Pain management is a critical aspect of effective long bone fracture treatment. Pediatric patients frequently report suboptimal pain management, which is an area of growing public concern. The purpose of this quality improvement project was to develop a protocol with the goal to administer pain medication to children presenting with suspected long bone fractures ≤47 minutes of emergency department arrival.A multidisciplinary team developed a standardized protocol for pain management of patients presenting with musculoskeletal pain utilizing acetaminophen as the first-line agent under a nurse-initiated order. Following education and implementation, weekly reports generated using the International Classification of Diseases codes of fractures were reviewed to assess compliance with the protocol. This study evaluates the frequency of a second pain medication administration and reduction in vital signs and pain scores.Implementation of a pain management protocol reduced median time to pain medication administration to 26 minutes. Overall, 63% (n = 638) of patients required a second pain medication. Of these, 66.5% (348/523) who initially received acetaminophen and 59.7% (286/479) who initially received an opioid required a second pain medication. No significant changes in pre and posttreatment vital signs were found between groups. Patients who initially received opioids experienced a greater reduction in posttreatment pain scores.Using a standardized pain management protocol in combination with comprehensive education effectively reduces median time to pain medication administration in pediatric patients with long bone fractures. Acetaminophen is a rapid and effective first-line agent for managing pain in this population. In 2012, CMS added the Median Time to Pain Management for Long Bone Fracture core measure to evaluate the “median time from emergency department (ED) arrival to time of initial oral, intranasal (IN), or parenteral pain medication administration for ED patients with a principal diagnosis of long bone fracture” (OP-21).3 Heilman et al.4 described a similar quality improvement process for pain medication administration utilizing nurse-initiated orders, documentation, and oral pain medication administration in triage. They reported a reduction in median time to pain medication administration from 95 minutes to 49 minutes.4Pain management is a critical aspect of the emergency care of pediatric patients with suspected long bone fractures; however, pain is often undertreated in this patient population.6From June 2014 to December 2014, Le Bonheur Children’s Hospital did not effectively meet the CMS OP-21 core measure. During this period, the median time to pain medication administration from ED arrival was 71.5 minutes. The goal of a new protocol was to administer pain medication to patients with suspected long bone fractures ≤47 minutes of ED arrival through nurse-initiated medication ordering in triage. The committee chose the goal of 47 minutes because it placed the Le Bonheur ED in the top quartile benchmark when compared with similar institutions. The protocol established acetaminophen as the first-line agent based on ease of access and safety profile. Acetaminophen is an effective pain medication frequently used in pediatric EDs.Le Bonheur Children’s Hospital is a 255-bed tertiary care children’s hospital located in Memphis, Tennessee, and includes a level 1 pediatric trauma center. The 54-bed ED has an average volume of 90,000 patient visits per year. In the ED, patients are evaluated and treated by fellowship-trained pediatric emergency medicine specialists, general pediatricians, and physician trainees (fellows and residents).A multidisciplinary committee comprised of ED physicians, hospitalists, ED nurses, pharmacists, information technology specialists, and hospital administrators established a protocol to address reducing administration times for pain medication. During the initial phase of the study, the committee met monthly to discuss implementation and evaluate its sustainability. Meeting frequency moved to quarterly before being dissolved. Pain medication administration times were monitored in the subsequent phase, and if the goal time were exceeded, the committee would reconvene.The committee established the goal as a median time of ≤47 minutes from ED arrival to pain medication administration for patients who present to the ED with musculoskeletal pain. Factors that contributed most to delay in care are time to triage assessment and time to physician assessment. These factors are primarily due to the department’s high patient volume. Not all long bone fractures have an obvious deformity; therefore, the protocol encompassed all musculoskeletal pain, including but not limited to, patients who present with obvious and suspected fractures, joint dislocations, immobility, inability to bear weight, guarding of an extremity, sprains, and nonaccidental trauma. By broadening the scope of the protocol, the committee sought to limit injuries that could be under triaged initially. Based on safety profile and ease of access, acetaminophen is the first-line medication to be administered under a nurse-initiated triage order for patients 3 months and older. Several non-narcotic analgesic options are available; however, nonsteroidal anti-inflammatory drugs may pose safety concerns in patients with renal dysfunction or bleeding disorders. Acetaminophen is stored securely in ED triage rooms and medication dispensing cabinets throughout the department.The stepwise protocol created a standard practice of care for the ED staff to rapidly identify patients with potential or suspected long bone fractures and initiate pain management. Implementation began in January 2015 with coinciding education for the staff. ED pharmacists and nursing supervisors educated physicians, nurses, ED technicians (EDTs), and inpatient pharmacists regarding the rationale, goals, and the protocol process. Not only is the protocol applicable to patients presenting to the waiting room but also via emergency transport vehicles; therefore, the entire team needed to understand the protocol, roles, and responsibilities in different scenarios. Committee members placed protocol flow charts  records the chief complaint on a paper assessment form. Pain evaluation was added to the paper assessment form as an additional protocol intervention. This brief evaluation included a section to document pain score, pain medication before arrival , and initiation of acetaminophen order (yes or no). A patient chart is created in the electronic medical record at the registration desk using this assessment form. The triage greeter notifies a triage nurse to initiate the triage process as quickly as possible after registration if the musculoskeletal pain is reported. Patients who present via emergency transport vehicles for immediate bedding in the ED are triaged at the bedside by a nurse who completes the triage form in the electronic medical record.9 Generally at Le Bonheur, the ED staff utilizes Face, Legs, Activity, Cry, Consolibility scale for children 2 years and younger and the FACES scale for school-age children. The numeric pain scale is usually reserved for children 8 years and older. Next, the patient, parent, and/or emergency medical responder undergo an interview regarding medications given before arrival and any known drug allergies. The triage nurse documents the pain score and prearrival medications on the triage form in the electronic medical record. Exclusion criteria include an allergy to acetaminophen, risk of aspiration, or received acetaminophen within 4 hours before arrival. If no exclusion criteria exist, acetaminophen 15 mg/kg per dose (maximum of 650 mg) is ordered as a protocol order, to be signed electronically by an attending ED physician, then administered to the patient. Nurses administer acetaminophen as 160 mg/5 mL suspension or 325 mg tablets and document the time of administration in the patient’s chart. Nil per os status is assumed for all patients; therefore, nurses administer acetaminophen with clear liquid in minimal quantity. Nurses can request verbal medication orders from physicians, such as IN fentanyl or intravenous (IV) morphine if additional pain control is indicated as long as the administration is not significantly delayed. Once the protocol became routinely initiated, more liberty was given to the nurses to choose pain medications other than acetaminophen as the initial medication administered to patients with obvious deformities and/or patients complaining of severe pain. Alternative medications, such as acetaminophen-hydrocodone, IN/IV fentanyl, or IV morphine are available following a physician order if there is no delay.The initial step of the protocol is to assess the patient for musculoskeletal pain immediately upon arrival, followed by scoring of the patient’s pain using an appropriate pain scale for the developmental stage of the child. The ED uses 3 pain scales: Face, Legs, Activity, Cry, Consolibility scale, FACES scale, and numeric pain scale (0–10).3 Exclusion from the analysis was based on the following criteria: pain medication administered before arrival, the parent or patient refused pain medication, unknown time of injury, or injury occurring ≥24 hours before presentation. The committee shared average administration times on a weekly basis with the ED team. Charts of patients who did not receive pain medications ≤47 minutes of arrival were further reviewed and evaluated by a nursing supervisor who then provided education to the department or individual as needed. Performance evaluations for nurses and EDTs included adherence to the protocol and reduction in administration times as a department goal.Following implementation, ED pharmacists reviewed weekly reports generated using the International Classification of Diseases codes of long bone fractures to assess compliance. The protocol applied to patients 3 months and older who presented to the ED with musculoskeletal pain. However, this study only included patients 2 years and older with confirmed long bone fractures. The age cutoff was based on the inclusion parameter of ≥2 years used in the CMS OP-21 core measure.The primary outcome measure is establishing a median time from ED arrival to pain medication administration of ≤47 minutes for patients with confirmed long bone fractures. This analysis includes patients 2 years to younger than 18 years from January 2015 to October 2016 based on CMS OP-21 parameters; this core measure limits inclusion to patients older than 2 years of age. Secondary outcomes include administration of a second pain medication and reduction in vital sign values and pain scores.Data points collected for analysis include patient demographics , discharge diagnosis, International Classification of Diseases codes, first pain medication administered and administration time, and subsequent pain medication(s) administered and administration time(s). Vital signs pre- and postpain medication administration including heart rate, systolic blood pressure, diastolic blood pressure, and respiration rate were collected. Pre- and posttreatment pain scores were recorded. Pain scores were reported for the overall group and for the subset of subjects scored utilizing the same pain scale for both pre- and posttreatment scores.All continuous variables are presented as medians and interquartile ranges (IQRs) while categorical variables are presented as frequencies and percentages. Descriptive statistics summarize all vital signs and pain scores before and within 2 hours after the administration of the medication. Patients are stratified according to pain medications received and age groups. Boxplots demonstrate a visual representation of the change between pre- and posttreatment vital signs. A line graph shows the median time to pain medication administration by month before and after the implementation of the protocol. Only the first ED visit during the study period for each patient was used in analyses. Statistical analyses were performed using SAS 9.4 . The institutional review board approved this retrospective review at the University of Tennessee Health Science Center.There were 1,011 patients aged 2 to younger than 18 years with confirmed long bone fractures who presented to the ED during the study period. The median (IQR) age was 8.98 (5.9–12.2) years. Sixty-seven percentage of patients were male, and 53% of patients were African American. Demographics are shown in Table Eighty-four percentage of patients (n = 846) received a pain medication ≤47 minutes of ED arrival with 54% of them receiving acetaminophen. For the entire study population, 52% of patients n = 523) received acetaminophen as their initial pain medication with a median (IQR) time to administration of 20 (11–32) minutes. Patients who received an opioid as their initial medication (n = 479), including acetaminophen-hydrocodone, acetaminophen-oxycodone, fentanyl, morphine, and hydromorphone had a median (IQR) time to administration of 29 (22–47) minutes. Of these patients, 368 (76.8%) received IN fentanyl initially. Nine patients received ibuprofen as their first medication with a median administration time of 58 (27–78) minutes. Sixty-three percentage (n = 638) of patients required a second pain medication. Of these, 66.5% (348/523) who initially received acetaminophen and 59.7% (286/479) who initially received an opioid required a second medication. Changes in pre- and posttreatment vital signs are shown in Figure  received10 Several barriers attribute to inadequate treatment of pediatric pain including concern of prescribing opioids to children, fear of adverse drug reactions, and difficulty assessing pain in pediatric patients.11 Various factors such as fear, anxiety, and lack of social support can further exacerbate pain in pediatric patients making it difficult to properly assess pain in these patients.2 This can lead to increased pain stimuli and psychological enhancement of pain known as hyperalgesia. Therefore, early and aggressive management of pain is recommended.12 Before implementation of this pain protocol, the median time from ED arrival to pain medication administration was 71.5 minutes over a 7-month period. The goal was to reduce this time to ≤47 minutes to provide the highest quality of care to patients and significantly improve quality scores, which impact reimbursement rates and top-tier designation.Decades of literature have documented suboptimal management of pediatric pain in ED settings, prompting the World Health Organization to declare pediatric pain treatment a public health concern of major significance.The primary objective assessed the efficacy of a standardized pain management protocol in reducing median time to pain medication administration in pediatric patients with long bone fractures to ≤47 minutes. The median time was consistently ≤47 minutes during the study period, demonstrating the sustainability of the protocol. Standardizing a stepwise protocol through a multidisciplinary approach and comprehensive education for all members was critical to the success of implementation. By broadening the protocol to encompass musculoskeletal pain, potential fractures were less likely to be missed. Nurse-initiated orders facilitated faster administration of acetaminophen before physician assessment. Assessing pain in musculoskeletal injuries upon ED arrival is now second nature for the team and is emphasized upon the addition of any new team members.13 Nonsteroidal anti-inflammatory drugs and opioids may not be appropriate for all patients. IV administration may cause delays due to order verification process and/or obtaining IV access. Additionally, national medication shortages have significantly affected the availability of many commonly used opioids limiting their use.Secondarily, several parameters evaluated the efficacy of acetaminophen as a first-line agent. The committee chose acetaminophen as a first-line agent due to ease of administration and proven safety profile in the pediatric population.2 To ensure exceptional patient care, the protocol allows for administration of a second pain medication, including opioids, when the provider deems necessary. However, this was only needed in 66.5% of patients initially receiving acetaminophen.Use of a nonopioid analgesic, such as acetaminophen, is an effective opioid-sparing technique. Limiting opioid usage can reduce the incidence of opioid-related adverse effects such as respiratory depression, nausea, vomiting, and addiction.Similar differences between the acetaminophen and opioid groups were found when evaluating changes in pre- and posttreatment vital signs. Vital signs are reported in age-stratified groups to represent age-dependent variability better. Patients receiving opioids had a greater reduction in pain scores across all age groups; however, patients in the opioid group had higher initial pain scores, potentially indicating more severe or painful injuries in this group. Additionally, pain scales used for assessment were inconsistent. To account for this, results for patients whose pre- and posttreatment pain scores were measured with the same scale and overall pain scores regardless of the pain scale used. During the implementation of the protocol, a task reminder was added to the electronic medical record to notify the ED team to reassess pain following the administration of a pain medication. Opioids provide stronger analgesia than non-narcotic analgesics; however, in patients with lower baseline pain, acetaminophen is likely sufficient. Of those who initially received acetaminophen, 66.5% required additional pain medication while 59.7% of those who initially received an opioid required a second medication. Given the clinical similarity in vital signs between medication groups and the comparable need for additional pain medications, acetaminophen is an acceptable first-line option in this study’s population.There are several limitations to this study including potential lack of generalizability. Nurse-initiated medication orders and access to acetaminophen were crucial for the success of this protocol given the department’s high census; therefore, other institutions may not be able to incorporate a similar process. Inconsistent use of patient pain scales may have led to measurement bias. Another limitation was missing vital sign and pain score documentation, which eliminated several patients from certain evaluations and restricted the use of statistical inference techniques. This study did not evaluate adverse events. Finally, revisions to the protocol allow triage nurses to choose among pain medication options, which were ultimately up to provider discretion.Implementation of a standardized stepwise pain protocol resulted in a median time to pain medication administration consistently less than the goal of ≤47 minutes. Acetaminophen was effectively administered under a nurse-initiated order protocol and is an acceptable immediate first-line option for pain control in pediatric patients with suspected long bone fractures. Through the use of this protocol, the ED complies with CMS guidelines without compromising a high standard of patient care.The authors have no financial interest to declare in relation to the content of this article.


The Pain Management Index (PMI) is widely used in the assessment of pain management, and negative scores are traditionally considered to indicate inadequate pain management. However, it is not known whether negative PMI scores are always problematic.In this prospective observational study, we examined the data of 1156 patients with cancer and pain who were hospitalized in a cancer care hospital in Japan from July 2012 to January 2015 and compared the proportion of patients with PI across various PMI scores in this cohort. We further evaluated the predictive validity of PMI scores for PI using different cutoffs. This study aimed to examine the association between PMI scores and the proportion of patients whose pain interferes with their daily lives .We found that lower PMI scores were generally associated with a higher percentage of patients with PI. A smaller proportion of patients with PMI scores of − 1  reported PI compared with those with PMI scores of 0 . The sensitivities of PMI scores < − 1 and < 0 for predicting PI were 0.16 and 0.37 and the corresponding specificities were 0.95 and 0.71, respectively.These findings suggest that PMI scores are inversely associated with the proportion of patients with PI. However, PMI scores of − 1 do not always indicate inadequate pain management; pain management should therefore be evaluated from multiple perspectives. A substantial proportion of patients with cancer experience pain , which sThe Pain Management Index (PMI) is used worldwide to evaluate cancer pain management . The PMIAnother indicator for evaluating pain management is pain interference [PI], defined as whether pain interferes with daily life. The Brief Pain Inventory (BPI), another popular instrument for assessing pain, assesses the intensity of pain and interference from pain in seven areas of daily life . PMI andAccording to Deandrea et al., the process–outcome link is an important validity check for any performance measure . HoweverWe performed this study to test these clinicians’ claims by analyzing in more detail the overall trend in PI scores across various PMI and PI scores. We aimed to assess the performance of the PMI as an indicator of the quality of pain management by relating the scores to PI, an outcome measure of pain management. We also expected that differences in prevalence of PI across PMI scores would provide insights on the how PMI scores should be used to assess quality of pain management.Participants were recruited for this study from patients with cancer who were hospitalized at Aomori Prefectural Central Hospital, a general hospital in rural northern Japan, between July 2012 and January 2015. This hospital has approximately 700 beds and provides care to approximately 1200 new patients with cancer annually. All patients aged 20 years and older with a diagnosis of cancer who had cancer-related pain or had taken any analgesic medications in the past 24 h were invited to participate, provided their primary physicians assessed that they were capable of participating in the study. Participants were asked by staff nurses about pain and cancer-related PI as part of routine care during morning rounds every day. The patients’ reports on pain status during hospital days 1 to 7 were analyzed. Medications used were recorded by a staff nurse, who also documented the cause of pain .Patients who had experienced cancer-related pain or taken any analgesic drugs in the past 24 h were eligible for the study. Given that patients with cancer can experience pain caused by various factors, including cancer itself, treatment, and coexisting illness , patientPI was defined as cancer pain that resulted in the patient feeling troubled or being incapable of doing something. Participants were asked a single question “Do you have trouble with pain or is there anything you cannot do because of pain?” They could respond “yes” or “no” .Pain intensity can be determined at its strongest, as the average amount of pain in the past 24 h, or at rest and in motion. The strongest pain in the past 24 h was chosen as the basis for the PMI, in accordance with the original method of Cleeland et al. . Pain inPMI scores were calculated by subtracting the pain score from the analgesics score as in the WHO pain relief ladder . An NRS P value of less than 0.05 was considered to indicate statistical significance. To further clarify the relationship between PMI scores and PI, the distribution of pain intensity experienced within each PMI score category was calculated. For the comparison of proportions of patients with the PI across categories, Pearson’s chi-square test was used. Because the ultimate target of pain management is to eliminate PI, the PMI can be viewed as a tool that tests “inadequate pain management” and thus assesses the process of achieving this target. Therefore, sensitivities and specificities of PMI < − 1 and PMI < 0 for predicting PI were computed. Although PMI < 0 is the conventional criterion for inadequate pain management, a PMI of − 1 is a looser criterion. The sensitivity of the PMI score was defined as the proportion of patients with PI who actually scored positive , and the specificity was defined as the proportion of patients without PI who scored negative . All analyses were performed with Stata version 13.1 .The proportion of patients with PI for each PMI score from − 3 to + 3, overall, and stratified by hospital day were calculated, after which the trend in proportion of patients with PI for each PMI score was assessed by using the Cochran–Armitage test. A P < 0.001).Of 7369 patients with cancer who agreed to be screened for pain as potential participants in the study, 2692 reported experiencing some pain on admission. Among the 1200 patients whose pain was attributable to cancer, 1156 reported pain on the NRS and were eligible for analysis. A total of 6732 responses about pain from these 1156 patients were analyzed . A large proportion of patients with PMI scores of − 2 or − 3 reported PI, whereas this proportion was much smaller among those with PMI scores of − 1, approximating the proportions of those with positive PMI scores of 1 or 2; no patients with positive PMI scores of 3 reported PI. The proportion of patients with PI was lower for those with PMI scores of − 1 than for those with PMI scores of 0 (P < 0.001). Figure Figure Figure The sensitivities of PMI scores < − 1, < 0 and < 1 for predicting PI were 0.16, 0.37, and 0.67, respectively; the corresponding specificities being 0.95, 0.71, and 0.53, respectively.Negative PMI scores are widely accepted as indicating inadequate management of pain, whereas non-negative (0 to 3) scores are thought to denote acceptable pain management , 15, 16.This finding suggests caution must be exercised when evaluating pain management using the PMI. A PMI score of − 1 should be considered as ambiguous, rather than denoting inadequate pain management, and treated differently according to the purpose of the evaluation. When the aim is to identify definitively inadequate care, PMI scores of − 2 and − 3 should be considered, and not scores of − 1. However, when the aim is to broadly capture potentially deficient care for further evaluation, patients with scores of 0 and − 1 should be included. In previous studies that used the PMI to evaluate the quality of pain management, all negative PMI scores were considered to denote inadequate pain management , 15, 16.The explanation for fewer persons with PMI scores of − 1 having PI than those with PMI of 0 may relate to the difference in distribution of pain intensity experienced by these patients. Most patients with PMI scores of − 1 had untreated mild pain, whereas those with PMI scores of 0 had a more balanced distribution of mild and severe pain. A possible reason for this finding is that patients with some mild pain decline pain medications because they have no PI, or because of cost or other reasons; this may be true of the group of patients with PMI scores of − 1 in our study. Scenarios such as patients with mild pain receiving no analgesics versus patients with moderate or severe pain taking appropriate classes of analgesics require more attention when exploring how to improve pain management. Assessment of quality of pain management by the PMI at best reflects only one aspect of the multidimensional factors involved in pain and pain management.Our study has several limitations. First, it was conducted in a single facility in rural Japan, is a cancer care hospital that plays a central role in cancer diagnosis and treatment in a prefecture of Japan. Most of the patients with cancer were in the early stages and receiving active anti-tumor treatment. Thus, our results may not be generalizable to other settings, such as hospitals in large cities that have a higher proportion of patients receiving end-of -life care. However, even in different types of settings, we consider that not all negative PMI scores indicate inadequate pain management. Evaluation needs to be more comprehensive and consider various factors. Second, we used PI as a dichotomous variable, that is, we did not take into account the extent of PI. PI may be more severe in patients with large negative PMI scores than those with other scores. Assessing only the proportion of patients reporting PI may have resulted in missing some important aspects of the problems. Additionally, the simplicity of the single question used to assess PI meant that it did not go through as rigorous a validation process as when developing the measurement tool. It is possible that some patients misunderstood the PI question. However, the mean value of the NRS of pain in the no PI patients was substantially lower (mean 2.0) than that of patients with PI (5.4). Third, PI is a subjective measure and can therefore be affected by patients’ personal perceptions of pain, expectations of their own function, their ability to coping with their pain, and lifestyles. An example of this is that bedridden patients may have low expectations concerning function and may therefore report no interference by pain. Additionally, PI has the limitation that patients sometimes have difficulty in distinguishing interference by pain itself from limitation by other factors, such as their general physical condition. Furthermore, similar to other outcome measures , PI is an inclusive measure of care, and is sometimes influenced by factors other than care. Finally, in the present study PI was assessed from the patient’s response to a single question. This could account for slight differences in results between this study and other studies that assessed PI by other means.Lower PMI scores predict a large proportion of patients who experience interference with their daily lives by pain. However, negative PMI scores do not necessarily indicate that pain is interfering with a patient’s daily life, and non-negative PMI scores do not necessarily indicate adequate pain management. The PMI is a useful tool for quickly assessing pain management. However, it captures only one aspect of pain management, namely the balance of pain intensity and analgesics used. The PMI misses other important factors that may affect patients’ wellbeing, such as dosage of analgesics and response to breakthrough pain. Our findings also indicate that judging the quality of pain management solely on PMI scores is an oversimplification of a complex issue. The PMI is effective in promoting assessment of care in broad settings; however, detailed interpretation by other means would facilitate further improvement in assessment of pain management.


Elderly patients are at a higher risk for hip fracture. Moreover, hospitalized elderly patients with hip fracture are vulnerable to adverse outcomes including higher mortality rate and long-term disability. Treatment decision-making with respect to surgical procedure and perioperative management of these patients is typically challenging owing to the presence of multiple comorbid conditions.The purpose of this study was to investigate the relationship between comorbidities in elderly patients with hip fracture and the treatment decision-making.884 geriatric patients (age ≥ 60 years) with hip fracture were included. Comorbidities related to age were measured using the Charlson Co-morbidity Index (CCI) and age-adjusted CCI. The CCI of each geriatric hip fracture patient was calculated based on data retrieved from the medical records. The relationship of CCI and age-adjusted CCI with surgical procedure, time-to-surgery, length of hospital stay, and perioperative management  was assessed.P = 0.004), surgical treatment (P < 0.001), and transfusion (P = 0.023). The age-adjusted CCI was significantly associated with surgical treatment (P < 0.001), analgesia (P = 0.003) and transfusion (P < 0.001). The length of hospital stay was associated with both CCI (P = 0.041), age-adjusted CCI (P = 0.002), and hypertension (P = 0.012). Hospital expenses showed a significant association with CCI (P = 0.000), age-adjusted CCI (P = 0.029), osteoprosis (P = 0.007), and hypertension (P = 0.001).Mean age of patients was 78.01 ± 8.62 years. The mean CCI was 0.79 ± 0.036; the mean age-adjusted CCI was 4.15 ± 0.047. The CCI was significantly associated with time-to-surgery  contains supplementary material, which is available to authorized users. Hip fractures are a major cause of mortality and disability in the elderly population. Moreover, it increases the burden on caregivers, families, as well as the society at large. The number of geriatric patients with hip fracture has dramatically increased over the last decade –3. Hip fIn the last decade, several studies have sought to identify factors that influence the clinical outcomes of these patients , 7. TimiWhen compared with elderly hip fracture patients without comorbidities, those with comorbidities may accept less-aggressive medical therapy, and experience extended duration of hospitalization, decreased quality of life, and increased health care costs. This is because prolonged immobilization is likely to increase the incidence of urinary and pulmonary complications . Thus, tThe primary objective of this study was to investigate the association between comorbidities [as assessed by Charlson Comorbidity Index (CCI) and age-adjusted CCI] , 15 and This was a cross-sectional observational study of patients with femoral neck fracture or intertrochanteric fracture who were admitted to the West China Hospital of Sichuan University, Chengdu, China between January 2011 and December 2015. The inclusion criteria were: patients aged ≥ 60 years with femoral neck fracture or intertrochanteric fracture diagnosed by computed tomography (CT) or X-ray for the first time; presence of comorbid conditions  was used to evaluate patient comorbidity. The CCI incorporates the number of pre-existing comorbid conditions and their severity , 15. It T score < − 2.5 on dual energy X-ray absorptiometry (DXA); (3) presence of fragility fractures of proximal humerus, pelvis, or distal forearm with − 2.5 < T score < − 1.0.Hypertension and osteoporosis, which are not included in the CCI, were also included in the analysis. Hypertension was defined as a systolic blood pressure > 140 mmHg and/or diastolic blood pressure > 90 mmHg or by history of antihypertensive therapy. Patients who fulfilled one out of the following three criteria were considered osteoporotic: (1) occurrence of adulthood hip or vertebral fracture in the absence of major trauma; (2) Data pertaining to chronic diseases that were already diagnosed were obtained from the medical records. The differential diagnosis had been completed in the past.t test. Categorical variables are expressed as percentages and compared using the Chi-squared test. The CCI and other comorbidities were used as independent variables. Binary logistic regression models were used to examine the relationship of CCI with complications, surgical choice, time-to-surgery, transfusion, anti-coagulation, analgesia, and complications after hip fractures. Linear regression analysis was performed to examine the relationship of length of hospital stay and hospital expenses with CCI, age-adjusted CCI, osteoporosis, and hypertension. The results are presented as crude and adjusted regression coefficients and 95% confidence intervals, standardized coefficients, and P values. All statistical tests of significance were two-tailed, and P values < 0.05 were considered statistically significant. Statistical analyses were performed using SPSS 16.0 statistics software .Continuous variables are expressed as mean ± standard deviation (SD) and compared using Student’s P = 0.053). The age-adjusted CCI for male patients was significantly higher than that for female patients (P = 0.019). The mean age-adjusted CCI of patients with intertrochanteric fracture was significantly higher than that of patients with femoral neck fracture (P = 0.010)  after hip fracture. The CCI had a tendency to associate with venous thrombosis and urinary tract infection. However, age-adjusted CCI was a predictor of venous thrombosis  and urinary tract infection . Additionally, hypertension contributed significantly to the increase in venous thrombosis . Conversely, osteoporosis was not associated with complications after hip fracture , surgical choice , and transfusion   and transfusion .In logistic regression, the CCI remained remarkably associated with time-to-surgery , age-adjusted CCI , and hypertension . Hospital expenses showed a significant association with CCI , age-adjusted CCI , osteoporosis , and hypertension   was associated with time-to-surgery in excess of 48 h, which implies that increase in the CCI increased the risk of delayed surgery. However, it showed no significant association with time-to-surgery in excess of 48 h after adjusting for age. Additionally, the weight of comorbidities in elderly patients with hip fracture (as assessed by age-adjusted CCI) was associated with unavailable operation, increased transfusion, increased hospital stay, and hospital expenses.To the best of our knowledge, this is the first study that investigated the possible association of comorbidities in elderly patients with hip fracture and their treatment preferences, especially with respect to surgical timing and approach. Several studies have shown that patients with hip fracture who are operated within 48 h experience better clinical outcomes and functional recovery –20. MoreHowever, in a study of 56,500 patients with hip fracture  conducted by Librero et al.  early suSeveral strengths of the present study should be noted. Identification of the weight of patients’ comorbidities may have been an important contributor to the delay in surgery when the surgeons were unavailable. A study conducted by Gretchen M. Oroszfor quantified the time interval between injury and hospitalization in older patients with hip fracture ; they foSurgical intervention in geriatric patients with hip fracture has been shown to decrease the risk of mortality up to 1 year, prevent progression to disability, and help maintain functional status of the patient –28. Kau Several limitations of our study should be taken into account while interpreting the findings. First, the present study was a cross-sectional observational study; hence, the influence of confounding factors on our results cannot be ruled out. Secondly, there is lack of a unified comorbidity index for assessment of comorbidities in geriatric patients with hip fracture, which maIn this study, comorbidities were positively associated with the surgical procedure and perioperative management in elderly patients with hip fracture.Below is the link to the electronic supplementary material.Supplementary material 1 (DOCX 23 KB)


The aim of this study was to investigate relations between psychosocial factors, signs and symptoms of orofacial pain and jaw dysfunction in patients with juvenile idiopathic arthritis (JIA).Forty-five patients with JIA (median age 12 years) and 16 healthy matched controls (median age 13 years) were examined according to the diagnostic criteria for temporomandibular disorders (DC/TMD). The subjects answered the DC/TMD questionnaires regarding psychosocial factors .JIA patients with orofacial pain had higher degree of stress, depression, catastrophizing and jaw dysfunction compared to subjects without. In turn, these factors were associated with orofacial pain intensity. Also, patients with orofacial pain had higher systemic inflammatory activity.Orofacial pain in patients with JIA is associated with stress, psychological distress, jaw dysfunction and loss of daily living activities. Pain intensity seems to be the major pain aspect related to these factors. In addition, systemic inflammatory activity appears to be an important factor contributing to orofacial pain in JIA. Juvenile idiopathic arthritis (JIA) is defined as arthritis of unknown origin with onset before the age of 16 and persisting for at least 6 weeks. JIA is categorized into seven subtypes: systemic arthritis, oligoarthritis, polyarthritis , psoriatic arthritis, enthesitis-related arthritis and undifferentiated arthritis , 3.JIA can involve any joint, including the temporomandibular joints (TMJ), but symptoms and signs may vary. The prevalence of JIA is estimated to be 56 individuals per 100,000 in the Swedish population. The estimated annual incidence is 12 cases per 100,000 . These cForty to 96 % of children with JIA develop TMJ arthritis . TMJ paiThe aim of this study was to investigate whether pain and function of the masticatory system, including the TMJ, are related to psychosocial factors and systemic inflammatory activity in patients with JIA.This case-control cross-sectional study was conducted at the Centre of Oral Rehabilitation in Linköping, Sweden between 2015 and 2018. Forty-five JIA patients aged between 6 and 16 years (33 girls and 12 boys) were included (Table Nineteen (43%) of the patients had oligoarthritis, 15 (33%) had polyarthritis and 11 (24%) other subtypes of JIA . The patient sample in the present study was representative for JIA patients in Scandinavia . At inclSixteen healthy age- and sex- matched individuals were recruited from the public dental health clinic in Linköping, Sweden. Inclusion criteria were healthy age- and sex- matched individuals with no subjective pain from the orofacial region. Exclusion criteria were rheumatic disease, diabetes, inflammatory-bowel disease, other chronic pain conditions and psychiatric disease .The diagnostic criteria for temporomandibular disorders (DC/TMD)  was usedThe clinical examination for Axis I diagnostics requires a pain history, assessed by a questionnaire, and a well-defined and structured clinical examination. Clinical assessments evaluate familiar pain localizations, jaw movement capacity , familiar jaw movement pain, TMJ noises and familiar pain upon palpation of the masticatory muscles and TMJ. The criteria for DC/TMD Axis I diagnoses are validated from 18 years of age  and compThe DC/TMD Axis II assesses the patient’s psychosocial function and distress as well as pain-related disability. Axis II is based on validated instruments (questionnaires) and interpretation guidelines. It includes instruments for assessing pain behavior, jaw function, and psychosocial functioning and distress .All patients and healthy individuals were examined by one dentist (ADC) calibrated in the clinical and research use of DC/TMD by the DC/TMD Training and Calibration Center at the Department of Orofacial Pain and Jaw Function, Faculty of Odontology, Malmö University, Sweden.All the participants completed the questionnaires before clinical examination. The participants 12–16 years of age answered all questions.Pain intensity and pain-related disability were assessed with the Graded Chronic Pain Scale (GCPS). GCPS is a reliable seven-item questionnaire that assesses pain intensity and pain-related disability . The twoJaw function limitation was assessed using the Jaw Functional Limitation Scale (JFLS-8). JFLS-8 contains eight items regarding jaw function  that the patient grades separately on a 11- point scale (from no limitation to severe limitation) . JFLS-14The four-item Patient Health Questionnaire (PHQ–4) was used to assess the degree of symptoms from depression and anxiety. There are established cut-off limits for “normal”, “mild”, “moderate” and “severe” degree of symptoms from depression and anxiety , 21. TheThe Pain Catastrophizing Scale (PCS) was used to assess degree of catastrophizing . PCS incThe 10-item Perceived Stress Scale (PSS-10) , 28 desiThe disease-specific Childhood Health Assessment Questionnaire (CHAQ) was used to assess functional ability in daily life activities among children with JIA. CHAQ is designed to capture the physical and psychosocial well-being of children with JIA. CHAQ is a reliable and valid tool and it comprises 30 questions , 32.The body drawing in the McGill Pain Questionnaire was used to record pain locations. In this study, we distinguished between local , regional  and widespread pain  , 34.The Juvenile Arthritis Disease Activity Score (JADAS) is a composite disease activity score specific to JIA . It is sP < 0.05 was considered as significant.Non-parametric statistics were used. For descriptive statistics, median and 25th/75th percentiles were reported. For analytical statistics, the Mann-Whitney U-test was used to calculate the significance of differences between groups and the Spearman ranked correlation coefficient was used to calculate the significance of correlations between variables. A probability level of Table Regarding pain locations and distribution, two (4%) of the patients had local pain distribution, 35 patients (78%) had generalized pain distribution and 8 (18%) patients did not report any pain location. Of the patients with generalized pain distribution, 46% had pain in the masticatory system as well. None of the healthy individuals indicated any self-reported pain.Five (26%) of the patients with oligoarthritis and ten (71%) of the patients with polyarthritis had orofacial pain.Table Table This study indicates that orofacial pain in patients with JIA is associated with stress, psychological distress, jaw dysfunction and loss of daily activities. Pain intensity seems to be the major pain aspect related to these factors. In addition, systemic inflammatory activity seems to be an important factor contributing to orofacial pain in JIA. Myalgia is probably a major reason for orofacial pain in these patients. When assessing the masticatory system in JIA and planning treatment, it seems to be of particular importance to also consider stress and systemic inflammatory activity.In the JIA patients, orofacial pain intensity and perceived stress were related in our patient sample, i.e. stress scores were higher in patients with orofacial pain compared to those without and there was a strong relation between degree of stress and orofacial pain intensity in these patients. Also pain-related disability, distress and catastrophizing were associated with orofacial pain intensity even though there was no difference between JIA patients with or without orofacial pain.. TMJ pain among JIA patients is neither common in general  nor in oOn the other hand, adolescent JIA patients have been found to experience equivalent levels of anxiety and depressive symptoms as healthy adolescents, as also found in our study. For adolescent JIA patients, anxiety and depressive symptoms have been associated with pain and disability but not with inflammation .Stress and chronic pain in the general adolescent population have been found to be related. For example, both musculoskeletal pain and perceived stress appears prevalent among 15- and 16-year adolescents . Pain inThe Perceived Stress Scale used in this study assesses how often subjects have found their lives unpredictable, uncontrollable and overloaded in the last month . ElevateThe strong relation we found between stress and pain intensity support the findings by Österås et al. (2016) . In thatThere was an interesting relation between orofacial pain intensity and limitations in general functional ability during daily life activities like arising, dressing, walking, hygiene, use of aids/devices, reach and grip, as assessed by the CHAQ. CHAQ is certainly not specific for orofacial pain and our findings may therefore likely be due to the systemic inflammatory activity found in the JIA patients with orofacial pain. Our findings are supported by a study of RA patients, where there was a significant impact of TMJ pain and discomfort regarding activities of daily living, including physical exercise and jaw movements . In thatIn the present study, consequences of TMJ pain on maximum mouth opening was related to limitation of jaw function, which is reasonable. Our results thus suggest that the limited jaw function is due to joint pain rather than internal derangements like disc displacement or fibrous adhesions. The maximum mouth opening capacity was not abnormally low at a group level in the patients, where 75% had a mouth opening capacity of 44 mm or more. This suggests that reduced jaw function, in some patients is not due to a limited mouth opening capacity but rather to chewing or communicative  difficulties.Less than half of the JIA patients, reported orofacial pain. Among these, pain in the masticatory muscles, including headache attributed to TMD, was more common than TMJ arthralgia. Only two of the healthy individuals reported orofacial pain.A difficult question to answer is to what extent the orofacial pain is related to the JIA disease, or due to other factors, like masticatory muscle hypertension. JIA is a systemic inflammatory condition that not always will result in TMJ inflammatory activity, causing signs and symptoms from the jaw system. A common feature of JIA, and most rheumatologically disorders, is that pain, when present, is rarely limited to the joint(s) but is also located in the surrounding musculoskeletal system. This is most likely due to sensitization, peripheral and central, of the joints and adjacent areas  and contThe incidence of TMD pain in the general population has been found to rapidly increase from the age of 13–14 years , 47 in gJIA can cause TMJ arthritis and arthritis may cause pain, cartilage and bone tissue destruction and growth inhibition. There are no established diagnostic criteria for TMJ arthritis in JIA and contrast-enhanced magnetic resonance imaging is usually considered as the gold standard for assessing TMJ arthritis. The classical criteria for inflammation  are not applicable regarding the TMJ since these are rare events in TMJ arthritis compared to other peripheral joints. Of these signs, TMJ pain is most common but still not common in JIA. The aim of this study did not include assessment of TMJ arthritis per se, but rather description and analysis of clinical and psychosocial factors related to JIA and orofacial pain. There is, however, an urgent need to develop clinical criteria to enable early identification of JIA patients with established or a risk for TMJ arthritis.http://barnreumaregistret.se) [The study sample of patients had a median systemic disease activity of 6.0 according to JADAS71. This was somewhat higher than the median national systemic disease activity in JIA, approximately 4.0, as reported to the Swedish pediatric JIA-register 2016 (tret.se) . JADAS71tret.se) .This study indicates that orofacial pain in patients with JIA is associated with stress, psychological distress, jaw dysfunction and loss of daily living activities. Pain intensity seems to be the major aspect related to these factors. In addition, increased disease activity with more joint involvement seems to be an important factor contributing to orofacial pain in JIA. Myalgia, in addition to arthritis, seems to be an important source of orofacial pain in these patients.


Subacromial impingement syndrome (SAIS) is a commonly diagnosed disorder of the shoulder. Though this disorder has been known for a long time, it remains a poorly understood entity. Over the years several hypotheses have been put forward to describe the pathogenesis of SAIS but no clear explanation has been found. Two mechanisms, the extrinsic and intrinsic mechanism, have been described for the impingement syndrome. The intrinsic mechanism theories which deny the existence of impingement are gaining popularity in recent years.The various shoulder tests used to diagnose SAIS have low specificity with an average of about 50%. Meta-analysis shows that neither the Neer sign nor the Hawkins sign has diagnostic utility for impingement syndrome.Several randomised controlled trials have shown that the outcome of treatment of SAIS by surgery is no better than conservative treatment. Physiotherapy alone can provide good outcome which is comparable to that achieved with surgery without the costs and complications associated with surgery.Since decompression with surgery does not provide any additional benefits as compared to conservative treatment for patients with SAIS, the impingement theory has become antiquated and surgical treatment should have no role in the treatment of such patients. There are calls by some practitioners to abandon the term impingement syndrome and rename it as anterolateral shoulder pain syndrome. It appears that SAIS is a medical myth. There are others who called SAIS as a clinical illusion. The subacromial space lies between the coracoacromial arch above and the humeral head and greater tuberosity of the humerus below. It contains the rotator cuff tendons, the long head of biceps tendon, the shoulder joint capsule, the glenohumeral ligament, coraco-humeral ligament and the subacromial bursa.1 described rotator cuff pathology and he was of the opinion that humeral head and acromion impingement during shoulder abduction was the cause of rotator cuff lesions and he suggested that lateral acromioplasty would resolve the patient's symptoms.Subacromial pathology has attracted the attention of orthopaedic surgeons for a long time. In 1934, Codman2. He proposed anterior acromioplasty as a mode of treatment for impingement syndrome.In 1972, Neer coined the term impingement syndrome and he was of the opinion that impingement occurred anterolaterally at the anterior acromion and the coracoacromial ligament3.Subacromial impingement syndrome (SAIS) of the shoulder is probably the most common disorder of the shoulder and accounts for about 48% of all shoulder complaintset al4 examined the American Board of Orthopaedic Surgery database from 1999 to 2008 and found a 142.3% increase in the number of arthroscopic acromioplasties performed during the period. These figures raise the question of the role of such surgery in patients with SAIS and whether such surgery is justified in patients with SAIS.There has been a dramatic increase in the incidence of acromioplasty over the years. Vitale 2 introduced the idea that rotator cuff problems were the result of contact or “impingement” of the rotator cuff tendons to the acromion, the coracoacromial ligament or the undersurface of the acromioclavicular joint. Subacromial impingement syndrome (SAIS) now includes a spectrum of subacromial space pathologies which include rotator cuff tears, calcific tendinitis, biceps tendinopathy, rotator cuff tendinosis and subacromial bursitis5.In 1972, Dr Charles NeerThe aetiology of SAIS remains a mystery. Different hypotheses have been put forward to describe the pathogenesis of SAIS but no clear explanation has yet been found.7. The intrinsic mechanism theories are gaining popularity in recent years9.Two mechanisms, the extrinsic and intrinsic mechanisms, have been proposed for the genesis of the impingement syndrome. In the intrinsic mechanism, it is believed that damage to the rotator cuff tendons leads to impingement and in the extrinsic mechanism the impingement is believed to cause damage to the tendons7. The damage to the tendon fibres increases in size as we age, and the damage is more common in patients who are diabetics10. Histological examination of the tendon often shows a “failed healing response”11.As is the case with the tendo Achilles, the supraspinatus tendon too has poor vascularity near its insertion on the greater tuberosity. There is an avascular zone called the critical zone and it is here that the degenerative tears of the supraspinatus tendon originate12.Proponents of the extrinsic mechanism tried to correlate shoulder pain to shoulder “impingement”. Hooked (type III) acromions were believed to cause “impingement” as a result of the reduced distance in the subacromial space. To date, however, it is not known whether the shape of the acromion is age-related or congenitalA protracted scapula and weakness of the scapular muscles, particularly the serratus anterior and trapezius have also been implicated in shoulder impingement. Abnormality of the glenohumeral joint and weakness of the rotator cuff muscles can lead to superior migration of the humeral head which can cause impingement as well.13 have also been implicated in the genesis of rotator cuff disease and shoulder pain. According to Neer, trauma may enlarge a rotator cuff tear but is rarely the principal factor14.Several other extrinsic factors including, heavy physical loading, vibration, injury, smoking, infection, genetic factors, and fluoroquinolonesThe history of patients with SAIS is usually consistent. They complain of shoulder pain which usually develops insidiously over a period of weeks to months. The pain is usually localised anterior and lateral to the acromion and frequently radiates to the lateral aspect of the mid-arm. The pain is more common at night and is exacerbated by lying on the involved side and sleeping with the arm overhead. Overhead activities produce pain in the shoulder. Sometimes weakness and stiffness may be present due to pain.15. Hegedus et al16 in their meta-analysis concluded that neither the Neer nor the Hawkins sign had diagnostic utility for impingement syndrome.There are several clinical tests used to diagnose SAIS such as the Neer test, Hawkins-Kennedy test, Impingement test, Drop arm test, and Jobe's test. The specificity for these tests is poor. The average specificity for the Neer’s test is about 36±22% and for the Hawkins sign, the specificity is about 41±19%Imaging studies are of not much value in elucidating the cause of shoulder pain and in the diagnosis of SAIS. An MRI will show rotator cuff pathology and bursitis but it will not pinpoint the cause of shoulder pain.A. Non-Operative Treatment17 in 1997 showed that most patients with shoulder impingement syndrome eventually recover with non-operative intervention21. The most common non-operative treatment modalities used include modification of activity, the use of non-steroidal anti-inflammatory drugs, subacromial steroid injections and physical therapy programs17.A review of the literature by Bigliani and Levineet al22 retrospectively reviewed the outcome of conservative treatment of 616 patients (636 shoulders) who had subacromial impingement syndrome. All the patients were treated with NSAIDs and isometric and isotonic muscle strengthening exercises. The average follow-up period was 27 months. Sixty seven percent of the patients had a satisfactory outcome, 28% had an unsatisfactory outcome and were treated with surgical decompression and 5% of the patients had an unsatisfactory outcome but they declined surgical intervention.Morrison The outcome was better in patients who were 20 years old or less and those who were between 41 years to 60 years old as compared to those who were 21 years to 40 years of age. The outcome was worse in patients who were more than 60 years of age. The outcome was better in patients with type-I acromion as compared to patients with type-II or type-Ill acromion.et al23 carried out a systematic review and meta-analysis to assess the effectiveness of exercises in SAIS. They found that there was strong evidence that exercise decreases pain and improves function on short-term follow-up. They also found moderate evidence that exercise results in short-term improvement in mental well-being and long-term improvement in function.Hanratty 24. There is, however, growing evidence that resistance and proprioceptive exercises are more effective than movement-based exercises alone27. In recent years there has been an emphasis on the need to restore normal scapular kinematics by improving strength, balance, and flexibility of muscles which control scapular position and motion31. The recommendations for duration of conservative treatment before surgery is contemplated has varied widely in the literature. In most studies, it has ranged from twelve months to eighteen months17.The exercise programs include scapular stabilisation exercises, rotator cuff resistance exercises, range of motion as well as stretching exercises. Of these exercise programs which is most effective is not knownDespite the fact that there has been so much research on exercise therapy for SAIS, there still remains insufficient evidence to support or disprove specific exercise programs for the treatment of patients with SAIS.B. Operative treatmentMany surgeons resort to operative treatment when conservative treatment fails to provide pain relief. The commonly performed operation is an anterior acromioplasty with resection of the coracoacromial ligament.2 or by the arthroscopic technique described by Ellman32. Other surgeons carry out arthroscopic subacromial decompression where decompression of the subacromial space is done by removing bone spurs and soft tissue.Anterior acromioplasty can be performed with an open technique which was first described by Neer36. Similarly, there are several authors who have reported good results with arthroscopic acromioplasty43.Several authors have reported good outcome in 73% to 93% of the patients who were treated with open acromioplastyet al44. They reviewed the results of 110 consecutive arthroscopic acromioplasties in patients who were followed-up for at least two years. Satisfactory results were only seen in 46% of the patients. The authors were of the opinion that open decompression yields superior results.The worst results for arthroscopic acromioplasty were reported by Hawkins 46. The most common complication has been insufficient removal of bone leading to a need for a revision operation. Acromion fracture as a complication has also been reported47.Complications are low at between 0.76% to 6.5% with arthroscopic acromioplasty48. Musculocutaneous nerve, median, ulna, and radial nerve injuries can occur during shoulder arthroscopy49.Infection rates of between 0.04% to 3.4% have been reported for arthroscopy of the shoulder50 reported four cases of arthroscopic shoulder surgery that resulted in one death and severe brain damage in three others. Ophthalmoplegia, stroke, brain death and loss of vision has also been reported52.Several reports of devastating complications with beach chair position for shoulder arthroscopy have been reported. Pohl and Cullen53. Stiffness of the shoulder is probably the most common complication after shoulder surgery. It leads to significant morbidity, loss of function and disability. The incidence of shoulder stiffness after shoulder arthroscopy varies between 2.8%46 to 15%54.Fractures of the clavicle, acromion, and humerus can also occur during shoulder arthroscopy55. Thermal probes used during shoulder surgery are known to raise the intraarticular fluid temperatures to above 45ºC which can cause chondrocyte death56.Chondrolysis following shoulder arthroscopy is a rare but devastating complication. Intraarticular pain pumps using bupivacaine have been implicated in the causation of chondrolysis59.Another devastating complication of arthroscopic shoulder surgery is avascular necrosis of the humeral headAll these years the Neer concept of “impingement” has been accepted as the cause of rotator cuff disease and also formed the basis for clinical testing as well as describing radiographic and magnetic resonance imaging (MRI) changes.8.Over the years, contact with the coracoid, superior glenoid, posterior and superior labrum were also implicated in the genesis of shoulder impingement syndrome8. Some of these abnormalities are characteristic of changes due to ageing. Physical loading, infection, smoking, vibration, injury, genetic factors, and use of fluoroquinolone antibiotics are factors which are known to produce such histologic features13.In recent years, however, impingement as a cause of rotator cuff disease has been questioned. Rotator cuff disease is now believed to be a form of tendinopathy similar to tendinopathies in other parts of the body. It is believed to be overuse tendinopathy and not a form of tendinitis. Histologically the findings are that of a failed healing response with little or no evidence of inflammation. Histological examination of the tendons show abnormalities of tenocytes proliferation, intracellular abnormalities in the tenocytes, collagen fibres disruption and an increase in the non-collagenous matrix60.The rotator cuff tendons have few nerve fibres. Mechanoreceptors and free nerve endings are found in the superior, middle, inferior, and posterior glenohumeral ligaments. They are also found in the coracoclavicular, and coracoacromial ligaments. Only the outer half of the glenoid labrum has nerve endings. Large numbers of free nerve endings are found in the subacromial bursae61.The rotator cuff tendons play a role in generating pain through some indirect mechanism where some peptides or transmitters produced by the degenerated tendon initiate a pain response from the pain fibres in the bursa, ligaments of the joint and the joint capsule8. Studies show that patients with failed rotator cuff repair obtain pain relief from surgery which means that rotator cuff tendon healing to bone is not necessary for a good surgical outcome. It also means that impingement is not the cause of the pain. Some other mechanism is responsible for the pain8.There is no direct relationship between the presence of a rotator cuff tear and the presence of pain. Patients with large rotator cuff tears can have no pain while some patients with small tears can have severe pain8. This new concept which refutes the existence of impingement is supported by several randomised controlled trials66 which show no supremacy of surgery over conservative treatment.Since the impingement theory has become outdated, the surgical treatment should have no role in the treatment of shoulder pain. Some authors have even proposed that the impingement syndrome should be renamed as anterolateral shoulder pain syndromeet al62. They carried out a multicentre, randomised, placebo-controlled, three-group trial at 32 hospitals in the UK. Included in the trial were patients with subacromial pain of three months duration who had completed conservative treatment and had at least one steroid injection and were eligible for arthroscopic surgery. Patients with full-thickness rotator cuff tear were excluded. They randomly assigned 106 patients to decompression surgery group, 103 patients to arthroscopy only group and 104 patients to no treatment group. At six months, Oxford Shoulder Score data was available for 90 patients in the decompression group, 94 patients in the arthroscopy group, and 90 patients in the no-treatment group. There was no difference in the mean Oxford Shoulder Score between the decompression and arthroscopy group at six months. Both surgical groups showed a small benefit over no treatment but these differences were not clinically significant. Surgical decompression offered no extra benefit over arthroscopy only. The authors believe that the difference between the surgical groups and no treatment group may be the result of a placebo effect or post-operative physiotherapy which the surgical group had. The authors questioned the value of subacromial decompression for shoulder pain.The most outstanding study was the one by Beard et al67 carried out Cochrane systematic review of the literature to assess the benefits and harms of subacromial decompression surgery as compared with placebo, no intervention or non-surgical interventions in patients with subacromial impingement and rotator cuff disease. Patients with full-thickness rotator cuff tears were excluded.Karjalainen The authors concluded that the evidence available does not support the use of subacromial decompression in the treatment of rotator cuff disease in patients with painful shoulder impingement. High-quality evidence shows that subacromial decompression does not provide clinically important benefit as compared to placebo as far as pain, function and health-related quality of life is concerned.Physiotherapy provides good outcome which is comparable to that achieved with surgery. Conservative treatment also avoids the costs and the complications which are associated with surgery. Some of the complications associated with shoulder arthroscopy are devastating though rare.Subacromial impingement syndrome (SAIS) of the shoulder has been known for a long time and is probably the most common disorder of the shoulder. Several hypotheses have been put forward to describe the pathogenesis of SAIS but no clear explanation has been found. Two mechanisms have been described for impingement syndrome, the extrinsic and the intrinsic mechanism. The intrinsic mechanism theories are gaining popularity in recent years. The various shoulder tests used to diagnose SAIS have poor specificity with an average of about 50%. Meta-analysis shows that neither the Neer sign nor the Hawkins sign has diagnostic utility for impingement syndrome. Several randomised controlled trials have shown that the outcome of treatment of SAIS by surgery is no better than conservative treatment. Physiotherapy alone can provide good outcome which is comparable to that achieved with surgery without the costs and complications associated with surgery.14.Since decompression with surgery does not provide additional benefits compared to conservative treatment for patients with SAIS, the impingement theory has become antiquated and surgical treatment should have no role in the treatment of such patients. There are calls by some to abandon the term impingement syndrome and rename it as anterolateral shoulder pain syndrome. There are others who have called SAIS as a clinical illusion


Pain is a common condition with a significant physical, psychosocial, and economic impact. Due to enormous progress in mobile device technology as well as the increase in smartphone ownership in the general population, mobile apps can be used to monitor patients with pain and support them in pain management.The aim of this review was to assess the efficacy of smartphone or computer tablet apps in the management of patients with pain.In December 2017, a literature search was performed in the following databases: MEDLINE, EMBASE, CINAHL, Cochrane, and PsycINFO. In addition, a bibliography search was conducted. We included studies with at least 20 participants per arm that evaluated the effects of apps on smartphones or computer tablets on improvement in pain.A total of 15 studies with 1962 patients met the inclusion criteria. Of these, 4 studies examined the effect of mobile apps on pain management in an in-clinic setting and 11 in an out-clinic setting. The majority of the original studies reported beneficial effects of the use of a pain app. Severity of pain decreased in most studies where patients were using an app compared with patients not using an app. Other outcomes, such as worst pain or quality of life showed improvements in patients using an app. Due to heterogeneity between the original studies—patient characteristics, app content, and study setting—a synthesis of the results by statistical methods was not performed.Apps for pain management may be beneficial for patients, particularly in an out-clinic setting. Studies have shown that pain apps are workable and well liked by patients and health care professionals. There is no doubt that in the near future, mobile technologies will develop further. Medicine could profit from this development as indicated by our results, but there is a need for more scientific inputs. It is desirable to know which elements of apps or additional devices and tools may improve usability and help patients in pain management. Mobile device technology has improved enormously in the past years. With higher screen resolution or better processor performance, not only has the hardware improved but also many software programs known as mobile apps have been developed, thereby setting up a technological revolution. Use of internet on smartphones and the proportion of total internet use have increased within the past few years -3 and arPain, acute and chronic, is a substantial burden on individuals, health care systems, and employers . PatientThis systematic review is based on the preferred reporting items for systematic reviews and meta-analyses (PRISMA) .At the end of December 2017, a systematic literature search was commissioned to the Careum Bibliothek of the University of Zurich. The following electronic databases were searched by an experienced librarian: MEDLINE, EMBASE, CINAHL, Cochrane, and PsycINFO. We used, among others, the following search terms as medical subject headings and other subject headings: “Pain+,” “Pain Management,” “Pain Measurement,” “Cellular Phone+,” “Mobile Devices,” “Mobile Applications,” “Telehealth,” and “Telemedicine+.” Detailed description of one search strategy is provided in Studies included in this review evaluated the effects of mobile apps (which we refer to as apps and are defined as a type of application software designed to run on a mobile device ) on smarStudies were excluded if devices other than a smartphone or computer tablet  or if an app not defined as above was used for data collection . Furthermore, exclusion criteria were the use of apps designed for diagnosis of a medical condition or not explicitly designed for pain-level recording, management, or treatment . These exclusion criteria did not apply if there was another app that was designed to take part in the study, for example, pain diary. In addition, studies were excluded if they included patients with a cognitive handicap, did not provide sufficient baseline data, described the development process of an app without measuring the effects of app use on pain, were conducted in the field of veterinary health, or were not available for purchase.All references were initially screened by title and abstract by 2 reviewers (SET and JMB) for relevance. Finally, full-text analysis for eligibility was performed by SET and JMB independently. Disagreements were discussed and resolved by consensus or third-party arbitration (JS).The primary outcome of interest of this systematic review was improvement of pain. Other outcomes of interest assessed in the studies, such as worst pain  or improvement in mobility were also included in analysis.The checklist of the Scottish Intercollegiate Guidelines Network (SIGN)  for randFor before-after studies , no checklist is required .The primary objective of this study was to assess the mean pain difference between intervention and control groups or before and after intervention. If data for several time points were available, the last one was considered to be the most relevant to our analysis. Heterogeneity of studies did not allow meta-analysis; so, only descriptive and comparative analysis was used to summarize findings across all studies.A secondary objective was to summarize other outcomes as well as applicability and feasibility of the apps in a qualitative way. Most of the additional outcomes reviewed were too heterogeneous to compare statistically. Qualitative descriptive exploration was performed, and the most important results were summarized in a table.For the primary comparative analysis, studies were included if sufficient data were available and measurement scales were comparable. Only study results with very similar pain rating scales were included , and where necessary, different pain score scales were rescaled to a 0- to 10-point scale. We graphically show the mean pain scores over time separately for each study arm where available. The effects of treatment in the multiple-arm studies with sufficient data for comparison are shown in a forest plot. Studies that did not have an observational period—all of which have an in-clinic study setting—are shown in a separate graph. If data were missing and could not be calculated from the other available data, corresponding authors were contacted twice via email. If authors did not respond, data were considered missing.As shown in Characteristics of included studies are shown in One study did not report mean pain values but only mean change in pain values. Therefore, description of results but no graphic representation was possible . Schatz Blödt et al  reportedAll studies evaluating changes in quality of life revealed a statistically significant improvement in the groups using an app ,27,31,32worst pain or quality of life, showed improvements in patients using an app. Due to heterogeneity between the original studies—patient characteristics, app content, and study setting—a synthesis of the results by statistical methods was not performed.The main objective of this review was to evaluate the efficacy of apps on smartphones or tablets for the management of patients with pain. The results of 7 RCTs, 6 before-after studies, 1 controlled before-after study, and 1 retrospective data analysis were included in this review. The majority of the original studies reported beneficial effects of the use of a pain app. Severity of pain decreased in most studies in patients using an app compared with those not using an app. Other outcomes, such as To the best of our knowledge, this is the first systematic review about the efficacy of smartphone or computer tablet apps for the management of patients with pain. There are published systematic reviews that study the quality of the content  and ease of use of commercially available apps for pain management -15,17. NAuthors of 3 reviews -12 critiOther studies not meeting our inclusion criteria  showed results similar to the studies included in our analysis. In the study of Kristjánsdóttir et al , patientReviews about the effects of apps in other medical fields showed reduction in anxiety  and deprOne study reported no improvement in systolic blood pressure with app use, although there was a small improvement in medication adherence . HurkmanFor the sake of overview, we depicted acute and chronic pain outcome studies in the same figures. However, acute pain and chronic pain are two different entities; therefore, direct comparison is difficult, and this should be considered when interpreting the results. Furthermore, part of our results showing no effect of app use on pain management can be explained. The app examined by Raj et al  was a clThe main limitation of our review is the heterogeneity of the included studies for the synthesis of study results. On the other hand, this enables existing data to be represented in general without selection bias. Furthermore, apps are a new element in telehealth and their development is still progressing. Indeed, apps were only made available for a wide population in 2008 and 2009, when the Apple’s App store and Google Play for Android, respectively, were introduced. Our strength is that this review is based on the PRISMA guidelines  and thatIn the management of patients with pain, apps can provide patients a wide range of features such as pain diary, educational features, reminders, treatment recommendation aspects, and direct communication with health care personnel in a single mobile app. Furthermore, intelligent systems such as chatbots or virtual assistants are already part of daily life for many people. These new technologies should be introduced into telehealth in the near future, and their testing for validity and usability is crucial. Correspondingly, there is a need for more high-quality studies for the evaluation of the efficacy of these new instruments.Furthermore, our review showed that a standardized assessment of pain is lacking in the included studies, and therefore, it would be desirable that the scientific community agrees on a standardized protocol for pain assessment. In addition, there is a need for detailed reporting of the structure, data assessment, and functions of the apps and studies to investigate the elements of the apps or additional devices or tools that may improve usability and help patients in pain management. This information would strengthen future studies and allow researchers to synthesize the results of different studies.Apps for pain management may be beneficial for patients, particularly in an out-clinic setting. Studies have shown that pain apps are workable and well liked by patients and health care professionals. There is no doubt that in the near future, mobile technologies will develop further. Medicine could profit from this development as our results indicate, but there is a need for more scientific inputs. It is desirable to know which elements of apps or additional devices or tools may improve usability and help patients in pain management.


In contrast, when interference was high on activity, more physical well-being problems were evident e.g. weight: mean BMI 31.0 (SD 7.3) kg/m2, diminished exercise: mean of 1.5 (SD 1.6) exercising sessions per week, and avoidance behavior: mean PASS-20 Escape/Avoidance subscale 3.7 (95% CI: 1.7 to 5.8) scores higher in comparison to activity interference remaining low. With high affective interference, more depressive symptoms: mean BDI-II score 17.7 (SD 7.3), and more cognitive pain anxiety: mean PASS-20 Cognitive Anxiety subscale 2.8 (95% CI 0.7 to 4.8) scores higher in comparison to affective interference remaining low, emerged. Having high interference on both dimensions indicated accumulated risks for reduced physical well-being: mean BMI 29.9 (SD 6.1) kg/m2, mean of 1.2 (SD 1.7) exercising sessions per week, mood problems: mean BDI-II 20.3 (SD 10.6), and negative psychological reactions to pain: mean total PASS-20 score 53.2 (18.4). The results suggest that low interference on both dimensions may allow assessment with only physician consultations, while high interference on either dimension may call attention to distinct issues to be addressed with the help of a physiotherapist or a psychologist, whereas high interference on both dimensions highlights the need for a full multidisciplinary assessment.Chronic pain patients enter treatment with different problem profiles making careful assessment a necessity for more individualized treatment plans. In this cross-sectional study we assigned 320 patients entering tertiary multidisciplinary pain treatment into four categories based on whether they scored low or high on the activity and the affective pain interference dimensions of the Brief Pain Inventory (BPI). To determine whether this categorization system delineates issues that should be assessed further, the categories were compared with ANOVA and MANOVA analyses on three domains: variables affecting physical well-being , psychological resources (mood), and pain-specific psychological factors . The results indicated that subjects who scored low on both interference dimensions compared similarly in weight: mean Body Mass Index (BMI) 27.0 (SD 6.0) kg/m Multidisciplinary pain treatment aims to address the biological, psychological, and social factors contributing to the chronic pain problem . PatientThe Brief Pain Inventory (BPI)  is a widThe study analyses whether categorizing pain patients by activity and affective interference will reveal the issues that may appear in the treatment regarding the three domains: risks for physical well-being , psychological resources (mood), and pain-specific psychological factors (pain anxiety and pain acceptance). Should categories with different problems appear, the findings may help in choosing the areas that require further assessment.Previous research has linked higher pain interference to less recreational exercise , weight In both prospective ,14 and cPatients with less pain catastrophizing and more self-efficacy  or betteIn this study, we categorize pain patients to those who are low on both activity and affective interference, to those with high interference on either dimension, and to those with high interference on both dimensions at the same time. Our hypothesis is that high activity interference is associated with less exercise , and higThis study employs a cross-sectional design. Patients seeking care for a persistent pain problem completed the Brief Pain Inventory and were then classified according to their scores on both activity and affective pain interference to either a “low” (under 7.00) or “high” level  ,21,22. TThe cohort comprised 320 patients participating in the KROKIETA study, which explores relationships between socioeconomic factors, lifestyle aspects, biochemical variables, psychological factors, and quality of life of patients with chronic non-malignant pain . The KROPatients received an invitation to the KROKIETA study before their first visit to the pain clinic by a leaflet included in the mailing containing the pre-appointment questionnaires on pain, health, and lifestyle factors. If the patient agreed to participate in the study, he/she signed the informed consent form at the clinic and filled in further questionnaires on psychological factors and quality of life, which were then input into the study database along with data from the pre-appointment questionnaires. During the visit a nurse measured the patient’s weight, height, and blood pressure, while the physician recorded information on diagnoses, medications, and treatments. Approximately half of the invited patients declined participation in the study.Brief Pain Inventory  is a queSeveral reports have presented a proposed factor structure with pain intensity, activity interference, and affective interference factors ,24,25, aFor this study, we used the mean score of the pain intensity items and constructed the interference scales as proposed by Cleeland et al. : activit2) and obesity (>30.0 kg/m2) from measurements taken by the nurse during the first visit at the clinic.Body Mass Index (BMI) was calculated as an indicator for overweight   was usedBeck Depression Inventory-II (BDI-II)  was usedPain Anxiety Symptoms Scale is a measurement assessing pain-related anxiety. In this study, we used the 20-item version (PASS-20) . PASS-20There are no established cut-off values for what constitutes an abnormal anxiety score in PASS-20. Abrams et al.  proposedChronic Pain Acceptance Questionnaire (CPAQ)  measuresCPAQ consists of 20 items that the subject answers on a 7-point scale ranging from “never true” to “always true”. Items on the pain willingness scale are reverse-scored so that increasing scores on both scales mean increasing acceptance. Psychometric studies have reproduced the measurement’s factor structure  and founData analysis started from screening of missing data on BPI. Nine subjects had completely missing data on interference items. They were excluded from subsequent analysis, leaving 311 subjects for the final data set, as shown in Subjects were then assigned a low/high status on both activity and affective interference dimensions using 7.00 as the cut-off. The analysis continued by inspecting the formed groups against demographic variables and variables affecting physical well-being, mood, and pain intensity. Group differences were investigated through a series of one-way analysis of variances (ANOVA) and chi-square test with post hoc comparisons using Hommel’s correction.Then, to determine whether the four groups differed on the various pain anxiety and pain acceptance dimensions, two multivariate analyses of variances (MANOVA) were conducted, first with PASS-20 subscales and then with CPAQ subscales as the dependent variables. To aid comparing groups across PASS-20 and CPAQ measurements, the raw sum scores on the subscales were converted to z-standard scores. Due to missing data on PASS-20 and CPAQ measures, there were 285 subjects in the data set for these analyses. Post hoc comparisons for group differences were conducted with a series of ANOVAs with Tukey’s Honestly Significant Difference (HSD) test. The bootstrap method was used when the theoretical distribution of the test statistics was unknown or in case of violation of the assumptions . The effects of age, gender, and education were controlled in all analyses. The Stata 15.1, StataCorp LP  statistical package was used for the analyses.The mean age of the subjects (64.4% women) was 46.9 years (SD 13.4). Most of the patients were married or co-habiting (62.3%), and the rest were either single (23.8%), divorced (10.9%), or widowed (2.2%). For most subjects, the highest educational level was either vocational or high school (65.5%) or higher education (20.4%). Slightly over half were in the work force, one in four was on a pension, and the rest were either unemployed, studying, or outside working life for other reasons. Pain had lasted between one and two years for 14.0% and over two years for 72.4% of the subjects. Of the subjects 79.3% reported pain in two or more locations. Subjects reported most often pain in the lower limbs (68.4%), low back area (57.8%), and upper limbs (46.6%) and least often pain in the stomach (19.4%), chest (14.3%), and neck areas (13.1%).The correlation between pain intensity and activity interference was 0.63 (95% CI: 0.56 to 0.69) and between pain intensity and affective interference 0.59 (95% CI: 0.51 to 0.65).The groups were similar in age, gender, education, and whether pain had lasted over two years, as shown in 2 higher compared with group C. The average exercising frequency was half of that of group C, and 47% reported being incapable of doing any exercise. For group B, the mean BDI score was in the moderate depressive symptom range (20–28) .Subjects with low interference on both dimensions (group C) had a mean BMI in the overweight category and they exercised on average >2 times per week, with 11% of the subjects stating that they were not able to do any exercising. The mean score in BDI showed no depressive symptomatology. In contrast, when interference was high on both dimensions (group B), the mean BMI was 2.9 kg/mWhen activity interference was low, but affective interference high (group A), the mean BMI and exercising frequency  were similar to those in group C, but the mean BDI score was significantly higher (P < 0.001) and reflected mild depressive symptomatology. Lastly, for the group with high activity interference and low affective interference (group D), the picture was reversed–the mean BMI was significantly higher, reaching the obese category, and exercising frequency was significantly lower  than in group C (both P < 0.001). The mean BDI score was at the same level as that of group C, indicating no depressive symptomatology.Smoking was less prevalent in group C, where approximately every third patient smoked, than in group B, where every other subject smoked (P = 0.045). For alcohol risk use, the AUDIT score was below the cut-off point for alcohol risk use in all groups, with no group differences in mean scores.MANOVA analyses indicated a significant difference between the groups on the combined dependent variables both on PASS-20 (P < 0.001) and CPAQ (P < 0.001). ANOVAs for post hoc comparisons showed a significant difference in subscale scores between the groups . Due to missing data, analyses on PASS-20 and CPAQ included 285 subjects.Group A  had a mean value that was 2.8 (95% CI: 0.7 to 4.8) scale scores higher than group C on the cognitive anxiety dimension (P = 0.02), while group D  had a mean value that was 3.7 (95% CI: 1.7 to 5.8) scale scores higher than group C on the escape/avoidance dimension (P = 0.001). Groups A and D remained at the same level as group C on fear and physiological anxiety dimensions.The average total PASS-20 score was 36.4 (SD 17.9) for group C, 53.2 (SD 18.4) for group B, 43.2 (SD 13.0) for group A, and 43.35 (SD 18.0) for group D (P < 0.001).Groups C and B had a similar pattern for pain acceptance as for pain anxiety, as shown in This study grouped pain patients starting multidisciplinary pain treatment based on the type and level of reported pain interference. There were two main findings. First, adverse changes appeared in different sets of variables when pain interfered highly with either the activity dimension  or the affective dimension . Second, when interference was high on both dimensions, adverse changes accumulated within variables affecting both physical well-being and psychological resources. There was also more pain-related fear and physiological anxiety compared to when pain interfered highly with only one of the two dimensions. The findings may help in deciding what components of multidisciplinary assessment and treatment individual patients need.Overall, 38% of the subjects fell into the group that scored low on both activity and affective pain interference (group C). Being slightly overweight and exercising slightly over two times per week, they represented Finns as a whole . Every tPain interference was high on either of the interference dimensions for 24% of the subjects. When interference was high on the affective dimension (group A), adverse changes were seen in mood and cognitive anxiety symptoms, as expected [On the other hand, if interference was high on the activity dimension (group D), significant changes emerged, such as less exercise, as expected , but alsA total of 38% of the patients scored high on both dimensions of interference (group B) with an associated set of adverse scores in the areas encompassed in the two previous groups (A and D). Rather worryingly, almost every other subject in group B reported being unable to participate in any exercise. Additionally, every other subject in group B smoked. Compared with the three other groups, fear and physiological anxiety were also elevated in group B patients. The mean total pain anxiety was in the “moderate” range, if using the classification by Brede et al. , and regThe pronounced negative cognitive-emotional reactions to pain in group B are an interesting finding. Previous studies have underscored the role of catastrophizing in pain interference ,50, and The findings of our study on the different levels of complexity regarding patients’ problems  between the groups echo those of previous research categorizing pain patients in order to decide who requires more multidisciplinary components in the treatment. In the STarT Back Tool, a questionnaire categorizing back pain patients in primary care to low, medium, and high risk for pain chronification, psychological distress and pain catastrophizing are the critical indicators for high risk . Low-risSurprisingly, no differences emerged in alcohol risk use between the groups. In prospective studies, higher pain interference has been associated with increased risk for alcohol dependence, especially in men ,13. GendA limitation must be noted when considering the findings of this study. Approximately half of those invited to the study declined participation, which may affect the generalizability of results. However, we performed a comparison with a previous study conducted at one of the clinics participating also in this study and collecting data on all the patients entering treatment . This coThe results of this study may benefit the assessment process of chronic pain patients entering multidisciplinary treatment. The findings indicate that if the patient presents with low interference on both activity and affective interference dimensions, the probability of benefitting from the treatment is likely to be good: less weight problems, regular exercising, better mood and the most helpful psychological reactions to pain among this patient population. This may allow proceeding in the assessment with only physician consultations. If only affective interference is high, then assessment may benefit from a more in-depth inquiry into mood, maladaptive thought patterns about pain, and lost life-fulfilling activities, e.g. a consultation with a psychologist. When only activity interference is high, inquiry should focus more on issues of weight gain, exercise, and pain avoidance behavior. The patient might benefit from seeing a physiotherapist as part of the assessment. Finally, when the patient presents with high interference on both dimensions, the risk for reduced physical and psychological well-being have likely accumulated, and the psychological reactions to pain seem highly important targets in the assessment. For these patients, the findings support the need for full multidisciplinary assessment.Future research should seek whether the pain interference categories identified in this study and their relationships to the studied variables can be replicated. A longitudinal study would provide an opportunity to investigate whether the four categories differ in treatment pathways and outcomes. Another interesting question would be to find out whether the introduction of the pain interference categories could streamline the allocation of chronic pain patients into appropriate components of multidisciplinary assessment and management.