Chronic joint injury of the elbow joint is common in patients with hemophilia. Myofascial release is used for the management of pain and functionality in patients with chronic restrictions.To evaluate the effectiveness of myofascial release in patients with hemophilic elbow arthropathy.Sixty-nine patients with hemophilia took part in this randomized controlled trial. They were recruited from 10 hemophilia patient Associations. They were randomly allocated to experimental (n = 35) or control group (n = 34). The intervention consisted of three 50-min sessions of fascial therapy over a 3-week period. The intervention included 11 bilaterally administered maneuvers in both upper limbs (from shoulder girdle to forearm). The study variables were frequency of elbow bleeding (self-report), joint status , and joint pain  at baseline, after the intervention, and at the 3-month follow-up.P < .001) in the repeated measures factor in the frequency of hemarthrosis (F = 20.64), joint status (F = 31.45), and perceived joint pain (F = 30.08). We found group interaction with the (P < .001) in the frequency of hemarthrosis (F = 21.57), joint status (F = 99.98), and perceived joint pain (F = 44.26). There were changes (P < .01) in the pairwise comparison analysis between the pretreatment assessment and the posttreatment and follow-up assessments.There were significant changes (Myofascial release decreases frequency of elbow bleedings, and improved joint status and perception of elbow pain in patients with hemophilic elbow arthropathy. Myofascial release may be recommended to improve joint status and joint pain in patients with hemophilic elbow arthropathy. The recurrence of bleeding episodes leads to the development of synovial hypertrophy and bone and cartilage destruction. Consequences for the joint as a result of a succession of repeated hemarthrosis events in a single joint include hemophilic arthropathy.Hemophilia is a X-linked congenital coagulopathy characterized by a deficit of clotting factors: hemophilia A (clotting factor VIII [FVIII]) or hemophilia B (clotting factor IX [FIX]). The elbow, along with the ankle and knee, are the joints most affected by arthropathy in patients with hemophilia.The only treatment that has shown to be effective in the prevention of the development of hemophilic arthropathy is the prophylactic treatment. However, research on the safety and efficacy of physiotherapy in elbow arthropathy is limited. Some interventions based on swimming and endurance training have shown an improvement in the perception of joint pain, and a reduced frequency of elbow bleeds, respectively.Hemophilic arthropathy in the elbow joint is characterized by hypertrophy of the head of radius, together with the destruction of the humeroulnar joint, which may cause a severe restriction of forearm mobility, debilitating and chronic pain, and even joint ankylosis.,12 The aim is to manipulate the fascial complex over long periods of time, to improve tissue mobility, pain, and joint, muscular, and proprioceptive functionality. Fascial therapy in patients with hemophilia is contraindicated due to the risk of developing muscle or joint hemorrhages as a result of superficial, deep, or telescopic techniques typically applied with this therapy. Although pilot and cohort studies,14 have demonstrated the effectiveness of this technique in patients with hemophilic ankle arthropathy, no studies have evaluated the safety and efficacy in the approach to elbow arthropathy. The use of these techniques, following definite protocols and applied by professionals trained in the management of patients with hemophilia, appears to be safe.Fascial therapy is indicated in the treatment of chronic degenerative lesions. The myofascial release technique is a manual physiotherapy technique that applies the principles of biomechanical loading of the soft tissue and the modifications of the neural reflexes, through stimulation of the mechanoreceptors in the fascia with the purpose of releasing fascial restrictions and restoring healthy tissue.We hypothesized that an intervention protocol combining manual therapy in patients with hemophilic elbow arthropathy would improve frequency of clinical hemarthrosis, joint health, and perceived pain, as compared to a sham intervention. The objective of this study was to examine the effectiveness of manual therapy through myofascial release regarding the frequency of joint bleedings in patients with hemophilic elbow arthropathy, and to explore the myofascial release-induced changes in joint status and elbow joint pain.22.1A single-blind randomized controlled trial with a 3-month follow-up period was approved by the Research Ethics Committee of the University of Murcia (ID: 1505/2017) and registered in the clinical trial.gov . All participants provided written informed consent, while all procedures were conducted in accordance with the principles of the Declaration of Helsinki.The sample size was established taking into account the frequency of joint bleedings for the evaluation of safety as a primary outcome, and was carried out on the basis of the following assumptions: significance level (α) = 0.05, type 2 error (β) = 0.2; with an 90% test power. For sample calculation, G∗Power 3.1.9.4 was used based on an effect size of 0.8 (large effect size as Cohen) and the Bonferroni correction for multiple comparisons. Twenty-eight patients per group thus determined the calculated sample size. Considering a 20% drop-out, the total sample was made up of a minimum of 67 patients.An administrative assistant, blinded to the objectives of the study, carried out patient allocation to each of the groups. Patients were randomly allocated into groups receiving myofascial release treatment (n = 35) and no intervention (n = 34), according to an opaque envelope system.2.2Patients with hemophilic elbow arthropathy were recruited from 10 hemophilia patient associations around Spain  from March 2018 to February 2019. The inclusion criteria to participate in the study were: patients diagnosed with hemophilia A and B; type of hemophilia severity (severe or moderate); of legal age; and medical diagnosis of hemophilic elbow arthropathy .Similarly, patients excluded from the study were those: without walking ability; with neurological or cognitive disorders that prevented understanding the questionnaires and physical tests; and failing to sign the informed consent document. This study did not exclude patients with hemophilia based on their type of medical treatment, including both patients on demand and prophylactic treatments. Patients on prophylactic treatment continued to receive the dose of FVIII/FIX concentrates prescribed in accordance with the orders given by their hematologist. Similarly, patients who had developed antibodies to FVIII/FIX (inhibitors) but currently had no inhibitor titers were included.2.3 included 11 maneuvers, including the administration of 7 superficial maneuvers, and 4 deep maneuvers. The intervention included manual therapy techniques on both lower limbs, including forearm, elbow, arm, and shoulder girdle.The experimental group received 3 interventions of myofascial release. Each session lasted 50 minutes, with 3 physiotherapy sessions over a 3-week period. The manual therapy intervention was carried out by a physiotherapist with more than 10 years of experience in fascial therapy and hemophilia. The treatment program implementedThe 7 superficial techniques were:(1)longitudinal surface sliding maneuver on the surface fascia in the anterior region of the arm and forearm;(2)transverse sliding maneuver of the flexor muscles of the wrist and fingers;(3)transverse sliding maneuver on the brachial biceps;(4)longitudinal surface sliding maneuver on the surface fascia in the posterior region of the arm;(5)transverse sliding maneuver on the tendon of the brachial triceps;(6)transverse sliding maneuver for the pectoralis major muscle; and(7)transverse sliding maneuver for the posterior axillary region .All surface techniques were applied using 3 strokes of 15 slides, 1 minute per technique approximately.The 4 deep techniques applied were:(1)induction maneuver of the fascia of the posterior axillary fold;(2)induction maneuver: hands crossed on the brachial region and forearm Fig. ;(3)transverse plane maneuver for the cervicothoracic region; and(4)telescopic maneuver of the upper limb Fig. .The duration of these deep techniques was 3 to 5 minutes in the first 2 and 5 minutes in the remaining 2.The subjects included in the control group received no intervention and continued with their usual routine of activity and physical exercise, as well as with their prescribed treatment with FVIII/FIX concentrates. After the follow-up period, the patients in the control group received the same intervention and under the same conditions as the patients in the experimental group.2.4Three evaluations were carried out in this study: before intervention (T0), following intervention (T1), and after a 3-month follow-up period (T2). The evaluations were carried out on the premises of the hemophilia associations included in the study. All elbow joints with hemophilic arthropathy were evaluated, regardless of dominance. The same physiotherapist with more than 15 years of experience in the treatment of patients with hemophilia, was responsible for conducting the assessments following the same guidelines and under the same conditions, blinded regarding the allocation of patients to study groups.The primary outcome was the frequency of joint bleedings developed by patients with hemophilia during the treatment and intervention period. This frequency of hemarthrosis was determined by a self-report provided at the beginning of the study. This self-report was given to the patient during the various evaluations. Similarly, within 48 hours following the intervention, telephone follow-up was carried out to establish the presence of hemorrhagic complications during that period, as a result of the intervention. and has been widely used in the assessment of pain perception in patients with hemophilic arthropathy.,18The perception of elbow joint pain was evaluated with the visual analog scale. This measuring instrument is 10-cm line, with an end point of 0 indicating “no pain” and 10 representing “the worst pain.” Patients were asked to make a mark on the line to represent their intensity of pain in the elbow joint, assessing the level of intensity of pain by measuring the distance from the “no pain” end to the mark made by the patient. The reliability and validity of this scale in the assessment of pain has been demonstrated using the validated Spanish version of this specific hemophilia questionnaire for the assessment of the joint health. This scale that includes 8 items , scores from 0 to 20 points per joint . It is applied to the joints of the knees, ankles, and elbows, as well as a global gait score.The joint state was evaluated using version 2.1. of the Hemophilia Joint Health ScoreFor the measurements, a pilot was run to determine the interrater reliability. The physiotherapist who performed the assessments and another expert physiotherapist, took part in this pilot study of 7 patients with hemophilia with elbow arthropathy. The frequency of elbow hemarthrosis, joint status, and elbow pain were measured.At the beginning of the study, the main anthropometric independent variables , clinical variables , and sociodemographic variables  were evaluated.2.5The statistical analysis was carried out with version 19.0 of the statistical package SPSS for Windows .The intraclass correlation coefficient (ICC) was used to evaluate the interrater reliability. This intraexaminer reliability was obtained using the measurements performed by the examiner in this trial. Clinical and anthropometric characteristics were compared between both groups using Fisher exact tests for categorical variables and Kolmogorov–Smirnov for continuous variables.pre∗√1-R, with R being the reliability coefficient. As a measure of reliability we use Cronbach alpha coefficient. Based on the SEM, the MDC was obtained (MDC = Z-score ∗ √2∗SEM). The confidence level was set at 95% (Z-score = 1.96). An analysis of variance of repeated measures was carried out to compare the experimental and control groups at the 3 assessment times: baseline (T0), posttreatment (T1), and follow-up (T2). The results of the F test depend on whether the Mauchly spherical test was significant or not. If significant, the Greenhouse–Geisser correction was used. Bonferroni correction has been applied to control the error rate of the significance level. When the interaction was significant, pairwise comparison tests were performed on the group. The partial eta-squared value was calculated as an indicator of effect size .The minimum detectable change (MDC) was calculated. For its calculation, the standard error of measurement (SEM) was estimated. SEM was calculated using the following formula: SEM = SDWhen performing the statistical analysis, all subjects were considered based on an intention-to-treat analysis. The chosen level of significance was α = 0.05.3Sixty-nine patients with hemophilic elbow arthropathy were included in the study. During the intervention period, 2 patients in the experimental group and 1 in the control group dropped out of the study for work reasons. During the follow-up period, none of the subjects left the study and were evaluated 3 months after the end of treatment. Thus, 66 patients with hemophilic elbow arthropathy completed the study , with significant interrater correlations for frequency of elbow hemarthrosis (ICC = 1.00), joint status (ICC = 0.89), and elbow pain (ICC = 1.00).Interrater reliability for the physical variables was high  and at follow-up compared with the baseline value (T0–T2) for all the dependent variables evaluated Table .4The data obtained in the present investigation showed that physiotherapy intervention through myofascial release technique is safe and effective for the treatment of patients with patients with hemophilia and elbow arthropathy.,14,25 In addition to the safety of myofascial release reported in this study, improvements in pain and joint health of the elbow joint are noted. These findings have also been observed in connection with sports such as swimming for which a 10-month program showed improvements in joint condition and pain in patients with hemophilic elbow arthropathy.The implementation of this physiotherapy program has caused no events of elbow hemarthrosis during the intervention period, significantly decreasing the frequency of bleeding throughout the follow-up period. One of the main risks in the administration of physiotherapeutic treatment in patients with hemophilia is the possible development of hemarthrosis, although most manual techniques have shown to be safe and effective in reducing the frequency of bleeding. Chronic pain, characteristic of hemophilic arthropathy, significantly affects the performance of daily life activities and the perception of quality of life in patients with hemophilia. Following a myofascial release intervention, we observed a significant improvement in the perception of pain in the elbow joint. The improvements were maintained even after the follow-up period. This finding is a relevant aspect considering the severe joint damage of the joints treated at the beginning of the study. Likewise, it should be considered that patients on demand treatment, without prophylaxis or hemostatic coverage with factor VIII / IX, were included. These results are consistent with the improvement achieved through the use of manual orthopedic therapy with joint traction to reduce pain. However, the results obtained with myofascial release became apparent after only 3 treatment sessions.Controlling the perception of pain combined with the administration of a prophylactic treatment are key aspects to reduce the frequency of bleeding and pain, thus improving joint function. The alteration of fascial pliability could be a source of body misalignment, potentially leading to poor muscular biomechanics, altered structural alignment, and decreased strength and motor coordination. This paper reports the clinical improvement of the joint condition in patients with hemophilic elbow arthropathy, and thus improving functionality and performance in the daily activities of patients.When arthropathy is established, the elbow extension movement is restricted, following the antalgic pattern of the acute hemarthrosis process, characterized by antalgic flexion . Both the acute and chronic process lead to the shortening of the periarticular structures, mainly soft tissue and flexor muscles. The improvement in joint condition after the intervention period, also maintained after the 3-month follow-up, may suggest the effectiveness of this intervention. In fact, the administration of myofascial release techniques has already shown to effectively reduce pain and disability, and to improve flexibility and functionality in every-day activities. This stimulation aims to reduce fascial system restrictions by promoting the reorientation of collagen fibers may promote improvements in terms of pain and functionality, and thus in the perceived disability in patients with hemophilic arthropathy.This protocol of myofascial release techniques involves performing a slight biomechanical load on the soft tissue and, through the stimulation of the mechanoreceptors in the fascia, releasing the fascial constraints and restoring healthy tissue. A recent study through joint traction found a significant improvement of frequency of joint bleedings of 0–1 and elbow joint pain of 0.5–0 after treatment period. Our effect size reported is important as they give clinical professional the means to objectively interpret improvements seen after myofascial release treatment between assessment sessions in patients with hemophilic elbow arthropathy.Consideration of the effect size in the context of the hypothesis test is a way to control both the value of α (probability of making a mistake of type I), and the value of β (probability of making a type II error). Our study showed that statistically significant differences with large effect sizes were obtained posttreatment and at 3-month follow-up in patients treated with myofascial release techniques. This is highly relevant considering the small, but statistically significant changes reported in the literature following various treatments. A training program which lasted twelve months included physical exercise routines and swimming practices showed decrease of elbow pain.The MDC is defined as the smallest amount of change outside the measurement error in the score of an instrument used to measure a symptom. Our results provided changes slightly lower than this value for the variables frequency of hemarthrosis (0.67 vs 1.99), joint status (1.53 vs 1.90), and joint pain (1.67 vs 2.31). These results should be interpreted taking into account the sample size and advanced joint damage of the patients included in the study.The safe administration of this physiotherapy technique provides new therapeutic possibilities in the approach to hemophilic elbow arthropathy. The short duration of the intervention involved for the administered protocol, the scarce means needed to carry it out and the perception of improvement in the subjects since the very first session can favor its implementation as a treatment tool. have been met. Randomized trials on myofascial release include a-priori calculated sample sizes, limiting the sources of bias, follow-up time points beyond 24 hours, appropriate levels of significance, and appropriate registration. Randomized clinical trials should present between group differences and not report from reporting within group differences as evidence of effectiveness.In this study with hemophilia patients, the requirements indicated in a recent publicationSome limitations of this study must be reported. An experimental control group with another intervention was not included as it was decided to compare the association of the protocol of myofascial release techniques with a group of patients who do not usually receive physiotherapy treatment. The measurement of the functionality or quality of life could have offered more complete results on the effectiveness of the manual therapy in patients with hemophilic elbow arthropathy.5The results of this study demonstrated the safety of a physiotherapy protocol using myofascial release in patients with hemophilic elbow arthropathy. This study provides evidence for the use of manual therapy through myofascial release to decrease frequency of hemarthrosis and improve joint status and elbow pain in patients with hemophilic elbow arthropathy. These improvements are maintained for a 3-month period. Thus, manual therapy treatment through myofascial release may be the treatment of choice in patients with hemophilic elbow arthropathy reporting high levels of joint deterioration and joint pain.The authors are especially grateful to the Spanish Federation of Haemophilia, and Galician Malaga, Vizcaya, Community of Valencia, Aragón-La Rioja, Valladolid-Palencia, Murcia Burgos, and Salamanca Associations of Hemophilia for their help in recruiting the sample.Conceptualization: Rubén Cuesta-Barriuso, Raúl Pérez-Llanes, José Antonio López-Pina, Javier Meroño-Gallut.Data curation: Raúl Pérez-Llanes, Elena Donoso-Úbeda, José Antonio López-Pina, Javier Meroño-Gallut.Formal analysis: Rubén Cuesta-Barriuso, José Antonio López-Pina.Funding acquisition: Rubén Cuesta-Barriuso.Investigation: Rubén Cuesta-Barriuso, Javier Meroño-Gallut.Methodology: Rubén Cuesta-Barriuso, Raúl Pérez-Llanes, Elena Donoso-Úbeda, José Antonio López-Pina, Javier Meroño-Gallut.Project administration: Rubén Cuesta-Barriuso.Resources: Rubén Cuesta-Barriuso, Raúl Pérez-Llanes, Elena Donoso-Úbeda.Software: Rubén Cuesta-Barriuso, José Antonio López-Pina, Javier Meroño-Gallut.Supervision: Raúl Pérez-Llanes, Elena Donoso-Úbeda, José Antonio López-Pina, Javier Meroño-Gallut.Validation: Rubén Cuesta-Barriuso, Javier Meroño-Gallut.Visualization: Elena Donoso-Úbeda, José Antonio López-Pina.Writing – original draft: Rubén Cuesta-Barriuso, José Antonio López-Pina, Javier Meroño-Gallut.Writing – review & editing: Rubén Cuesta-Barriuso, Javier Meroño-Gallut.


Regardless of the technique applied for chemomechanical preparation, postoperative pain is a very relevant matter in endodontics. Objective: To evaluate postoperative pain after endodontic treatment of necrotic teeth submitted to large apical preparation (LAP) using oscillatory kinematics. The sample included 60 asymptomatic necrotic teeth with or without apical radiolucency, and with normal periodontal status, referred for endodontic treatment. Following initial procedures, the position and approximate size of the apical constriction were determined by using an apex locator and K Flexofiles, respectively. The chemomechanical preparation was conducted using oscillatory kinematics and 2.5ml of 2.5% NaOCl at each file change to achieve LAP, and the filling was done with Tagger’s hybrid technique and EndoFill sealer. Phone calls were made to all the patients at 24, 48 and 72 hours after treatment to request their classification of postoperative pain, and data were submitted to statistical analysis. P = 0.000). However, paired analyses showed a statistically significant difference only between 24 and 72 hours (P = 0.001), and 48 and 72 hours (P = 0.014). Age and tooth type did not influence the postoperative pain, regardless of time (P> 0.05). After 72 hours, women experienced significantly more pain than men (P = 0.012), and teeth without periradicular lesion were more sensitive that teeth with perirradicular lesion (P = 0.027). Only 3 patients (5%) reported severe pain after 72 hours. Moderate pain was reported by 17, 9 and 1 patient after 24, 48 and 72 hours, respectively (Acute or moderate postoperative pain was uncommon after endodontic treatment of necrotic teeth submitted to LAP using oscillatory kinematics. Key words:Endodontic treatment, oscillatory kinematics, postoperative pain, pulp necrosis. Endodontic treatment aims to maintain or reestablish the health of periapical tissues by cleaning and filling the root canal system (RCS) ,2. ChemoThe amplitude of apical root canal instrumentation is a controversial issue in endodontics ,6. The eThe introduction of nickel-titanium (NiTi) instruments has allowed safer and easier chemomechanical preparations to be performed, even in cases of anatomical complexity . The rotThe oscillatory mechanical systems, such as M4 , 3LD , TEP E-10 and 16R , are boosted by electric or pneumatic motors, and has the advantage of being used with both stainless steel and NiTi hand files . When coRegardless of the technique applied for chemomechanical preparation, postoperative pain is a very relevant matter in endodontics. Some important points associated with this negative consequence include bacterial remnants in the RCS, and mechanical, chemical and infectious trauma to periradicular tissues ,19. ReceConsidering that there is a direct relationship between extrusion of debris and postoperative pain, and that no study has yet been performed to evaluate the latter after conducting endodontic treatment of necrotic teeth submitted to LAP using oscillatory kinematics, the current research was conducted to achieve this objective.This study received the approval of the Human Research Ethics Committee of the Pontifical Catholic University of Paraná - PUC/PR, Curitiba, Paraná, Brazil (CAAE. 99497118.6.0000.0020), and was reported in accordance with the Consolidated Standards of Reporting Trials Statement .-Sample size calculationThe sample size to validate the results of this research was determined through a pilot study showing that less than 5% of the patients reported significant postoperative pain (acute or moderate) after treatment. The proportion-sampling method was used to determine the sample size, which was set at 60 teeth, considering a confidence level of 95%, and a maximum margin of error of 5.5% .-Case selectionThis study was conducted on patients ranging in age from 16 to 80 years, referred to the Centro de Especialidades Odontológicas de Navegantes - CEO, Navegantes, Santa Catarina, Brazil, for endodontic treatment between September and October 2019. The inclusion criteria were necrotic teeth with or without asymptomatic apical periodontitis, and with a periodontal probing depth of 3 mm at most, accessed previously at the Public Basic Health Units of the aforementioned city. The exclusion criteria were consumption of anti-inflammatories, analgesics of any kind, or antibiotics within the last 10 days before treatment, presence of root resorption, sinus tracts, trismus, periodontal probing greater than 3 mm, systemic diseases, history of trauma, pregnancy, severe malocclusion associated with traumatic occlusion, lack of patient compliance, and history of intolerance to nonsteroidal anti-inflammatory drugs.-Treatment protocolAfter the health status of the patients was evaluated, followed by clinical and radiographic examinations of their teeth, the patients were informed of the available alternative treatment options and the postoperative care that needed to be done. Information on the study and the endodontic treatment protocol were also provided to all the patients or their caregivers (for patients under 18 years old), and written consent was obtained. First, the teeth were anesthetized using 2% mepivacaine with epinephrine 1:100.000 . After rubber dam placement and disinfection, the temporary restoration was removed using a 1014 or 1016 HL bur . When reaching the pulp chamber, copious irrigation was performed with 5 mL 2.5% sodium hypochlorite (NaOCl) , and the canals were flooded continuously with irrigation solution from a NaviTip 31 G needle . An initial exploration was conducted with a manual stainless-steel #15 K Flexofile . Cervical and middle thirds were prepared with #1, 2, 3 or 4 Gates-Glidden drills (Dentsply-Maillefer), depending on the anatomical features of each tooth. Afterwards, the position of the apical foramen was established by #10 or larger manual, stainless-steel K Flexofiles (Dentsply-Maillefer), coupled to an apex locator , and confirmed by radiographs. The working length (WL) was established 1 mm short of this length  . The appChemomechanical preparation was performed by manual stainless-steel K files and K- Flexofiles (Dentsply-Maillefer) attached to the handpiece of a TEP E-16R oscillatory system driven by a pneumatic engine , using a crown-down approach. A 2.5 mL aliquot of 2.5% NaOCl (Fórmula & Ação) was used as an irrigating solution at each file change, applied with a NaviTip 31 G (Ultradent) needle up to 5 mm short of the apical constriction, as established by rubber stops. All the teeth received the same amount of irrigant. LAPs were performed by using 6 files larger than the corresponding file of the anatomical diameter.Pinhais, PR, Brazil) or Cimpat . A final radiograph was taken after occlusal adjustment, and the patients were referred back to the Public Basic Health Unit of origin to receive the definitive restoration. No medication was prescribed, and the patients were instructed to take either paracetamol (750 mg every 6 hours) or ibuprofen (600 mg every 6 hours) if they felt significative pain  for 3 minutes. A final flush was made with 5 mL of saline solution, and the canals were dried with absorbent paper points . A master cone was introduced into each canal, corresponding to the last instrument used during chemomechanical preparation, stabilized to approximately 1 mm from the apical foramen to avoid overextension. After radiographic analysis of the level of the master cone, the root canal filling was performed using Tagger’s hybrid technique and Endofill sealer (Dentsply-Maillefer), and the temporary restoration with Cavitec .,28.27,28P < 0.05).The findings were recorded on an Excel spreadsheet  for statistical evaluation with SPSS software version 25.0 . Kolmogorov-Smirnov’s test was used to evaluate data normality. Mann-Whitney U, Friedman’s ANOVA and Friedman’s multiple 2 to 2 comparison tests were used to determine any significant difference among the variables (P = 0.000). However, paired analyses showed a statistically significant difference only between 24 and 72 hours (P = 0.001), and 48 and 72 hours (P = 0.014). Age and tooth type did not influence the postoperative pain, regardless of time (P > 0.05). After 72 hours, women experienced significantly more pain than men (P = 0.012), and teeth without periradicular lesion were more sensitive that teeth with perirradicular lesion (P = 0.027) (The demographic data are shown in = 0.027)  cont..Postoperative pain in endodontics is a relatively frequent event and is a topic of great interest to both clinicians and researchers. It may occur between sessions or after endodontic treatment has been concluded and is mainly attributed to periradicular tissue injuries of chemical, mechanical or infectious cause. The factors responsible for the incidence and severity of postoperative pain in endodontics have not yet been fully elucidated, owing to the limitations inherent to the applied research. In general, pain is influenced by several factors, in addition to the independent variables under investigation, which are impossible to eliminate in a clinical setting. Another important limitation is that pain is a highly subjective and personal sensation. Nevertheless, there are several well-designed studies able to provide valuable information on this subject ,30. The The factors that act at different time periods in relation to the endodontic treatment  can influence postoperative pain, and can therefore act as confounding factors. Age, gender, tooth type and preoperative pain are considered pre-treatment confounding factors. The number of sessions, the irrigating solutions or intracanal dressing used, the chemomechanical preparation technique, and the sealer represent the intra-treatment confounding factors, whereas the analgesic intake after the treatment represents the posttreatment confounding factor ,31-34. Tet al.  ,52, scoret al.  performe  reported acute pain after 72 hours. Similar results were obtained by Relvas et al. , in the  . However, paired analyses showed a statistically significant difference only between 24 and 72 hours (P = 0.001), and 48 and 72 hours (P = 0.014). These results are in line with those obtained by a prospective, randomized, double-blind clinical trial performed by Shokraneh et al. . The biological difference between men and women could explain why . Marshall and Liesinger (et al. (et al. (The nature of the pulp and periapical status could modulate postoperative pain in endodontics. Teeth with nonvital pulps associated with periapical lesions are densely contaminated, and have a 83.2% prevalence of foraminal resorption , which ciesinger  observed (et al.  found th (et al.  found th (et al. . It can  (et al. ,69. Othe (et al. . These f (et al. ,65,66, aSome studies showed that postoperative pain was more frequent and greater in posterior teeth ,33,52. TThe main limitation of the present study was the use of a single group. Analyses comparing different research results should be performed with caution, because of the potential methodological differences among them. Future studies should be carried out to assess postoperative pain after endodontic treatments performed by oscillatory versus other types of kinematics.The incidence and levels of postoperative pain after performing endodontic treatments in necrotic teeth submitted to LAP using oscillatory kinematics were low and not influenced by age and tooth type. When postoperative pain occurred, it tended to decrease over time.


The purpose of this article is to examine the applicability of the Beliefs about Pain Control Questionnaire (BPCQ) among cancer patients and develop norms that allow differentiation of patients with diagnosed cancer in terms of beliefs about pain control. Normalization aims to establish the value of test results in the study population. The study involved 1187 patients diagnosed with cancer in outpatient care Maria Sklodowska-Curie Cancer Center and Institute of Oncology, in Warsaw. The applied tool was the Beliefs about Pain Control Questionnaire developed by S. Skevington. The results are most strongly differentiated in each dimension of pain control by education, income, and professional status. Sten norms were developed to determine the level of beliefs about pain control in low, average, and high categories. The BPCQ assessment applies to cancer patients, and the assessment of the location of pain control in patients will allow for the identification of patients whose standard therapy should be supplemented with psychotherapeutic support. Cancer is the second cause of death in Poland, and forecasts indicate that in the next decade, cancer will be the leading cause of death ,2. AdditCancer is associated with various ailments, the most common of which is pain. According to the definition of the International Association for the Study of Pain (IASP), pain is an unpleasant sensory and emotional experience associated with current or potential tissue damage or described in terms of such damage.Studies show that 30–50% of people experience pain during active cancer therapy, and even up to 90% of patients in the later stages of the disease. Moderate-to-severe pain occurs in approximately 40% of patients in moderate stages of the disease, and pain attacks in approximately 80% of patients in advanced stages of cancer [Pain has its cognitive, emotional, and behavioral consequences. Pain is a subjective and multidimensional experience, which is why there are significant difficulties in its direct and objective assessment . The paiAmong other factors, the localization of sense of control is also a variable associated with pain . The senStudies indicate the relationship between the location of health control and undertaking health behaviors ,10. The Beliefs and the attitude of patients toward pain affect the severity of pain, as well as the feeling of other symptoms associated with the illness, compliance with medical recommendations, and the final results of treatment ,14,15. SBeliefs about pain control are measured using the Beliefs about Pain Control Questionnaire (BPCQ), developed by S. Skevington . The queThe main objective of the study is the normalization of the Beliefs about Pain Control Questionnaire (BPCQ) for cancer patients. Normalization allows norms regarding test results to be established for a specific population. This procedure allows for an understanding of what the result obtained by a specific person in the questionnaire means, including whether the result is high or low.The normalization sample included results of 1187 respondents aged 21–96 , 666 women aged 21–96  and 521 men aged 22–96 . The criteria for enrolling patients were the patient’s availability at the Maria Sklodowska-Curie Cancer Center and Institute of Oncology, in Warsaw, for the duration of the study and the patient’s consent to participate in the study.The structure of diagnoses among the studied women was as follows: breast cancer, 29%; ovarian cancer, 25.8%; endometrial cancer, 17.4%; colorectal cancer, 14.9%; stomach cancer, 6.8%; pancreatic cancer, 3.6%; bladder cancer, 2.6%. In the studied group of men, the following types of cancer occurred: prostate cancer, 43.8%; colorectal cancer, 26.9%; bladder cancer, 15.9%; stomach cancer, 9.2%; pancreatic cancer, 4.2% .In the studied group, the majority of patients had secondary education (37.7%) or higher education (33.1%). The largest group of people lived in cities over 500,000 inhabitants (36.0%), and the average monthly income per person in a household was over 2000 PLN for 27.7% of people, 1001–1500 PLN for 26.7% of people, and 1501–2000 PLN for 25.2% of people. The majority of patients were pensioners (52.1%), but a large number of participants were also professionally active (39.1%). Patients were mainly married (68.4%). Detailed information about the sample is presented in The BPCQ assessment, measuring the strength of individual beliefs about pain control, consists of 13 statements that make up three factors of pain control:Internal factors ;Influence of physicians (a belief that pain is controlled by others);Random events (a belief that there is no self-influence on pain control).The questionnaires used in the study are the only version of the BPCQ test available in Poland through the Psychological Testing Laboratory of the Polish Society of Psychology (translation by Juczyński) . The staThe Cronbach’s alpha internal compatibility index, according to Juczyński, was 0.75 for the whole scale and 0.86 for the influence of physicians, 0.82 for the area related to internal factors, and a low value of 0.58 for the impact of random events . In the t-test when comparing two groups  and on the values of one-way analysis of variance when analyzing education. The analysis of variance was followed by Gabriel’s post hoc test which was designed for analyzing unequal groups [Statistical analysis was performed with the use of IBM SPSS 25.0 software. The analysis regarding between groups comparisons was based on the values of an independent l groups . The grop < 0.05). It was found that the intensity of the location of pain control in the influence of physicians was the lowest in the group of people with higher education (M = 15.50), compared with the average of people with secondary education (M = 16.77) and primary/vocational (M = 17.04); it was lower in the group of people with a monthly net income per person in the family above 1500 PLN (M = 16.00), compared with people with an income of up to 1500 PLN (M = 16.90) and lower in the group of working people (M = 15.74) than retirees/pensioners (M = 17.03).Based on Gabriel’s post hoc test, it was found that statistically significant differences in the internal location of pain control occurred between the group of people with primary or vocational education (M = 16.38) and the group of people with higher education (M = 14.12) (It was found that the intensity of the location of pain control in random events was the lowest in the group of people with higher education (M = 14.12) in comparison with people with secondary education (M = 15.66) and primary/vocational education (M = 16.38). The location of pain control in random events was also lower in the group of people with a monthly net income per person in the family above 1500 PLN (M = 14.69), compared with people with lower income (M = 16.09), and lower in the group of employed people (M = 14.71) than in the group of retired people/pensioners (M = 15.97).p > 0.05. Correlation between the age of the respondents and the location of pain control for the group attributing control to the influence of physicians was statistically significant but weak. Identically, age and the location of pain control for the group attributing control to random events, was statistically significant and positive but weak. It was, respectively, r (548) = 0.15, p < 0.001 for the location of pain control in the group attributing control to the influence of physicians and r (548) = 0.17, p < 0.001 for the location of pain control in the group attributing control to random events.No statistically significant differences between the genders were found; therefore, the norms were determined for the whole sample studied together. Based on the value of the Pearson correlation coefficient r, no statistically significant correlation was found between the age of the respondents and the internal location of pain control, r (548) = 0.08, p < 0.05).Analysis of the results did not show statistically significant differences in the method of pain control depending on the type of patient treatment or metastases  or believe that all events are random . An exteJuczyński also indicates a link between the location of pain control and acceptance of the disease—patients who accept the disease less often attribute pain to the influence of physicians than patients who do not accept the disease .The results of the authors’ study indicate that patients diagnosed with chronic pain, migraine, multiple sclerosis, and malignant neoplasms obtained average results  in each area of pain control. Some studies prove that the external location of control is more common among women than men ,25, althIn the study conducted by Basińska et al., among patients with lung cancer, the dominant location of control concerned the area of influence of physicians , which was also observed among patients with colorectal cancer . In both groups, patients attributed the least importance to the impact of random events . In the In the study of cancer patients, both treated causally as well as symptomatically, it was observed that patients treated symptomatically placed control in the area of the influence of physicians  and random events  in comparison with causally treated patients . In the same study, it was demonstrated that patients at the terminal stage assigned much more importance to physicians and random events than to internal factors. It was also noted that people dominated by anxiety attributed a greater role to the influence of physicians or random events, while people showing a positive approach to the disease were more often characterized by an internal location of pain control [BPCQ test results were varied among other groups of patients. Patients with chronic lower limb ischemia attributed the greatest importance in pain control to the influence of physicians (M = 19.04). Patients attributed less importance to random events. The average point value described the impact of random events (M = 16.85), and these beliefs were reflected by a significant share of lifestyle risk factors. Patients who were not convinced of their own influence on the control of ischemic pain did not take responsibility for their own health and well-being. They undertook behaviors unfavorable for the course of the disease, including smoking even though it increased the level of pain .Additionally, among people with spine diseases, the external location of control dominated (mainly in the area of random events) . In anotIn patients with osteoarthritis of the spine, it was also noted that people with higher education less often pointed to the significant influence of physicians on the perception of pain. A significant relationship was also observed in relation to the gender of the respondents—men more often indicated the role of internal pain control .Among patients after cardiac surgery, older patients , compared with younger patients , placed greater emphasis on the influence of physicians in controlling pain, and they also attributed a greater role to random events, which in older people was at the level of M = 16.1 (SD = 2.9), while in younger people, M = 12.0 (SD = 2.82) ,30.In turn, a study involving patients with a history of chronic pain lasting over 12 weeks conducted at a pain clinic indicates that patients’ behavior, related to the sensation of pain, as well as the results of treatment, is influenced by their knowledge about health , including the ability to understand it and implement specific health-promoting behaviors . This stThe authors’ study has limitations; firstly, the influence of the stage of the disease or the type of treatment was not taken into account in the results obtained. Further research in this area may reveal additional links between pain control and other factors that affect the type of perception of pain control in a patient.Studies on pain should take into account the biological, psychological, and social contexts. Pain is a psychosomatic symptom that requires both the use of appropriate medications and, above all, psychological support. The perception of pain by patients is not homogeneous, and therefore, patients with the same disease should not be treated equally in terms of their approach to pain relief.The tool used in the assessment of pain control of cancer patients is the Beliefs about Pain Control Questionnaire. The assessment of the location of pain control translates into the level of pain experienced by patients, assessment of patients’ coping resources, or the effectiveness of using these resources in the treatment process. This kind of approach to patients allows for the isolation of the group of patients who will require psychological support as a supplement to standard treatment.The conducted study allowed the norms (mean results) of the BPCQ assessment o be established for oncological patients. This information is especially valuable for psychologists working with patients. Knowledge of norms and sociodemographic variables that may affect the results allows health professionals to distinguish those groups of patients who have, for example, a low sense of self-control of health and thus should receive psychological support.


It is challenging to rule out acute coronary syndrome among chest pain patients without both ST-segment elevation in electrocardiography and troponin elevation at emergency departments (ED). The purpose of this study was to develop a prediction model for rapidly determining the occurrence of significant stenosis in coronary computed tomography angiography (CCTA). Retrospective observational cohort study was conducted with 904 patients who had presented with chest pain without troponin elevation and ST-segment changes and underwent CCTA between January 2017 and December 2018. The primary endpoint was the presence of significant stenosis on CCTA, defined as narrowing above 70% diameter. The logistic regression model was used for development a new predictive model. One hundred and thirty-four patients (14.8%) were shown severe stenosis. The independent associated factors for significant stenosis were age ≥65 years, male, diabetes, history of acute coronary syndrome, and typical chest pain. Based these results, we developed a new prediction model. The area under the curve was 0.782 . Moreover, score of ≥5 was chosen as cut-off values with 86.6% sensitivity and 56.4% specificity. In conclusion, among chest pain patients without ST changes and troponin elevation, the new score will be helpful to identify potential candidate for CCTA such as patients with significant stenosis. Chest pain is the second most common cause of patient visits to emergency department (ED) and they result in approximately $12 billion in costs in the United States . On arriCoronary computed tomographic angiography (CCTA) is a non-invasive method to evaluate the coronary arteries ,10. ReceDespite improvement in the diagnostic care of chest pain patients presenting ED, the rule-out of ACS in patients without ST changes in EKG and without elevation of cardiac biomarkers  is still challenging ,13. RoutWe performed a retrospective, observational, cohort study between January 2017 and December 2018 at ED, which has an annual volume of approximately 130,000 patients in tertiary referral center in Seoul, Korea. All adult patients with acute chest pain those who were examined CCTA for ruling out ACS were reviewed. Exclusion criteria were those who had any ischemic EKG patterns, had been conducted CCTA other than assessing for ACS, and had elevated cardiac enzymes. Furthermore, we also precluded patients with previous history of coronary artery bypass graft surgery and non-determined results on report of CCTA because both cases were hard to determine and classify the culprit arteries. The study protocol was approved by the institutional review board of Asan Medical Center (No. 2019–0452), which waived the requirement for informed consent due to the retrospective nature of this study.The data were extracted from electrical health records, included demographics, initial vital signs, underlying illnesses, cardiovascular risk factors, and associated symptoms. The primary physicians on duty described the pain characteristics on medical records and the co-authors of this study  classified the typical and atypical chest pain based on Diamond-Forrester criteria ,17. In bMultidetector coronary CTA was performed using a dual source scanner . Isosorbide dinitrate  were scattered into the patient’s oral cavity before contrast injection. A 50–70 mL bolus of iodinated contrast  was administrated at a rate of 4.0 mL/s, followed by saline. The tube voltage and tube current-time product were adjusted in accordance with each patients’ body sizes. All CCTAs were reported by experienced board-certified cardiovascular radiologists on duty and reviewed by the emergency medicine physicians  with blinding patients’ information. The primary endpoint was the presence of significant stenosis on CCTA, defined as narrowing above 70% diameter in cross-section at any main branches, including right, left anterior descending, left circumflex arteries, diagonal, and obtuse marginal artery.p value < 0.1). A risk scoring model was created with the five variables associated with severe stenosis in results of CCTA: age 65 years or older, male, typical chest pain, diabetes, and previous history of ACS. We assigned each point based on the adjusted odds ratio (OR). The Hosmer-Lemeshow test was conducted to check the fitness of the model . Receiver operating characteristic (ROC) curve with the area under the curve (AUC) of the prediction model were conducted to evaluate the discriminatory power of new model. Calculating cut-off values were used by the Youden’s index (sensitivity + specificity − 1). Sensitivity and specificity were computed through standard statistical method. A p-value of < 0.05 was considered significant.All statistical analyses were performed using IBM SPSS Statistics V23.0 . We classified the study population into two groups . Categorical variables were presented as counts with percentages and analyzed using the Chi-square test. Continuous variables were expressed as median with interquartile range (IQR) and using the Mann-Whitney U test because of a non-normal distribution of data. In the model development cohort, univariate analyses were conducted to explore the association between various risk factors and the occurrence of significant stenosis on CCTA. Furthermore, the logistic multivariate regression models were conducted to finding independent risk factors with statistically different parameters between groups in univariate analysis  were also performed coronary angiography based on decisions of the cardiovascular physicians on duty and only 2 patients (1.3%) were found significant stenosis on angiography  and more male gender  than that of not significant group. All initial vital signs were similar between two populations. Regarding to underlying illnesses, hypertension , diabetes , obesity , and previous history of AMI  were more frequent in patients with severe stenosis. Moreover, patients with significant narrowing coronary artery had more common sensation of typical chest pain and less atypical characteristics than that of patients without significant stenosis. Among laboratory results, severe stenosis group showed lower platelet , higher D-dimer , TnI , and creatinine levels  than that of not severe group.The baseline characteristic of the study population is presented in p = 0.848).p < 0.001. Cut-off value of 5 point which was calculated by using the Youden index showed 86.6% of sensitivity and 56.4% of specificity  guidelines for chronic coronary syndromes updated the assessment tool for patients with stable chest pain, called pre-test probability for obstructive CAD . This scWe noticed several limitations in our study. It was conducted within a single center and thus may not be applied in other ED practice environments. Because of the retrospective esign, the results should be interpreted with caution, because even though we use a standardized format for electronic medical records, not all patients were able to give exact information required for chest pain characteristics, which would reflect data abstraction errors. In case of unstable angina, defined as negative results of cardiac biomarkers and no ischemic EKG changes, young patients (≤65 years old) with atypical chest pain could have low score and could discharge without any further tests. However, the past research reported that age under 65 with atypical angina showed a quite low prevalence of significant stenosis on CCTA and coronary angiography . TherefoIn conclusion, among chest pain patients without ST changes and troponin elevation, the new score would be helpful to identify potential candidate for CATA such as patients with significant stenosis. Further validation studies are needed.


Patients completed cognitive testing  Tower, Conner's Continuous Performance Test), sleepiness , and HRQOL (PedsQL Sickle Cell Module) at baseline. Patients reported pain burden (Sickle Cell Pain Burden Inventory-Youth) each month over 8 visits. Caregivers provided demographic information and reported their child's executive function  at baseline. Data from our analysis demonstrated that demographic factors  and treatment variables  did not independently predict HRQOL, and laboratory values  were not significantly correlated with HRQOL (ps > 0.05). However, sleepiness, pain burden, ED visits, and executive dysfunction independently predicted HRQOL (R2 = 0.66) with large effects (η2 = 0.16 to 0.32). These findings identify specific, measurable symptom categories that may serve as targets to improve HRQOL that are responsive to change. This knowledge will be useful for multimodal interventions for paediatric patients with SCD that include sleep management, pain coping strategies, and executive function training.Sickle cell disease (SCD) refers to a group of inherited blood disorders with considerable morbidity that causes severe pain, reduces life expectancy, and requires significant self-management. Acute painful episodes are the hallmark of SCD, but persistent daily pain is also highly prevalent in this population. Characterising the impact and experience of SCD-related morbidity  on health-related quality of life (HRQOL) requires multiple assessment methods to best capture the underlying mechanisms. To gain a greater understanding of the effect of common symptom categories on HRQOL and to determine potential pain coping targets, the present study investigated whether demographic, socioeconomic, sleepiness, pain burden, frequency of emergency department (ED) visits, and cognition predicted HRQOL in a paediatric sample of patients with SCD. Our study was a secondary analysis of baseline assessment data of children with SCD aged 8–15 years ( Sickle cell disease (SCD) is a group of genetic disorders that affect the structure and oxygen-carrying capacity of haemoglobin in red blood cells  is often associated with comorbid psychological symptoms   that people employ to manage or reduce stress when faced with adverse experiences, including pain or disease-related distress  or more negative   and that pain coping interventions often aim to improve HRQOL, the purpose of our secondary analysis is to assess whether biopsychosocial factors that are frequent pain coping targets predict HRQOL. Gaining a deeper understanding of these factors will allow for targeted interventions for paediatric patients with SCD. Through the inclusion of multiple assessment tools that are often used when examining the effects of pain coping, we collected baseline data in the paediatric arm of the Prevention of Morbidity in Sickle Cell Disease Phase 2b (POMS2b) trial  collected before randomisation for the single-blind, randomised, controlled phase II trial (POMS2b). Baseline included all visits  up to and including the day of randomisation (see n = 30) to standard care alone (n = 30) in paediatric patients (children ≤16 years of age) and adults with sickle cell anaemia (HbSS genotype). The trial aimed to determine whether the intervention was safe and whether there were posttreatment improvements in cognition and brain structure. Descriptions of the study design and findings have been published elsewhere , serving ~460 and 480 patients with SCD, respectively. Trained PhD and MSc neuropsychology students administered cognitive testing in a quiet room at University College London. Inclusion criteria for the paediatric arm of the POMS2b trial were being 8 to 15.99 years of age, having the ability to speak and understand English, a diagnosis of sickle cell anaemia (HbSS genotype). Exclusion criteria included mean overnight saturation of <90% for >30% of the night , current or prior experience with overnight respiratory support, respiratory or decompensated cardiac failure, hospital admission for acute sickle complications within the past 1 month and more than 6 hospital admissions in the last 12 months, receiving chronic transfusions, or contraindications to APAP therapy or MRI. The study received ethical approval from the NRES Committee East of England—Cambridge South (14/EE/0163).Caregivers reported on child demographics. We obtained medical information through electronic medical chart review, including identifying if patients received common disease-modifying SCD treatments . Active medical problems documented in electronic medical records were reviewed to obtain neurological complications such as stroke history, abnormal magnetic resonance imaging , medical laboratory results , and the number of emergency department (ED) visits within the past year.The English Indices of Deprivation are widely used open-source data that provide official government measures of relative deprivation in England .Patients completed the Epworth Sleepiness Scale (ESS) Johns,  at baselParticipants completed the D-KEFS  Conners,  at baselCaregivers completed the 86-item Behavioural Rating Inventory of Executive Function (BRIEF) at baseline. The BRIEF assesses EF behaviour in the school and home environments  ] and medical variables  were only included in linear regression models if they were significant predictors of HRQOL (ps < 0.05).The R statistical package was used to conduct analyses Team, . Descripp < 0.05 two-tailed as statistically significant. Partial eta squared  and attention  predicted HRQOL over and above the influence of symptom categories . We considered y Cohen, . Bias anBaseline demographic characteristics are displayed in Descriptive data from patient-reported outcomes indicated some variability in overall pain burden across study visits, but scores were generally low in the sample see . Sleepinps > 0.05). Regarding patient-reported outcomes, HRQOL was significantly negatively correlated with the SCPBI-Y (r = −0.35) and the ESS (r = −0.57), indicating that those with poorer HQROL had higher pain burden and more sleepiness. In terms of cognition, HRQOL was significantly negatively correlated with CPT-3 commission errors (r = −0.33) and the BRIEF GEC (r = −0.48), indicating that those with poorer HQROL had more impulsivity and greater executive dysfunction  (ps > 0.05), so they were not considered in subsequent linear regression models. As correlation analyses determined that the CPT-3 commission errors (impulsivity) and BRIEF GEC (executive dysfunction) were correlated with HRQOL, we assessed only these measures of cognition in regression analyses (a priori cut-off of r > 0.2).Preliminary analyses indicated that no demographic  or medical variables  were significant predictors of HRQOL (p = 0.06).Each regression model determined if attention and executive function predicted HRQOL within models that included ESS (sleepiness), SCPBI-Y (pain burden), and ED visits within the past year. The variance-inflation factors (VIF) in regression analyses were within the acceptable range (1.14 to 1.62), indicating that correlations between independent predictors are not inflating the regression coefficient due to multicollinearity. Our regression analyses indicated that ESS (sleepiness) and ED visits within the past year were significant predictors of HRQOL in both models, including CPT-3 commission errors and the BRIEF. Scores on the SCPBI-Y (pain burden) approached significance (p = 0.84). However, the regression analysis including the BRIEF GEC was the most explanatory  and demonstrated that the BRIEF GEC significantly predicted HRQOL (p = 0.04). Effect sizes for all predictors were large (η2 = 0.16–0.32)  see . Based opost hoc analysis of data from the POMS2b RCT demonstrated sleepiness, pain burden, ED visits, and executive dysfunction predicted HRQOL. All effect sizes were large and clinically significant. Although impulsivity was negatively correlated with HRQOL (r = −0.33), it was not a predictor within regression models. Demographic factors  and treatment variables  did not independently predict HRQOL and laboratory values  were not significantly correlated with HRQOL.Our should be incorporated into the design, development, and implementation of skills-based programmes to ensure equitability and access. Within the context of pain coping interventions, however, the symptom targets that predicted HRQOL in the present study are defined, measurable, and most importantly, amenable to change.Patients with SCD often experience marked inequities influenced by geographic region, population density, socioeconomic status, care and pain outcomes, and disease management, along with reduced access and use of comprehensive specialist clinics , acceptance and commitment therapy (ACT), biofeedback, and acupuncture  may have a greater effect on HRQOL, emphasising the need for future studies to incorporate ecologically valid measures  and analyses of specific PedsQL subscales could not be assessed. Replication in a larger sample would provide greater clarity. This study was conducted at large, urban institutions in the UK, and the cohort may not be representative of the paediatric patients internationally. Although we collected data to assess hydroxyurea use, adherence to this treatment was not included in our study protocol. Our study did not include a direct measure of pain coping, which would have allowed us to test the relationship with our variables of interest. However, not having a specific pain coping measure allowed us to consider whether more generic coping scales that assess a range of outcomes might be more useful, given the complexity of the challenges faced by patients with SCD.Our study aimed to elucidate the symptom categories influencing HRQOL to determine targets for future multimodal pain coping and HRQOL interventions. We found that demographic and medical variables were weakly related to HRQOL; whereas, sleepiness, pain burden, ED visits, impulsivity, and executive dysfunction were more strongly related to HRQOL. Notably, almost all of the strongly correlated variables (except impulsivity) independently predicted HRQOL. Although thoughtfulness about sociocultural factors is critically needed to develop programmes and retain patients with SCD in research and clinical practise, we have shown that specific symptom-based targets for pain coping are measurable and may be responsive to change through intervention. As we consider helping to improve the lives of this paediatric population, it is necessary to expand beyond the measurement of pain intensity and instead integrate the assessment of measurable symptom categories that may serve as targets to improve HRQOL that are responsive to change.fenella.kirkham@ucl.ac.uk.The datasets presented in this article are not readily available because the datasets generated and analysed during the current study are available from the corresponding author on reasonable request and in accordance with ethical restrictions imposed by the Ethics Committees that approved this study. Requests to access the datasets should be directed to The study received ethical approval from the NRES Committee East of England – Cambridge South (14/EE/0163). Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.FK is the chief investigator, she conceived the study, grant application, and protocol development. CL made significant contributions to the design and implementation of the study. AH drafted this work and managed all revisions. AH, HS, MK, JK, and AS contributed to the study design and development of the proposal. BI, MP, JH, SC, SH, and MA made contributions to the conception of the study, the design of the work, and data acquisition. All authors read and approved the final manuscript.The National Institute for Health Research  provided funding for patient recruitment. AH was supported by a grant from the National Heart, Lung, and Blood Institute, National Institutes of Health (1F32HL143915). MK and HS were funded by Action Medical Research (GN2509) and JK by Great Ormond Street Children's Charity (V4615).FK has received honoraria from Novartis and Bluebird Bio and has served as a consultant for Global Blood Therapeutics. AS is currently employed by Axio Research LLC and has served as a consultant for Providence Medical Technology, Intuitive Surgical Inc., Laborie, Janssen Pharmaceuticals, Pulse Biosciences, Stryker Corporation. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Arthrocentesis is the simplest surgical intervention for the temporomandibular joint (TMJ). It can be performed on an outpatient basis at a low cost and with low morbidity. The objective is to release the articular disc by disrupting the adhesion formed between its surfaces and the mandibular fossa through hydraulic pressure generated by irrigation of the upper compartment of the TMJ. Viscosupplementation with hyaluronic acid during or after arthrocentesis improves clinical outcomes, increases mouth opening, and reduces pain levels. The aim of this study was to evaluate the efficiency of arthrocentesis plus hyaluronic acid viscosupplementation through clinical examination and preoperative magnetic resonance imaging in patients with unilateral disc displacement without reduction (DDwoR).This analytical retrospective cross-sectional study clinically and radiologically evaluated 72 patients of both sexes with unilateral DDwoR. The following data were collected: sex, pain, age, duration of pain, maximum mouth opening, and patient pain perception on a visual analog scale. TMJ arthrocentesis was performed only once for each of the indicated joints. Data were collected before arthrocentesis (baseline) and at 7, 14, 30, 60, 90, and 180 days after the procedure .p=0.001) and restoration of articular function. In addition, there was a significant increase in maximum mouth opening (p=0.001).Between the baseline and final evaluation, there was a significant reduction in pain (Patients with DDwoR undergoing arthrocentesis combined with hyaluronic acid injection showed significant improvement in the perceived pain and maximum mouth opening in the mid-term follow-up periods. Temporomandibular disorder (TMD) is an umbrella term that covers all abnormalities of the masticatory muscles, temporomandibular joint (TMJ), and accessory structures . ClinicaInternal disorders of the TMJ are characterized by an abnormal relationship between the mandibular condyle, tubercle, and articular disc , as wellThis surgical procedure was first described by Nitzan et al. . ExceptiThe aim of arthrocentesis is to remove inflammatory mediators and cellular debris, and release adhesions between the disc and articular fossa by washing out the upper compartment of the TMJ with simultaneous manipulation of the jaw . In addiHyaluronic acid (HA) is a natural hydrophilic mucopolysaccharide glycosaminoglycan, and a component of both synovial fluid and cartilage tissue. This fluid combines with glycosaminoglycans to form proteoglycans, which disintegrate and disperse in the synovial cavity under pathological conditions. Although its half-life is only 13h, HA demonstrates beneficial effects when administered by intraarticular injection ,22.Elucidation of the advantages of arthrocentesis with HA viscosupplementation in patients with DDwoR will help oral and maxillofacial surgeons indicate or employ this technique in a more consistent and qualified manner, thereby offering, a simpler and more effective treatment to patients suffering from this disease.This was an analytical, retrospective, and cross-sectional study. This study was approved by the Research Ethics Committee of the Federal University of Rio Grande do Sul (CAAE: 59616416.8.0000.5347) and was conducted in accordance with the Declaration of Helsinki and the Consolidated Standards of Reporting Trials (CONSORT) statement. All patients provided written informed consent for participation.For 90% statistical power and a 5% level of significance, the sample size was calculated as 34 subjects (68 observations) to observe reduction in pain and reestablishment of the maximum mouth opening (MMO).Adult individuals (age ≥18 years) of either sex, diagnosed with DDwoR causing unilateral TMJ pain that did not respond to ≥3 months of conservative treatment  were deemed eligible.The diagnosis of DDwoR was confirmed by clinical examination, based on axis I of the Research Diagnostic Criteria for Temporomandibular Disorder -25, and Patients with rheumatoid arthritis, agenesis, hyperplasia, hypoplasia, and/or malignant neoplasm of the mandibular condyle, bony ankyloses, myopathies, a history of previous TMJ surgery or arthrocentesis , and extreme needle phobia, were ineligible for participation.In addition, we excluded patients who had disc displacement with reduction, systemic inflammatory diseases of the joints; a history of trauma to the chin or other facial bones, cardiovascular or hematological diseases, chronic use of medications such as anticoagulants or antihypertensives, neuropathic pain syndromes such as trigeminal neuralgia , neuralgia of the intermedius, glossopharyngeal, or upper laryngeal nerves, Eagle syndrome, Ernest syndrome, confirmed or suspected pregnancy, and any relative or absolute contraindications to MRI (such as a history of claustrophobia or permanent makeup/tattoos performed <3 months before examination), as well as those currently taking analgesics or anti-inflammatory agents. Patients who were self-medicating with the latter were accepted if they completed a washout period of at least 1 week before evaluation.®; range, 150 mm), presence of effusion at baseline, and perceived pain on a visual analog scale (VAS). MMO and VAS score were obtained before arthrocentesis (baseline), and at 7, 14, 30, 60, 90, and 180 days after the procedure .All patients were evaluated, diagnosed, and treated between March 2014 and July 2016 at the Center for Orofacial Pain and Deformity (CENDDOR), Porto Alegre, Rio Grande do Sul, Brazil. The research was led by a doctor of dental surgery (EG) who was familiar with the evaluation protocol. The following data were collected: sex, age, duration of pain, in months, maximum mouth opening (MMO) in millimeters, measured with a digital caliper (VonderMRI was performed using a 1.5-Tesla (T) magnetic field scanner  at Serviço de Investigação Diagnóstica, an independent imaging center. T1-weighted  and T2-weighted  sequences were performed using a 9-cm diameter bilateral surface coil. The matrix employed for T1 was 288x192, 3 NEX, and for T2, 288x160, 4 NEX, with a field of view of 110x110 mm. Six oblique sagittal slices  perpendicular to the axis of the mandibular condyle were obtained for each TMJ, at maximum intercuspation and MMO. Before axial slices were obtained, a sagittal scout view was acquired for the localization of the mandibular condyle. Six slices of each TMJ were obtained in the oblique coronal plane , parallel to the axis of the mandibular condyle, all in habitual occlusion (maximum intercuspation). To keep the patient relaxed, minimize movement, and maintain MMO, an occlusal splint was placed in the interincisal space. The mean scan duration was approximately 30 min. Twelve 3x4 images at 1.5x magnification were documented on a 43x35 cm film.All the MRI films were read and interpreted by an experienced radiologist. The evaluation protocols and MRI reports were reviewed and transcribed into a Microsoft Excel spreadsheet (Microsoft Corporation).® tape, leaving only the TMJ area exposed. A surgical site marker was used to draw a straight line from the midpoint of the tragus to the corner of the eye , and two points were marked on this line for needle insertion: the first and most posterior point, 10 mm anterior to the tragus and 2 mm below the cantho-tragal line; the second, 20 mm anterior to the tragus and 10 mm inferior to the cantho-tragal line. Antisepsis was performed with 2% chlorhexidine solution, which was applied liberally to the entire face, mainly in the preauricular area and pinna. The next step was an auriculotemporal nerve block , followed by anesthesia of the posterior deep temporal and masseteric nerves (one or two tubes). The objective of analgesia was to prevent any discomfort and/or pain during the procedure, thus rendering sedation unnecessary. The patient was then requested to open the mouth as far as possible, effecting downward and forward displacement of the condyle, which enabled access to the posterior recess of the upper compartment of the TMJ, where the first needle  was introduced. The needle was directed anteriorly, superiorly, and medially until its tip hit the mandibular fossa within the upper compartment. The needle was then connected to a 5-mL syringe, and 4 mL of 0.9% saline solution was injected to distend the joint space. Next, the syringe was removed and the needle was connected to a 100-cm long clear plastic extender . A second needle, with the same dimensions as the first needle, was introduced into the distended compartment, at the prior point of entry, and connected to a 60-cm long, 20G flexible clear catheter  that was used to visualize the flow of the articular washout. The other extremity of this catheter was connected to a rubber suction tip , which was driven by a vacuum pump .TMJ arthrocentesis was performed only once for each of the indicated joints. The procedure was performed following the technical protocols reported in the literature ,27,28. FUsing 60 mL syringes, 200 mL of 0.9% saline solution was injected through the extender connected to the first needle and withdrawn through the cannula connected to the second needle. No other substances or drugs were added to the injected solution. The cannula connected to the second needle was occluded for approximately 10s while injecting the last 5 mL of saline, increasing the hydraulic pressure within the upper compartment of the TMJ. The patient was then instructed to open his or her mouth and move the mandible laterally to break up any possible adhesions, thus allowing gain of vertical and lateral range of motion, which was measured intraoperatively. After arthrocentesis was completed, the second needle was removed, and 1 mL of HA solution  was injected. The needle was removed, and the puncture sites were covered with a spot bandage  that was left in place for 1h. Patients were instructed to take 750 mg paracetamol every 6h for 3 days, intermittently apply ice locally for the first 48h, consume only liquids and pureed foods for 5 days, wear a thermoplastic maxillary occlusal splint  for the same period, removing it only during meals and for oral hygiene, and avoid physical activities and local heat application for 1 week.Categorical variables  were analyzed using the chi-square test and are shown as numbers and percentages. The variable with normal distribution (age) was analyzed using Student’s t-test and is presented as the mean and standard deviation. The variable with asymmetric distribution (pain duration) was assessed using the nonparametric Mann-Whitney test and is presented as the median and interquartile range. To observe the efficacy of the therapy, we compared the MMO values before and after the procedure. To evaluate test tolerance, pain perception before and after surgical intervention was assessed. In these cases, the nonparametric Wilcoxon test was used for analysis.p<0.05).All analyses were performed using PASW Statistics for Windows , at a significance level of 5% . However, this correlation was strong when effusion was present in both compartments (p<0.001). This suggests that the study intervention effectively improved both variables (p<0.001)  .Arthrocentesis has been proposed as an effective approach for the treatment of patients with DDwoR. Beneficial effects on mandibular mobility are well established, and may be attributed to the removal of adhesions, reduction, or elimination of negative pressure within the joint, distension of the joint space, and modification of the viscosity of the synovial fluid, thus facilitating movement of the articular disc and condyle ,10,28.Effusions are defined as large collections of synovial fluid in the joint space and are associated with DDwoR . The finp=0.001) in pain perception after arthrocentesis. This was expected because the abundant irrigation with biocompatible substances allows removal of debris from the degenerating joint tissues, eliminating algogenic substances and, especially, inflammatory mediators  and mean age (32.46±8.19 years).Finally, one of the major benefits of arthrocentesis is its analgesic sparing effect. It is important to emphasize the chronic nature of the disease, which is caused by harmful habits and inadequate posture. Clinical follow-up and patient education can improve therapeutic success and quality of life.In the current study, patients with DDwoR, who were treated with arthrocentesis combined with HA injection showed a significant improvement in perceived pain and maximum mouth opening in the mid-term follow-up periods.Rossini R was responsible for the data analysis and interpretation, statistical analysis, and manuscript preparation, writing and critical revision. Grossmann E provided substantial scientific and intellectual contributions to the study conception and design, data acquisition, analysis and interpretion, technical procedures and was responsible for the approval of the final version of the manuscript. Poluha RL and Dos Santos MF performed the manuscript critical revision, and provided substantial scientific and intellectual contributions to the study. Setogutti ET performed the acquisition and interpretation of MRI scans.


Complex regional pain syndrome is a rare, intractable disease causing chronic pain. For improved subjective and personal experience, an individualized treatment approach based on a thorough understanding of the patient’s perceptions is required for pain management. In this study, we examined the experiences and challenges of 11 Korean patients diagnosed with complex regional pain syndrome. The patients described their experiences during in-depth, face-to-face interviews, and data were subjected to a thematic analysis. We identified the following three main themes: “my own non-stereotyped pain,” “complex emotions caused by pain,” and “a careful life endured alone.” Enduring pain alone was difficult, and the lack of support from family members, caregivers, or society amplified the patients’ hardships. As these patients often felt alone when coping with internal difficulties, including pain, they frequently coped through self-management of the condition. The importance of offering realistic support to complex regional pain syndrome patients is underscored via a multifaceted approach and may aid in the development of educational programs for medical personnel, families, and caregivers of these patients. Complex regional pain syndrome (CRPS) is a rare, intractable disease characterized by chronic pain. The condition presents with inflammatory changes and signs at sites of pain, changes in skin color and temperature, sweating, severe hyperalgesia and allodynia, edema, altered patterns of hair and nail growth, reduced strength, dystonia, and tremors . The IntThe diagnosis and treatment of CRPS are difficult. As CRPS is associated with several causes and diverse clinical presentations, the disease etiology is not fully understood . Thus, CThe incidence of CRPS is 26.2 per 100,000 person-years in the Netherlands  and 29.0To date, research on CRPS has explored the disease’s diagnosis, causes ,13,14, aThis study was a thematic analysis of data collected through individual, in-depth interviews of adult patients diagnosed with CRPS.The study included six men and five women aged 20–65 years who had been diagnosed with CRPS at a university hospital in accordance with the International Association for Study of Pain criteria. Eight patients were married. The most common cause of CRPS was reported as “after a road traffic accident”  where the research was conducted. Before the interviews, the participants were provided written and oral explanations of the research objectives and methods and asked to provide written informed consent for participation. Participants were informed that the interview recordings would be used only for research purposes and that observations or recordings from the interviews may be quoted in this research and that their anonymity would be guaranteed by not quoting potentially identifiable personal information. Participants were free to refuse or terminate participation at any time, including during the interview or if the pain was making it difficult for them to continue the interview. We made every effort to protect the participants from any mental or physical discomfort that might arise due to the interview.Data were collected between October 2011 and May 2013. We conducted an in-depth, non-structured interview to encourage participants to speak honestly and openly about their own disease experiences. Interviews were conducted by one of the authors at a hospital in an outpatient consultation room.The interview was completed in 60–90 min (in consideration of the participants’ pain and condition). Participants were informed that they could stop the interview at any time if they felt discomfort due to pain, but most participants did not stop the interview. Participants who experienced severe pain during the interview showed a pattern of frequent resting between words.The interview questions were semi-structured, and the core question was, “What have your experiences as a patient with CRPS been like?” Specific questions included the following: “What were your thoughts and experiences after you were diagnosed?”, “What were the effects of the disease and treatment?”, “What have you experienced between the diagnosis and now?”, “How have you dealt with the disease?”, and “What has affected your experience of the disease?” The researchers encouraged participants to describe their experiences completely. During the interview, researchers noted any non-verbal responses or other observed details that they considered important. The recorded interview content was transcribed for analysis.We performed a thematic analysis based on the method of Braun and Clarke , focusinWe examined four criteria to validate the trustworthiness of this qualitative study, as suggested by Lincoln and Guba , namely The pain experienced by each patient differed in the pattern, intensity, and cause, but most patients reported experiencing severe pain that was difficult to tolerate. Because this pain was not stereotypical, patients had often endured a difficult period until CRPS was recognized and diagnosed. As such, patients perceived their condition as a form of personal suffering. Although the pain became familiar and the intensity of pain decreased over time, it did not disappear in any of the patients.Although there was diversity in the patterns, intensity, frequency, duration, and aggravating/alleviating factors for pain, most patients described the pain as extremely severe and unbearable. Patients consistently described CRPS symptoms as unusual pain unlike any that they had previously experienced. They said that the pain made them feel afraid.“It feels like touching a glass shard that’s buried beneath my skin. And what would I do then? That fear keeps me awake at night.”(Participant 3) “Lately, about once a day, I feel a sudden pain that climbs up my leg. It’s so bad that I can’t even move. I don’t know how I’ll survive if that sensation keeps coming …” (Participant 4) omitted) That’s why I’m thinking about taking leave from school again.” “When the pain comes, I can’t bear it; I bent over on the spot and started screaming. Because it hurts … I don’t want people to see me like that… ( (Participant 6)At first, patients suffered from their pain and spent time searching for different treatment methods. Yet, in the end, treatments were ineffective, and the patients found that there was no specific treatment method available. As patients became accustomed to the uniqueness of the pain, they started recognizing its patterns and the aggravating and alleviating factors. Over time, they were better able to anticipate the pain to some extent, resulting in steady improvements in pain intensity and duration. Patients reported that they became more familiar with their pain over time.“It’s better than it used to be. If it was strong-to-moderate before, now it’s moderate-to-light.” (Participant 10) “I received all kinds of treatments. I tried nerve blocks, medication …, but none of it was of any use … (omitted) … It’s a lot of pain, but in the end, I have to get through it by myself. I do feel like I’m getting used to it more and more.” (Participant 3) The fact that family members, doctors, and other individuals did not understand their pain caused physical and psychological hardship in patients. Patients showed a strong desire for acknowledgment, understanding, and compensation for their pain and distress. Yet, the preconception of CRPS being a rare, intractable disease caused patients to be conscious of others’ attention and therefore tried to hide their diagnosis.These patients reported experiencing suffering alone due to severe physical pain that was not understood, acknowledged, or compensated by others. The lack of clear methods for the diagnosis and treatment of CRPS caused complex emotions and psychological problems, such as anger, shock, surprise, stress, fear, disappointment, despair, and helplessness. Therefore, patients showed secondary mental health problems resulting from their physical pain.“I cried for days after receiving the diagnosis. I couldn’t believe that I had a rare disease and had become a cripple …” (Participant 2)“At first, I didn’t know what this disease was. But then I saw a TV program about the disease … It was awful… I was scared that there wasn’t really any way to treat it.” (Participant 4) “To be honest, I was shocked when I learned what disease it was. I couldn’t sleep, and I took antidepressants.” (Participant 6) “It’s not covered by insurance, and no one knows my pain. When I go to the hospital, I’m in pain, but sometimes they tell me I’m not … My family doesn’t know how much I’m hurting either.” (Participant 7) Although patients showed a strong desire to have their pain acknowledged and understood, they also showed a conflicting desire to hide their disease due to misguided preconceptions about CRPS. In other words, although the patients reported wanting others to recognize their pain and suffering, they ultimately acknowledged that no one would be able to solve their problems and that others were likely to have negative preconceptions about CRPS.“At first, I felt angry and unfairly treated because no one knew my pain … (omitted) … And the people who do know think this disease is so serious that you can’t move at all. Other people say that it’s not a common disease … They look at you like you’re abnormal, so I prefer not to say anything.”  (Participant 6)“Because I feel like people think I’m strange. I try not to tell anyone as much as possible and to keep a low profile. I tend to worry a lot.” (Participant 10) Patients with CRPS described different ways of coping with their pain, whether they continued to fight the disease, gave up and accepted the disease, or learned to control the disease themselves. As patients recognized that no one understood their pain and that there are no effective treatment methods, they persisted alone and endured a careful life trying to avoid pain.Initially, patients showed proactive coping behavior by trying different methods to treat or alleviate their pain. Yet, as patients experienced various complications of treatment and related secondary problems, they often abandoned the idea of treatment and eventually accepted that there was no clear, precise treatment method for CRPS. Patients gradually learned their own means of coping by making efforts to control the pain themselves or by depending on somebody else.“At first, I received analgesic injections, I had a cast, I tried physiotherapy … (omitted) … I tried taking pain medication, but I still feel a dull pain. It doesn’t stop the pain; it just dulls it … I feel a little zoned out … (omitted) … There is no real solution. Just keeping yourself warm.” (Participant 4) “This disease feels a little better when I’m emotionally at peace. So, I just try to live my life without worrying.” (Participant 2) “My mother has helped me a lot. That’s because she’s a teacher, so she understands students’ state of mind. I depend on my mother.” (Participant 5) Patients reported experiencing a time of distress before learning that CRPS was poorly understood and largely untreatable. They endured pain while learning their own coping methods and led a constantly careful life. Although the patients depended significantly on the help or support of their family, they said that they ultimately understood that they themselves had to endure the pain and make careful judgments to avoid causing further pain. Therefore, they changed their lifestyles and led careful lives.“I became incredibly sensitive. I am surprised whenever something touches my skin … (omitted) … I’ve completely given up now and accepted that this is my life, just as long as it doesn’t get any worse. If this is as bad as it gets, I can just about live with it.” (Participant 4) “It’s something I experienced before, but the pain returns when I think about something I failed before. That’s why I try to live my life without thinking about anything.” (Participant 5) Pain is a subjective, personal experience, and as such, it requires individual management. In this study, we analyzed the experiences of patients with CRPS to better understand their subjective experiences with the disease.The first theme was “my own non-stereotypical suffering.” The pain experienced by patients with CRPS showed diverse patterns, intensities, frequencies, and causes but was commonly described as unbearably severe pain. The pain was also somehow different from previously experienced pain. In patients with CRPS, unbearable pain occurred irregularly and even at rest, making them incredibly tense at all times. Previous study has also found that patients with CRPS show persistent pain even after treatment and that they often experience fear regarding continued treatment and using their limbs . A studyKim et al.  investigIn our study, the symptoms of CRPS were intractable with extreme changes, a gradual spreading of the affected regions, little therapeutic response, and/or disease recurrence despite treatment. Patients had reported significant suffering until they accepted the disease, after which they gradually became accustomed to the pain. The path to acceptance is not smooth and requires patience, motivation, and strength . These pThe second theme was “complex emotions caused by physical pain.” While patients wanted people to recognize their emotional and mental anguish secondary to physical pain, they also experienced a conflicting desire to hide their diagnosis of CRPS. This is because the participants were misunderstood as strange people or experienced negative gazes due to their diagnosis. Patients with chronic pain require mental and psychological support, as they often exhibit features of generalized anxiety, panic, social anxiety, posttraumatic stress, and/or obsessive-compulsive disorder . In the Family is an important source of support for patients with CRPS. Yet, 57% of families of CRPS patients reported feeling burdened, and 53% reported experiencing negative emotions as a result of the CRPS diagnosis . TherefoThe third theme identified in this study was “living carefully, enduring alone”. Each patient had adopted different coping methods to address CRPS symptoms, but all of them sought methods to help them manage CRPS by themselves and led careful lives to avoid causing pain. Seeking independent coping methods can give the impression of a positive or successful adaptation to the disease. Rodham et al.  exploredStudying individuals who experience complex phenomena such as pain can provide a multidimensional understanding of pain within the context of physiology, psychology, and social aspects while also helping to develop all areas of medicine and related research . The comOur study had several limitations. First, this study was conducted in Korea, and all included patients were Koreans; as such, the experiences described herein might differ from those of patients in other countries and of other ethnicities or cultural backgrounds. Second, our results only address the experiences of adults currently receiving hospital treatment and did not include those of children or adolescents with CRPS or of patients who did not seek medical treatment at a hospital. Despite these limitations, we consider our study to be valuable: there is a lack of research on CRPS in Korea, and although it is difficult to fully understand patient experiences, this study facilitates a deeper understanding of CRPS.We performed a thematic analysis to investigate the experiences of adult patients with CRPS in Korea. Three main themes were derived from this study: “my own non-stereotypical suffering”, “complex emotions caused by physical pain”, and “living carefully, enduring alone.” Patients endured internal difficulties alone while trying to find their own methods to alleviate pain, but they required mental, psychological, and social support. Therefore, it is important to educate medical personnel, family members, and caregivers so that patients can receive the appropriate support, maintain employment, obtain sufficient pain control and rehabilitation, and preserve their quality of life.CRPS remains a poorly understood disease even for medical personnel. Our results can be utilized for the better education of medical personnel to provide a deeper understanding of patients’ experiences with CRPS. Our study outlines important concepts for caregiver programs and can be utilized for the development of awareness and educational programs to change the public perception of CRPS. Our findings also call for the development of various programs, including coping strategies, rehabilitation programs, and social adjustment programs, for patients with CRPS.