After total knee arthroplasty with conventional surgical approach, more than half of the quadriceps extension strength is lost in the first postoperative month. Unicompartmental knee arthroplasty (UKA) operated with minimally invasive surgery (MIS) results in less operative trauma. We investigated changes in leg-extension power (LEP) in the first month after MIS Oxford UKA and its relation to pain, knee motion, functional performance, and knee function. In 35 consecutive Oxford UKA patients, LEP was measured 1 week before and 1 month after surgery together with knee motion, knee swelling, the 30-second chair-stand test, and Oxford knee score. Assessment of knee pain at rest and walking was done using a visual analog scale. 30 patients were discharged on the day after surgery, and 5 on the second day after surgery. LEP and functional performance reached the preoperative level after 1 month. Only slight postoperative knee swelling was observed with rapid restoration of knee flexion and function. A high level of pain during the first postoperative night and day fell considerably thereafter. None of the patients needed physiotherapy supervision in the first month after discharge. Fast-track MIS Oxford UKA with discharge on the day after surgery is safe and leads to early recovery of knee motion and strength even when no physiotherapy is used. After total knee arthroplasty (TKA), more than half of the preoperative quadriceps strength is lost in the first month after surgery . TKA surWe studied changes in LEP within the first month after fast-track MIS Oxford Phase III medial UKA in relation to pain, knee motion, functional performance, knee function, and the need for physiotherapy after discharge.This prospective study included 39 consecutive patients who were scheduled for primary unilateral Oxford medial UKA  at the Department of Orthopedics, Holstebro Regional Hospital from May 2010 through January 2011. The patients were included according to the criteria described by the Oxford Group .All patients were operated under spinal or general anesthesia by one of two surgeons with good experience of MIS and Oxford UKA. Cefuroxime (1.5 g) was administered intravenously before surgery and tranexamic acid (1 g) was administered intravenously at the end of surgery. Local infiltration analgesia (LIA) was used intraoperatively . No draiAll patients followed the same fast-track program for elective UKA that had been used at the hospital since 2009 . It inclThe patients were ambulatory 2–4 h after surgey. Low molecular heparin  was given 6–8 hours after surgery and was continued daily until discharge. The compression bandage was removed in the morning on the day after surgery, and free active knee movement was allowed. The patients were discharged according to well-defined discharge criteria and were given written advice on potential problems with a 24-h emergency contact telephone number. They were also contacted by telephone on the day after discharge. All patients were seen at the outpatient clinic after 1 and 2 weeks, and at the outpatient physiotherapy unit after 4 weeks to re-assess and adjust home exercises.The maximal leg-extension power (LEP) was measured 1 week before and 1 month after surgery using a leg extension power rig  as described by Barker et al. (2011); this measures the power in a single leg extension. The patient is seated in the rig with the most comfortable knee and hip flexion, with a seat belt attached across the hips and with the foot of the operated leg on the dynamometer pedal. The patient is then instructed to extend the leg as forcefully and quickly as possible, and strong verbal encouragement is provided during the contractions. 5 contractions are performed, and the highest value of the 5 is used. Leg-extension power is expressed as power (in Watts) per kg of body mass. LEP measurements were obtained for both legs.Active range of knee motion (ROM) was measured before surgery, on days 1, 7, and 14, and 1 month after surgery using a standardized manual . The patKnee swelling was measured before surgery, on days 1, 7, and 14, and 1 month after surgery. With the patient relaxed in supine position, the circumference of the extended knee was measured 1 cm proximal to the base of the patella . 2 measuFunctional performance was evaluated 1 week before and 1 month after surgery by the 30-second chair-stand test. The test measures how many times the patient is able to rise from a chair and sit down again in 30 seconds. The test has been shown to be a reliable and valid indicator of lower body strength . ChangesKnee status was assessed by using the summed score from the Oxford knee score (OKS) questionnaire . The OKSAssessment of pain was done using a 100-mm visual analog scale (VAS). A pain diary was given to the patients 1 week before surgery, and they were asked to note pain at rest and during walking 3 times a day as well as pain at night preoperatively, from day 0 to day 14 and on day 30. Use of strong and weak opioids was recorded for the same period.Box plots were prepared to illustrate the results. The box plots show the median, interquartile range (box), range (whiskers), and outliers (data more than 1.5 times the interquartile range from the box). Correlations were calculated as Spearman's rho. The program R, version 2.10.0, was used for all statistical calculations.39 patients were scheduled for surgery. 1 patient was excluded because of preoperative cognitive dysfunction and 2 refused to participate. 1 patient with heart disease and anticoagulation therapy developed tense hemarthrosis and subcutaneous wound hematoma postoperatively and was excluded because of deep infection diagnosed 2 weeks after surgery. No other complications were registered. Thus, 35 patients (18 men) with a mean age of 66 (51–81) years completed the study. 13 patients had bilateral knee osteoarthritis and 5 had a prosthesis in the other knee.30 patients were discharged on the day after surgery—after training and after measurement of knee motion and swelling. 5 patients were discharged on the second postoperative day because of postoperative pain or side effects of pain medication. None of the patients had physiotherapy consultations before the 1-month visit and none were referred for physiotherapy.Before surgery, LEP in the operated knees was 1 (0.4–2.3) W/kg, and after 1 month it was 1 (0.4–2.0) W/kg. The corresponding values in the contralateral knees were 1.3 (0.5–3.1) W/kg and 1.4 (0.4–3.5) W/kg . Before Patient-reported pain (with correction for missing data) was as follows. Preoperatively, 15 of 24 patients reported moderate or severe pain at night, 14 of 27 reported moderate or severe pain at rest, and 24 of 29 reported moderate or severe pain during walking. The night after surgery, 27 of 31 patients experienced moderate or severe pain. 28 of 31 patients reported moderate or severe pain at rest on the day after surgery whereas 29 of 31 reported moderate or severe pain during walking. 1 month after surgery, 9 of 35 patients experienced moderate or severe pain at night, 3 of 35 experienced moderate pain at rest, 5 of 35 experienced moderate pain during walking, and no patients had severe pain at rest or during walking . Use of Minzer et al. (2005) found that 1 month after TKA, quadriceps muscle strength decreased by 62% relative to the preoperative level. Holm et al. (2010) found that there was a correlation between knee swelling and loss of knee-extension strength early after TKA with conventional approach, with a 12% increase in the average circumference of the knee joint at discharge (2.4 days after surgery). We found maximum knee swelling to be 6% in the first week after UKA. The Oxford Group  used a pIn the accelerated recovery protocol of Local infiltration analgesia (LIA) gives effective pain relief with the possibility of early mobilization. In a double-blind study, In the present study, the patients reported a high level of pain during the first postoperative night and the next day, but the level of pain fell sharply thereafter. Our results confirm that fast-track Oxford UKA with discharge on the day after surgery is a safe procedure . A press


An instrument known as the Mechanical and Inflammatory Low Back Pain (MAIL) Scale was drafted using the results of a previous expert opinion study. A pilot survey was conducted to test the feasibility of a larger study designed to determine the MAIL Scale's ability to distinguish two potential subgroups of low back pain: inflammatory and mechanical.Patients with a primary complaint of low back pain (LBP) presenting to chiropractic clinics in Perth, Western Australia were asked to fill out the MAIL Scale questionnaire. The instrument's ability to separate patients into inflammatory and mechanical subgroups of LBP was examined using the mean score of each notional subgroup as an arbitrary cut-off point.Data were collected from 50 patients. The MAIL Scale did not appear to separate cases of LBP into the two notionally distinct groups of inflammatory (n = 6) or mechanical (n = 5). A larger "mixed symptom" group (n = 39) was revealed.In this pilot study the MAIL Scale was unable to clearly discriminate between what is thought to be mechanical and inflammatory LBP in 50 cases seen in a chiropractic setting. However, the small sample size means any conclusions must be viewed with caution. Further research within a larger study population may be warranted and feasible. Low back pain (LBP) is a common condition, with about 79% of Australians experiencing LBP at some time in their lives . In overOver 90% of primary contact clinicians believe NSLBP is not a single condition, with three-quarters believing subgroups are already identifiable . HoweverA recent study has shown that people diagnosed with NSLBP might be categorised as having mechanical (MLBP) or inflammatory (ILBP) low back pain . In thisSimilarly, other studies suggest that ILBP might be defined by pain that wakes the person, pain on morning waking, pain associated with morning stiffness longer than 30 minutes and improvement of LBP with exercise but not rest -8.Additionally, several studies into treatment-based classification have shown that people with certain clinical signs and symptoms may exhibit a preferential response to corresponding treatment modalities -12.The aim of this study was to pilot a survey that tests the feasibility of discriminating cases of NSLBP into two subgroups, mechanical and inflammatory, based on clinical signs and symptoms.This study included consecutive patients with a primary complaint of LBP who voluntarily presented for treatment to the Murdoch University Chiropractic Clinic and three private chiropractic practices in Perth, Western Australia, from March 2008 until July 2008. The study was approved by the Murdoch University Human Research Ethics Committee.Any patient aged 18 years or older with a primary complaint of LBP, with or without referral to the lower extremity was eligible for inclusion. Exclusion criteria included those with the of presence any 'red flags' for serious spinal pathology , prior surgery to the lumbar spine, pregnancy, diagnosed bipolar disorder or schizophrenia, seeking legal advice regarding their condition or claiming treatment under a Worker's Compensation/Third Party insurance claim and finally chiropractic students. Chiropractic students were excluded as patient participants, as some had prior knowledge of the study methods.LBP was defined as any pain in the region between the lower ribs and gluteal folds .All patients received routine questions on LBP history and a physical examination of active lumbar range of motion, lower limb neurological examination , straight leg raise and various orthopaedic tests professed to identify dysfunction in the lumbopelvic region. Levels of pain, disability and fear avoidance beliefs were recorded using a numerical rating scale (NRS), Oswestry Disability Questionnaire (ODQ) and Fear Avoidance Beliefs Questionnaire (FABQ), respectively.Baseline demographics, self-reported pain and disability data were collected on all patients prior to treatment. The location of LBP was assessed using a body pain diagram. Current pain severity was assessed on an 11-point numerical rating scale (NRS), ranging from 0 (no pain) to 10 (worst pain imaginable) ,15 and LAlso at baseline, each study participant filled out the new instrument known as the Mechanical and Inflammatory Low Back Pain (MAIL) Scale, Figures  and 2.The MAIL Scale, comprised three parts and asked the patient to answer 'yes' or 'no' to a series of 19 questions relating to notional mechanical and inflammatory back pain.Part A consists of 6 signs and symptoms thought to characterise inflammatory pain Figure . Of thesPart B consists of 13 signs and symptoms thought to characterise MLBP Figure  6]. Fro. Fro6]. For this pilot study, an arbitrary sample size of 50 was used. Sample size calculations for a fully powered study may be derived from the pilot study results.Data were entered, cleaned and analysed using Statistical Package for the Social Sciences (SPSS) version 16.0 . NormaliSubject to normality being shown, the mean scores of each of the Inflammatory (Part A) and Mechanical (Part B) subscales of the MAIL Scale would be used as a notional and arbitrary cut-off point to indicate "Inflammatory LBP" and "Mechanical LBP". Those with scores greater than the mean in one subscale and less than the mean in the other subscale were categorised as either purely inflammatory or mechanical LBP. Any MAIL Scale scores that did not meet these criteria were categorised as "mixed" LBP.Data were collected from all 50 patients in the pilot study; their main clinical features are presented in Table Of the 50 included patients, 38 were recruited through Murdoch University Chiropractic Clinic and 12 through private chiropractic practices in the Perth metropolitan area.The MAIL Scale scores for all participants are shown in Table The number of positive and negative responses to each of the inflammatory and mechanical signs and symptoms are listed in Table 'Morning stiffness' and 'Stiffness after resting' received the most positive responses in the inflammatory section, with 80% (n = 40) and 92% (n = 46) of patients answering "yes", respectively. In the mechanical section 'Pain on repetitive bending' , 'Pain on lifting'  and 'Pain on arching backwards'  were the most prevalent.Seven patients (14%) responded "yes" and 1 (2%) responded "no" to all six inflammatory signs and symptoms. The number of patients responding "yes" to all 13 mechanical signs and symptoms was 2 (4%), with 1 (2%) patient responding "no" to all. There were no reports of participants having difficulty completing the MAIL Scale.The Pearson correlation co-efficient assessing the general relationship between the MAIL Scale Part A Inflammatory and Part B Mechanical scores was calculated and showed a positive correlation of r = 0.45, p = 0.01. This is shown as a scatterplot in Figure The mean scores of the Inflammatory and Mechanical subscales of the MAIL Scale were used as an arbitrary cut-off point to classify "Inflammatory LBP" and "Mechanical LBP". Those with scores greater than the mean in one subscale and less than the mean in the other subscale were categorised as either purely inflammatory or mechanical LBP. By this method, 6 cases were classified as ILBP, 5 cases were classified as MLBP, with the remaining 39 cases classified as "mixed LBP". The frequency of each 'type' of LBP is shown in Figure This study found that the MAIL Scale was easy and relatively quick for participants to complete, but was unable to effectively categorise the majority of patients into either inflammatory or mechanical LBP. There are many reasons for this including that the sample size was too small to detect a difference (Type II error), the instrument is unable to distinguish between these two notional categories, the concept of mechanical and inflammatory causes in NSLBP is not valid, the population of patients did not have severe enough forms of NSLBP to be detected by the instrument or the majority of patients have mixed patterns of NSLBP. Of those 50 who entered the study, characteristics for age, sex and measures of health status Table  are simiThe items in this questionnaire were selected based on expert opinion and a search of current literature, and thereby have a level of both face and content validity .While the MAIL Scale was unable to discriminate LBP into two groups, certain signs and symptoms appeared more prominently in each subscale and may be important for future research into this area.Part A of the MAIL Scale dealt with those signs and symptoms thought to be associated with inflammatory LBP Table . 'StiffnIt is worthy of note that stiffness after seated rest may also have a mechanical cause as it has also been attributed to intervertebral disc herniation of the lumbar spine. The discs at the L4-5 and L5-S1 levels bear high loads ,22 and i'Morning stiffness' scored the second highest "yes" response  and of those 40 patients, 28 56.7%) experienced stiffness for 30 minutes or less, while for 11 (22.4%), the stiffness lasted over 30 minutes. Six of these 11 participants also experienced morning pain for longer than 30 minutes. In previous studies of morning stiffness, durations of greater than 30 minutes seemed to be the agreed threshold for determining the presence of inflammation % experie. As suchPart B of the MAIL Scale dealt with MLBP Table . The relWhen lumbar flexion is coupled with lifting, the load increases significantly. Lifting a 20 kg weight with a flexed spine and straight knees results in 340 kgf load on the lumbar spine . With pr'Pain developing later in the day' and 'Pain on coughing or sneezing' did not appear commonly, with only 15 (31.2%) and 14 (29.2%) of subjects responding "yes" respectively. The small number experiencing pain with coughing or sneezing may relate to the fact that only one respondent was diagnosed as having a disc herniation, and the presence of pain with these actions is commonly regarded as suggestive of a disc injury .The correlation between the mechanical and inflammatory subscales of the MAIL Scale showed a significant positive correlation of 0.45 Figure . This suLBP was arbitrarily classified into "inflammatory", "mechanical" or "mixed" subgroups. Over three-quarters of the sample were classified into the "mixed" subgroup, with only 6 and 5 patients classified as "inflammatory" and "mechanical" cases, respectively Figure . This diThe aim of this pilot study was to test the feasibility of a survey instrument that could potentially differentiate between the notional subgroups "inflammatory" and "mechanical" LBP. The results are not encouraging within the setting we chose.We have shown that the frequency with which participants respond to each question in the MAIL Scale can be described, and their MAIL Scale scores derived. This can be used to assign them to an arbitrary subgroup classification, however it is less clear what contribution this makes.The potential division of LBP into mechanical and inflammatory sub-groups based on an instrument of this type may rely on a much larger sample size. Analysis of a larger sample using an item-response theory approach such as Rasch analysis  would alIn any future research it may be best to recruit participants from other healthcare environments  as this may give a broader and more representative sample and decrease the potential for any selection bias. The broader spread of signs and symptoms may improve the ability of the instrument to discriminate between potential subgroups. In addition, consideration may be given to surveying active spondyloarthropathy patients from rheumatology clinics to ascertain whether they have a different frequency of the so-called mechanical signs and symptoms identified and present in the MAIL Scale instrument. It may be hypothesised that these patients have predominantly inflammatory pain and should exhibit less mechanical signs and symptoms that the NSLBP group.Finally, it may be worth considering an alternative study design that uses an external reference standard, such as blood inflammatory markers which may assist the analysis by identifying systemic inflammatory cases. Depending on the study design selected, a sample size would need to be generated for a fully powered study. A power calculation has not been performed here, however the results shown in Table In this pilot study, the MAIL Scale was simple to administer but was unable to clearly discriminate between notional mechanical and inflammatory LBP in a chiropractic setting. Sample size restrictions and the research setting limit any conclusions from these findings. Further research with a larger and more diverse study population may be warranted. However, based on the findings in this pilot study, separation of NSLBP into mechanical and inflammatory subgroups may not be possible.BW is the Editor in Chief of the journal Chiropractic & Osteopathy.JR and OW declare that they have no competing interests.JR contributed to the design, carried out the data collection, performed the literature search, and drafted and wrote the manuscript which is based on her Honours thesis. BW and OW contributed to the supervision, concept and design, and editing and revision for the intellectual content of the article. BW provided statistical advice, and critical review of the manuscript. All authors read and approved the final manuscript.Mail Scale Raw Scores. An additional file containing the raw data of 50 subjects for individual items on the MAIL Scale.Click here for fileMail Scale Variable Legend. An additional file containing the variable view of an SPSS data output and explanations of any abbreviations/numerical legends used within the MAIL Scale raw scores spreadsheet (additional file Click here for file


Aim: The aim of this study was to assess quality of life (QoL) and degree of satisfaction among outpatients subjected to surgical extraction of all four third molars under conscious sedation. A second objective was to describe the evolution of self-reported pain measured in a visual analogue scale (VAS) in the 7 days after extraction. Study design: Fifty patients received a questionnaire assessing social isolation, working isolation, eating and speaking ability, diet modifications, sleep impairment, changes in physical appearance, discomfort at suture removal and overall satisfaction at days 4 and 7 after surgery. Pain was recorded by patients on a 100-mm pain visual analogue scale (VAS) every day after extraction until day 7. Results: Thirty-nine patients fulfilled correctly the questionnaire. Postoperative pain values suffered small fluctuations until day 5 (range: 23 to 33 mm in a 100-mm VAS), when dicreased significantly. A positive association was observed between difficult ranked surgeries and higher postoperative pain levels. The average number of days for which the patient stopped working was 4.9. Conclusion: The removal of all third molars in a single appointment causes an important deterioration of the patient’s QoL during the first postoperative week, especially due to local pain and eating discomfort. Key words:Third molar removal, quality of life, sedation. Although the dental profession has witnessed a dramatic reduction in dental disease during the last century, the problems associated with the third molars still persist . Many peIn the past, third molar dental literature had focused on extraction criteria and its complications , howeverThe aim of our study was to assess QoL and degree of satisfaction among outpatients subjected to surgical extraction of all four third molars under conscious sedation. A second objective was to describe the evolution of self-reported pain measured in a visual analogue scale (VAS) in the 7 days after extraction.Healthy patients (ASA I or II) beyond 16 years of age requiring surgical removal of all four third molars were consecutively selected. At the first appointment, the purpose of the intervention was explained, clarifying all possible complications and the anticipated postoperative course. All patients signed an informed consent. Several weeks later the four third molars were removed at a single appointment. All surgeries were performed under local anesthesia (4% articaine with 1:100.000 epinephrine) complemented by conscious endovenous sedation . Intraoperatively, antibiotic, analgesic and antiinflammatory prophylaxis were administered endo-venously . All surgical material used was sterile. Just before surgery, patients rinsed with 0.12% clorhexidine digluconate for 1 minute. The surgical technique used was similar to that described by Leonard . A buccaThe following variables were recorded: age, gender, educational level , professional activity , and tooth position according to the Pell-Gregory classification . In ordeLikewise, patients were given a questionnaire to fill in on day 4 after the surgery, and again on day 7, immediately after suture removal. Questionnaires were identical to those used in a previous study carried out in the same ins-titution to evaluate quality of life after the extraction of a lower third molar under local anesthesia . These qIn addition, patients were asked to quantify postoperative pain every day until day 7. To this effect, a 100-mm visual analogue scale (VAS) was used.Data were processed using the Statistical Package for Social Sciences (SPSS), version 15.0. The duration in days of the alterations was compared with t-tests for gender and professional activity and with oneway ANOVA test for level of surgical difficulty. The association of gender, professional activity and discontinuation of work was assessed with Pearson’s chisquare tests. Pain VAS scores were assessed with an analysis of variance (ANOVA) test for repeated measures with the Grenhouse-Geisser correction of the degrees of freedom if sphericity did not hold. Post hoc comparisons were made with the Bonferroni correction. In all cases, significance level was set at 0.05.Thirty-nine out of 50 patients returned their questionnaires correctly filled and attended the follow-up visits . Eleven patients, who either lost their questionnaire or failed to complete it correctly, were excluded from the study. The mean age was 22.3 ± 4.7 years. The mean difficulty score for the surgeries was 17 ± 2.5, which corresponds to the moderate difficulty-category. Questionnaire results are shown on Pain VAS scores significantly varied across time . VAS scores with 95 % confidence intervals are shown in figure There were no differences in VAS scores between male and female patients , having a similar evolution of pain values over time . Professional activity  did not influence either the VAS scores . Conversely, the level of surgical difficulty  did have an impact on pain scores . “Simple” extractions had 95 % confidence intervals of estimated marginal means between 8.02 and 37.5, “moderate” extractions ranked between 11.8 and 27.1 and “difficult” extractions between 28.7 and 60.5. Differences were only significant between moderate and difficult extractions. If the Bonferroni correction to minimize the possible type I error would not have been performed, significant differences would have aroused also between simple and difficult-ranked extractions.No association was proved between work discontinuation and VAS scores . Pain evolution seemed similar whether the patient discontinued work or not . Neither, gender or professional activity, influenced postoperative sick leave . In these two analyses a housewife was excluded, because she did not need a sick leave. Surgical difficulty did not influence either the days of work/study cessation .There were no significant differences in the number of days with eating difficulty , changes in speech , or sleep alterations  between men and women. Females noticed changes in physical appearance that were perceived to last significantly longer  than in males (4.0 days with a SD of 2.6 days versus 2.3 with a SD of 2.2 days). No differences were observed between the different surgical difficulty categories  in number of days with eating difficulty , speech impairment , sleep alterations  or perceived changes in physical appearance .The results of this study illustrate the considerable interference the surgical removal of all 4 third molars under local anesthesia and conscious sedation has on several aspects of patients’ daily life during the early postoperative period, especially due to local pain and interference with eating. Exploring the influence surgery has on patients’ life can be beneficial both for the patient and the surgeon. The patient will receive more truthful information in what to expect in the postoperative period and will permit him plan the best moment to undergo surgery, minimizing the impact in his life activities. On the other hand, by surveying his patients, the surgeon can evaluate the treatment approach chosen and compare the outcome with that of other techniques used .However, analyzing pain perception and surgery’s impact in patients’ quality of life is always difficult due to the multifactorial nature of this process. Although the patient himself is probably the best assessor of the influence of surgery on his daily life ,24, subjAnother limitation encountered in this study was that only the first 7 postoperative days were evaluated, even though some studied parameters had not reached baseline by the end of day 7. For instance, even though pain decreased significantly after postoperative day 5, the mean score at day 7 was still 12.4 in a 100-mm VAS. Similar studies comprising 4 third molar extractions in a same surgical appointment confirm that by postoperative day 7 pain scores are low but still present ,16,19,20Interestingly enough, comparable findings have been reported when a single third molar extraction was evaluated. Colora-do-Bonnin et al. found thA positive association between increasing surgical difficulty and higher levels of postoperative pain has been demonstrated in this study. Nevertheless, this did not correlate with the number of days involving working isolation, eating and speaking disability or changes in physical appearance. These associations should allow the clinician give a more precise prediction of the expected postoperative period once the initial radiographic molar position diagnosis is established.Substantial findings were observed when assessing working isolation caused by these surgeries. Nearly 80% of the patients discontinued working in the postoperative period, with a sick-leave extension of approximately 5 days. Conflictingly, other studies concerning the same surgical protocol have reported lower periods of sick leave, being around 2.5 days ,9,18,20.The greatest inconvenience met by our patients was the inability to continue with a normal diet. Chewing ability and mouth opening were the main concerns. A complete incapability to continue with a normal diet by postsurgical day 4 was reported by 57.1% of our patients, while Colorado-Bonnin et al.  reportedInterpreting treatment satisfaction can be misleading. While every patient in our study admitted to be satisfied with treatment and would recommend it, 35.7% would not repeat it. Some authors interpret similar results as incorrect indications for surgery in asymptomatic patients . HoweverIn conclusion, the removal of all third molars in a single appointment caused an important deterioration of the patient’s QoL especially during the first five postoperative days, mostly due to local pain and eating discomfort. A positive association was observed between difficult ranked surgeries and higher postoperative pain levels. The average number of days for which the patient stopped working was 4.9. The analysis of the repercussions of these surgical interventions on patients’ QoL is important for an optimal preoperative assessment and development of appropriate indications for surgery. Moreover, it enables the surgeon to give the patient realistic expectancies of the postoperative period, giving rise to a truthful informed consent and helping the patient to choose the best moment to undergo the procedure, trying to minimize major interferences with everyday life.


One-half of patients with cancer have pain. In nearly one out of two cancer patients with pain, this was undertreated. Inadequate pain control still remains an important problem in this group of patients. Therefore, in 2008 a national, evidence-based multidisciplinary clinical practice guideline 'pain in patients with cancer' has been developed. Yet, publishing a guideline is not enough. Implementation is needed to improve pain management. An innovative implementation strategy, Short Message Service with Interactive Voice Response (SVS-IVR), has been developed and pilot tested. This study aims to evaluate on effectiveness of this strategy to improve pain reporting, pain measurement and adequate pain therapy. In addition, whether the active role of the patient and involvement of caregivers in pain management may change.A cluster randomised controlled trial with two arms will be performed in six oncology outpatient clinics of hospitals in the Southeastern region of the Netherlands, with three hospitals in the intervention and three in the control condition. Follow-up measurements will be conducted in all hospitals to study the long-term effect of the intervention. The intervention includes training of professionals  and SMS-IVR to report pain in patients with cancer to improve pain reporting by patients, pain management by medical oncologists, nurses, and general practitioners, and decrease pain intensity.This innovative implementation strategy with technical tools and the involvement of patients, may enhance the use of the guideline 'pain in patients with cancer' for pain management. Short Message Service alerts may serve as a tool to support self-management of patients. Therefore, the SMS-IVR intervention may increase the feeling of having control over one's life.NTR2739Netherlands Trial Register (NTR):  As illurtreated .A key barrier to adequate treatment of pain is ineffective communication between patients and healthcare providers about their pain ,13. PatiProfessionals do not ask their patients systematically about their pain ,23. MoreOne further aspect of underreporting pain concerns assessment and documentation. There is evidence that careful and regular, systematic assessment of pain improves the perception of physicians and nurses concerning cancer pain and enhances the quality of pain management ,30.Healthcare providers tend to show a lack of attention to and knowledge about pain management ,31-33 anThe prevailing principle for treatment of cancer pain is the World Health Organization (WHO) three-step pain ladder, published in 1986 . If thisBased on this pain ladder, a more detailed European recommendation for the use of morphine and alternative opioids has been published by the European Association for Palliative Care (EAPC). The finThe Dutch guideline 'Pain in patients with cancer' is one oThe present study aims to evaluate the implementation of the Dutch guideline 'Pain in patients with cancer' to improUsing Short Message Service (SMS) as a reminder and as tool to collect data on pain scores is innovative and promising . Mobile We expect that SMS-IVR will increase the percentage of patients with cancer who receive adequate pain treatment and reduce pain intensity in patients with cancer, because pain will be measured systematically. In addition, patients are expected to become less reluctant to report pain and physicians will ask patient more frequently about pain.The primary research question of the present study is: Will implementation of the Dutch guideline improve pain reporting, pain measurement, and adequate pain therapy?A RCT will be implemented, with clustering based on number of beds and number of medical oncologists to increase comparability of hospitals and to reduce contamination . DiffereThe primary objective of this RCT is to reduce pain intensity of patients with cancer. The secondary objectives are to improve knowledge of the guideline of oncologists, nurses, and general practitioners (GPs) to increase pain reporting by patients and professionals, to increase systematic pain measurement by medical specialists and nurses working at oncology outpatient clinics, and increase quality of life of patients.It is hypothesized that this innovative implementation strategy--which includes use of technical tools, training of professionals, and patient involvement--may increase the use of the guideline for pain management in cancer patients, and consequently reduce pain intensity  and increase pain management. SMS-IVR alerts may serve as a tool to support self-management of patients.This study will be conducted from 2011 to 2015.A non-blinded cluster RCT, will be performed in six oncology outpatient clinics of hospitals in the Southeastern region of the Netherlands, with hospital as cluster. Stratified randomisation will be performed based on pairs of two comparable hospitals regarding number of beds and number of medical oncologists. For each pair, one hospital will be randomly allocated to the intervention condition and the other to the control condition. Allocation to the intervention or control condition will be done before start of the intervention period by asking a statistician to select three closed envelopes Figure . The all1. Training of oncologists and nurses involved in cancer care on the most important aspect of the CPG comprising of three one-hour sessions, one main session at baseline, session two at month six, and the final session at month twelve (intervention arm).2. Patients will receive SMS-IVR and personal advice by phone on how to reduce their pain if their pain rating is 5 or higher on a numeric rating scale (NRS) of 0  to 10 (worst pain you can imagine) (intervention arm).3. Patients will receive a leaflet on cancer pain of the Dutch Cancer Society (in both arms).4. Oncologists and nurses will receive a leaflet for professionals on pain treatment of the Comprehensive Cancer Centre organisation (VIKC) (both arms).5. GPs in the Netherlands will be offered a web-based training on the most important aspects of the CPG (intervention arm).Follow-up measurements in all hospitals will be conducted to study the long-term effect of the intervention. Regarding the patients recruited in this study, the intention to treat principle will be used Figure .Furthermore, four times, during a period of one week, transversal measurements will be performed in outpatient clinics of all six hospitals. Pain intensity of all patients who visit the oncology outpatient clinic during that week will be measured . Pain fluctuated more in patients included in this pilot study than would be expected in patients who will be included in the present study, because only patients in palliative care were included in the pilot study.Next, we developed a multifaceted intervention with hospital as cluster. Multifaceted interventions are proven to be more effective than single interventions ,67. OncoThe training for oncologists and nurses consists of three one-hour sessions, all given in-person; one main session at baseline, session two at six months, and the final session at 12 months. The first session will include the aim of the study, the main aspects of pain treatment in patients with cancer, pain measurement, and an instruction of the SMS-IVR system in detail. The next two sessions aim to summarise the first session and discuss problems associated with the implementation of the guideline.Figure If the highest pain score is 5 or more, the research nurse will contact the patient and will ask: 'at what time/period the patients experienced the worst pain and whether the pain limited daily activities?'Any patient who has 5 or higher on an NRS on Tuesday will again receive two SMS alerts the next day (Wednesday); the procedure will be repeated. For those who still have a pain score of 5 or higher on Wednesday, the procedure will be repeated again at Thursday.The whole procedure of the SMS-IVR system described in Figure In addition, both patients in the intervention and the control condition will fill in a pain diary on Tuesdays for 12 weeks. They will do this twice each Tuesday, once between 8:00 and 12:00 a.m., and once between 12:00 a.m. and 17:00 p.m.. However, there should be a minimum of five hours between the morning and afternoon measurement. The pain diary reports pain intensity with NRS, use of pain medication, and any side effects of the medication. Patients will also receive a leaflet on cancer pain of the Dutch Cancer Society. In addition, oncologists and nurses will receive a leaflet for professionals on pain treatment of the VIKC.Patients in the control condition will also receive a leaflet on cancer pain. These patients will also complete a pain diary on Tuesdays during the 12-week period in the same way as the patients in the intervention condition. In addition, professionals will be offered a leaflet on pain treatment as a summary of the pain management guideline will be offered to GPs in the control condition. This is done to study the effect of the 'active' implementation (interactive web-based training), with the 'inactive' control condition (offering the most important aspects of the guideline as a tool to use in practice).The primary outcomes of this implementation study include:The first primary outcome is the percentage of all patients that visit the medical oncology outpatient clinic with adequate pain therapy/medication. Pain treatment adequacy will be calculated with both the Cleeland's Pain Management Index (PMI) and WardThe second primary outcome is the mean pain intensity of cancer patients, measured with an NRS . The NRS is the most appropriate choice to use in practice for pain intensity ,71 . These data will be collected retrospectively via medical records.2. Quality of life of patients with The European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire Quality of life (EORTC QLQ-C30) questionnaire . EORTCQL3. Knowledge of medical oncologists and nurses of the content of the guideline with a self-developed and pilot-tested knowledge questionnaire and vignette study. This knowledge questionnaire and vignette study are based on the recommendations in the guideline, with input from specialists in pain treatment and GPs.4. Pain intensity and impact of pain on daily activities will be measured with the Brief Pain Inventory Short Form (BPI-SF) . This qu5. Insight in the multidimensional aspects of pain with the Short-form McGill Pain Questionnaire . To meas6. Performance status of patients will be measured with the Karnofsky scale . It is b7. We will identify neuropathic pain by using the two first questions of the Douleur Neuropathic 4 questions questionnaire, short form (DN4-SF) .et al.) related to cancer the distress thermometer (DT) will be used [8. To assess multidimensional problems , with the wording of the items modified to refer to communication about pain with oncologists  , we need 90 patients per condition. Accounting for clustering resulted in an intraclass correlation coefficient (ICC) of 0.015. Based on the ICC and three hospitals per condition, we need 30 patients per hospital. Taking into account a dropout rate of 15%, we need 35 patients per hospital, for a total of 210 patients.Clusters of hospitals will be determined based on number of beds and number of medical oncologists to increase comparability of hospitals and to reduce contamination . Of eachTo measure the effect of the implementation the PMI and NRS will be used and tested with general linear model analysis of variances (GLM ANOVA) repeated measures. Qualitative content analysis will be used to analyse the results of the focus group discussions and to analyse the interviews to evaluate the SMS alert intervention. Qualitative analysis will be supported by the use of the Atlas.ti software programme.Data collected via SMS-IVR will be analysed for descriptive data: how did pain scores change and fluctuate in the whole period, what actions were taken by the research nurse, and did this intervention help the patients to manage pain? Subgroup analysis will be conducted. Differences in subgroups of the effectiveness of the intervention are expected. Subgroups will be classified by: age, gender, race, education, performance status, and classification of malignant tumors (TNM stage). The most recent version of SPSS will be used to perform the statistical analysis.Many studies explored barriers in pain management of patients with cancer and professional caregivers in different countries. However, this has never been done in the Netherlands. Therefore, four focus group interviews will take place to explore barriers and incentives about cancer pain management with respectively: patients with cancer, oncologists, nurses and GPs. Focus groups offer an opportunity to obtain significant insight regarding the experiences, observations, and opinions of members of that group .In addition, semi-structured interviews by phone focused on patient empowerment will be used to evaluate the SMS-IVR intervention. Ten randomly selected participating patients per hospital will be interviewed. The aim of these interviews is to shed light on the results of the intervention and the effect on patient empowerment.To investigate how and how frequently pain has been reported in medical records retrospective analysis will be performed for the year 2010 (two years after the guideline has been published). Thirty-six medical records per hospital (the first three of each month) of oncology patients who came for their first consultation at the outpatient clinic will be obtained. Retrospective analysis of medical records will be repeated after the intervention period.Data on patients characteristics will be obtained from medical records: patient identification code, date of diagnosis, gender, age, postal code, marital status, primary cancer type, secondary cancer, history of cancer treatment, present treatment, cancer exact location, TNM stage cancer, and pain medication. Retrospective data of surgery and other cancer treatment during intervention period, and hospital admission(s)  will also be analyzed. Other data will be obtained via a patient questionnaire including questions about: SMS use, education level, and experiences with present pain treatment.The study has been approved by the Medical Ethics Committee (CMO) of the Radboud University Nijmegen Medical Centre (METC protocol number 2011/020)  with experience in research in pain and palliative care. CB, an anesthesiologist and pain therapist, was involved in the development of the guideline and is also a principal investigator in this study. KV is head of the Knowledge Center Of Pain And Palliative Medicine, and a medical specialist in pain control and palliative medicine. He was chairman of the developmental process of the guideline 'pain in cancer patients', and has a national and international respected knowledge and experience in the field of pain diagnosis and therapy. MVD has an extensive record of experience in research in palliative care, quality of care research, and in implementation research.Consort checklist. Checklist of items to include when reporting a cluster randomised trial.Click here for fileMedical Ethics Committee (CMO). Approval letter of Medical Ethics Committee.Click here for fileFinance. Funding letter by KWF, Dutch Cancer Society and Bergh in het Zadel (Dutch Association that funds research).Click here for file


Body image may be distorted in chronic back pain patients (Moseley 2008). We thus asked pain patients to complete (by drawing) pre-defined, printed body schematics, which were lacking the outlines of the particular body parts affected (neck and back). This way the patients were free to complete the outlines according to their subjective perception of their body. The primary aim of this study was to evaluate these drawings as an outcome tool for pain related CAM interventions.Ninety-one patients who participated in two waiting-list controlled randomized trials on wet cupping in chronic neck pain (N=45) and dry cupping in chronic low back pain (N=46) were included. Each patient completed two drawings, one pre and one post intervention. Each drawing was evaluated by three different raters by 37 pre-defined items which aimed to describe its characteristics. Raters were blind to group assignment, intervention, order of drawings, gender, and whether patients benefited from therapy. Inter-rater reliabilities were determined by linearly weighted Cohen‘s kappa (κ) coefficients (Berry and Johnston 2008).All kappa coefficients were significant and only two were lower that κ=.40. Raters agreed on group assignment (κ=.57) and on the order of the drawings (κ=.55). The highest level of agreement (κ = .66 to .74) were found for the six items asking for changes in pain related areas. All other values were acceptably high (κ = .40 - .60). Furthermore, consistent correlations between the raters’ judgements for pain related items, in particular regarding the trapezius muscle and the patients’ pain ratings, were found.Drawings represent a particularly difficult material to evaluate, nonetheless the inter-rater reliability was fairly good. Evidently, the schematic body drawings conveyed specific information about pain related changes in body scheme and should be regarded as an additional tool for the assessment of treatment effects in pain.


Total knee arthroplasty (TKA) is an effective procedure. However, for some patients, the outcomes are not satisfactory. Identification of TKA determinants could help manage these patients more efficiently. The purpose of this study was to identify pre- and perioperative determinants of pain, functional limitations and health-related quality of life (HRQoL) 6 months after TKA.138 participants were recruited from 3 hospitals in Quebec City, Canada and followed up until 6 months after surgery. Data were collected through review of the subjects’ medical files and structured telephone interviews before and 6 months after TKA. Pain and functional limitations were measured with the Western Ontario and McMaster Osteoarthritis Index (WOMAC) and HRQoL was measured with the SF-36 Health Survey. Independent variables included demographic, socioeconomic, psychosocial, clinical and surgical characteristics of participants as well as data on health services utilization. Stepwise multiple regression analysis was used to assess the strength of the associations between the independent variables and the WOMAC and SF-36 scores.Higher preoperative pain, cruciate retaining implants and the number of complications were significantly associated with worse pain 6 months after TKA (p < 0.05) and explained 11% of the variance of the WOMAC pain score. Higher preoperative functional limitations, being single, separated, divorced or widowed, being unemployed or retired and the number of complications were significantly associated (p < 0.05) with worse functional limitations 6 months after TKA and explained 16% of the variance of the WOMAC function score. Lower preoperative HRQoL, contralateral knee pain, higher psychological distress and comorbidities were significantly associated (p < 0.05) with worse HRQoL 6 months after TKA and explained 23% of the variance of the SF-36 physical functioning score.Several variables were found to be significantly associated with worse outcomes 6 months after TKA and may help identify patients at risk of poorer outcome. The identification of these determinants could help manage patients more efficiently and may help target patients who may benefit from extensive rehabilitation. Total knee arthroplasty (TKA) is a common surgical procedure that allows for an effective reduction of pain and adequate restoration of function for the majority of patients suffering from advanced knee osteoarthritis or other forms of arthritis ,2. ThereAlthough TKA is an efficacious intervention for treating pain, loss of function and diminished HRQoL, 10 to 30% of patients report poor outcomes or no improvement following the intervention -8. IdentThe identification of factors affecting the outcomes of TKA and of patients at risk of poorer outcomes remains a challenge. The outcomes of TKA are clearly complex and investigations of possible determinants have been primarily directed toward perioperative surgical complications and prosthetic-related factors . SurgicaIt thus remains a challenge to identify which TKA candidates will likely do well, or do poorly following TKA and may need extensive rehabilitation ,9. The pThis study adopted a longitudinal prospective design with repeated measures. It was part of a broader investigation that measured the impacts of pre-surgery wait in patients undergoing TKA ,22.From 02/2006 to 09/2007, patients were recruited from the surgical wait lists of the departments of orthopaedic surgery of 3 university hospitals in Quebec City, Canada . Because of the extensive wait times, the post-surgery follow-up was only concluded in 2010. All 7 surgeons performing elective TKA in these hospitals participated in the study.Every week, patients newly enrolled on the wait lists of the hospitals were contacted by a research nurse. Eligible subjects had to meet the following inclusion criteria: 1- Aged ≥40 years; 2- Contacted within 3 weeks of being enrolled on the orthopaedic wait lists for primary unilateral TKA; 3- Resident of the province of Quebec, with provincial universal health insurance coverage; 4- Understand and speak French. Patients were excluded if they were suffering from a severe cardiac condition, any severe degenerative disease (except osteoarthritis) such as Alzheimer's disease, Parkinson's disease, any type of dystrophies, multiple sclerosis or other type of sclerosis that could interfere with the patient recovery following surgery or if they were suffering from a severe mental disorder that could interfere with the ability to answer the protocol questionnaires . Patients with a previous joint arthroplasty (hip or knee) were also excluded. Those who suffered a major trauma to the knee in the previous year or underwent surgery urgently within 30 days of being assigned on the wait list were further excluded.Data were collected through review of the subjects’ medical files and structured 45 minutes telephone interviews conducted by trained interviewers. The interviews were conducted a few days before surgery (mean ± SD: -5.7 ± 3.4 days) and 6 months after TKA (mean ± SD: 188.7 ± 5.4 days). The results of another interview that took place at the inclusion on the surgical wait list, regarding the effects of wait time, have been reported previously ,23.The first dependent variable was the Western Ontario and McMaster Osteoarthritis Index (WOMAC), which measures pain and functional limitations related to the knee . WOMAC sThe second dependent variable addressed HRQoL and was measured with the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36), a generic questionnaire on health status and HRQoL related to 8 dimensions of health . It alloMarital status, household living status , and clinical variables such as initial diagnosis (osteoarthritis or rheumatoid arthritis), body mass index (BMI) and comorbidities were collected through review of the subjects’ medical charts. The Cumulative Illness Rating Scale (CIRS) was used to assess the burden of comorbidities. This index measures the burden of chronic illness while taking into consideration the severity of chronic diseases through the review of 14 body systems. Each system is scored on a scale of 0 to 4 where 0 = no problem and 4 = extremely severe problem. The total score ranges from 0 to 56 and was kept as a continuous variable for the statistical analyses. This tool has been found to be reliable and valid in various settings -40. The Duration of disease symptoms (years) and use of a walking aid were also documented. Pain in the contralateral knee was assessed using the 5 questions of the WOMAC pain scale. For the analyses, the score was dichotomized . Formal education, employment status, household income and social support were measured with questions drawn from the questionnaire of the 1998 Quebec Health Survey . The valPsychological distress was documented with a modified version of the Psychological Symptom Index (PSI), that measures depression and anxiety during the last week (range: 0–42) . Its FreSurgical variables such as type of implant, bearing type, implant fixation, patella resurfacing and the number and type of in-hospital complications  following TKA were documented through the review of the subjects’ medical files . HospitaSix months after surgery, patients were asked about the number of community physiotherapy treatment hours they received following discharge from the hospital.Descriptive statistics were used to summarize subjects’ characteristics as well as WOMAC and SF-36 scores before and after surgery. Less than 2% of the data on the WOMAC and SF-36 questionnaires were missing. Missing data was handled according to both tools respective guidelines ,29. PairStepwise multiple regression analysis was used to assess the strength of the associations of the independent variables considered with the WOMAC and SF-36 scores. Significance levels for independent variable selection were set at 0.10 for initial model entry and at 0.05 to remain in the final model. Confounding was defined as a change ≥ 10% in the regression coefficient of at least one independent variable of a model . When deAll participants signed an informed consent form. The study was approved annually by the Research Ethics Boards of all 3 hospitals.Figure Specific to the objectives of the current paper, of the 153 participants who completed the interview conducted just before surgery, 138 answered the interview conducted 6 months after TKA. Three had a hemiarthroplasty performed instead of a TKA, 7 participants underwent contralateral TKA within 6 months of the first TKA and 1 patient died (unrelated cause). Three participants withdrew from the study and one could not be reached .Table Mean SF-36 scores at 6 months after surgery for the three sub-scales were all significantly below the age matched Canadian normative data (p < 0.05), as the mean normal scores for the physical functioning, role-physical and bodily pain scales are respectively: 75.7 (95% CI: 74.9 – 76.5), 76.2 (95% CI: 74.9 – 77.5) and 74.0 (95% CI: 73.1 – 74.8) .Because there were no differences in conclusions whether we used untransformed or rank-transformed dependent variables, the final models were built with untransformed scores. In the final models, all potential confounders were assessed and no other adjustments were necessary.Results of multivariate analyses on the WOMAC pain and function scores are presented in Table Results of multivariate analyses on the SF-36 scores are presented in Table Lower preoperative HRQoL on the SF-36 role-physical scale, the burden of comorbidities measured by the CIRS and the number of in-hospital complications were significantly associated with worse HRQoL 6 months after TKA and explained 17% of the variance of the SF-36 HRQoL role-physical score (multiple correlation coefficient r = 0.41).Lower preoperative HRQoL on the SF-36 bodily pain scale, presence of contralateral knee pain before surgery, the burden of comorbidities measured by the CIRS and the number of in-hospital complications were significantly associated with worse HRQoL 6 months after TKA and explained 13% of the variance of the SF-36 HRQoL bodily pain score (multiple correlation coefficient r = 0.36).In this prospective cohort study, 138 participants were recruited and followed up 6 months after TKA to measure pain, functional limitations and HRQoL and to identify preoperative and perioperative determinants associated with these outcomes. Several variables were found to be significantly associated with worse outcomes 6 months after TKA. The identification of these determinants could help identify patients at risk of poorer outcome and help manage these patients more efficiently.Participants showed a significant improvement 6 months after TKA in terms of pain, functional limitations and HRQoL. Several determinants of 6-month TKA outcomes were identified in this study, with multivariate models of the WOMAC and SF-36 scales explaining variances ranging from 11% to 23%. Although for some outcomes (e.g. WOMAC pain score) the explained variance was small, these results are in accordance with those of other studies that used the WOMAC and SF-36 to model determinants of post-surgery outcomes ,12,13,16Pre-operative status in terms of pain, functional limitations and HRQoL was significantly associated with post-operative status and these associations were consistent across the 2 scales of the WOMAC and the 3 scales of the SF-36 used in this study. Other authors have identified that pre-operative status is associated with post-operative status, and the strength of the associations we found is very similar to the results presented in other studies regarding TKA patients ,15,16,51Although there is abundant literature on the predictors of complications such as cardio-vascular events, embolisms, thrombophlebitis, wound infection or blood transfusions following TKA, there are relatively few studies that have looked at the association of surgical and perioperative complications with the outcomes of TKA as we did. We found that the number of in-hospital complications was significantly associated with post-operative outcomes 6 months after TKA in terms of pain, functional limitations and HRQoL. This determinant was found significant for the pain and the function scales of the WOMAC as well as for the role-physical and bodily pain scales of the SF-36, but was not significant for the physical functioning scale of the SF-36 (p = 0.09). Two other studies, which measured TKA complications, but after hospital discharge, found this determinant significantly associated with the WOMAC scores after surgery ,52. In tThe burden of comorbidities measured with the CIRS tool was significantly associated with worse HRQoL for the three SF-36 scales 6 months after TKA. The strength of the association was fairly consistent across these 3 scales, as shown by the unstandardized linear regression coefficients ranging from −1.97 to −2.60, even though the confidence intervals were large. Interestingly, this determinant was not found to be significant in the WOMAC models. Notwithstanding that physical functioning, role physical and bodily pain scales are responsive to physical limitations related to knee disorders, TKA and post-surgery recovery, one potential explanation for this finding is that the SF-36 questionnaire, a general HRQoL questionnaire, does not focus only on the involved knee contrary to the WOMAC questionnaire [The presence of contralateral knee pain before surgery was found to be a significant determinant of post-surgery HRQoL SF-36 physical functioning and bodily pain. This represents an interesting finding confirming again the negative impact of bilateral knee pain on the outcomes of TKA. These results are in line with previous published results for this cohort of patients, where participants with contralateral knee pain at inclusion on pre-surgery TKA wait lists had worse pain, functional limitations and HRQoL ,23. OnlyIt is interesting to note that participants who received a cruciate retaining implant had significantly more pain 6 months after TKA than patients who received a postero-stabilized implant, although the magnitude of the difference found may not be considered clinically important. A similar trend was seen in functional limitations measured by the WOMAC function scale, but it was not statistically significant for this model (p = 0.08). There is no consensus among surgeons whether to use a cruciate ligament retaining design or a posterior-stabilized design for TKA. However, the surgical technique for cruciate retention is technically more challenging especially if the posterior cruciate ligament requires balancing, as it may lead to pain and instability of the reconstructed knee . ClearlyPsychological distress level was low in this cohort of patients. Nonetheless, it was significantly associated with worse HRQoL physical functioning scores. Other studies have outlined the important role of psychological distress on the health status of patients suffering from knee pain or undergoing TKA ,54,55. IStrengths of this prospective cohort study include an initial high participation 81.8%) and follow-up (90.1%) proportions. There is no indication of a selection bias, as there were no significant differences between participants and eligible non-participants on age and gender and no significant differences in terms of pain, functional limitations and HRQoL before surgery between participants who did and those who did not complete the 6-month interview (data not shown). Also, orthopaedic surgeons acting as treating physicians during the study could not influence the patients’ participation as they had not been informed of the study start and stop dates. Several pre- and perioperative factors were significantly associated with worse pain, functional limitations or poorer HRQoL at follow-up. One of the strengths of our study is that many of these factors have a consistent effect across the scales of the WOMAC or the SF-36, which further supports the validity of our results. Other strengths include thorough and relevant independent variables selection. Further adjustments of the regression models with other potential confounding factors (presented in Table .8% and fAlthough our study had adequate statistical power, the precision of some estimates was low, as shown by the large confidence intervals found in different models. A larger cohort of participants would have allowed for a more precise estimation of the strength of the associations found here.We used the total number of in-hospital complications and did not take into account the severity of the complications. To our knowledge, there is no validated tool that exists to assess the severity of complications for that population and we therefore resolved to use only the number of complications in the analyses. Another limitation was that the main outcome measures were self-reported and performance-based measures were not included. The WOMAC and the SF-36 have been found to be valid instruments; still, it has been reported that performance-based measures provide distinct impressions of pain and function that complement self-reported measures . TherefoSeveral preoperative and perioperative variables are associated with pain, functional limitations and HRQoL 6 months after TKA, namely baseline levels of pain, functional limitations and HRQoL, type of implant, occupational and marital statuses, number of in-hospital complications, contralateral knee pain, psychological distress and comorbidities. The magnitude of these associations taken separately may not be clinically important but if more than one of these characteristics is present in a patient, they are likely to have a clinically important impact. The patient’s characteristics found in this study could help identify patient who are at risk of complications or may have a poorer outcome following surgery. These results will contribute to manage TKA patients more efficiently. These results will also help in the design of clinical trials aimed at the evaluation of interventions to optimize management of TKA patients at higher risk of poor outcome.The authors declare that they have no competing interests.FD participated in the design, coordination and collection of data. He performed the statistical analysis and drafted the manuscript. CED participated in the design, coordination and helped drafted the manuscript. ELB participated in the design, coordination and helped drafted the manuscript. RB participated in the design and helped drafted the manuscript. FC participated in the design and helped drafted the manuscript. PF participated in the collection of data and helped draft the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/2052-1847/5/2/prepub


The eight-item Brief Illness Perception Questionnaire is used as a screening instrument in physical therapy to assess mental defeat in patients with acute low back pain, besides patient perception might determine the course and risk for chronic low back pain. However, the psychometric properties of the Brief Illness Perception Questionnaire in common musculoskeletal disorders like acute low back pain have not been adequately studied. Patients’ perceptions vary across different populations and affect coping styles. Thus, our aim was to determine the internal consistency, test-retest reliability and validity of the Dutch language version of the Brief Illness Perception Questionnaire in acute non-specific low back pain patients in primary care physical therapy.A non-experimental cross-sectional study with two measurements was performed. Eighty-four acute low back pain patients, in multidisciplinary health care center in Dutch primary care with a sample mean (SD) age of 42 (12) years, participated in the study. Internal consistency (Cronbach’s α) and test-retest procedures (Intraclass Correlation Coefficients and limits of agreement) were evaluated at a one-week interval. The concurrent validity of the Brief Illness Perception Questionnaire was examined by using the Mental Health Component of the Short Form 36 Health Survey.The Cronbach’s α for internal consistency was 0.73 ; and the Intraclass Correlation Coefficient test-retest reliability was acceptable: 0.72 , however, the limits of agreement were large. The Intraclass Correlation Coefficient measuring concurrent validity 0.65 .The Dutch version of the Brief Illness Perception Questionnaire is an appropriate instrument for measuring patients’ perceptions in acute low back pain patients, showing acceptable internal consistency and reliability. Concurrent validity is adequate, however, the instrument may be unsuitable for detecting changes in low back pain perception over time. The natural course of recovery from acute nonspecific low back pain (ANLBP) is favorable, but recurrence within a year is high and primary care physiotherapy may be indicated ,2. RecurThe multidimensional representations of the Common Sense Model (CSM) of self-regulation of illness reflect five cognitive dimensions: identity, consequences, cause, timeline, and cure or control -6. In thThese findings demonstrate the importance of assessing patients’ perceptions of their ANLBP, as their perceptions can influence their treatment and recovery. The Brief Illness Perception Questionnaire (IPQ-B) has been used widely in Dutch primary care for measuring the five cognitive representations of common musculoskeletal disorders, with the goal of altering patients’ perception towards their ANLBP. Broadbent et al.  derived The psychometric properties of the IPQ-B have already been examined in a wide variety of illnesses and its correlation coefficients have been reported . MoreoveThe study sample consisted of 84 patients with ANLBP consecutively recruited from three different primary care physical therapy providers localized in two medium-sized towns and one of them in rural areas in the northern part of the Netherlands. General practitioners screened all participants. Participants had a mean (SD) age of 42 (12) years; 43% were female.Inclusion criteria: age 20–60 years, a new episode of acute non-specific low back (time since onset < 6 weeks) with or without radiating pain in the leg. Be capable to read and understand Dutch language.Exclusion criteria: specific cause of low back pain like nerve root disorders, lumbar spinal stenosis, spondylolisthesis, after injury, infection, osteoporosis, tumour or rheumatic diseases such as M. Bechterew.Before patients were included in the study, we obtained oral and written informed consent and explained to them the study protocol. Patient characteristics  and IPQ-B and SF-36 responses were obtained in a separate room prior to each patient’s scheduled standard care service. At this initial contact only anamnesis and physical examination were carried out after the data was collected. After one-week interval and before the second contact moment data of IPQ-B and SF-36 responses were again obtained. Physical therapists were instructed to avoid giving any information what might influence patients’ perception of low back pain. Intervention was carried out according to the Dutch guideline for ANLBP patients without controlling participants or conditions as every patient with ANLBP and as a result ethical approval was not required. All data were confidential to protect the health status of the participant and anonymity was guaranteed in electronic database. Ethics approval was not required because a purely observational, non-interactive study was carried out without interference in standard usual care and in accordance with normal practice and approvals. Research involving tests on cognitive, diagnostic or attitude procedures does not require ethics approval when data are completely and truly anonymous, participants can’t be identified, data will not cause any damage and participants consented to the use of the data. The study was performed in agreement with the directives given in the Helsinki Declaration as revised in 1975 ). This reduces the reliability of the IPQ-B, with a mean difference of 4.1 . Test-retest over a one-week period showed an acceptable correlation, measured by an ICC of 0.72  two-way random effects model, absolute agreement.There was a significant difference between the first assessment and second assessment (t=−3.5 [The 95% upper and lower LOA was 21.2 (− 4.1 ± 21.2) LOA ranged from −25.3 to 17.1 as shown in the Bland Altman plot , indicating adequate validity between the two instruments. Correlation coefficients of the four separate scales of the Mental Health component of the SF-36 with the IPQ-B showed: Vitality: rp = 0.54**; Social Functioning rp = 0.45**; Role Emotional rp = 0.43**; Mental Health rp = 0.59**. **Correlation is significant at the 0.01level (two-tailed)  of the SF-36, concurrent validity of the IPQ-B had an ICC of 0.65 . The Pearson’s correlation coefficient was This is the first study to evaluate the Dutch version of the IPQ-B in ANLBP patients. The internal reliability, test-retest reliability, and concurrent validity indicate that the Dutch IPQ-B is of moderate psychometric quality. Even though the IPQ-B measures a psychological construct by means of a multidimensional scale with a few items, we found its internal consistency of 0.73 to be adequate . None ofP < 0.05). Therefore, it was preferable to shorten the test-retest interval time in the study. Most ANLBP decreases within the first weeks after onset, and as a result, negative perceptions concerning ANLBP also decrease [In contrast to the ICC values, which demonstrated adequate test-retest reliability, the LOAs in the Bland Altman plot were large. The large LOAs might have been due to fewer low back complaints over time resulting from intervention-related changes in the patients’ perception of their back pain. Participants reported more positive perceptions on the IPQ-B retest than test  competing interest in relation to this manuscript is present.JH initiated the study and was responsible for the acquisition of data. All authors contributed substantially to the study including the conception and design , analysis and interpretation of data  drafting the article or revising it critically for important intellectual content. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/14/53/prepub


Low back pain was evaluated by a traditional VAS scoring system, the Oswestry Disability Index (ODI), and a new detailed VAS scoring system in which pain is independently evaluated in three different postural situations . No significant differences were observed in traditional VAS and ODI scores between the two groups. The results of the detailed VAS showed no significant differences between the two groups while in motion and standing. However, the elderly group showed significantly lower VAS score while sitting compared to the young group. In this study of the first use of a new detailed VAS scoring system, differences in characteristics of NSLBP between elderly and young patients were successfully detected. This minor modification of the traditional VAS may be useful for characterizing and evaluating low back pain.Because we have a clinical impression that elderly patients have low back pain while in motion and standing, but less pain when sitting, we investigate characteristics of nonspecific low back pain (NSLBP), using a new detailed visual analog scale (VAS) scoring system. One hundred eighty-nine patients with NSLBP were divided into an elderly group (≥65 years old,  Low back pain is a common clinical problem and a significant socioeconomic problem. Although the lifetime prevalence of back pain is 60–80% , little Nonspecific low back pain is defined as low back pain not attributable to a recognizable, known specific pathology, such as infection, tumor, osteoporosis, fracture, structural deformity, inflammatory disorder, radicular syndrome, or cauda equina syndrome . The intPrevious studies suggested that low back pain varies in different situations , 4. SomeIn our institution, we have used the traditional VAS and ODI to evaluate low back pain; however, those are usually unable to detect the difference between elderly and young patients. To improve evaluation of low back pain, we established a detailed VAS scoring system, which independently evaluates the low back pain of a patient while in motion, standing, and sitting. We hypothesized that the detailed VAS may detect the difference between elderly and young patients with nonspecific low back pain. In this study, we used our new detailed VAS scoring system, together with more traditional methods, to evaluate patients with nonspecific low back pain.n = 56) and younger patients . The study protocol was approved by the institutional ethics committee. One hundred eighty-nine patients who had suffered from back pain for at least three months were included. All patients were examined by plain radiography of the lumbar spine and showed no obvious pathological finding to explain the origin of their back pain. Patients who showed any indication of such pathological problems as vertebral fractures, tumors, or infectious diseases were excluded. To exclude the possibility of radicular back pain, patients with lower extremity symptoms were excluded. Patients under 20 years old were also excluded. Low back pain was evaluated using a VAS (0–10 cm) to evaluate the patient's worst pain during the week just passed and the ODI. In addition, an VAS for low back pain in three different situations, which we established for this study, was used for a detailed evaluation. The detailed VAS evaluates low back pain while the patient is in motion, standing, and sitting . To estat-test for VAS comparison, and the Mann-Whitney U test for ODI comparison. Analyses among the VASs in the three situations in each group used the repeated ANOVA. Probability values <0.05 were considered significant. Values are expressed as the mean ± standard deviation.Statistical analyses between the two groups used the unpaired No patient in the elderly group  or the young group  was diagnosed with a specific pathologic condition in the lumbar spine or showed lower extremity symptoms. P < 0.01). Mean scores for the traditional VAS for low back pain were 4.8 ± 2.2 cm in the elderly group and 5.0 ± 2.4 cm in the young group . No signTo date, there has been no scale measuring the intensity of low back pain in different situations used and reported in the literature. As O'Sullivan reported, nonspecific low back pain can be subclassified into flexion, active-extension, and multidirectional patterns , 4, thusOur study also shows that young patients showed higher VAS scores while sitting than did elderly patients, although young patients showed similar VAS scores in all three situations. The elderly group showed low VAS scores when sitting, indicating that a characteristic of nonspecific low back pain in elderly patients may be less pain in a sitting posture. In this study of the first use of the detailed VAS in a clinical setting, differences in nonspecific low back pain between elderly and young patients were successfully detected. This finding clearly supports our clinical impression that elderly patients have low back pain while in motion and standing, but less pain when sitting. There are no previous studies showing such clear characterization of nonspecific low back pain in elderly patients. While it is impossible to characterize low back pain using the traditional VAS evaluation, our detailed VAS will help clinicians characterize a patient's low back pain. Disc degeneration, one of the age-related changes of the disc structure, is thought to be a cause of chronic discogenic low back pain . During To evaluate chronic pain states, Dones et al. proposed a two-dimensional VAS system assessing both intensity and frequency . These aIn the present study, our new detailed VAS could detect the difference between elderly and young patients with nonspecific low back pain, while the difference could not be detected by the traditional VAS and ODI. Thus, we believe our hypothesis is correct, and this minor modification of the VAS will not only be useful and easy to use for scoring patients with low back pain, but may help clinicians treating patients with low back disorders.


Objective: A study is made of the clinical course of patients with episodic cluster headache following the injection of corticosteroids in the proximity of the sphenopalatine ganglion of the affected side. Study Design: A retrospective observation study was made corresponding to the period between 2006 and 2010. Patients with episodic cluster headache received corticosteroid infiltrations in the vicinity of the sphenopalatine ganglion. Data were collected to assess the clinical course, quantifying pain intensity and quality of life. A total of 23 patients (11 women and 12 men) with a mean age of 50.4 years (range 25-65) were included. Forty percent of the patients had undergone dental extractions in the quadrant affected by the pain, before the development of episodic cluster headache, and 37.8% underwent extractions in the same quadrant after appearance of the headache.Results: Most of the patients suffered 1-3 attacks a day, with a duration of pain of between 31-90 minutes. The mean pain intensity score during the attacks at the time of the first visit was 8.8 (range 6-10), versus 5.4 (range 3-9) one week after the first corticosteroid injection. On the first visit, 86.9% of the patients reported unbearable pain, versus 21.7% after one week, and a single patient after one month.Conclusions: The evolution of episodic cluster headache is unpredictable and variable, though corticosteroid administration clearly reduces the attacks and their duration. Key words:Episodic cluster headache, vascular pain, sphenopalatine ganglion, corticosteroid infiltration. Episodic cluster headache (ECH) is characterized by unilateral attacks of pain in the upper premolar, periorbital or temporal region, or in a combination of these locations, accompanied by ipsilateral conjunctiva injection, tearing, nasal congestion, perspiration of the affected side of the face, mitosis, and homolateral palpebral ptosis and edema. The attacks typically last 15 to 180 minutes, and patients experience one or several attacks a day in the course of an outbreak of variable duration (weeks or months). The episodic presentation of the disorder is characterized by periods of complete remission .The etiopathogenesis of cluster headache is unclear, but appears to involve the activation of parasympathetic nerve structures in the sphenopalatine ganglion, which would explain many of the associated symptoms. In addition, activation of the ipsilateral hypothalamic gray matter could explain the typical circadian and circumannual periodicity of the disorder . The sphTreatment efficacy in cluster headache is difficult to evaluate, due to the great variations in the duration of each outbreak. Until improved knowledge is gained of the etiopathogenic mechanisms of cluster headache, the most useful treatment option is to counter one of the phenomena giving rise to the pain: arterial vasodilatation. The management of ECH includes three treatment modalities: non-pharmacological , pharmacological (abortive drugs and preventive treatment) and surgical.Abortive therapy aims to arrest individual attacks, and comprises the use of subcutaneous sumatriptan, ergotamine and oxygen inhalation ,7. The aThe present study evaluates the clinical course of patients with episodic cluster headache following the injection of corticosteroids in the proximity of the sphenopalatine ganglion of the affected side.Patient selectionA retrospective, descriptive and follow-up clinical case study was carried out between the years 2006 and 2010 in patients with episodic cluster headache seen in a University oral surgery clinic. Episodic cluster headache (ECH) was diagnosed according to the criteria of the International Headache Society (HIS) (The following patient inclusion criteria were used: 1) attacks of cluster headache; 2) treatment with corticosteroid injections close to the sphenopalatine ganglion; and 3) a minimum follow-up of 12 months. The criteria used for corticosteroid injection were: 1) patients with active ECH even after the start of some other treatment; and 2) the absence of general contraindications to corticosteroid injection . Episodic cluster headache was finally diagnosed in 26 patients; three patients were excluded due to a clack of the required minimum 12 months of follow-up. We thus included 23 patients with ECH, with a mean age of 50.4 years (range 25-65) (11 women and 12 men). Forty percent of the patients had undergone dental extractions in the quadrant affected by the pain, before the development of episodic cluster headache, and 37.8% underwent extractions in the same quadrant after appearance of the headache.Data collection and follow-up of painThe following data were collected: patient age and gender, dental surgical treatment in the affected quadrant before and after appearance of the pain, and characteristics of the pain: location, frequency (number of attacks/day), duration of the attacks (minutes), and intensity , where 10 corresponds to maximum pain intensity).Patient disability and quality of life were evaluated by means of a clinical scale scored from 0-6, where 1 = no pain, 2 = mild pain , 3 = bothersome pain , 4 = moderate pain , 5 = important pain  and 6 = terrible pain . We documented the days with pain corresponding to the period from the last outbreak to the time of the first visit , and the autonomic manifestations associated with the pain.The patients received corticosteroid injections in the proximity of the sphenopalatine ganglion of the affected side. In the case of more than one attack a day, we prescribed prophylactic treatment in the form of 2 mg of ergotamine via the oral route. In patients with a single daily attack of pain we only administered corticosteroids in the vicinity of the sphenopalatine ganglion. One infiltration a week was carried out during four weeks, and in the absence of pain throughout the week, no further infiltrations were made. The possible side effects of the medication were recorded.Injection techniqueTruncal superior posterior dental nerve block was carried out using an auto-aspirating metal syringe and long needle (25-30 mm) with 4% articaine and adrenalin 1:100,000 . The injection site was on the posterolateral surface of the upper maxilla, at 1 cm above and behind the last molar. The needle penetrated mesial to the upper first molar and was advanced towards the zygomatic process until reaching the vestibular depth of the upper second molar, directing inwards, upwards and backwards to form an angle of approximately 45 degrees with respect to the upper occlusal plane. The anesthetic solution was slowly injected after negative aspiration.While waiting a few minutes for the anesthetic solution to exert its effect, the empty anesthetic carpule was filled with 40 mg of triamcinolone acetonide , and the full contents of the carpule were injected into the vicinity of the sphenopalatine ganglion (in the same way as the anesthetic block).Clinical course The patient clinical course and improvement were assessed according to the pain intensity  and the clinical disability scale . The duration of the outbreak was classified as follows: less than 10 days, 11-20 days, 21-40 days, 41-60 days and over 60 days.In 47.8% of the patients the pain was located in the premolar region, irradiating towards the orbit and temporal region; in 39.1% of the cases the pain was located in the periorbital region, irradiating towards the temple; and in 13% of the subjects the pain was diffusely located in the upper maxillary, temporal and mandibular region. The pain affected the right side in 56.5% of the patients, and the left side in 43.5%. Most of the subjects experienced between 1-3 attacks/day, and in most cases the attacks lasted 31-60 minutes .The pain had been present for under 10 days in 26% of the patients, between 11-20 days in 17.3%, between 21-40 days in 13%, between 41-60 days in 17.3%, and for over 60 days in 26% of the patients. The mean intensity of pain on the first visit was 8.8 (range 6-10). The clinical scale on the first visit showed patient disability to be moderate in 13% of the case, important in 56.6%, and terrible in 30.4%. The pain was accompanied by vegetative manifestations in 73% of the cases – particularly nasal secretion, tearing and reddening in the affected zone.Corticosteroid treatment involved a single infiltration in 26% of the cases, two injections in 52.1%, and three injections in 21.7%. A total of 73.9% of the patients received additional drug treatment.The data relating to the number and duration of the attacks after the treatment received is reported in . One weeFig. . After 1Episodic cluster headache usually manifests in the second or third decade of life, though it can also appear in older age groups. In effect, the literature describes cases of first attacks of ECH manifesting within the 8-62 years age range . In our Many patients with cluster headache are wrongly diagnosed with symptomatic headache due to dental disease – this often leading to unnecessary and ineffective dental treatments . Bahra aThe pain is located in the periorbital and temporal area, extending to the ear and even to the occipital-cervical region . In the Most patients experience 1-3 attacks a day . AccordiA variety of treatments have been investigated for prevention or symptoms relief in these patients, including triptans ,23, ergoMir et al.  administAccording to Torelli and Manzoni , 85.7% oThe evolution of the patients with episodic cluster headache is unpredictable and variable, though the administration of corticosteroids clearly reduced the duration and intensity of the pain attacks, and the duration of the outbreaks.