 17 (73.9%) in the hypnotic group and, 20 (87.0%) in the music group (p = 0.355)  Table .Table 2p = 0.010). Compared to standard application, anxiety was significantly lower in the hypnosis group after the application (p = 0.007 after Bonferroni adjustment). There was no significant difference between the standard and music arms, or between the hypnosis and music arms (p = 0.271 and p = 0.423 respectively after Bonferroni adjustment). There was also a significant difference between groups in terms of the perceived duration of the application , and between the standard and music arms (p < 0.001 after Bonferroni adjustment), but not between the hypnosis and music arms (p = 0.424 after Bonferroni adjustment).For anxiety Table , scores This study aimed to address the adverse effects that may occur during application of a capsaicin patch  by proposing a standardized hypnotic message to be played while the patch was in place. Even if expected results on pain reduction were not obtained, patients who listened to the hypnosis recording had a significantly lower level of anxiety compared to the standard patch application procedure. We included a group that listened to music during the application of the patch since the effects of music on pain and anxiety have previously been demonstrated  and coulWe did not observe any difference in pain scores between groups, which is surprising in view of the results previously obtained with hypnosis for pain . PerhapsWe observed that pain and anxiety scores tended to be lower before patch application in patients in the hypnosis and music arms, as compared to those in the standard treatment arm. This observation could be explained by a possible placebo effect when the patient is informed of the treatment group they have been assigned to by the randomization process , 18. IndIt is noteworthy that patients in the hypnosis and music arms had a subjective impression that the patch was in place for a much shorter time compared to patients in the standard treatment arm. This distorted perception of time can be explained by several factors. Firstly, by the simple fact of distracting attention by listening to, and concentrating on the audio recording. Secondly, temporal distortion has been described as a characteristic of the hypnotic phenomenon , 21. We It should be underlined that all patients included in this study had previously had a capsaicin patch applied, and were attending for a second application. Although the purpose of this was to ensure a homogeneous population, it is possible that the patients were already familiar with the sensations, and could anticipate them once informed of their randomization group. Secondly, although the one-item question used in this study is a validated method to assess anxiety , we did Patients’ expectations of analgesic therapy, maintaining an acceptable level of anxiety, and the perception of the passage of time during the delivery of healthcare, all appear to be determinant in shaping the patient’s overall subjective experience. Our study focused on cancer patients with at least one previous application of a capsaicin patch. Since the standardized hypnosis message is easy to use, without the need for additional human resources, its use could easily be generalized to all patients receiving treatment with a capsaicin patch. It would be also interesting to investigate the same procedure among patients who were having a patch applied for the first time and who had never previously been exposed to capsaicin.In this study, although it had no effect on the perceived level of pain as compared to standard procedures, listening to a standardized hypnotic message during application of a capsaicin patch was found to lower anxiety. This study opens interesting avenues for improving the comfort of patients during treatment. These findings warrant further evaluation in other indications where treatments may generate pain or anxiety using specific analgesic suggestions rather than suggestions only based on sensations. Using recorded standardized hypnotic messages and procedures could enable the use of this approach in healthcare centers with limited facilities.


Two cases dropped out, leaving 22 cases. Each case was evaluated in terms of the numerical rating scale (NRS) of the pain, activities of daily living (ADL), pain catastrophizing scale (PCS), and quality of life (QOL) at pretreatment and post-treatment. The endpoint of the method was to achieve the long-term goals set by the patients. The mean treatment period was 11.2 months. The outcomes were as follows: improvement of presenteeism: nine cases; enhanced participation in hobbies: seven cases; improved school attendance: two cases; return to work: one case; improvement of self-care and/or self-efficacy: three cases. The NRS, ADL, PCS, and QOL were significantly improved after the treatment. This method is possibly valuable for educating patients about the cause and treatment of chronic pain and actively facilitating exercise and social participation. Further studies are needed to investigate the effectiveness of using this notebook for the patient with intractable chronic pain.Recent clinical practice guidelines for chronic pain indicate, with a high evidence level, that the combination of exercise and cognitive behavioral therapy (CBT) is effective. The purpose of this study was to evaluate the effectiveness of an exercise facilitation method in combination with CBT using the “Ikiiki Rehabilitation Notebook” for patients with intractable chronic pain. “Ikiiki” means active in Japanese. A total of 22 cases with chronic low back ( An epidemiologic survey of approximately 11,000 Japanese people aged 18 years and over revealed that the prevalence of chronic pain  was 15.4% , suggestFor high-quality guidelines, exercise therapy for chronic low back pain is recommended under the supervision of a physical therapist . In addiThe purpose of this study was to describe a novel exercise facilitation method combined with CBT using the “Ikiiki Rehabilitation Notebook” for patients with intractable chronic pain, and to evaluate the effectiveness of using this method for patients.n = 24) ranging in age from 19 to 77 years (average ± SD: 51 ± 18). Chronic pain locations were low back (n = 14), lower extremities (n = 8), or neck (n = 2). Clinical diagnoses included chronic low back pain (n = 10), lumbar spondylosis (n = 5), chronic lower extremity pain (n = 3), chronic knee pain (n = 2), chronic neck pain (n = 2), osteoarthritis of the knee (n = 1), and chronic plantar pain (n = 1). The period (months) from the occurrence of pain to the first visit to the Niigata University Hospital ranged from 5 to 200 months (average ± SD: 58.0 ± 43.5). The duration of the treatment using this notebook was 10.8 ± 4.7 months on average, ranging from 3 to 22 months. The average number of medical facilities visited by the patients before coming to the Niigata University Hospital was 3.8 ± 2.0.The patients in the present study were 8 men and 16 women (Inclusion criteria in this study were as follows: (1) Numerical Rating Scale (NRS) for pain > 3/10, (2) all patients had pain somewhere in the body, other than headaches, for more than 3 months, resulting in disability in activities of daily living (ADL), (3) inadequate effects of medication to effectively improve the pain intensity or ADL, and (4) patients were eager to do rehabilitation therapy. Exclusion criteria were as follows: (1) patients were under litigation or had accepted insurance payments for a traffic accident and (2) patients suffered from severe psychological diseases, such as depression and schizophrenia.The present study received ethical approval from the Ethics Committee of Niigata University (No.2016-0090), and written informed consent was obtained from each subject prior to this study.The patients were evaluated at pretreatment, every 3 months, and at post-treatment, as described previously . The NRSTo clarify the pretreatment factors affecting the QOL at post-treatment, we examined the relationship between all data at pretreatment and the EQ-5D at post-treatment.In a study reported by Hirase et al., to evaluate a combined protocol of CBT and exercise therapy, physical therapists providing support for the community exercise classes checked the participant’s diaries once a week and advised participants to alter their pain awareness by focusing on increasing their daily activities . The diaTherefore, the first author of the present study  assumed leadership of the study and recruited members from the boards of the same associations to develop the notebook used here. Members comprised 2 psychosomatic physicians, a psychiatrist, a physical therapist, 2 rehabilitation physicians, and a pain clinician. For the exercise therapy, the physical therapist, rehabilitation physicians, and pain clinician mainly discussed examples of short-term and long-term goals, exercise therapy types and methods, and methods for monitoring the number of steps taken per day. For CBT, the psychosomatic physicians and psychiatrist discussed methods of describing thoughts and feelings in daily records based on CBT theory. The idea of writing a “message to thank oneself for the effort”, as the most distinctive feature of this notebook, was suggested by the psychosomatic physician (second author in the present study) from the perspective of improving the low self-efficacy that is considered a characteristic of chronic pain patients. Following submission of the springboard for discussion from each member, all members together discussed the inclusion and exclusion criteria, pre- and post-treatment evaluation, medications, goal setting, daily records, and notebook content. After discussion by the members for 6 months, the first edition of this notebook was published in 2014. The fifth edition of this notebook and the fourth edition of the manual for medical professionals were published in 2018 after several modifications.All statistical analyses were conducted using SPSS version 24 for Windows . The values for each subject were compared between pretreatment and post-treatment using the Wilcoxon rank sum test. Spearman’s rank correlation coefficient was used to analyze the correlation between the values of 2 measures. The significance level was set to less than 5%.This notebook was developed to encourage cooperation between physicians and medical staff  in treatment that incorporates the three components of exercise therapy, CBT, and patient education. “Ikiiki” means active in Japanese. To make this notebook as compact as possible and easy to use, the size was set to A5 , and theCBT is explained in an easy-to-understand language with examples . ChronicPatients were asked to write their feelings and thoughts in the notebooks daily to once a week, as well as to record their daily behavior and exercise routine  . In addiOn the daily entry page, patients are asked to write notes about their daily activities and the status of performing the prescribed exercise within a reasonable range. This is expected to provide a small sense of achievement and accumulation of effort every day, in addition to the analgesic effects of exercise. Separately entering daily “thought” and “feeling” helps the patients to objectively view themselves and makes it easier to correct their nonfunctional thinking . The purThe patients were asked to reflect on their achievements and short-comings relating to their short-term and long-term goals at 1 month. If a patient’s physical performance improves, a new goal should be set, even a month later. Patients with chronic pain are likely to have endured it for a long time, preventing them from reaching their goals, so medical staff members should explain that treatment will take time and encourage them to continue with long-term outpatient support. To encourage the patient to be positive, medical staff members must focus on celebrating the achievements, no matter how small, and to not become critical. Mainly, patients themselves complete the notebook. Physicians and medical staff such as physical therapists can also write brief comments in the space of the notebook near the patient’s comments.The final goals are to achieve the long-term goal at 6 months to 1 year, establish self-reliance, and to not be dependent on medical care . At the end of the outpatient clinic, the points of reflection and future matters are described on the reflection entry page, and the use of the rehabilitation notes is terminated. It is important that the outpatient clinic does not end suddenly, but that the frequency gradually decreases.A 90-minute formal training seminar for this method, covering the exercise protocol and psychological approaches (including CBT), has been performed annually since 2014. The medical staff  supervising the treatment in the present study have participated in coaching this seminar.p < 0.05, p < 0.05) scores. : nine cases; enhanced participation in hobbies: seven cases; improved school attendance: two cases; return to work: one case; improvement of self-care and/or self-efficacy: three cases; dropout because of patient desire: one case; dropout because of experiencing aggravated symptoms: one case . In term scores. b.Patients with chronic pain suffer from kinesiophobia, a fear that physical activity may increase pain, as an explanation of the fear-avoidance model . InactivPrevious studies demonstrated that combining exercise and CBT significantly improves the intensity of pain, degree of dysfunction, catastrophizing thinking, and kinesiophobia with a moderate effect size at 1 month after the end of the treatment, compared with exercise only , with thA report from a Japanese multidisciplinary pain center showed significant improvement in a number of measures  after treatment for patients with chronic pain in group programs with physical exercise and CBT (weekly 2 h sessions for 9 weeks) . In the Only a few studies have reported the effects of combining CBT and exercise therapy in Japan, but Hirase et al. conducted a study targeting community-dwelling elderly people . The patSeveral studies have investigated the relationship between catastrophizing and both pain intensity and degree of disability ,25. CataThe present study has some limitations. First, there was no adequate control group; thus, it is unclear if using the Ikiiki Rehabilitation Notebook was better than exercise or CBT alone. This study included a small number of participants and a non-systematic approach to utilizing the notebook. The main purpose of this research, however, was to provide a detailed technical explanation of the method and to evaluate its effectiveness in a pilot study for patients with intractable pain. The outcome of the present study is consistent with data of previous Japanese studies ,16. A prSecond, the treatment period varied from 3 to 22 months because the goal in this method differs from that of other methods in which a routine protocol is completed ,16,17,22In this study, we aimed to describe a novel exercise facilitation method combined with CBT using the “Ikiiki Rehabilitation Notebook” for patients with intractable chronic pain, and to evaluate the effectiveness of using this method for patients. In 22 cases with chronic pain treated using this notebook, the pain intensity, ADL, catastrophizing thoughts, insomnia, self-efficacy and QOL were significantly improved after treatment. It is unclear if the score changes are clinically meaningful because the treatment results may reflect several types of therapeutic interventions using this notebook. Further investigation in a prospective study, such as a randomized controlled trial, is needed to evaluate the effectiveness of using this notebook.


Burn injuries and their associated treatments are exquisitely painful and often require hospitalization to achieve adequate pain control. Hospitalized patients have their pain managed aggressively, with rigorous monitoring. However, once patients are discharged from the hospital, the assessment of ongoing pain management becomes more difficult. The purpose of this study was to examine our current practices in the outpatient setting regarding pain management.This was a retrospective review of patients treated in the outpatient burn clinic following discharge home from the burn center over a one-year period. Patients with a significant history of premorbid pain and those discharged initially to a post-acute facility were excluded. Patients were stratified into those requiring opioids ≤ 4 weeks/ > 4 weeks, autografting/no autografting, opioids required following 95% wound closure/not required and those with and without a history of significant substance abuse.There were 206 evaluable patients in this study. The mean number of days to healing was 19.5 days. The mean percent total body surface area injured was 5% yielding a mean number of days to healing per percent total body surface area burn of 4. Overall, narcotic pain medications were discontinued 8 days prior to wound closure. The majority of patients, 83% (n=170) had their narcotic pain medications discontinued before 95% wound closure was achieved; 17% (n=36) number of patients had their narcotic pain medications continued beyond wound healing. Subgroup analysis revealed the following findings. Patients who were on narcotic pain medication > four weeks following the time of injury (n=37) had a mean duration of narcotic pain therapy of 57 days compared to 11 days in patients who received ≤ four weeks . Likewise, patients who were grafted had a longer narcotic pain duration, 28 days vs 12 days in patients who were not grafted (p < .00001). Finally, the presence of previous or current substance abuse appeared to have no impact on the duration of narcotic therapy 19. 8 days vs 19.3 days.Most patients followed in the burn outpatient clinic demonstrated cessation of narcotic analgesic use around the same time as burn wound closure. Factors tending to extend the duration of narcotic use included longer inpatient narcotic use, and the necessity of skin grafting for burn wound management. Interestingly, previous substance abuse history did not influence length of post-hospital narcotic use.


Optimal postoperative analgesia has a significant impact on patient recovery and outcomes after cesarean delivery. Multimodal analgesia is the core principle for cesarean delivery and pain management. For a standard analgesic regimen, the use of long-acting neuraxial opioids  and adjunct drugs, such as scheduled acetaminophen and nonsteroidal anti-inflammatory drugs, is recommended unless contraindicated. Oral or intravenous opioids should be reserved for breakthrough pain. In addition to the aforementioned use of multimodal analgesia, preoperative evaluation is critical to individualize the analgesic regimen according to the patient requirements. Risk factors for severe postoperative pain or analgesia-related adverse effects will require modifications to the standard analgesic regimen . Further investigation is required to determine analgesic drugs or dose alterations based on preoperative predictions for patients at risk of severe pain. Outcomes beyond pain and analgesic use, such as functional recovery, should be determined to evaluate analgesic treatment protocols. The rate of cesarean delivery has been increasing over the past decades, and it is one of the most commonly performed surgeries in the world, with nearly 18.5 million cesarean deliveries performed annually , 3.Pain following cesarean delivery is a complex experience that is personalized to each patient. The degree of tissue injury triggers a response in the pain matrix, forming peripheral sensitization and central pain pathways to fear, anxiety, and frustration. Patients have reported concerns about pain during and after cesarean delivery as their highest priority . The intIn addition to improving clinical outcomes and functional recovery. Enhanced recovery after surgery has been shown to lead to a reduction in complications and duration of hospital stay, as well as earlier resumption of normal activities . OptimalTo optimize pain control with faster recovery and fewer side effects, stepwise multimodal analgesia is crucial for the management of postoperative pain. However, perioperative pain management should be individualized according to patient conditions  or anesthetic techniques . This narrative review presents key considerations and approaches to the management of postoperative pain in cesarean delivery.To optimize postoperative analgesia, pain management protocols have moved toward a standardized approach to personalized analgesic management. A large cohort study assessed pain resolution, opioid-free status, and functional recovery after vaginal and cesarean delivery. The time to pain resolution after delivery varied between 0 and 85 days [th percentile of the evoked pain score. The results revealed modest sensitivity (68%) and specificity (67%) [Several studies have evaluated patient risk factors during the preoperative period, including demographic and psychological factors and quantitative sensory tests (QSTs). In patients undergoing general surgery, female sex, younger age, preoperative anxiety, and a history of chronic pain were significant predictors of worse postoperative pain . In patity (67%) . HoweverAnother approach is giving patients more of a role in analgesic regimen selection. In a randomized controlled trial study, patients were selected to receive either high-dose (200 mcg) or low-dose (100 mcg) intrathecal morphine based on information regarding pain relief and side effects . The resPreemptive analgesia is limited by concerns in utero fetal drug transferThe anesthetic technique is exclusively neuraxial anesthesiaPotential analgesic drug transfer to breastfeeding neonates should be considered. Opioids are associated with breast milk transfer and may cause neonatal sedation. Therefore, opioid-sparing multimodal analgesia is preferable.The transition to oral medications as soon as possible is preferred. Early mobilization and enhancing the mother's ability to be independent and to care for her newborn baby is critical.Compared with other procedures, optimal pain control in cesarean delivery involves several key considerations:To achieve effective analgesia, postoperative opioid requirements and side effects should be decreased. Postcesarean delivery analgesia may be enhanced by many intraoperative interventions for multimodal analgesia, such as neuraxial opioids, nonopioid analgesics, regional blocks, or local analgesia infiltration.Neuraxial anesthesia is the preferred anesthetic technique for cesarean delivery . NeuraxiNeuraxial morphine binds to G-protein-like pre and postsynaptic opioid receptors in the dorsal horn, causing potassium channel opening and calcium channel closure, with an overall reduction in intracellular calcium. This reduces glutamate and substance P release from presynaptic C fibers and decreases nociceptive transmission . In addiIntrathecal morphine is the gold standard single-shot drug for postcesarean pain. The duration of action of intrathecal morphine is between 14 and 36 h . A meta-As part of multimodal analgesia, a randomized double-blinded control study determined the dose response of intrathecal morphine when administered with intravenous ketorolac. The results suggested that 50 mcg intrathecal morphine produces analgesia similar to that produced by either 100 mcg or 150 mcg . In summEventhough most cesarean deliveries are performed mainly with spinal anesthesia , unplannNeuraxial morphine is well known for its high-quality postcesarean delivery, pain control, simplicity of administration, and cost-effectiveness . TherefoRegional anesthesia is strongly advocated within a nonobstetric surgical setting as part of multimodal analgesic strategies . As partLocal anesthetic wound infiltration and infusion are alternative strategies to reduce IV and oral opioid consumption and decrease opioid-related side effects. A meta-analysis included single-shot and continuous wound infusion in patients undergoing cesarean delivery with and without intrathecal morphine. The results showed that these techniques provided an opioid-sparing effect ) but had a minimal effect on pain scores  . In the Single-shot wound infiltration in cesarean delivery has a limited analgesic duration of 4–12 h , 52. TheLiposomal bupivacaine infiltration administered above and below the fascial layer and within the subcutaneous tissue in patients who received intrathecal morphine showed that wound infiltration with liposomal bupivacaine can reduce postoperative pain scores without increasing side effects . HoweverIn conclusion, local anesthetic wound infiltration and wound infusion have opioid-sparing effects in woman undergoing cesarean delivery under general anesthesia or where intrathecal morphine has been omitted. Subfascial continuous wound infusion is preferable to a single infiltration. Data in women receiving multimodal analgesia, including intrathecal morphine, are sparse and suggest limited benefit , 59. Theth–11th intercostal nerves and the ilioinguinal and iliohypogastric nerves [μg, rectal diclofenac 1 mg/kg, and rectal acetaminophen 1 g at the end of surgery. The results revealed that bilateral TAP blocks provided superior analgesia up to 48 h compared with placebo. The point of injection plays a central role in local anesthetic spreading. A posterior approach to the TAP block provides more spread to the paravertebral space and therefore improved analgesic efficacy compared with the lateral approach [The TAP block is an abdominal field block between the internal oblique and transversus abdominis muscles that contain 7c nerves . In 2008c nerves . All patapproach .μg intrathecal morphine, ibuprofen, and acetaminophen. The bilateral TAP blocks with the liposomal bupivacaine group had a significant opioid-sparing effect of 52% in the first 72 h and 49% at 1 week [Multiple randomized controlled studies, including the posterior or lateral TAP block for multimodal analgesia, indicated that bilateral TAP blocks had analgesic benefits and opioid-sparing effects compared with placebo. However, the TAP block provides mainly somatic pain but not visceral pain relief, and it has a limited analgesic duration of 6–12 h, whereas intrathecal morphine has analgesic effects up to 36 h. Therefore, compared with intrathecal morphine (100–200 mcg), bilateral TAP blocks provide inferior analgesic efficacy, but they have a lower incidence of opioid-related side effects. In addition, the combination of bilateral TAP blocks to intrathecal morphine did not improve analgesic efficacy or decrease opioid consumption in patients . To overt 1 week .However, the TAP block may cause local anesthetic systemic toxicity in cesarean delivery , 66. ObsIn summary, bilateral posterior and lateral approach TAP blocks provide a valuable analgesic option in patients who cannot receive intrathecal morphine. A posterior approach bilateral TAP blocks is preferred over a lateral approach because it provides more effective analgesia. A bilateral TAP blocks may also be used as a rescue technique in patients with severe incisional pain after cesarean delivery.A QL block is a fascial plane block where a local anesthetic is injected adjacent to the quadratus lumborum muscle into the thoracolumbar fascia layer. The dermatomes that are affected by QL block depend on the approach and vary from T6 to L4 –73. The P = 0.004) and lower morphine consumption (48 h morphine use: 11 (4.5–18) vs. 20 (13.0–48), P = 0.012) than the control group [In 2015, the first bilateral QL blocks randomized double-blinded study was conducted to compare bilateral lateral approach QL blocks and control groups in patients undergoing cesarean delivery. All patients in both groups did not receive intrathecal morphine. The patients who received bilateral QL blocks had significantly lower pain scores up to 48 h (VAS at rest: 0 (0-1) vs. 0 (0–3), ol group . A meta-ol group  and Tan ol group  showed tP = 0.011) and lower 24 h morphine consumption (5.5 (0–25) vs. 20 (1–46), P = 0.006) than patients who received bilateral posterior approach QL blocks (0.25% bupivacaine 25 mL each side) [When comparing neuraxial morphine with bilateral QL blocks, Pangthipampai et al. showed that patients who received intrathecal morphine (200 mcg) had lower VAS scores at rest (1 (0–2) vs. 3 , P = 0.0ch side) . Severalch side) , 81. Howch side) . A meta-ch side) .In terms of the addition of a bilateral QL blocks as part of multimodal analgesia, Tamura et al. compared the postoperative analgesic effect in patients who received posterior approach bilateral QL blocks with and without intrathecal morphine (100 mcg) . The resRegarding potential side effects, the peak concentration of local anesthetic is lower after bilateral QL blocks than after bilateral TAP blocks . HoweverIn summary, based on the current knowledge, bilateral QL blocks provided analgesic benefits in patients who did not receive neuraxial morphine. Bilateral QL blocks were shown to reduce opioid consumption and pain scores when compared with bilateral TAP blocks. The addition of bilateral QL blocks to patients who received neuraxial morphine did not improve the analgesic benefits.The possible advantages and disadvantages of each regional anesthetic technique are given in NSAIDs are analgesic, antipyretic, and anti-inflammatory drugs that inhibit the cyclooxygenase enzyme (COX) pathway of prostaglandin production. NSAIDs reduce postoperative morphine consumption by 30%–50% after major surgery  and cesaKetorolac is one of the popular intravenous NSAIDs that can be administered via the intravenous or intramuscular (IM) route. In a randomized double-blinded control study of 44 elective cesarean deliveries, intravenous ketorolac 30 mg reduced the 24 h use of morphine by 31.7% . ParecoxIn summary, for women undergoing cesarean delivery, scheduled NSAIDs should be administered in the postpartum period in the absence of contraindications. The type of NSAIDs should be based on the patient's condition , drug availability, and drug safety profile while breastfeeding , 92, 100Acetaminophen is the most common analgesic used worldwide and has a long record of safe use and few side effects. Acetaminophen inhibits peroxidase, leading to a reduction in prostaglandin formation . TherefoThe inclusion of acetaminophen in multimodal analgesia produces opioid-sparing effects. A significant reduction in 24 h morphine consumption is observed with acetaminophen compared with placebo after major surgery  and cesaP ≤ 0.001) [In a retrospective study of patients who received intrathecal morphine and scheduled acetaminophen for 48 h, patients who received scheduled oral acetaminophen needed less intravenous morphine than the as-needed group  . Compari≤ 0.001) .Because combining acetaminophen and NSAIDs has an additive analgesic effect, both drugs should be administered routinely after cesarean delivery , 113. InSteroids are well known as the drug of choice for the prevention of postoperative nausea and vomiting . MoreoveFour randomized controlled trials evaluated the use of intravenous dexamethasone 8–10 mg –125. TheThus, eventhough single dose dexamethasone did not clinically improve pain scores, it reduced the need for rescue analgesia by 30% and had antiemetic properties . TherefoIn recent years, multiple research trials have suggested the usefulness of ketamine as a strong analgesic when used in subanesthetic intravenous doses. The proposed mechanism of ketamine is the blockade of postsynaptic N-methyl-D-aspartate (NMDA) receptors, neuronal hyperpolarization-activated cationic currents, nicotinic acetyl-choline ion channels, and delta and mu-opioid receptors . KetaminP = 0.033) but no statistically significant difference at 6, 24, or 48 h after surgery. Pain scores at 2, 6, 24, and 48 h were comparable between groups [μg and ketorolac 30 mg IV every 6 h) [In 2005, the first subanesthetic intravenous doses of ketamine (0.15 mg/kg) were administered to patients undergoing cesarean delivery under spinal anesthesia. The results revealed that ketamine prolonged the time to the first analgesic requirement (53 min) and decreased the total analgesic consumption and pain score . Han et n groups . Bauchatery 6 h) . The paiery 6 h) .A recent meta-analysis evaluated the analgesic effect of low doses of ketamine in 20 cesarean delivery studies  . The resCurrently, ketamine is not recommended as a routine drug for postoperative pain strategies. However, the addition of ketamine as part of a multimodal regimen may be effective in patients with escalating opioid requirements or in women with a history of chronic pain .α2δ subunit of calcium channels and enhance the inhibitory serotoninergic pathway. Gabapentinoids are the most commonly used to manage chronic neuropathic pain. Their use in the perioperative period was proposed, as trials suggested that gabapentinoids may have a protective effect and prevent persistent postsurgical pain [Gabapentinoids inhibit the cal pain  and reducal pain .P = 0.001), without a significant difference in opioid consumption. Severe maternal sedation was observed more often in the gabapentin group  [P = 0.047) with greater patient satisfaction in the gabapentin group  [P = 0.026) [Gabapentinoids as an adjunct analgesic for cesarean delivery have been evaluated. In a randomized control study, preoperative oral gabapentin 600 mg was administered 1 h before surgery as part of a multimodal analgesia regimen . The pain score  on movement at 24 h was 21 mm (95% CI 13–28) in the gabapentin group and 41 mm (95% CI 31–50) in the placebo group ( = 0.04) . Monks e = 0.04) . The res= 0.003) . However= 0.026) . In cont= 0.026) . A meta-= 0.026) .There are several limitations of gabapentinoid use. First, gabapentinoids have a high umbilical vein-to-maternal vein ratio. Therefore, gabapentinoids should be avoided as preemptive administrations in patients undergoing cesarean delivery . Second,Effective postoperative pain management is paramount for faster recovery. A good pain score does not imply that the patient has good functional recovery. As an example, a prospective observational study using activity trackers in women who underwent vaginal delivery and women who underwent cesarean delivery revealed similar pain scores. Vaginal delivery was associated with greater early ambulation than cesarean delivery. This observation confounds the importance of using pain scores or opioid consumption as the prime quality of care indicators in obstetric anesthesia and analgesia.Enhanced functional recovery is becoming a prime success indicator of modern perioperative healthcare . The QuaPostpartum pain and functional recovery were more comprehensively assessed in obstetric patients. Komatsu et al. conducted a prospective observational study of 213 nulliparous patients after vaginal or cesarean delivery . The patStepwise multimodal analgesia has been confirmed to be effective in pain management and opioid-sparing effects. The regimens currently recommended by the ERAS, SOAP, and PROSPECT guidelines are given in Stepwise multimodal protocols are recommended to reduce postoperative opioid consumption. The general approach and analgesic recommendation in patients undergoing cesarean delivery with neuraxial anesthesia include intrathecal morphine in conjunction with scheduled NSAIDs and acetaminophen . Additio


IntroductionDysphagia is a common complication after anterior cervical discectomy and fusion (ACDF), but it is not a routinely asked question in legacy patient-reported outcome measures (PROMs). This study analyzes whether there are associations between dysphagia and legacy outcome measures.MethodsWe retrospectively reviewed 168 patients who underwent ACDF surgery from 2017 to 2019 at a single institution. Demographics, anthropometric data, Neck Disability Index (NDI), Visual Analog Scale (VAS)-Arm and VAS-Neck Pain scores, Patient-Reported Outcomes Measurement Information System (PROMIS)-Physical and PROMIS-Mental scores, Charlson Comorbidity Index (CCI), and Eating Assessment Tool-10 (EAT-10) were obtained for each patient preoperatively and at one, three, six, and 12 months postoperatively. Pearson’s correlation coefficients were used to evaluate the bivariate correlations between legacy, PROMIS, and EAT-10 measures.ResultsSignificant but weak correlations existed between NDI and EAT-10 at one, three, and six months postoperatively (correlation coefficient (R) = 0.31, 0.42, and 0.34 at one, three, and six months, p < 0.001) and VAS-Neck Pain and EAT-10 scores at one, three, and six months postoperatively . Both PROMIS-Physical and PROMIS-Mental scores showed significant but weak correlations with EAT-10 scores at three and six months postoperatively . In all comparisons of EAT-10 scores with legacy outcome measures, the significance of correlations disappeared by 12 months postoperatively. In addition, there was a positive association between CCI and EAT-10 score .ConclusionWeak correlations exist between self-reported dysphagia scores and legacy patient-reported outcome measures in patients undergoing ACDF. The correlation strength decreases over time; therefore, dysphagia scores should be reported separately when looking at outcomes after ACDF. Patients with more comorbidities are also at increased risk for dysphagia. Anterior cervical discectomy and fusion (ACDF) is one of the most commonly performed spinal surgeries in the United States . PatientPatient-reported outcomes (PROs) after surgery are essential metrics in determining the success of any operation. A recent study discussed how PROs, including legacy and Patient-Reported Outcomes Measurement Information System (PROMIS), have revolutionized the definition of success in cervical spine surgery . Legacy Various measures have been utilized to assess patients’ self-reported dysphagia after ACDF. The most commonly utilized scales include the Bazaz and SWAL-QoL, both of which have limitations in validity and reliability ,10-12. TThe primary objective of this study is to quantitatively assess whether legacy and PROMIS-Physical/PROMIS-Mental measures correlate with self-reported dysphagia as assessed by EAT-10. Since dysphagia is the most common complication after ACDF, if correlations are not found, it may be necessary to collect dysphagia data on all ACDF patients to fully assess their PROs after any cervical surgery. In addition, we also assess the effects of baseline patient characteristics on dysphagia (EAT-10) after ACDF using the regression approach.Study design and selection of participantsThis retrospective study was approved by the Institutional Review Board of Beaumont Research Institute. All patients who underwent ACDF between January 2017 and December 2019 by the senior author (DP) at a single institution were identified in electronic medical records and the operating surgeon’s surgical database. All operative and nonoperative patients seen in the senior author’s office are required to answer various patient-reported outcome measures (PROMs) on a provided iPad prior to their office appointment.Of those patients who underwent ACDF between January 2017 and December 2019, patients were included if they are older than age 18 years, if they underwent a single or multilevel ACDF for primary or revision purposes, and if follow-up occurred in the senior author’s private orthopedic clinic. Patients were excluded if they were not cognitively able to complete questionnaires at baseline; were seen in the emergency department prior to surgery, thus having no preoperative PROs; or if postoperative follow-up was performed at the tertiary care resident-run orthopedic clinic, thus having no postoperative PROs collected. A total of 168 patients met the selection criteria and were included in the study.Surgical techniqueAn anterior approach to the cervical spine was utilized for all patients. A left-sided transverse skin incision was made as is preferred by the senior author. After dissection through the platysma, the soft tissues were undermined, and a standard Smith-Robinson approach was utilized. Self-retaining retractors were used, and the endotracheal cuff was routinely deflated and reinflated. Dexamethasone 8-10 mg IV was administered commonly by the anesthesia team, and no local steroids in the wound were utilized. Variable plates  were used, and PEEK interbody cages  were implanted in all patients.Study variablesBaseline patient characteristics, including age, sex, body mass index (BMI), Charlson Comorbidity Index (CCI), daily opioid use (yes/no), and depression (yes/no), were collected. Neck Disability Index (NDI), Visual Analog Scale (VAS) pain scores, PROMIS-Physical and PROMIS-Mental scores, and Eating Assessment Tool-10 (EAT-10) were obtained for each patient preoperatively and at one, three, six, and 12 months postoperatively.Statistical analysisDescriptive analyses were used to summarize the baseline characteristics of patients. Continuous and categorical variables were expressed as means (standard deviations (SDs)) and frequencies (percentages), respectively. Bivariate correlations were used to examine legacy and PROMIS measures with self-reported dysphagia EAT-10) at each preoperative and postoperative time point. To increase the stabilization of estimate of correlation coefficients and reduce the odds of errors of inference resulting from pairwise deletion or available case analysis on missing follow-up observations in calculating the Pearson’s correlation coefficients, missing observations were imputed by the procedure of multiple imputation through the fully conditional specification method, accounting for the arbitrary missing patterns . Multiva at each Of 254 patients who underwent ACDF from 2017 to 2019, 168 patients met the selection criteria and were included in this study. The average age of patients was 57 (SD: 12), and 52.4% of the patients were females. Baseline patient characteristics are summarized in Table Bivariate correlations, NDI versus EAT-10, PROMIS versus EAT-10, and VAS-Neck Pain versus EAT-10 scores are illustrated in Table Table Regarding surgical and postoperative complications, there were no cases of epidural hematoma, symptomatic recurrent laryngeal nerve palsy, cerebrospinal fluid leak, wound infection, esophageal perforation, or Horner’s syndrome. Early complications included one case each of pulmonary embolism, respiratory failure requiring reintubation due to hematoma, urinary retention, C5 nerve palsy, and symptomatic hematoma from a postoperative fall that resolved with monitoring. Late complications included one case each of odynophagia and hardware screw failure requiring revision.Patient-reported outcome measures (PROMs) are utilized to help determine success after surgical procedures. In cervical spine surgery, legacy  and PROMIS-Physical/PROMIS-Mental scores are routinely collected for this purpose; however, these scores do not specifically ask about the most common complication after ACDF surgery - dysphagia. Historically, dysphagia was not as widely discussed when initial studies on cervical spine outcome measures were performed, possibly explaining the lack of cervical spine literature where self-reported dysphagia was an outcome. The primary objective of our study was to see if correlations exist between self-reported dysphagia and PROMs. While weak correlations exist between EAT-10 and NDI, VAS-Neck, and PROMIS-Physical/PROMIS-Mental scores up to six months postoperatively, by 12 months postoperatively, these weak correlations became weaker and lost significance. Our secondary objective was to assess patient-specific risk factors for self-reported dysphagia after ACDF. We found that CCI was positively associated with EAT-10 scores and that patients with a BMI ≥ 30 and a CCI ≥ 1 trended toward having mild or severe dysphagia compared with their healthier counterparts. These findings suggest that EAT-10 scores should be collected on all patients to fully assess their PROMs after ACDF.The current global spine literature is not lacking in studies evaluating outcomes after ACDF surgery. However, the most common complication after ACDF, dysphagia, is not always included as an outcome measure. A retrospective study on data from 2011 to 2016 analyzed patient-reported outcomes after ACDF in 318 Danish patients. With a one-year minimal follow-up period, the study included all legacy outcome measures but did not include any measures on dysphagia . ButtermOur discovery that self-reported dysphagia has weak initial correlations with NDI, VAS-Neck, and PROMIS-Physical/PROMIS-Mental scores, which become even weaker and lose significance over time, further suggests that self-reported dysphagia should be collected as an outcome measure in all ACDF studies. It is important to realize that legacy and PROMIS-Physical/PROMIS-Mental outcome measures do not ask direct questions regarding dysphagia.The NDI is made up of 10 scored sections including neck pain intensity, personal care (not relating to dysphagia), lifting objects, reading, headaches, concentration, working, driving, sleeping, and recreation. No section has an option that relates to dysphagia. However, people may associate dysphagia with difficulty performing personal care such as feeding oneself. The ability to engage in recreational activities may also be affected by dysphagia. For instance, patients may struggle to go out to dinner for social events as a result of their dysphagia. Furthermore, VAS-Neck Pain scores utilize a 10-cm visual analog scale that patients mark from no pain to worst pain imaginable - dysphagia is not represented. However, correlations between dysphagia and neck pain may exist if patients associate their dysphagia as a contributing factor to their neck pain.Finally, PROMIS is a scoring system developed by the NIH that was developed as a way to simplify and standardize the collection of PROs by researchers. PROMIS is divided into multiple domains, including physical function and mental health domains, which are commonly used as orthopedic surgery outcome measures . HoweverThese weak correlations also suggest that self-reported dysphagia does in fact cause patient morbidity and QoL alterations. Following ACDF, dysphagia typically plateaus after six months ; thus, tWe also aimed to assess patient-specific risk factors for self-reported dysphagia after ACDF and found a positive association between CCI and EAT-10 scores and that patients with a BMI ≥ 30 and a CCI ≥ 1 trended toward having mild or severe dysphagia compared with their healthier counterparts. Other published studies have looked at risk factors for dysphagia after ACDF. From 2013 to 2017, Yew et al. looked at risk factors for postoperative dysphagia using the EAT-10. They found that obstructive sleep apnea, asthma, and increased American Society of Anesthesiologists (ASA) score were associated with increased risk of dysphagia in the later postoperative period . This stTo our best knowledge, this is the first study to compare self-reported dysphagia scores to legacy and PROMIS outcome measures. The patients in this study exhibited clinically significant improvements in VAS-Neck Pain scores and NDI scores, which meet standards in the literature for minimal clinically important differences (MCIDs) ,28. Our The current study is not without limitations. This study was a retrospective review without patient randomization and with potential confounders. In addition, while EAT-10 is currently the most accurate and reliable noninvasive outcome measure to assess dysphagia, it is a subjective score calculated from a patient’s report. To better assess dysphagia, more invasive techniques such as endoscopic and videofluoroscopic swallow studies could be performed to assess objectively swallowing dysfunction. Future studies may benefit from these techniques in combination with EAT-10.This study found that weak correlations exist between self-reported dysphagia scores and legacy patient-reported outcome measures in patients undergoing ACDF. By 12 months postoperatively, these weak correlations lost significance. In addition, patients with more comorbidities prior to surgery were more likely to have dysphagia after surgery. Obese patients or those with a CCI ≥ 1 trended toward having mild or severe dysphagia compared with their healthier counterparts. Given the lack of correlation between dysphagia and other patient-reported outcome measures, self-reported dysphagia scores should be reported separately when looking at outcomes after ACDF.


Successful health outcomes in older patients are linked to the quality of the patient-provider relationship. Our study objective was to further understand the role of this relationship specific to pain management through perspectives from older adults and healthcare providers. Semi-structured interviews and focus groups were conducted with 9 older adults and 11 multidisciplinary healthcare providers. Transcripts were analyzed using a thematic analysis. Three main concepts emerged: (1) defining pain management goals — differences in providers and patients’ goals for pain and function, with sub-themes of realistic goal setting and a shift in pain treatment to minimize opioids as a first-line medication; (2) communication — perceived gap in providers communicating and coordinating across disciplines and with patients, with sub-themes of improving positive communication and inconsistent messaging among providers; and (3) therapeutic alliance — all parties feel that developing a relationship is built on consistent trust and open dialogue. Although providers and older adults often expressed similar perspectives, there were several areas of misalignment identified within each concept, representing areas of disconnect within the patient-provider pain management relationship. Our findings indicate providers could benefit from education on improving communication around realistic goals and patient-centered outcomes and incorporation of more holistic pain management approaches when working with older adult patients. Further study should focus on developing educational interventions to address the identified shortcomings.


This study aims to examine the association of orofacial pain and oral health status and oral health behaviours in facial burn patients. The participants in this cross-sectional study were randomly recruited from the Burn Care Center, Institute of Medical Sciences, Islamabad, Pakistan. An intraoral evaluation was carried out to record the DMFT and OHI-S. A self-administered questionnaire was used to collect information on sociodemographic status, brushing frequency, and dental visits. Orofacial pain during mandibular movement was assessed using the Visual Analogue Scale (VAS). Psychological status was assessed using the Generalized Anxiety Disorder Scale and Impact of Events Scale. ANOVA and simple and multiple linear regression tests were used to analyse the data. From the 90 facial burn patients included, the majority were below 34 years of age, female, single or divorced, and unemployed. The mean DMFT was 10.7, and 71% had poor oral hygiene. 56% of the participants had moderate-to-severe anxiety, and 68% had posttraumatic stress disorder. 53% of the participants had moderate-to-severe pain during mouth opening or moving the mandible with a mean score of 41.5. Analyses showed that orofacial pain was associated with less frequent brushing, irregular dental visits, greater DMFT score, and more plaque accumulation (OHI-S). It was also associated with employment status, the severity of a burn, anxiety, and stress. The treatment and management of dental and oral conditions in burn patients need judicious balance in controlling and accurate assessment of the pain and improving psychological problems in burn patients. Burn injuries are an example of the most debilitating physical and traumatic injuries that can potentially lead to severe physical  and psychological morbidity  and mortality . The preBurn patients go through a long journey towards recovery which lasts for years or decades while enduring acute, healing, and rehabilitation phases . The phyA burn to the orofacial region involving the lips and mouth has compounding impacts. The skin contraction or tightening during the healing process and scarring can lead to lip distortion and microstomia . This, iIn this cross-sectional study, burn patients who visited the Burn Care Center, Pakistan Institute of Medical Sciences, Islamabad, for follow-up were randomly recruited after the ethical approval was approved from the Ethics Review Board, Shaheed Zulfiqar Ali Bhutto Medical University, Islamabad, Pakistan (F.1-23/2020/ERB/SZABMU). Participants over the age of 15 years with a burn injury to the face and neck region for more than one year and able to feed exclusively by mouth were included in this study. The participants were briefed about the purpose of the study. Written informed consent was obtained before data collection from all the participants and their parents in case of minors. All the participants underwent an intraoral examination by one investigator to record the dental (DMFT) and oral hygiene (OHI-S) status using a standard survey method by the WHO , 11. TheThe participants also completed self-administered questionnaires that included information related to sociodemographic , tooth brushing frequency , and dental check-ups in the past year (Yes or No). The information regarding the severity of burn injury  and time elapsed after that burn injury was taken from the patients' medical records.X” on the Visual Analogue Scale (VAS) [X” and ranges between 0 and 100, with a higher score suggesting greater pain intensity. The score was categorized as no pain (0 to 4 mm), mild pain (5–44 mm), moderate pain (45–74 mm), and severe pain (75–100 mm) [Pain assessment was carried out by asking the participants to open the mouth widely and perform mandibular movements and then rate the pain experience by making “le (VAS) , 13. The–100 mm) , 15. The–100 mm) . The Urd–100 mm) . The 15-Descriptive analysis was carried out to describe the sample and summary statistics of measures included in the study. Associations between pain related to mouth opening, jaw movement, and the factors were examined using simple and multiple linear regression. All ordinal variables were treated as continuous variables to examine the effect linear trend of exposure variables. Analyses were performed at a 5% significance level and carried out using IBM SPSS software v26.0.A total of 95 patients with a facial burn were invited to participate and 90 patients had consented and completed the oral examination and self-administrated questionnaires with a response rate of 94.7%. The sample included a high percentage of females (67%), below 25 years of age (41.1%), single, divorced, or widowed (71%), and unemployed (70%) individuals . Most suThe simple linear regression analysis showed that pain during movement of the mouth was associated with employment status, the severity of the injury, and time since the incidence . More seThe standardised coefficient for the DMFT in the multiple linear regression analysis was the largest compared to other factors, indicating that caries experience was the most important factor associated with pain.This is the first study that examines the relationship between orofacial pain related to mandibular movement and dental health status and oral health behaviours in facial burn patients and it found a significant association between them. Greater pain levels are associated with poorer dental and oral hygiene status, less frequent tooth brushing, and no visit to the dentist in the past year. The dental health status and oral hygiene were similar to a previous study on facial burn patients  . The strThis study also found that pain is more severe in older participants and those with a more recent injury, anxiety, and stress. Being older does not lower pain tolerance, likely due to ineffective pain inhibitory processes . NeverthUnemployment is another social characteristic related to higher pain expression. Chronic pain can impair working lives through a sudden change in the working environment and job loss . The chaThe findings of this study should be interpreted with caution. Limited causal inference can be made due to the cross-sectional design and associations are based only on statistical analysis. The severity of pain in relation to the need for medication and whether it truly affects oral hygiene care were not assessed. A qualitative study to assess how pain influences oral hygiene care and the extent of its effect is recommended to justify the posit. Among the greatest challenges of this study is to gain the trust of the participants who suffer from physical and psychosocial problems that make them nervous, cautious, shy, hesitant, and scared and seek sensitive information related to the dire experience and ask them to perform manoeuvres that are uncomfortable and painful.This study suggests that there is a link between orofacial pain from jaw movement and oral health behaviours and poor oral conditions in facial burn patients. Factors including burn severity, time since burn injury, and psychosocial problems are also associated with orofacial pain. The findings can raise the awareness of oral health care professionals regarding the complex and multifactorial nature of dental and oral health problems in burn patients and help in preparing safe and effective strategies and practice guidelines for the care of patients with a facial burn injury. Treatment and management of dental and oral conditions in these patients require judicious balance in controlling and accurate assessment of the pain while at the same time addressing the psychological issues. Further investigations on the negative impact of orofacial pain and psychological conditions on oral health status and behaviours in burn patients are recommended.


Poorly controlled postoperative pain has been known to be characterized by longer post-operative care, longer hospital stays with increased readmission rates, and decreased patient satisfaction. Post-operative pain has been continuously addressed in the past three (3) to four (4) decades and has been shown that 20 to 80% of post-operative patients suffer ineffective pain management.The study was aimed at assessing the factors that may predict the satisfaction of patients with early postoperative pain management following abdominal surgeries at the Komfo Anokye Teaching Hospital, Kumasi.A descriptive cross-sectional study was conducted among patients who had undergone abdominal surgeries between October 2019 and December 2019 at the Komfo Anokye Teaching Hospital. Structured questionnaires based on the IPO-Q were used to obtain responses from the patients. Descriptive and Inferential statistical analysis were employed in analyzing the data obtained from the respondents of the study.138 patients were involved in this study. The mean age of patients in the study was 45.81 (±16.81) years. A higher percentage, 58.7% of the patients were males. 39.1% had completed their tertiary level of education. The majority (50.7%) of the patients had had persistent pain for more than three (3) months. The satisfaction of the patients with the post-operative pain management received was generally high among a significant majority of the patients. Meanwhile, among the factors that influence the satisfaction of the patients with the post-operative pain management received, type of analgesia and pain relief methods , patient’s ability to request more pain relief, , patient’s access to information about their pain treatment options from the Nurses , were the only predictors of satisfaction in patients.This study found out that patients were generally satisfied with the post-operative pain management offered by their healthcare providers although the degree of satisfaction depended largely on the type of analgesia and pain relief methods, the ability to request for more pain relief, and access to information on pain treatment. Management of postoperative pain that is effective has become a major health care concern for practitioners as well as patients who undergo surgical processes . NegativPostoperative pain that is not controlled properly is characterized by longer post-operative care, longer hospital stays with increased readmission rates, and decreased patient satisfaction . After bPostoperative pain management is an integral part of nursing practice and thus, nurses should have a holistic approach to post-operative care to improve the effectiveness of pain management as well as the satisfaction of patients in this postoperative pain management. Postoperative pain has been continuously addressed in the past three (3) to four (4) decades and has been shown that 20 to 80% of post-operative patients suffer ineffective pain management . A lot oGlobally, there has been a force driving the management of postoperative pain, however, postoperative pain is still undertreated especially in the developing countries with the incidence ranging from 47–100% . WorldwiIt seems postoperative assessment and management have not had the necessary consideration in developing countries since adequate data for the management of postoperative pain are not accessible but patients who undergo surgical procedures still battle with pain control. It is, therefore, necessary to investigate more into this situation and appreciate the factors influencing the satisfaction of patients’ post-operative pain management. Clarification for the unending high levels of post-operative pain as well as suggestive ways of enhancing its management will be detailed.A descriptive cross-sectional design with a quantitative approach was employed in conducting the study in the surgical unit of the Komfo Anokye Teaching Hospital (KATH). KATH is a tertiary hospital with a 1200- bed capacity that takes direct referrals from 12 out of the 16 administrative regions in Ghana. It also receives patients from neighboring countries like Ivory Coast and Eastern Faso. It is the second-largest hospital in the country. The general surgery ward where participants were recruited has four wards of which females are admitted in two (2) wards with 16-bed capacities each and males being admitted in the other two (2) wards with 18-bed capacities each. The study population comprised patients who were 18 years and above and had undergone general abdominal surgeries within the first 72-hours post-surgery at the surgical wards. The surgeries were performed between October 2019 and December 2019.A convenience sampling technique was adopted in sampling 138 patients who went through general abdominal surgeries at KATH. The sample size was estimated based on a 95% confidence interval, a 10% estimated proportion and, a 5% error rate.Data was collected between October 2019 and December 2019, patients aged 18 years and above who were within 72 hours after abdominal surgery and had signed the consent form were included in the study. However, patients who had had polytrauma experience after undergoing abdominal surgery were excluded. A written letter was obtained from the head of the department of surgery where it was sent to various wards where the study was to be done. Permission was given by the in-charge of the ward to commence the collection of data. Data were collected at the patient’s bedside after the ward in-charge clears the patient to be stable. Research assistants were coached on how to recruit participants for the study and on assessing patients’ ability to understand the information given about the study and to partake in the study. Patients were made aware of the main aim of the study as well as its nature, risks, and processes. Written consents were gotten from participants after an extensive explanation of the study before data collection was done. Participation in the study was purely voluntary and participants were given the option of opting out of the research at any point. Patients were assured that opting out of the study would not affect the care rendered to them in the hospital. Participants were also assured of the confidentiality of data gathered.Certificate of registration (RD/CR18/231) was obtained from the Research Unit of the Komfo Anokye Teaching Hospital. Ethical clearance and consent forms were sought from the Committee on Human Research Publication and Ethics, KNUST, with the clearance number CHPRE/AP/061/19 before the commencement of data collection.The International Pain Outcome questionnaire (IPO-Q) which was developed by Pain Out  based onAfter data collection, all questionnaires were stored in files with access restricted to the principal investigator only. This aided in guaranteeing the confidentiality of the participants. Questionnaires were given codes for archiving and easy retrieval. Data from the questionnaires were double-checked before entry was done into a computer by the principal investigator. Data entered on the computer were protected with a password.Analysis of data was conducted with IBM SPSS statistics 25. The sample was described using descriptive analysis, where means and standard deviations (SDs) were used for continuous variables and frequencies and percentages for categorical variables. A mean interference score on a numerical rating scale (NRS 1–10) was calculated, with higher scores reflecting greater pain intensity and greater interference with physical activities. To establish the correlation strength, and direction between the variables, a correlation analysis was used by estimating Pearson’s correlation ratios. The relationships among demographic variables and procedural characteristics of patients as predictors of satisfaction with post-operative pain management were examined by Pearson’s correlation, Chi-square test, and one-sample t-tests. All tests were conducted at a level of significance of P<0.05.The mean age of the participants was 45.81 (±16.81) years with the majority of the patients belonging to middle adults aged 36–55 years. More than half of the patients, 58.7% were males with 41.3% being females. A higher percentage, 31.9% of the participants who had formal education had completed the tertiary level, with only 7.2% who had no form of formal education in their lifetime. Moreover, the majority of the patients were Christians 79.0% with only 21.0% being Muslims. The study also recorded the type of surgery the patients received. A higher proportion of the total sample population, 44.9% had exploratory laparotomy performed on them, followed by 30.4% who received herniorrhaphy, 19.6% who received appendicectomy, 4.3% who received cholecystectomy, and only 0.7% who received gastrectomy. After the surgery, 97.1% responded to have received general anesthesia, with only 4 (2.9%) who received spinal anesthesia. For most of the patients, 98.6% received a combination therapy of opioids and NSAIDS as their post-operative analgesia with only 1.4% who received only opioids postoperative analgesia. Regarding the severity of persistent pain assessed with the numerical rating scale (NRS), 73.1% had Moderate (NRS 4–7) persistent pain, 23.9% had Severe persistent pain (NRS 8–10), whereas 3% had Mild (NRS 0–3) persistent pain. Regarding the location of persistent pain, the majority of patients 52.2% had experienced the pain both at the site of the surgery and elsewhere, and 44.8% experienced the pain only at the site of the surgery. The rest of the patients (3%) however felt the persistent pain elsewhere away from the site of the surgery .The pain characteristics of the patients were recorded on a numerical rating scale (NRM 0–10). The patients further described how the pain interferes with their physical activities with a mean scale of 6.89 (±2.48) of interference with activities in bed, a mean scale of 5.93 (±3.58) of interference with breathing deeply or coughing, and a mean scale of 4.74 (±2.27) of interference with sleep. The mean scale of the interference of pain with activities out of bed was also 6.02 (±3.26). The study further recorded how pain affects the emotion of the patients and causes them to be anxious and helpless. The mean scale of the respondents on how pain causes them to be anxious was 3.53 (±2.55) with a mean scale of 3.41 (±2.57) for the feeling of helplessness. The pain was also described to have had side effects on the patients. The patients described nausea as an effect of the pain with a mean scale of 1.57 (±2.106), drowsiness with a mean scale of 2.69 (±2.04), itchiness with a mean scale of 0.25 (±1.23) and, dizziness with a mean scale of 2.46 (±1.96). On an NRS of 0–10, the mean scale of patient’s response to their involvement in the decision concerning the pain treatment options was 0.03 (±0.24) with a mean scale of 6.97 (±0.94) for their satisfaction with the pain treatment they received . A substBased on the demographic and procedural characteristics as predictors of satisfaction in patients with the post-operative pain management, there was no statistically significant difference of satisfaction across the various levels of education (p>0.05), though patients who had pursued education up to the secondary level were found to be extremely satisfied with the POP management. Moreover, Christians were found to be extremely satisfied with pain management as compared to Muslims. This difference however was statistically insignificant (p>0.05). Also, there was no statistically significant difference of satisfaction across the type of surgery the patients received though most of the patients who received Laparotomy were found to be extremely satisfied. There was no statistically significant difference in satisfaction between males and females, though extreme satisfaction was found more in males than females (p>0.05). No significant association was found between age range and satisfaction with pain treatment (p>0.05). Extreme satisfaction however was found more in patients aged 36–55 years. A statistically significant association was found between the prescribed post-operative analgesia and satisfaction with postoperative pain treatment (p<0.05). Extreme satisfaction was found to be significantly higher in patients who received IV Morphine & IM Diclofenac .Regarding the outcome of pain management as a predictor of satisfaction in patients with postoperative pain treatment, there was a statistically significant positive correlation  between the Pain relief received and Satisfaction. Also, a statistically significant positive correlation  was identified between the patient’s ability to request more pain relief and Satisfaction. Surprisingly, the patient’s access to information about their pain treatment options from the Nurses produced a statistically significant negative correlation with their satisfaction in the whole process of postoperative pain management . Meanwhile, there was no statistically significant association of satisfaction with any side effects like Nausea, drowsiness, itching, and dizziness (p>0.05). .The study further accessed nursing-related pain care if they could be predictors of satisfaction in patients. How often nurses respond to the pain needs of patients, quality of care as judged by the patients, and time of administration of medications had no statistically significant correlation with satisfaction in patients .In patients who undergo surgical procedures in the hospital, post-operative management remains a challenge worldwide. In this present study, 44.9% representing a higher percentage of the sample population had exploratory laparotomy as compared to the others who had herniorrhaphy, appendicectomy, cholecystectomy, and gastrectomy respectively. All the surgeries were classified under major surgeries with no minor surgery recorded. A high percentage of exploratory laparotomy could be due to acute abdomen which most of the patients in our study presented with. This finding disagrees with a study at the University of Gondar Hospital where 84% of the patients had major surgery and the rest of the 16% had minor surgeries (26). The difference could be as a result of the type of population involved in our study in which patients wait for symptoms to exacerbate before coming to the hospital.et al., (2018) in a qualitative study of post-operative pain reported persistent pain in patients following total joint replacement surgery Reviewers' comments:Reviewer's Responses to QuestionsComments to the Author1. Is the manuscript technically sound, and do the data support the conclusions?The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: PartlyReviewer #2: Partly**********2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: I Don't KnowReviewer #2: Yes**********3. Have the authors made all data underlying the findings in their manuscript fully available?PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.The Reviewer #1: YesReviewer #2: Yes**********4. Is the manuscript presented in an intelligible fashion and written in standard English?PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.Reviewer #1: NoReviewer #2: Yes**********5. Review Comments to the AuthorPlease use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. Reviewer #1: There are two major revisions I would like to emphasize.First, the first paragraph of Material and Methods is mainly disconnected and there is no integrity of meaning. To understand the method of this study, it is necessary to read the manuscript three or four times. Material method section should be revised.Secondly, the current results of the study were not mentioned in the discussion section. The literature was well searched, but no correlation was made with the results found in the study or the differences of the study from the literature were not mentioned in the section.Reviewer #2: The period when the patients were operated on is not mentioned in the article. The period when patients are operated on should be specified in Abstract (Methodology) and Main Text  sections.**********what does this mean?). If published, this will include your full peer review and any attached files.6. PLOS authors have the option to publish the peer review history of their article  digital diagnostic tool,  24 Dec 2020Department of NursingCollege of Health SciencesKwame Nkrumah University of Science and TechnologyKumasi-Ghana24th December, 2020Editor-in-ChiefPLOS ONE Dear Sir/Madam, RESPONSE TO REVIEWERS’ AND EDITORIAL COMMENTS: PONE-D-20-32363We express our appreciation to the editors and reviewers for the comments and suggestions made in reference to the manuscript that we submitted titled: “Predicting factors that determine patients’ satisfaction with post-operative pain management following abdominal surgeries at Komfo Anokye Teaching Hospital, Kumasi, Ghana”. Authors have revised the manuscript using the reviewers’ and the editorial comments. Accordingly, we have provided the response to the comment in the table of changes below, and where the addition has been effected.Thank youPRISCILLA FELICIA TANOCORRESPONDING AUTHORReviewer # Page Number Reviewers’ Comments Authors’ ResponsesREVIEWER 1 6-919-22 The first paragraph of materials and methods is mainly disconnected and there is no integrity of meaning. To understand the method of this study, it is necessary to read the manuscript three to four times. Materials and methods section should be revised.The current results of the study were not mentioned in the discussion section. The literature was well searched, but no correlation was made with the results found in the study or the differences of the study from the literature were not mentioned in the section. We thank the reviewer for this important comment to revise the Materials and methods section. This comment has been addressed. Materials and methods section has been revised from page 6-9, line 122-199We are grateful to the reviewer for this significant comment to mention the current result of the study in the discussion section. This comment has been addressed in the discussion section in page 19-22, line 288-364.We appreciate this important comment to correlate or bring out the difference with the result found in the study and the literature. This comment has been addressed in the discussion section in page 19-22, line 288-364.Reviewer 2; 3,6 The period when the patients were operated on is not mentioned in the article.The period when patients are operated on should be specified in Abstract (Methodology) and Main Text  sections We thank the reviewer for this valuable feedback. The authors have included the periods when patients were operated on in the Abstract (Methodology) in page 3 line 57 and also in Materials and methods section in page 6, line 132.AttachmentResponse to Reviewers.docxSubmitted filename: Click here for additional data file. 19 Jan 2021PONE-D-20-32363R1Predicting factors that determine patients’ satisfaction with post-operative pain management following abdominal surgeries at Komfo Anokye Teaching Hospital, Kumasi, Ghana.PLOS ONEDear Dr. Tano,Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.plosone@plos.org. 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You should upload this as a separate file labeled 'Manuscript'.If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocolsIf applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: We look forward to receiving your revised manuscript.Kind regards,Emre BozkurtAcademic EditorPLOS ONEAdditional Editor Comments (if provided):Congratulations for your well written manuscript. You need to make some revisions for your manuscript before it can be published. The reviewer suggestions were as follows;Reviewer 1;There are two major revisions I would like to emphasize.First, the first paragraph of Material and Methods is mainly disconnected and there is no integrity of meaning. To understand the method of this study, it is necessary to read the manuscript three or four times. Material method section should be revised.Secondly, the current results of the study were not mentioned in the discussion section. The literature was well searched, but no correlation was made with the results found in the study or the differences of the study from the literature were not mentioned in the sectionReviewer2;The period when the patients were operated on is not mentioned in the article. The period when patients are operated on should be specified in Abstract (Methodology) and Main Text  sections.The manuscript will be re-evaluated after these revisions.https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool,  29 Mar 2021Reviewer # Page Number Reviewers’ Comments Authors’ ResponsesREVIEWER 1 The first paragraph of materials and methods is mainly disconnected and there is no integrity of meaning. To understand the method of this study, it is necessary to read the manuscript three to four times. Materials and methods section should be revised.The current results of the study were not mentioned in the discussion section. The literature was well searched, but no correlation was made with the results found in the study or the differences of the study from the literature were not mentioned in the section. We thank the reviewer for this important comment to revise the Materials and methods section. This comment has been addressed. Materials and methods section have been revised from page 6-9, line 125-197We are grateful to the reviewer for this significant comment to mention the current result of the study in the discussion section. This comment has been addressed in the discussion section in page 18-22, line 284-363.We appreciate this important comment to correlate or bring out the difference with the result found in the study and the literature. This comment has been addressed in the discussion section in page 18-22, line 294-295, 301-302, 324-316, 339-340, 345-346, 356-357.Reviewer 2; The period when the patients were operated on is not mentioned in the article.The period when patients are operated on should be specified in Abstract (Methodology) and Main Text  sections We thank the reviewer for this valuable feedback. The authors have included the periods when patients were operated on in the Abstract (Methodology) in page 3 line 58 and also in Materials and methods section in page 6, line 137.AttachmentResponse to Reviewers.docxSubmitted filename: Click here for additional data file. 7 May 2021Predicting factors that determine patients’ satisfaction with post-operative pain management following abdominal surgeries at Komfo Anokye Teaching Hospital, Kumasi, Ghana.PONE-D-20-32363R2Dear Dr. Priscilla Felicia TanoWe’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at onepress@plos.org.If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact Kind regards,Ehab Farag, MD FRCA FASAAcademic EditorPLOS ONEAdditional Editor Comments :Reviewers' comments: 14 May 2021PONE-D-20-32363R2 Predicting factors that determine patients’ satisfaction with post-operative pain management following abdominal surgeries at Komfo Anokye Teaching Hospital, Kumasi, Ghana. Dear Dr. Tano:I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. onepress@plos.org.If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact plosone@plos.org. If we can help with anything else, please email us at Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staffon behalf ofDr. Ehab Farag Academic EditorPLOS ONE


Patellofemoral pain syndrome (PFPS) is a common pathology usually presenting with anterior or retropatellar pain. It is associated with a relative imbalance between the vastus medialis oblique (VMO) and the vastus lateralis (VL) muscles. This can lead to considerable morbidity and reduced quality of life (QOL). This study aims to assess the long-term functional outcome of PFPS treated with VL muscle botulinum toxin A (BoNT-A) injection.A retrospective review was performed on 26 consecutive patients (31 knees) with a mean age of 50.1 years (± 19.7 years) who were treated with BoNT-A injections to the VL muscle followed by physiotherapy between 2008 and 2015. Pre- and post-treatment pain levels , QOL (SF-6D), and functional scores  were measured. Demographics, physical therapy compliance, previous surgeries, perioperative complications, and patient satisfaction levels were collected.P < 0.01), and the Kujala, Lysholm, and SF-6D scores improved from 58.9 to 82.7 (P < 0.001), 56.2 to 83.2 (P < 0.001), and 0.6 to 0.8 (P < 0.001), respectively. Similar delta improvement was achieved irrespective of gender, age, compliance to post-treatment physical therapy, or coexisting osteoarthritis. Patients who presented with a worse pre-treatment clinical status achieved greater improvement. Prior to BoNT-A intervention, 16 patients (18 knees) were scheduled for surgery, of whom 12  did not require further surgical intervention at the last follow-up.The mean follow-up time was 58.8 ± 36.4 months. There were significant improvements in all the examined domains. The average pain score (NRS) decreased from 7.6 to 3.2 (A single intervention of BoNT-A injections to the VL muscle combined with physiotherapy is beneficial for the treatment of patients with persistent PFPS.Retrospective cohort study. Patellofemoral pain syndrome (PFPS) is a common condition that may cause severe retropatellar or peripatellar pain, making it the leading cause of anterior knee pain . PFPS caThe diagnosis of PFPS is based on patient history and physical examination, and it is determined by the presentation of peripatellar or retropatellar pain that is exacerbated with loading the patellofemoral joint (PFJ) while the knee is flexed. Additional PFPS symptoms can include crepitus, tenderness on patellar facet palpation, knee effusion, knee instability, buckling, and pain while sitting that is exacerbated when standing from a sitting position . CorrectPFPS is mainly treated non-surgically, with surgery usually being reserved for severe cases that failed to respond to non-surgical treatment . While oClostridium botulinum. Following intramuscular injection, BoNT-A produces a functional “denervation” via inhibition of acetylcholine release at the neuromuscular junction . Lastly, this study was performed in a single medical clinic, thus limiting its external validity. Despite these limitations, the findings of our study are promising and can be used as a platform for future investigations on this topic.Treatment of PFPS by utilizing BoNT-A injections provides a cost and time effective alternative to not only ongoing conservative management but also surgical intervention for patients experiencing refractory anterior knee pain. It significantly improved functional outcomes and reduced pain in patients who had exhausted conservative treatment methodologies. However, larger prospective studies are needed to evaluate the effectiveness of the herein described intervention and characterize the patients who will benefit most from it.