Foot and ankle pain is common in the Australian adult population. People with musculoskeletal foot and ankle conditions are often referred for surgical opinion, yet how patients are managed prior to referral is largely unknown. The aim of this study was to determine the characteristics and management of patients with musculoskeletal foot and ankle complaints prior to public-sector orthopaedic referral in South Australia.People with non-urgent foot or ankle complaints were recruited over a 12-month period from the waiting-lists of three tertiary hospitals in Adelaide, Australia. Participants completed a questionnaire on their medical history, duration and location of their foot or ankle complaint, diagnosis of their condition, previous treatment and medical imaging. The Manchester-Oxford Foot and Ankle Questionnaire, and the EuroQol-5D-5 L measured foot/ankle pain severity and health-related-quality-of-life (HRQoL). Descriptive statistics were generated for sample demographics, medical history and foot/ankle symptoms. Multivariable regressions were used to explore factors associated with foot/ankle pain severity and whether participants considered an operation necessary.2 IQR 8.7). Half of the participants had seen a podiatrist (52.8%), and 36.5% did not see any other health professional prior to orthopaedic referral. Sixty-five (27.9%) had not yet been given a diagnosis. BMI was positively associated with foot/ankle pain severity , while HRQoL had a negative association . Participants told by their GP that they may need an operation were significantly more likely to consider surgery necessary , while older people were less likely .Two hundred and thirty-three adults returned questionnaires, with a survey response rate of 38.4% (66.1% female, median age 57.7 years IQR 18.5, BMI 29.3 kg/mMore than one-third of the participants had not accessed allied-health care prior to specialist orthopaedic referral. Participants may consider their GPs opinion on the necessity of surgery compelling, and most expected to undergo surgery, but many couldn’t report their diagnosis. The discordance between the expectation of surgery and historically low surgical conversion rates suggests more work is necessary to improve the management of this group. Musculoskeletal pain is a leading cause of burden of disease . Foot anPatients referred to a public hospital are usually characterised as urgent, semi-urgent or non-urgent by the orthopaedic surgeon, which dictates when they will be seen. This stratification is not necessarily based on a patient’s level of pain but rather on the diagnosis and history given by the referring GP. Patients considered non-urgent do not have life- or limb-threatening complaints, but they commonly have persistent, disabling foot/ankle pain. Despite often severe pain, and because of a high-demand and the relatively low number of foot/ankle surgeons in the public-sector in Australia, it is not unusual for a patient with a foot/ankle complaint to wait over 12-months for an initial appointment, with one study reporting patients may wait 2–3 years before being seen . Whilst Some health networks have implemented innovative management strategies in response to the expansion of waiting-lists and the poor surgical conversion rate. Podiatrists, providing non-surgical interventions or education, working with an orthopaedic department have efficiently discharged patients from orthopaedic waiting-lists across Australia , 13, 14.The referral to an orthopaedic department may be due to the lack of access to podiatrists, or due to the persistence of the condition, which both the GP and the patient think would benefit from operative intervention. Given the complexities and heterogeneity of persistent pain, using the severity of symptoms as an indicator for surgical intervention may be misguided, but somewhat understandable as both parties seek a solution. Orthopaedic surgeons spend limited time in Australian public outpatient clinics , and givParticipants were recruited consecutively over a 12-month period, from 1st November 2017 to 31st October 2018. All participants were recruited from the waiting-lists of the three major tertiary hospitals in Adelaide, Australia, which provide elective foot/ankle orthopaedic surgery. These hospitals provide services to people from the Northern, Central and Southern Adelaide Local Health Networks, along with Country Health SA Local Health Network. Potential participants were identified shortly after referral from their GP (within 3-months) and were posted a letter of invitation, a participant information sheet and a copy of the survey. Basic demographic characteristics  of non-responders was also recorded to determine the presence and potential impact of self-selection bias on the survey results. This study was given ethical approval by the Central Adelaide Local Health Network Human Research Ethics Committee (Study ID Q20180109).All patients on the orthopaedic waiting-list with foot/ankle complaints considered as non-urgent (category 3) were invited to participate in this study. Patients were excluded from invitation if they were categorised as either urgent (category 1) or semi-urgent (category 2) by the foot/ankle orthopaedic consultants. Only non-urgent cases were considered by this study given the known low surgical conversion rate and long waiting periods experienced by this group.Participants were asked to self-report their height and body weight. Information about medical conditions was gathered and whether the participants were current or ex-smokers was also collected.Participants were asked to report if; i) they had been given a diagnosis, ii) they knew the name of the diagnosis, iii) their GP had told them that they may need an operation and, iv) they thought they needed an operation.Participants were asked to report previous referrals and interventions including; i) referral for medical imaging , ii) referral to another health professional about their foot/ankle complaint  and, iii) non-surgical interventions they received .The duration of symptoms was recorded and the region of foot/ankle pain was documented using a foot/ankle manikin . Foot/anParticipants were asked to complete the EuroQoL-5-Dimensions-5-Levels (EQ-5D-5 L) to measure overall HRQoL. The EQ-5D-5 L is a descriptive system comprising of the following five dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. Each dimension has five levels: no problems, slight problems, moderate problems, severe problems and extreme problems. The participants were asked to indicate their health state by ticking the box next to the most appropriate statement in each of the five dimensions. The EQ visual analogue scale (EQ VAS) records the participant’s self-rated health on a vertical visual analogue scale where the endpoints are labelled ‘best health you can imagine’ and ‘worst health you can imagine’. The EQ VAS can be used as a quantitative measure of health outcome that reflects the participant’s own judgement and is graded from 0 to 100, with score of 0 being the worst imaginable health state. Both the EQ-5D-5 L and EQ VAS have undergone extensive, structured psychometric development and been previously used to assess HRQoL in people undergoing foot/ankle surgery , 22.Socio-economic disadvantage (SED) is a known factor for higher levels of musculoskeletal pain . The SEDU test was used to assess for between-group differences and the chi-squared test was used to assess for between-group differences in gender. Multivariable linear regression was used to determine if foot/ankle pain severity (outcome) was associated with age, gender, BMI, HRQoL, SED, depression or duration of foot/ankle pain. Standard homoscedasticity and normality checks of residuals were carried out. Multivariable binary logistic regression was used to determine if age, gender, BMI, HRQoL, depression, severity of foot/ankle pain, duration of foot/ankle pain, or if the GP told the participant they may need an operation were associated with the participant considering an operation necessary. The final model was tested for goodness of fit using the Hosmer and Lemeshow goodness-of-fit test. If the value of the chi-squared statistic in this test is low, the p-value is not significant and indicates that the model is a good fit for the data [Descriptive statistics were used to summarise the demographic and clinical characteristics of the participants, their diagnosis and beliefs regarding need for surgical intervention, prior treatments and investigations, their foot/ankle pain and HRQoL. All data distributions were checked for normality via the inspection of histograms and the Shapiro-Wilks test prior to inferential statistical analysis. As age and SED were not normally distributed in those that did and did not respond to the survey, the Mann-Whitney the data . ResultsThe study was exploratory in nature but estimates were made a priori about the number of variables to be included in the multivariable models. A conservative estimate of 20 participants per independent variable was accepted in the linear  and logiX2 = 0.011, p = 0.917 or SED with a median (interquartile range (IQR)) of 4 (4) versus 4 (4), p = 0.537 comparing those who participated in the study and those who did not. The participants, however, were significantly older than the people that did not participate with a median (IQR) age of 57.7 (18.5) years versus 53.1 (22.2) years, p <  0.001, respectively. The participants had a median (IQR) BMI of 29.3 (8.7) kg/m2 and reported symptoms for a median (IQR) of 55.0 (96.0) months. A total of 61 (26.2%) participants had previously had foot/ankle surgery. Over 20% of the participants had a score of 1 out of 10 for SED, and 75% had a score of 5 or less. Only 4 participants were rated as scoring 10 out of 10 for SED.A total of 606 questionnaires were posted to patients, with 233 participants completing the questionnaires, yielding a response rate of 38.4%. The Central Adelaide Local Health Network had the highest participation rate with 51/90 (56.7%) of patients responding to the survey. This was followed by the Northern and Southern Adelaide Local Health Networks, with 72/201 (35.8%) and 110/315 (34.9%), respectively. There were no significant between-group differences for the number of women 154 (66.1%) versus 245 (65.7%), The most prevalent co-morbidity was back pain (56.7%), followed by osteoarthritis (49.4%), hypertension 39.1%) and depression (33.9%). The frequency of all of the co-morbidities recorded are reported in Table % and depp = 0.030) and HRQoL was negatively associated with foot pain severity   foot pain severity as measured by the MOXFQ-index was 68.8 31.3) points. The three domains, other than MOXFQ-index, measured by the MOXFQ are reported in Table .3 pointsp <  0.001). Age was also a significant correlate, although this was negatively associated with the participant thinking surgery was necessary . Hosmer and Lemeshow goodness-of-fit X2 = 4.344, df = 8, p = 0.825 (Table Sixty-five participants (27.9%) had not been given a diagnosis and a further 23 participants who had been given a diagnosis could not report the name. One-hundred-and-sixty-one (71.2%) participants reported that their GP thought they may need an operation and 165 (77.1%) participants thought they needed an operation. Multivariable binary logistic regression found that the strongest correlate for a participant considering that an operation was necessary, was if their GP told them that they may need an operation  had seen a podiatrist and 23.2% had seen a physiotherapist prior to referral. These professions accounted for the majority of the other health professionals consulted prior to referral. Eighty-five (36.5%) participants did not see any other health professional prior to orthopaedic referral.General practitioners instigated a variety of pharmacological and non-pharmacological treatments prior to referral. The most common treatment was paracetamol which was used in 123 participants (52.8%), followed by a change of footwear (46.8%), oral non-steroidal anti-inflammatory drugs (NSAIDs) (45.5%), exercises (38.6%), foot orthoses (35.6%) and topical NSAIDs (35.2%). Oral codeine/opioids was not used as frequently as a number of other treatments but was still reported to be provided to 26.6% of the participants.The treatments instigated by health professionals other than the participant’s GP favoured non-pharmacological measures. Exercises, orthoses and a change in footwear were prescribed for 66 (44.6%), 66 (44.6%) and 63 (42.6%) participants, respectively. A detailed assessment of the treatments instigated prior to referral are reported in Table Most participants had undergone a plain film radiograph examination prior to referral 78.1%), over half had had an ultrasound (53.6%) and 14.2% had had magnetic resonance imaging. Nuclear bone scanning and computed tomography scanning were the less commonly used imaging modalities prior to referral  when patients with non-urgent foot/ankle complaints are initially triaged by podiatrists in public hospitals –13. ThesThere was a clear, positive association between foot pain severity and BMI, after adjusting for multiple confounding variables. Over 70% of the participants were classified as overweight and over 40% were classified as obese. Given people often over-estimate their height and under-estimate their weight in self-report , these fIt is unclear if the strong association between the patient’s and GP’s belief about the need for surgery is driven by both parties seeking a solution for a persistent problem, or if the risks and benefits of surgery have been understood and considered, and conclusions drawn that this is the most suitable option. In Australia, GPs may feel that surgeons are more capable in managing musculoskeletal foot/ankle pain, and a study found that GPs are significantly more likely to refer patients with foot/ankle osteoarthritis to an orthopaedic surgeon than to an AHP , but it unlikely to receive surgery which may assist in managing expectations. Less constrained, and early access to AHPs may also assist in giving practical, evidence-based advice and management to this patient group.Irrespective, given the historically low rates of surgical conversion for non-urgent patients in Australian public hospitals –13, therThe management of expectations is a key factor in managing musculoskeletal pain, particularly when pain may be a manifestation of other conditions or complaints. The participants in this study had a high prevalence of features known to predict or amplify chronic pain, notably depression and obesity and therefore resolving pain without addressing these factors may be challenging. Patients referred for evaluation of musculoskeletal complaints can often struggle to accept or acknowledge that there may be strong non-nociceptive drivers related to their foot/ankle pain. Furthermore, previous studies have found people with chronic pain may have compromised executive function  and therThis study does have limitations that must be considered. Firstly, the response rate is respectable for this type of study, but given it was less than 40% it may not be representative of all patients on the waiting-list. Secondly, given data were only collected from one state in Australia, these data may not be reflective of other regions and, furthermore, given the study is completed in the public-sector the results may not be generalisable to people seen in the private sector. This study did also not report or measure more detailed foot and ankle characteristics typically performed in clinical assessments, as this would involve a significantly larger investment of time and resources. Furthermore, self-report on management data may be affected by recall bias and specific details on each case would have been desirable, but outside of the scope of this study. Finally, given the cross-sectional nature of this study, how the foot/ankle pain and patient expectations change over time cannot be reported.This study does have a number of strengths. It provides a comprehensive assessment of foot/ankle pain, HRQoL, previous treatments and imaging, along with patient expectations. This is important for this group of patients as they can be on waiting lists for an extended period. Future work in this area may focus on evaluating the impact of strategies designed to provide patients with early access to appropriately skilled health professionals to offer a timely diagnosis, provide appropriate expectations, and finally to address factors that are associated with foot/ankle pain severity, such as BMI and HRQoL.In conclusion, this study has found that patients referred to orthopaedic departments in public hospitals with non-urgent foot/ankle complaints do undergo some non-surgical therapy prior to referral and most have medical imaging, but there is substantial heterogeneity in what is provided. Patients may not be well prepared or well advised about both the diagnosis and prognosis of their foot/ankle complaint, as most participants expect to have an operation, yet more than 25% did not know their diagnosis. Body mass index and HRQoL are both related to foot/ankle pain severity and further study to address and improve these findings may be prudent, particularly as waiting-lists continue to grow.


In type 2 diabetic patients affected by chronic shoulder pain, subacromial injection with corticosteroid could be an effective treatment. The aim of this study was to measure the risk-benefit ratio of this treatment. Twenty patients with well-controlled diabetes were included in a prospective study. In a first preinjection phase, patients were asked to measure glycemia for 7 days, before breakfast and dinner, and then 2 hours after lunch and dinner. Baseline data including Constant Score (CS), Subjective Shoulder Value (SSV), and Numerical Rating Scale (NRS) for pain were collected. Patients were treated with subacromial injection with 40 mg of Methylprednisolone Acetate and 2 ml of Lidocaine. At discharge, patients were asked to remeasure glycemia for the following week. The overall pain improved and patients graded their shoulder as “greatly improved”. At 30-day follow-up, the SSV and the CS improved, considering pain but not ROM. The average daily glycemia was 136 mg/dl before injection, 161 mg/dl the day of the injection (p<0.001), and 170 mg/dl one day after injection (p<0.001). Glycemia was not statistically different 3 days after injection.NCT03652480. The Protocol ID is SHOULDERDM2013. Subacromial injection is an effective short-term treatment in type 2 diabetic patients affected by shoulder pain, but a closed follow-up is recommended in all these patients. This trial is registered with  Among the conservative strategies to treat shoulder pain, the use of corticosteroids in the subacromial space has been shown to be particularly effective and safe. One of the main limitations for the use of the corticosteroid injections remains the potential effect on blood glucose levels especially in diabetic patients. On the other hand, diabetic patients with noncontrolled shoulder pain could have a major benefit from a corticosteroid injection due to the increased risk of surgical complication: they are often elderly patients, affected by other severe comorbidities, and are strongly reticent to undergo any type of surgery. Nevertheless, they often ask for a rapid, even if temporary, pain relief solution and injection with corticosteroids could be an effective option.The use of corticosteroids in joints, other than the shoulder, has been widely documented in nondiabetic and in diabetic patients, proving to be safe and effective –5. HowevIn our clinical practice, we have observed that (1) diabetic patients with subacromial pain respond very well to subacromial corticosteroid injections in terms of pain relief, but the effect on range of motion (ROM) seems to be unpredictable; (2) some patients report high levels of blood glucose after subacromial injections, an increase that seems to be different from what has been reported after intra-articular injections. The goal of our study was to document the effect of subacromial corticosteroid injections on blood sugar levels and short-term clinical outcomes in patients affected by type-2 diabetes, not suitable for surgery and nonresponsive to other conservative treatments.From 2013 to 2014, thirty consecutive type 2 diabetic patients were initially included in this analytic prospective study (level of evidence III). Patients examined in our outpatient department, complaining of chronic shoulder pain resistant to at least 6 months of conservative therapy , were considered eligible for this study .Consent to participate in the study.Severe overall pain and night pain: Numerical Rating Scale (NRS) for pain  above orNo significant improvement after at least 2 courses of physiotherapy .Clinical signs of subacromial tendinobursitis, with or without signs of rotator cuff tear, defined as positive Neer, Yocum, and Hawkins tests –15. PainNo indication for surgery due to the age, concomitant comorbidities, or patient's refusal to undergo surgery.Well-controlled type 2 diabetes, defined as follows :Fasting and preprandial blood glucose levels in the range of 90-150mg/dL.Hb1Ac <64mmol/mol (corresponding to 8%) measured within 6 months.A device for self-measurement of blood sugar levels at home.To be included in the study, patients needed to have a recent (within 6 months) X-ray and an MRI or ultrasound of the affected shoulder. Other inclusion criteria were as follows:Corticosteroid treatment in the past 3 months.Complaints of shoulder stiffness more than shoulder pain.Symptomatic glenohumeral arthritis defined as shoulder stiffness plus moderate radiographic signs of arthritis .Glaucoma . Exclusion criteria were as follows: After an initial screening, patients were included in a prestudy phase and baseline data were recorded, including type of antidiabetes medications, range of motion (ROM), overall and night pain (NRS), Constant Score (CS) , 21, OxfMoreover, we asked the patients to measure their glycemia 4 times a day  for one week after the first examination. These data were used as control values and to confirm that patients had well-controlled diabetes. In this prestudy phase patients did not receive any injection, but only NSAIDs and painkillers were prescribed. A measurement of Hb1Ac for the patients that did not have one recent blood test (within 6 months) was also prescribed.A subsequent examination was scheduled after one week  when theAfter discussing the risks and benefits of the therapy, a subacromial injection of Methylprednisolone Acetate 40 mg (Depo-Medrol©) and 2 ml of Lidocaine 2% was performed the morning of day 7. The same expert shoulder surgeon performed the injections using the posterior approach to the shoulder , 26. ThePatients were asked to continue the same regimen of physical activity, rehabilitation, and antidiabetes medications. Patients were informed of the probable increasing of blood glucose levels and were asked to cut down on saturated fats, salt, and sugars. Severe hyperglycemia was defined as a single value of fasting/preprandial glucose blood levels higher than 250 mg/dL or postprandial glucose blood levels higher than 300 mg/dL. Patients were also asked to report any abnormal symptoms or signs  score , 28, andSix months after the injection, a telephone interview was performed to assess pain, OSS, and SOD score.The study was approved by the Institutional Review Board of our Hospital (Prot. CS/488) and have therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki. All persons gave their informed consent prior to their inclusion in the study.α: 0.05 and β: 0.2. The data collected were analyzed with Student's t-test, Fisher test, and the McNemar test for paired proportions. The blood glucose levels at each different time point were compared to the baseline levels  using the Student's t-test. All the collected variables had a normal distribution except the SOD score. The D'Agostino-Pearson test for normal distribution rejected a normal distribution for the SOD score. The median of SOD score was therefore reported.A power analysis was performed. A significant reduction of the overall pain was considered as principal outcome. Eighteen patients were required for an expected reduction of 30 points of pain, with Five out of 30 patients were excluded in the prestudy phase, since their diabetes was not well controlled. An additional 5 patients were excluded because they did not adequately record their glycemia after the injection (2 patients) or did not come back for the follow-up examination (3 patients). The 3 patients lost to follow-up were contacted by phone and they stated a significant improvement after injection. Twenty patients were ultimately included in the study. One patient was subsequently lost to follow-up at 6 months during the telephone interview phase. This patient was not excluded since the majority of the data important for the study were available for the analysis.The average age was 71 years (63-83), 12 patients were female, 7 were managing their diabetes with insulin therapy, and 13 were doing so with oral diabetes medications. The average baseline CS was 43±12, the OSS 28±8, and the NRS for pain 76±11. All the patients had positive tests for subacromial tendinobursitis. Four patients had a concomitant adhesive capsulitis. The imaging studies showed a cuff tear involving the supraspinatus in 12 patients, a massive cuff tear involving the infraspinatus and supraspinatus in 4 patients. Four patients had mild signs of eccentric osteoarthritis . The improvement in CS was more relevant considering the pain component of the score  at 30-day follow-up and to 38±30 at 6-month follow-up (p<0.001). However, the improvement in overall pain between 30 days and 6 months was not significant (p=n.s.). Nightly pain was reduced from 78±10 to 35±19 (p<0.001) at 30 days and to 31±25 (p<0.001) at 6-month follow-up. The improvement in nightly pain levels between 30 days and 6 months was not significant (p=n.s.).The SSV preinjection was 49±14; it improved to 64±19 thirty days after injection (p=0.001) and to 68±25 (p<0.001) at 6-month follow-up. Again, the improvement between 30 days to 6 months was not statistically significant (p=n.s.).One month after injection, the clinical improvement was also shown by a median SOD score of 6 points (= “Greatly Improved”). The median SOD value at 6 months remained 6 points.During the study period, 5 patients asked for a second subacromial injection.The average daily blood glucose levels are reported in Five patients (25%) had severe hyperglycemia: 2 patients had one episode of fasting/preprandial glycemia >250mg/dL the day after the injection, 2 patients had a postprandial glycemia >300mg/dL (330 and 308 mg/dl), 1 patient had one episode of fasting glycemia of 265 mg/dL followed by a postprandial glycemia of 304 mg/dL. All the episodes of severe hyperglycemia were recorded the day and the day after the injection. Three out of these 5 patients were managing their diabetes with oral medications.A posthoc analysis of the patients that experienced severe hyperglycemia revealed that they had an average preinjection fasting glycemia worse than the patients who were not affected by this complication .One patient reported insomnia the night of the injection not related to shoulder pain. No other complications were reported.The aim of this prospective study was to report the short-term benefits and the effects on glucose blood levels of a subacromial injection with corticosteroids in type 2 diabetic patients affected by severe shoulder pain, not responsive to conservative treatment and not suitable for surgery. The most important finding is that the injection significantly reduced the overall pain and the night pain and most of the patients had a perception of a greatly improved shoulder at 1- and 6-month follow-up.These data were consistent with previous reports. Yu  showed, In contrast to what has been reported previously, we did not observe a significant improvement in ROM and function after subacromial injection. The reason could be a difference in the patient population included in this study. We included older diabetic patients affected by shoulder pain with multiple etiologies including rotator cuff tears and mild osteoarthritis. Moreover, despite the fact that a clear diagnosis of adhesive capsulitis was present in only 4 cases, we cannot rule out the possibility that some of the patients had some minor forms of adhesive capsulitis secondary to diabetes , 32. TheThe second finding was the effect of subacromial injections on blood glucose levels in type 2 diabetic patients. Overall, the infiltration increased the average glycemia for three days, with a peak the day after the injection. No hyperglycemia-related symptoms were recorded. Although these data can be considered generally a good result, they must be interpreted with extreme caution. Twenty-five percent of the patients had a transitory severe hyperglycemia. These data are in contrast with the study of Habib  who showInterestingly, in our series the patients that had severe hyperglycemia had had a suboptimal fasting glycemia before the injection. This data could imply that a better control of diabetes should prevent postinjection hyperglycemia and improve the safety of the treatment with corticosteroids.The comparison of our results with other studies , 6, 33 rOne option for the treatment of persistent shoulder pain in diabetic patients is the injection with hyaluronic acid. However, the effect of this injection in diabetic patients has never been proven effective. Three patients in our study cohort have been injected with hyaluronic acid before being included in our study. None of them had reported a significant improvement.Penning  comparedThis study has some limitations. The injections were performed without use of ultrasound guidance. A study, however, showed that there is little evidence for the need of ultrasound guided needle placement . Our patSubacromial injection with 40 mg of Methylprednisolone Acetate is effective as a short-term treatment in type 2 diabetic patients affected by shoulder pain. Patients must be informed about the possibility of transient hyperglycemia for the 3 days after injection and that 20% could have a transient severe hyperglycemia, especially the day of and the day after the injection and they must be closely followed up.


Background and Objectives: Electrocautery adenoidectomy (ECA) is a common procedure performed in paediatric otolaryngology. ECA has been preferred over curettage adenoidectomy due to its lower intraoperative bleeding rates, decreased procedure time, and higher subjective success. However, post-ECA symptoms of pain and halitosis have never been studied. The objective of our study was to identify the pattern of post-ECA halitosis and pain in the paediatric population. Materials and Methods: This is a single centre, prospective observational study that uses visual analogue scales (VAS) by parent proxy to assess post-ECA pain and halitosis in paediatric patients (age < 18) in South Australia. A total of 19 patients were enrolled in the study and followed for seven days. Results: Postoperative pain and halitosis reaches a peak 3 days post-ECA  but resolves 7 days post-ECA (median = 0 for both). Conclusions: Our study demonstrates that halitosis and pain occur over a seven-day period in patients undergoing ECA and will resolve post-operatively with simple analgesia and without antibiotics. Adenoidectomy in combination with tonsillectomy and/or myringotomy is a commonly performed paediatric surgical procedure. Indications for adenoidectomy include nasal obstruction, sleep-disordered breathing, and recurrent otitis media . Variousp < 0.0534) [A meta-analysis performed by Reed et al. in 2009 comparing electrocautery adenoidectomy (ECA) and curettage adenoidectomy outcomes found decreased intra-operative bleeding (4.1 mL vs. 24.0 mL) and reduced operative time (10 min vs. 18.4 min) in ECA patients [Halitosis is anecdotally reported by parents of children undergoing ECA. The literature is sparse in assessing the post-ECA halitosis and degree of post-ECA pain. Halitosis is a common, troublesome symptom of oral malodour post- adenoidectomy . HalitosThere are many challenges when comparing symptoms such as pain and halitosis, especially in the paediatric population. Visual Analogue Scale (VAS) is a simple validated method of rating health-related outcomes. VAS allows for identification of the location of a health state on a scale between two selected reference states . It is pHence, for this study, we have investigated the prevalence of halitosis and pain post-adenoidectomy using a VAS by parental proxy. The main objective was to outline the natural course of symptoms of pain and halitosis over a seven-day period. Understanding these symptoms can help counsel parents on expected outcomes of the surgery and reduce anxiety in both children and parents postoperatively.This is a single centre, observational prospective cohort study from May 2016–March 2018. All patients that underwent adenoidectomy with or without myringotomy and ventilation tube insertion between the age of 1–16 years were included in this study. Patients were recruited consecutively. Exclusion criteria included patients that underwent a concurrent tonsillectomy, dental, or septal surgery. Patients with chronic neurological disorders or cleft palate were also excluded.All subjects gave their informed consent for inclusion before they participated in the study. The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Southern Adelaide Clinical Human Research Ethics Committee .Demographic data including age, gender and operative details were deidentified and recorded from the operation note. Data including adenoid size , indicatAll consenting parents of eligible children were provided with a seven-day postoperative diary which was posted to the principal researcher on completion. Parents rated perceived pain and halitosis for 7 days post-surgery. Parents rated pain on a 0–10 visual analogue scale, 0 being no pain; and 10 being worse pain ever. Halitosis was rated on a similar 0–10 visual analogue scale, 0 being no odour, and 10 being the worst odour they have encountered. A sample of the diary and VAS is provided in the p-value of 0.05 was considered statistically significant.All data was collected, analysed and plotted using GraphPad Prism . ANOVA was used for multiple data sets, with the Tukey post hoc analysis for parametric data. The Kruskal–Wallis ANOVA was used for non-parametric tests with the Dunn’s post hoc analysis. A TM suction coagulator  at a setting of 20 W. Routine post-operative instructions included simple analgesia with paracetamol. No antibiotics were prescribed post-operatively.A total of 19 patients undergoing suction monopolar adenoidectomy under general anaesthesia were included. All adenoidectomies were performed by an experienced ENT consultant using the ValleylabPre-school and school children had higher pain scores . Adolescp < 0.3 and p < 0.5, respectively).As shown in Overall, halitosis was reported highest at post-operative day 2 and continued to improve, reaching below pre-operative levels on day 7 .Parents of infants generally reported lower scores for halitosis compared to pre-school children and adolescents .Higher grades of adenoids reported relatively higher VAS halitosis scores .Electrocautery adenoidectomy is a safe and effective procedure to manage paediatric patients with recurrent otitis media with effusion and sleep-disordered breathing. Even though complications of adenoidectomies have been well studied, there is insufficient evidence for common post-operative symptoms and their trends. Understanding the typical post-operative recovery is important so that appropriate informed consent can be obtained from patients, parents and carers of children undergoing adenoidectomy. It also helps to avoid unnecessary anxiety and to set realistic expectations for the post-operative period and care.Pre-school and school children had higher pain scores in our study. Adolescents and toddler scores had decreased variability in pain scores. Factors contributing to a higher variability in pain scores include varying ability of children to communicate with different age groups, pain thresholds between children, parents’ interpretation of symptoms, and administration of regular analgesia. Around-the-clock paracetamol analgesia can decrease pain peaks as opposed to an as-needed regimen.The objective of this study was to study the pattern of post-operative halitosis and pain. Our study describes the self-limiting and transient nature of post-adenoidectomy halitosis and pain. The majority of parents reported pain and halitosis for about seven days post-operatively in their child, which resolved without a need for antibiotics. Overall postoperative pain was generally rated as mild (median score of 2 and highest being just below a score of 6) by parents of children undergoing ECA in this study.VAS is an easy to administer, cost effective observational rating tool used by adults to assess symptoms like pain and halitosis in children. We felt that VAS was the most appropriate method of reporting symptoms. However, due to the large variation in ages, some can communicate verbally, but others that cannot, making it difficult to draw exact comparisons. This is especially true in halitosis for toddlers, since we are reliant on parents to report their perception of halitosis.In 2009, Taddio et al. randomized infants undergoing immunization to pre-anaesthetizing with 4% amethocaine gel or placebo . ParentsA systematic review commissioned by Paediatric Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials assessed commonly used behavioural scales in varying clinical scenarios . The majA limitation of this study is the small cohort size, which makes it difficult to compare various groups for statistical analysis. Another limitation is the lack of a control group. Our institution’s surgical preference is to use the ECA technique instead of curettage. We also felt that using the patient pre-operative VAS scores would suffice as a baseline given the aim of the study was to document the natural history of pain and halitosis in children undergoing ECA. It is also possible that parents may not have given sufficient analgesia to their children, resulting in some children having higher pain scores. Similarly, oral hygiene was not standardized, which could heavily influence the prevalence of halitosis. Some children that had concurrent powered turbinoplasty would have crusting, pain and halitosis contributing to post-operative halitosis and pain scores. In future a case control study comparing curettage and ECA will further help evaluate incidence of halitosis and pain post-adenoidectomy.In summary, this prospective observational cohort study of children undergoing ECA demonstrates that post-operative pain and halitosis occurs up to seven days post-operatively. The children in this study continued to have normal oral intake with simple analgesia. Post-operative halitosis can be a source of anxiety for parents of these children and misinterpreted as an infection. However, our study demonstrates that the natural course of halitosis is that it will resolve post-operatively without antibiotics. This is important to explain to parents with regards to pain and halitosis as part of the informed consent.


In summary, administration of a medical device, based on hyaluronic acid and chondroitin sulfate, improves gastritis-related upper abdominal pain/discomfort and decreases mucosal erosions, blood oozing, and hyperemia (redness)/edema at 5-week follow-up in patients affected by gastritis.Gastritis is an inflammation of the gastric mucosa. In this study, we investigated the efficacy of a medical device, Esoxx®, based on hyaluronic acid and chondroitin sulfate on gastritis-related upper abdominal pain/discomfort and endoscopic features. Fifty patients, affected by gastritis, were randomised to receive the medical device or placebo. The primary endpoint was the medical device efficacy on upper abdominal pain/discomfort associated with gastritis and measured by Visual Analogue Scale (VAS). The secondary endpoints were the efficacy of the medical device on gastritis-related mucosal erosions, blood oozing, and hyperemia (redness)/edema, as assessed by endoscopy, and the patients’ rating of their compliance with the treatments. A significant reduction in VAS pain was observed in the treatment group after a 5-week treatment, if compared with placebo (The online version of this article (10.1007/s13346-018-0531-7) contains supplementary material, which is available to authorized users. Helicobacter pylori infection, biliary reflux into the stomach, use of non-steroidal anti-inflammatory drugs, unbalanced diet, chemical injuries such as alcohol and acids, and long-term physical and mental stress  who had appealed to our “Second Opinion Medical Network”  between 2016 and 2017 due to gastritis symptoms were included in this study. The concept of “Second Opinion Medical Consulting Network” has been reviewed elsewhere –31. BefoThe medical device  is based on a mixture of hyaluronic acid and chondroitin sulfate in a bioadhesive carrier Lutrol® F 127  that acts as a buffering agent to form a barrier and prolong the action on the esophageal mucosa . The forThe placebo composition was as follows: 10% Vaseline oil/water emulsion, viscosity enhancer, preservatives, aroma, and water. The used formulations were manufactured by Alfa Wasserman Spa . Ten milliliters of the placebo or medical device was administered four times a day  for 2 weeks. The 2-week treatment was followed by a week without any medication. Afterwards, the patients underwent 2-week further treatment according to the above-described protocol. We used a 5-week design as we hypothesized that this timecourse was necessary to allow long-lasting protection of the mucosa from gastric acid and promote the repair of histological lesions.VAS, a scoring system from 0 (minimum pain) to 100 mm (severe pain), was used to rate the primary endpoint, i.e., improvement in gastritis-related upper abdominal pain/discomfort at 5-week follow-up. In regard to the two children involved in this investigation, their parents were allowed to stay to give their support in relation to the VAS pain scoring. A month after the end of the study, a phone interview was used to determine if the patients’ improvement in gastritis-related upper abdominal pain/discomfort was still persisting.The secondary endpoints were evaluation of the effect of the medical device on gastritis-related mucosal erosions, blood oozing, and hyperemia (redness)/edema, compared to placebo, as assessed by photographic endoscopy evaluation performed by two blinded pathologists at 5-week follow-up. The pathologists gave a judgment according to the following ranges: (1) 1–30% = poor improvement, (2) 30–60% = moderate improvement, and (3) 60–100% = good improvement.The patients were also asked to rate their compliance/tolerability related to viscosity, taste, and difficulty to swallow the treatments as “poor,” “fair,” “good,” or “very good.”p value ˂ 0.05 was considered significant.VAS data were analyzed using a two-way analysis of variance (ANOVA) followed by Bonferroni post hoc test using GraphPad Prism . All data are presented as the means ± SEM. A At baseline, upper abdominal pain/discomfort was 65.56 ± 2.9 mm for the placebo group and 68.8 ± 3.4 mm for the treatment group. A significant reduction in upper abdominal pain/discomfort was observed in the treatment group, if compared with placebo at 5-week follow-up Fig. . Among tAt the phone interview, improvement in upper abdominal pain/discomfort was persistent in 23 patients from the medical device group. The 2 patients from this group who did not experience amelioration in upper abdominal pain/discomfort at 5-week follow-up started a different therapy. No amelioration in upper abdominal pain/discomfort in all patients receiving placebo was observed at the phone interview.Endoscopic assessment at baseline was compared to the endoscopy performed at 5-week follow-up in terms of erosions, blood oozing, and hyperemia (redness)/edema in the active treatment Fig.  and placn = 6) and very good (n = 19). Twenty-two patients in the placebo group rated their compliance/tolerability as very good, while 3 rated their compliance as good. No adverse effects were observed in both groups.The patients treated with the medical device rated their compliance/tolerability related to viscosity, taste, and difficulty to swallow as good /edema, and mucosal erosions, as assessed by two pathologists by photographic endoscopic examination at 5-week follow-up. A first-in-man attempt to treat gastroduodenal diseases by oral administration of CS was performed by Crandall and Roberts  on 22 paH. pylori-related gastritis have not been taken into account. In conclusion, we speculate that the effectiveness of Esoxx® may rely on HA and CS ability to coat the gastric epithelium, inhibiting gastric fluid acidity and pepsin-induced mucosal erosion. Further studies, involving larger cohorts of patients, are necessary to establish the long-term efficacy of Esoxx® and its underlying mechanism.The results from the present study strongly support the hypothesis that HA may cover the submucosal connective tissue inducing epithelial cell shifting and increasing cell motility. In turn, this tissue becomes softer and hydrophilic because of HA availability beneath the mucosa containing fibrin and mucous allowing the repair of the damaged gastric mucosa. At the same time, CS may act synergistically to promote, together with HA and the added adhesive biopolymer, the healing of ulcers and erosions. We speculate that the use of this composition may also be extended to manage the symptoms related to esophagitis, gastrointestinal reflux, and other gastroduodenal diseases although this will need to be proven by future clinical studies. Our investigation presents limitations such as the small number of patients and the lack of a long-term endoscopic follow-up to assess the effect of this treatment in the long run. Furthermore, patients presenting ESM 1(DOCX 2745 kb)


The aim of this study was to compare the short-term and intermediate-term efficacy of acupuncture plus fire needle therapy with that of acupuncture alone in the treatment of lateral epicondylitis (LE).t test.Thirty-eight patients with LE who had persisted for at least 2 months were enrolled in this prospective, assessor-blinded, randomized controlled pilot trial. Twenty-one patients were randomized to the acupuncture plus fire needle group and 17 to the acupuncture-only group. The primary outcome was the visual analog scale pain score for the previous 24 hours and the secondary outcomes were the maximum grip strength, Patient-rated Forearm Evaluation Questionnaire score, and Medical Outcomes Study 36-Item Short-form Health Survey score. The values at baseline (pretreatment), at the end of treatment, and at 3 months after treatment were used to assess the short-term and intermediate-term effects of treatment. The data were analyzed using the Chi-square test and Within-group analyses showed better results for acupuncture plus fire needle therapy in the short term and intermediate term. Differences in the severity of pain and secondary outcomes were significant in the intermediate term in the acupuncture group. At the end of treatment, none of the differences in outcome scores were significant, except for maximum grip strength in the affected hand in the acupuncture group. No significant between-group differences in short-term or intermediate-term outcomes were observed.Acupuncture plus fire needle therapy was effective in the short term in patients seeking improvement of LE. Twelve treatments were effective for relieving pain and improving disability in the intermediate term in patients with chronic LE in both study groups. The findings of the pilot study confirm the feasibility of proceeding to a larger randomized controlled study of the longer-term effects of acupuncture plus fire needle therapy in patients with LE. Although LE is classically regarded as an inflammatory process, the pathology suggests angiofibroblastic hyperplasia; therefore, many authors consider LE to be a degenerative process in the tendons rather than an inflammatory one. LE can be diagnosed by tests that increase pain, including palpation over the facet of the lateral epicondyle, resisted wrist extension, resisted middle finger extension, and passive wrist flexion. Although many management strategies have been used in patients with LE, including pain-relieving drugs, corticosteroid injections, physiotherapy, elbow supports, shock-wave therapy, platelet-rich plasma injections, and surgery, the optimal treatment is still unclear.,7 When conservative treatments are unsuccessful or not accessible for cost reasons, an increasing number of patients consider complementary medicine, particularly acupuncture.,9 In a systematic review by Trinh et al, acupuncture was found to relieve the pain of LE effectively, but its long-term efficacy could not be established. Another technique commonly used to treat chronic pain in patients with LE is fire needle therapy, which combines acupuncture and moxibustion. A case report demonstrated a significant short-term effect of fire needle therapy in a patient with LE. Moreover, it has been shown that a combination of rehabilitation and fire needle therapy is effective for at least 4 weeks in patients with LE.,13 However, although the early case report demonstrated effects lasting for 4 months, there has been insufficient evidence for the intermediate-term or long-term therapeutic effects of acupuncture or fire needle therapy in terms of reducing the pain associated with LE.,11Lateral epicondylitis (LE), also known as “tennis elbow,” is the most common diagnosis in patients with elbow pain.We hypothesized that the therapeutic effect of acupuncture plus fire needle therapy would be better than that of acupuncture alone. The aims of this pilot study were to investigate whether or not the short-term and intermediate-term outcomes of acupuncture used in combination with fire needle treatment are better than those of acupuncture alone in patients with LE and to determine the feasibility of proceeding to a larger-scale randomized controlled trial investigating the longer-term outcomes of this combination treatment in LE. In this study, we focused not only on the short-term ability of these treatments to improve symptoms but also on the subjective and objective outcomes in the intermediate term.22.1The study was approved by the human ethics committee at our institution . The protocol was registered with ClinicalTrials.gov (Identifier: NCT03820856). Patient confidentiality was ensured before, during, and after the trial.2.2This prospective, assessor-blinded, randomized pilot trial was designed to compare the effects of acupuncture plus fire needle therapy with those of acupuncture alone in patients with LE. The patients were recruited from the outpatient acupuncture clinic at Chang Gung Memorial Hospital between January 2010 and January 2011.2.3 Symptoms were required to have persisted for at least 2 months and be unilateral.All patients identified to have LE during the study period underwent a physical examination to determine their eligibility for enrolment in the study. Patients were selected for inclusion if 2 or more of the following were noted on the physical examination form: pain over the lateral aspect of the elbow; pain on palpation over the lateral epicondyle or the associated myotendinous junction of the common extensor tendon; pain on hand gripping; and pain with either resisted static contraction or stretching of the wrist extensor muscles.The following exclusion criteria were applied: signs and symptoms suggesting a cause other than overuse ; osteoarthritis of the elbow joints; pathologic, neurologic, and/or vascular findings in the arms; arthritis ; radiohumeral bursitis; ligamentous sprain; bilateral tennis elbow; painful shoulder; surgery or dislocation of the elbow; coagulopathy; pregnancy; infection; and malignancy. Patients who had been treated with other therapies or drugs for LE in the 2 weeks before the start of the trial, those who had received corticosteroid injections in the previous 6 months, and those who had already received acupuncture and fire needle therapy for LE were also excluded.2.4All patients provided written informed consent before inclusion in the study. The informed consent form was approved by the Chang Gung Memorial Hospital Institutional Review Board for Biomedical Research (IRB#98–3818A3). The patients were informed about the possible adverse effects of acupuncture and fire needle therapy, including bleeding, hematoma, mild pain during needling, local muscle pain, nerve irritation or injury, burning of the skin at the wound site, skin infection, and temporary weakness in the involved muscles. Patients were also informed of rare but serious adverse effects, such as fainting, dizziness, and unstable blood pressure.2.5Assignment was based on a predetermined randomization scheme (using a random number table) in a 1:1 allocation ratio. All participants were randomized by use of sealed, opaque, sequentially numbered envelopes.2.6Blinding of the acupuncturists and patients was not possible because of the nature of the intervention. However, the outcome assessor was blinded to study group allocation (acupuncture or acupuncture plus fire needle). The statistical analyses were performed by a researcher who was blinded to group allocation.2.7All of the acupuncture therapists in the study had at least 3 years of experience, were trained and board-certified in Taiwan, and understood the treatment protocol. The participants were randomly assigned to either the acupuncture group or the acupuncture plus fire needle group and then started their allocated treatment.2.8 Triple needling was performed at the Ah shi point, that is, the 1 to 2-cm area encompassing the most painful spot on the humeral epicondyle. We also manipulated acupuncture needles in the following areas: LI10 (Shousanli) and LI11 (Quchi) over the origin of the lateral extensor muscle group of the forearm, with LI10 being 2 cun  below LI11; LI12 (Zhouliao) comprising an area of 1 cun superolateral to LI11; and LU5 (Chize) in the cubital region . The red-hot needle was inserted rapidly into the Ah shi point  for approximately half a second and then removed. Pressure was then applied to the needle hole using a sterilized dry cotton ball.2.10Before randomization, a research assistant recorded the baseline demographic data, including sex and age, as well as duration of symptoms. The primary outcome was the visual analog scale (VAS) score for subjective severity of pain within the previous 24 hours. The secondary outcomes were maximum grip strength (MGS), the Patient-rated Forearm Evaluation Questionnaire (PRFEQ) score, and the Medical Outcomes Study 36-Item Short-form Health Survey (SF-36) score. All of the outcomes were evaluated at baseline (pre-treatment), at the end of treatment, and 3 months after treatment to test the short-term and intermediate-term effects of therapy, respectively.2.11The severity of the patient's elbow pain was evaluated using a 10-point VAS  at rest, during motion, and on exertion. Elbow pain lasting more than 24 hours was also evaluated using the VAS.2.12 The patient is required to stand with his or her arm alongside the body with the forearm pronated and the elbow extended while holding the dynamometer. The patient is then instructed to squeeze once with maximum pressure, and the measurement is recorded. The MGS is measured 3 times with a 30-second rest interval between each measurement. The average value is used to maximize reproducibility.MGS was measured using a Jamar Hydraulic Hand Dynamometer . The validity of this instrument in diagnosing and evaluating the response to treatment had been established in patients with LE. and appears to be useful for assessment of the outcome of treatment for LE. The PRFEQ is divided into 2 sections, that is, pain and function at the elbow. The first section contains 5 items and the second contains 10 items. Each item evaluates the average pain or function of the affected elbow during the previous week. The score ranges from 0 (no pain or difficulty in performing a task) to 10 (the worst pain imaginable or inability to perform a task) for each item. The total score represents the combined score for all questions. The score ranges from 0 to 50 for the pain section and from 0 to 100 for the function section; the value for the function section is then divided by 2 so that 50 is the maximum score. In this study, the Hong Kong Chinese version of the PRFEQ was used to measure functional impairment.The PRFEQ was developed by Overend et al The SF-36 measures 8 health dimensions that are divided into 2 broad categories. The first category is a physical component score (PCS) that includes physical function, role limitations related to physical problems, bodily pain, and general health perception. The second category is a mental component score (MCS) that includes vitality, social functioning, role limitations because of emotional problems, and mental health. The raw scores are linearly transformed into a scale of 0 to 100, with higher transformed scores indicating better health. In this study, the Taiwanese version of the SF-36 was used to measure general health status.Quality of life was assessed using the SF-36, which was self-administered.2.13t test was used to compare patient age, duration of symptoms, VAS pain score, the MGS score for the affected hand, and PRFEQ and SF-36 scores between the groups at baseline. To assess the treatment effect, the within-group differences in outcomes were analyzed using the paired-samples t test and the between-group differences in scores were analyzed using the independent-samples t test. All statistical analyses were performed using SPSS for Windows . A P value < .05 was considered statistically significant.The Chi-square test was used to compare the categorical data, that is, patient sex and elbow affected, between the groups. The independent-samples 3Forty-three patients  were enrolled in the study  and during motion (P < .01) and exertion (P < .01). The VAS scores continued to decrease in this group during the 3 months of treatment (P < .01). After 12 treatments with acupuncture plus fire needle therapy, there was a significant improvement in the MGS of the affected hand (P < .01) and in both sections of the PRFEQ, particularly for pain (P < .01) and function (P < .01). We also observed a significant improvement in the components of the SF-36, particularly in the PCS (P < .01) and MCS (P < .05) at the end of treatment; this improvement continued in the acupuncture plus fire needle group during the 3 months of treatment , except in the MGS score for the affected hand (P < .01). Three months after completion of acupuncture, there were significant improvements in VAS pain scores at rest (P < .05) and during motion (P < .01) and exertion (P < .01). After completion of 3 months of acupuncture, there was still a significant improvement in the MGS of the affected hand (P < .01) and in both sections of the PRFEQ (P < .01). There was a significant change in the MCS (P < .05) and PCS (P < .01) sections of the SF-36 after 3 months of treatment in this group . However, there was a tendency for better improvement in the short term in the acupuncture plus fire needle group than in the acupuncture group  group and sham acupuncture (control) group; however, significantly more improvement was noted in the treatment group than in the control group at the 2-week follow-up visit. The difference was still significant at 2 months, at which time function was more improved in the treatment group.Although some trials reported in the Chinese journals have demonstrated the efficacy of fire needle treatment for LE, to the best of our knowledge, there have been no relevant randomized controlled trials of this intervention reported in the English language. Several studies have reported an association between decreased grip strength and LE. Hence, fire needle therapy stimulates acupoints and has a moxibustion effect simultaneously, with the effect of promoting the circulation of blood and eliminating blood stasis. In traditional Chinese medicine, fire needle therapy has the effect of warming and freeing the yang qi of the body and therefore repels wind and cold dampness in the meridian. The effect is correlated with the most common traditional Chinese medicine patterns of LE, that is, a wind-cold dampness pattern as well as qi stagnation and blood stasis pattern. Therefore, according to traditional Chinese medicine theory, fire needle therapy seems to be an appropriate treatment for LE.Fire needle therapy was first described in the Yellow Emperor's Canon of Internal Medicine  over 2000 years ago. A burning needle was the key modality in this treatment. The needle must be heated until it glows a red color; subsequently, the glowing needle is inserted. The heat of a fire needle dissipates rapidly, so the needle is not irritating, even though the body of needle remains in the skin and focuses the heat directly on a specific area. and Zhu and Zhu, who showed that the signs and symptoms of LE in patients who received acupuncture plus fire needle therapy were reduced in comparison with those in patients who received conventional acupuncture treatment.In our study, the pain and functional impairment caused by LE was significantly decreased in the acupuncture plus fire needle group in the short term and the effect lasted well into the intermediate term. The pain was relieved more rapidly, albeit not to a statistically significantly extent, in the fire needle group than in the acupuncture group. These results are in agreement with the findings of DingThis study had several limitations that need to be acknowledged. First, our study participants had had symptoms of tennis elbow for up to 2 months, so our findings cannot be generalized to patients with symptoms of longer duration. However, the impact of this limitation was difficult to assess because it was not possible to include a second control group that received no treatment for 3 months. Second, the study participants were recruited solely from outpatient clinics, which might have introduced a degree of selection bias. However, had we not used this recruitment strategy, the sample size would have been too small and the study groups would not have been of equal size. The short follow-up period and use of single blinding rather than double blinding were additional limitations.We found preliminary evidence to support the use of acupuncture and acupuncture plus fire needle therapy in the treatment of LE over a 3-month period. After 3 months of treatment, the severity of pain and functional impairment were reduced in both study groups. Moreover, the decrease in pain and functional impairment in the acupuncture plus fire needle group was greater than that in the acupuncture group in the short term. However, there were no significant between-group differences in the intermediate-term outcomes, meaning that both treatment strategies could achieve significant outcomes in the intermediate term, and only the acupuncture plus fire needle therapy had a significant short-term effect.5The findings of this preliminary study indicate that acupuncture plus fire needle therapy may be effective in patients seeking improvement of LE in the short term and that 12 acupuncture sessions with or without fire needle therapy were effective for relieving pain and improving disability in the intermediate term in these patients. These preliminary findings confirm the feasibility of conducting a larger-scale randomized controlled trial that includes a placebo (or sham) group and a longer follow-up duration to evaluate the effects of this combination treatment for LE.The authors would like to extend their appreciation to all the patients who participated in this survey. We appreciate the assistance with the statistical analysis provided by the Biostatistics Center, Kaohsiung Chang Gung Memorial Hospital.KWB and CNL conceived and designed the study. CNL, JMS, and KWB recruited the study participants. KWB and CNL performed the intervention. TPH and KWB collected the patient data. SYW and CCC interpreted and analyzed the data. SYW and CJC drafted the manuscript. CEK and CNL critically reviewed and revised the manuscript. All authors read and approved the final manuscript.Conceptualization: Cheng-Nan Lu, Kuo-Wei Bi.Data curation: Cheng-Nan Lu, Jer-Ming Sheen, Tun-Pin Hsueh, Kuo-Wei Bi.Formal analysis: Szu-Ying Wu, Ching-Chih Chen.Methodology: Szu-Ying Wu, Cheng-Nan Lu, Kuo-Wei Bi.Project administration: Cheng-Nan Lu, Kuo-Wei Bi.Supervision: Cheng-Nan Lu, Kuo-Wei Bi.Writing – original draft: Szu-Ying Wu, Chia-Jung Chung.Writing – review & editing: Cheng-Nan Lu, Chun-En Kuo.


Non-specific chronic low back pain (nscLBP) has a high socio-economic relevance due to its high incidence, prevalence and associated costs. Therefore, it is essential to evaluate effective therapeutic strategies. This study examines the effects of moderate mountain exercise and spa therapy on orthopedic and psychophysiological parameters. Based on a three-armed randomized controlled trial, guided mountain hiking tours and balneotherapy in thermal water were compared to a control group.4 thermal water. The third group (CO) received no intervention. GE and GEBT group were treated for 6 days; all groups were followed up for 120 days.Eighty patients with diagnosed nscLBP were separated into three groups: The two intervention groups GE (green exercise) and GEBT  undertook daily mountain hiking tours, whereas the GEBT group got an additional treatment with baths in Mg-Ca-SOCompared to GE and CO group, the GEBT treatment showed significant improvements of pain, some orthopedic parameters, health-related quality of life and mental well-being in patients with nscLBP.4 spa therapy as a multimodal treatment of patients with nscLBP. Further studies should focus on long-term-effects of this therapeutic approach.The results of this study confirmed a benefit of mountain hiking combined with Mg-Ca-SOISRCTN99926592. Registered 06. July 2018 - Retrospectively registered.ISRCTN,  In industrialized western countries, complaints of lower back pain are one of the leading health problems regarding incidence and prevalence. This problem occurs in almost all population groups and is responsible for a considerable extent of medical and social services, and consequently also for high macroeconomic costs. An Austrian health survey conducted in 2015 showed that chronic back pain is the most frequent chronic illness in Austria: 1.8 million people were affected, which accounts for 24.4% of the population [Furthermore, a characteristic sex-  and age-dependency was observed. In 2015 there were 37,463 acute hospital stays due to complaints in the back with an average length of stay of 6.9 days, with 139 persons under 15 years, 5907 persons aged 15 to 44 years, 11,984 persons aged 45 to 64 years and 19,433 persons aged 65 years and older [Discomfort of the lower back, located centrally and paravertebrally to the spine - caudal to costal arch and cranial to os coccygis -, with or without radiations, is called low back pain (LBP). According to causality, a distinction is made between specific LBP, describing pain of a diagnosable genesis, and non-specific LBP (nscLBP), in which no clear diagnostic indications of a specific cause, i.e. a central pathomechanism or an irritated structure, can be detected . About 8In relation to the course of time, acute pain (less than 6 weeks), subacute (less than 12 weeks), and chronic or chronically recurrent (more than 12 weeks) back pain are differed .Using the hypothesis of the biopsychosocial pain model as an explanation for nscLBP, the complexity of this disease pattern becomes clear: The origin and duration of back pain is not only depending on physical , but also psychological  and social factors  . HoweverDue to multimodal causes and complex interactions of biological, psychological and social factors, nscLBP cannot be cured persistently, but various conservative therapy options to reduce pain and impairment are available, addressing the consequences of long-term pain . PrefereBased on these recommendations, we investigated the following therapy concept for the treatment of patients with nscLBP: green exercise (active therapy combined with experience of nature) and balneotherapy.Physical activity in natural environments such as meadow, forests or alpine pastures, is called green exercise. This nature therapy addresses patients in many ways –16. CurrIn addition to exercise, balneological treatment can be seen as a meaningful therapeutic option. Despite limited available data, there is encouraging evidence that balneo or spa therapy may be effective in the treatment of nscLBP . As tria4 thermal balneotherapy is an effective and economic nature therapy to reduce symptoms  and improve wellbeing of patients with nscLBP. Furthermore, we investigated whether green exercise or the combination of green exercise and spa therapy in Mg-Ca-SO4-type water discloses specific effects in intergroup comparisons. This RCT examines the hypothesis, whether a multimodal therapy (spa therapy and green exercise) can reduce the symptoms and improve the spinal mobility of patients suffering from nscLBP, in comparison to an intervention group without spa therapy and a non-intervention control group.This RCT was conducted to find out whether green exercise - in this case moderate mountain hiking - combined with Mg-Ca-SOWasser Tirol web page , advertisements in newspapers and by physicians. Requirements for study inclusion were diagnosed nscLBP pain and repeated medical treatment because of nscLBP during the past 3 years. Therefore, a medical certificate from the respective treating doctor was mandatory for inclusion. Exclusion criteria were as follows: malignant diseases, previous operations in the lumbar spine area, suspected disc herniation, acute pain, confirmed osteoporosis, contraindications of balneotherapy , hernia or pregnancy. No sample size calculation was possible with the available data at the time of study proposal for the selected outcomes.Eighty patients  were included in this study. The participants were primarily recruited all over Austria through communication via the The Ethics Committee of Salzburg (415-E/1487/4–2012) approved the study protocol and all participants gave written consent. This study adheres to CONSORT guidelines for reporting clinical trials.n = 27), all participants spent 8 days at the village of Grins , hosted in comparable hotels and receiving the same meals. The study procedure was carried out according to the following structure: Medical examinations were performed at arrival , after the intervention  and after 4 months . The arrival of the patients took place on Saturday followed by medical measurements and an anamnesis of medical history at the same day. From Sunday to Friday all persons undertook daily guided hiking tours in the mountains. The structured movement program included a daily 5 h hiking tour in and around the municipality of Grins. The weekly hiking program is shown in Table The study was set up as a randomized controlled clinical trial with three arms. Except for the non-intervention group  only participated in green exercise/GE, whereas the second group (n = 26) got an additional treatment with baths in thermal water in the Albenbad . The baths in a tub lasted 20 min. Thereafter, the patients could relax in a heated (room temperature) resting tent. The Albenbad houses two bathtubs; after each patient, the water was omitted, the tub was carefully cleaned, disinfected and newly filled with warm (37 °C) thermal water.The first group intervention has not been possible , the inclusion of a control group (CO) without any intervention was necessary. The participants of this group received no intervention and stayed at home, maintaining their usual lifestyle. In return for their participation the CO group participants received an amount of 150 Euros per person to cover their study-prone expenses. The patients of the GE and GEBT group got a one-week free holiday including food and lodging in hotels in the village of Grins in Tyrol, Austria. Patients were free to discontinue participation in the study at any time without giving reasons.The study was executed from September 2013 to January 2014 for the first two groups (GE and GEBT) and from September 2014 to January 2015 for the third group (CO) to exclude seasonal effects. Due to personnel restrictions, a parallel assessment of all three study groups was not feasible. Orthopedic, physiological and psychological data from day 0 and 8 were collected on-site in a medical field laboratory in Grins. Follow-up examinations on day 120 of the intervention-group members as well as all examinations of the CO group members were conducted at the Paracelsus Medical University of Salzburg, Austria. The participants were stratified by the Korff assessment (pain related disability)  and were4 – type with a 1.2 ratio of Ca/Mg. An overview of the water analysis can be seen in Table 4 in This randomized controlled study was performed in Grins, which is located 1015 m above sea level in the district of Landeck  in the submontane of the Lechtal Alps. In 2007, this village obtained the official therapeutic and thermal water status for its water. The water produced by the three springs derives predominantly from a deep-seated aquifer with a subordinated admixture of young water, which duration of dwell time can be estimated to be less than 50 years. From age modeling the residence time of the old groundwater component was estimated to be between 10′000 and 30′000 years. The water of the wells is very well protected by the surrounding. It is of the rare Mg-Ca-SOAlbenbad was established, in which the balneological part of the study was carried out. In the Albenbad, people can experience the water in form of undergoing Kneipp cures, drinking cures or bath cures. Additionally, a regional network of hiking trails, the Albigen paths, was set up in 2011, which also constituted the basic infrastructure for the present investigation.In 2010, a new bathing facility called At the beginning and end of the one-week intervention, as well as 4 months after the intervention, the functional spinal mobility was measured by parts of the Back Performance Scale, the Spine-Check Score MediMouse® and per trunk rotation measurements. Prior to the start, directly after the intervention week and also during the observation period, chronicity, pain, physical and psychological impairment as well as disability due to cLBP (chronic low back pain) of all subjects were assessed via different validated questionnaires . In a pain diary, the use of pain medication was documented during the whole study period. Furthermore, the days of incapacity to work and the number of medical consultations due to cLBP in the last months were assessed. These three parameters were collected two times (day 0 and day 120).The BPS is an assessment of mobility-related activities in patients with back pain. It is seen as a reliable and valid instrument for measuring functional spinal mobility and to detect relevant clinical changes , 24. TheThe MediMouse®  is a computer-supported skin surface device for measuring lumbar, thoracic and sacral spinal curvature and sagittal range of motion. The MediMouse® is guided along the spine of the patient from the spinous process of the 7th cervical vertebra to the spinous process of the 3rd sacral vertebra, recording the length and contour of the spine. The electronic 3D sensors simultaneously detect the local inclination in all three levels of the room. This information is transmitted via Bluetooth to the PC and evaluated by the software. By intersegmental angles this test calculates the Spine-Check Score© which includes the three criteria of posture, mobility and postural stability. The examination is carried out in the upright position, in flexion and a loaded recording of the spine column (Matthias test) . Since tFor the elevation of the individual trunk rotation degree, the patients were sitting on a treatment bed, while their feet had ground contact. A bar was placed over the shoulders behind the cervical spine and fixed with both hands. The patients were then asked to turn the trunk as far as possible to one side (right or left). It was important that the execution took place without pain and that the motion was not carried out abruptly. The mobility was measured with a digital goniometer . This survey was repeated three times for each side, the mean value was used for further calculation.The ODI contains ten items related to pain behavior and daily activities of living that may be affected by cLBP : pain inA modified visual analogue scale for pain and status of health assessed the subjective pain intensity of the patients. The Visual Analogue Scale is a unidimensional measuring instrument, often used for the pain monitoring of adults . The patThe SF-36 is a health status scale for measuring the subjective health-related quality of life. It includes the following eight dimensions of health: physical function, role behavior due to physical impairment, pain, general health, vitality and physical energy, social functioning, role behavior due to mental impairment, as well as mental function , 38.The WHO-5 is a brief self-contained questionnaire including five positively formulated phrases, which refer to positive mood, vitality and general interests for screening depression in chronic illness: good spirits, relaxation, being active, waking up fresh and rested, and being interested in things are topics of it . The ansp ≤ 0.05 (*), as p ≤ 0.01 (**) or as p ≤ 0.001 (***). For the per protocol analysis, missing values were not replaced. Evaluation of the data distribution was performed by Kolmogorov-Smirnov (with Lilliefors correction of significance) and Shapiro-Wilk normality test and yielded that more than 60% of the generated data follows normal distribution. Due to the smaller sample sizes in the three subgroups, the Shapiro-Wilk test was added for the individual evaluation of normal distribution in the GEBT, GE and CO group [Statistical analyses were performed using the SPSS software . Statistical significance was set at the 0.05 probability level for all tests and is expressed as CO group . To idenLinear mixed models (LMM) with treatment and time or treatment, time and the interaction of treatment and time as fixed factors were used to analyze the effects of the treatments over time. To account for individual differences, the patient ID was set as random effect for all models. In LMM1 the treatments GEBT and GE vs. CO, time and the interaction of treatment and time were included. In LMM2 the treatments GE vs GBT, time and the interaction of treatment and time were evaluated. In LMM3, only treatment (GEBT and GE vs. CO) and time were included.For measurements concerning claim of medical care , taken at two instants of time, Friedman test (non-parametric data) was applied. Means and corresponding standard deviations can be found in Table 6 in This randomized controlled clinical study comprised 80 persons with diagnosed nscLBP consisting of 35 men and 45 women  on day 8, reflecting a higher mobility     for the lifting test  shows significant changes over time in both intervention groups at all time points .LMM3 analysis of the trunk rotation to the right side detects significant changes over time in both intervention groups on day 8 (p = 0.001). Looking at the total trunk rotation, both intervention groups show a significant change in treatment (GEBT p = 0.002). Also, the GE group showed a long-term effect on day 120    Fig. , Table 35 Fig. , p = 0.026, day 120 p = 0.015. Analysis via LMM3 also reports positive significant changes in both intervention groups   . Both the ODI and the Korff graduation scale, monitoring pain related disability, elicit trends for improvement in all study arms (LMM 1), but no significant differences over time between the three study groups could be observed (Table The Oswestry Disability Index (ODI), a measurement for pain behavior and activities of daily living for patients with cLBP, recorded significant changes in both intervention groups over time at all measurement points . The GE group showed no significant changes  as well as on day 120 (p <  0.000) in both intervention groups concerning physical health   and day 120 (p = 0.040)  for the WHO-5 Index  in both intervention groups , but no statistically valid differences in-between the groups on day 120   alone or in combination with Mg-Ca-SOAs indicated by our results, it can be assumed that green exercise has the greatest therapeutic influence, besides the social component of the group constellation as an important contributing factor. Commonly used in multimodal treatments of the rehabilitative care sector, the impact of positive group dynamics is a well-known influencing aspect . This asMost data feature a high standard deviation. This could be attributed to the fact, that stratification by the Korff assessment achieved an optimal distribution of the patients with regard to pain related disability, also reflected in subjective health-related quality of life, mobility and further assessments.Since a pathophysiological change of pain perception occurs in the brains of chronic pain patients  , a persiInterestingly, the results of the functional spinal mobility are partly contradictory . A possible explanation for this could be avoidance mechanisms or movement patterns reflected in these tests, which chronic pain patients have appropriated over years (e.g. methods/tools to pull on socks).Through different approaches like sight , 45, noiAccording to Rogerson et al., the social interaction time during outdoor exercise is significantly greater than during indoor sports . MoreoveThe ideal characteristic of nature suitable for nscLBP-therapy is currently not investigated. In our study, significant positive effects of green exercise in patients suffering from nscLBP were obtained in a moderate alpine environment and can be recommend for this patient group. Since the average altitude at which the patients stayed during the hikes was a maximum of 1500 m above sea level, the influence of the altitude for the parameters collected in this study may be negligibly small. It would be interesting to investigate the influence of mountain hiking at high altitude (> 2000 m) on patients with nscLBP. In this regard, further physiological changes could be expected , 56.In comparison to mountain hiking alone, the combination of green exercise and relaxation due to spa therapy has additional and sustainable therapeutic effects. This might be attributed to the thermal effect, which has an influence on patients via four pathways: vasodilatation, gate control mechanism, elevation of beta-endorphin levels and muscle relaxation . The theAs the development of an exercise program with biomechanical and aerobic features or a combination of approaches is recommended, the therapeutic approach of this study offers optimal implementation. The efficacy of this multimodal therapy approach is evident in its results and corresponds to current therapeutic recommendations, like the NICE guideline for management of low back pain .NscLBP has a lot of influencing factors in its pathogenesis, as well as subgroups of pathology and heterogeneity in appearance , 8, whicWe did not record hiking with a small backpack, as most patients did in our study, as well as previous hiking experiences in this sport, which could affect the functional parameters especially.Whether movement during the orthopedic tests was stopped by pain, by a structurally caused limitation, or by a non-trust in one’s own body ability was not recorded. We instructed to carry out all movements during examinations without pain or rather without an increase of continuously present pain.The study did not address the lifestyle and activity level  of the patients within the follow-up time, which should be taken into account as possible important influencing factors regarding the results.Additionally, regarding the intervention groups, social influences of common activity in a group must be mentioned, which might influence the results.4 thermal water was not investigated in this study and could be content of further research, because mineral concentration dependent effects may be linked to simple thermal effects [4 thermal and tap water, a placebo balneotherapy could not have been used in this investigation because of the intense odor of Mg-Ca-SO4 water.The absorption of minerals dissolved in Mg-Ca-SO effects . However effects , has bet4 thermal spa therapy as a multimodal treatment of patients with nscLBP showed a benefit concerning pain, functional spine mobility, subjective health-related quality of life and depression in chronic illness. Balneotherapy seems to promote regeneration between physical demands and supports super-compensatory processes after mountain hiking tours. Based on our results, green exercise in moderate alpine environments and balneotherapy can be recommended as a fast acting and inexpensive therapy, which is easy to implement.Moderate mountain hiking and Mg-Ca-SOBecause the intervention time of this study was 1 week, further studies are necessary, to examine long-term effects and the sustainability of this nature therapy.


Patient-controlled intravenous analgesia (PCIA) and patient-controlled epidural analgesia are 2 common methods of maintaining analgesia after cesarean section. In recent years, transversus abdominis plane block (TAPB) has been gradually applied clinically to reduce opioid analgesics and has achieved good results. Therefore, we performed this study to compare the efficacy and side effects of TAPB and PCIA in analgesia after cesarean section.One hundred patients who underwent cesarean section were randomly classified into 2 groups. Following surgery, one group underwent ultrasound-guided TAPB and the other group underwent PCIA. Pain intensity according to the visual analog scale  was assessed at 2, 4, 6, 8, 12, and 24-hour postsurgery in both groups. The postoperative complication rate and patient satisfaction were also measured.P > .05). However, the incidence of postoperative complications in the TAPB group was significantly lower than that in the PCIA group (P < .05). Furthermore, patient satisfaction in the TAPB group was significantly higher than that in the PCIA group (P < .05).No significant differences were found in the VAS scores between the groups (This study demonstrated that ultrasound-guided TAPB can achieve the same analgesic effect as PCIA after cesarean section but with even higher patient satisfaction. The management of postoperative pain in these patients is equally challenging. Using pain control approaches without using opioids can effectively improve the quality of postoperative recovery. Presently, the most popular regional block after cesarean section is transversus abdominis plane block (TAPB).–4 TAPB is an effective technique to counter postoperative pain after abdominal surgery, particularly in patients undergoing postcesarean section. Ultrasound-guided TAPB could vastly improve the success of inguinal nerve blocks, reduce the volume of local anesthetic used, and prevent potential injury of adjacent structures. This study was performed to compare PCIA and TAPB in sparing postoperative rescue analgesics under spinal anesthesia and to provide rational coping strategies.With the enactment of the 2nd birth policy in China, an increasing number of people want a 2nd child. The new policy has also resulted in an increased number of cesarean sections being performed. Thus, postpartum analgesia has become a common concern. There are 2 traditional analgesic techniques: patient-controlled intravenous analgesia (PCIA) and patient-controlled epidural analgesia. Conventionally, opioids are the drugs that are most commonly used to provide effective pain relief during the postoperative period. However, opioids are associated with dose-dependent side effects, such as nausea, vomiting, pruritus, sedation, and respiratory depression,2Using a computer-generated random table, we selected 103 patients at the Beijing Tsinghua Changgung Hospital with American Society of Anesthesiologists class I and II physical status who were aged 26 to 40 years and were planned for emergency or elective lower segment cesarean section with spinal anesthesia. The study protocol and advantages and potential disadvantages of the block methods were explained to the participants, and those who provided written consent were included in the study. The exclusion criteria included lack of written consent, drug abuse, allergic reactions to local anesthetics, body mass index >35, body weight <60 kg, coagulopathies, and requirement of general anesthesia. In the operating room, an intravenous cannula (18-gage) was inserted into the hand or arm of all patients. The patients were then monitored by noninvasive blood pressure, electrocardiogram, and pulse oxygen saturation; fluid therapy was given using 500 cc of Ringer lactate solution. The patients were turned to the left lateral position and were administered single-injection spinal anesthesia under sterile conditions using a 25-G needle in the L3–L4 space with 2.5 mL of 0.5% ropivacaine. Surgery was initiated after attaining T8 sensor blockade, and each case was managed by the same anesthesiologist without using any narcotics intraoperatively.Following surgery, the patients were randomly divided into 2 groups: TAPB group  and PCIA group . In the TAPB group, the probe was placed perpendicular to the mid-axillary line between the iliac crest and subcostal margin, the 3 abdominal muscle layers were identified, and the transversus abdominis plane was located between the internal oblique and transversus abdominis muscle. Next, 30 mL of 0.33% ropivacaine was injected, and drug spread in the plane was observed. The same procedure was repeated on the other side of the abdomen. In the PCIA group, following surgery, the patients were administered PCIA comprising sufentanil 100 mcg and 98 mL of 0.9% physiological saline in their intravenous cannula at a background dose of 2 mL/hour.The pain intensity according to the visual analog scale  was compared at 2, 4, 6, 8, 12, and 24 hours postoperatively in both groups to evaluate the effectiveness in relieving pain, and side effects such as nausea, vomiting, pruritus, sedation, and respiratory depression were recorded. Furthermore, if the patient complained of pain (VAS > 4), they were provided language comfort and were told that lactation was required the following day and analgesics may be secreted through milk. The patients stated that they understood and could endure the pain.The analgesic satisfaction 24 hours after surgery was measured as follows: 0 = weak, 1 = medium, 2 = good, 3 = very good, and 4 = excellent. The recovery time of intestinal peristalsis  after surgery and time required for the patient's first ambulation were also recorded.2.1P value of <.05 considered significant. The Student t test was used for parametric data, and the Chi-squared test was used to compare differences between the variables obtained.We recruited at least 50 patients in each group to minimize any impact of data loss. SPSS 18 was used to statistically analyze the collected data, with a 2-tailed 3P > .05)  were excluded because of the loss of postoperative follow-up records. Thus, the results for 100 patients were analyzed in total. The general characteristics  between the 2 patients groups were not statistically significant  required verbal comfort; however, they reported that they could tolerate the pain and required no analgesics Table . In addi4 TAPB is associated with lower incidences of hypotension and motor blockade. According to previous study results, the use of local anesthesia reduces the need for analgesic medications and reduces pain after surgery. Using TAPB to reduce pain after cesarean section and hysterectomy improved patient recovery.,9 Under ultrasound guidance, the accuracy of TAPB is markedly improved. According to the results of this study, ultrasound-guided TAPB has the same analgesic effect as traditional PCIA on pain control after cesarean section, but TAPB provides higher patient satisfaction because of its convenience, lack of pump requirement, and lack of postoperative complications. Additionally, the minor effect on free movements in the TAPB groups resulted in added comfort. However, systemic and intrathecal usage of opioids after cesarean section results in obvious side effects and limits, such as respiratory depression, nausea, vomiting, itching, excessive sedation, reduced peristaltic intestine activity, and pruritus. These side effects make patients uncomfortable and might affect the prognosis.Provision of analgesia or anesthesia to the anterior abdominal wall by TAPB has been well documented. The technique yields high analgesic efficacy and potentially long duration, with reported analgesia lasting up to 36 hours.,11 This study focused on assessing pain in the postoperative period during the first 24 hours after cesarean section. On the 2nd day following surgery, the pain was not very severe and was markedly relieved. Even a very small amount of drug without analgesics can achieve a good analgesic effect. TAPB markedly avoids the influence of drug secretion with milk, vastly benefiting infants.Numerous authors believe that the most effective and longest-lasting analgesic duration is 11 to 24 hours in the postoperative period among patients after undergoing cesarean section. In the present study, TAPB was performed after surgery and morphine and other opioids were not used outside the epidural space. A previous study demonstrated that ultrasound-guided TAPB using 20 cc of ropivacaine 0.2% was effective on both sides for postoperative pain management in patients who had undergone cesarean section. However, in addition to lateral abdominal block, 1 g of Apotel was injected intravenously every 8 hours within 15 minutes, and 25 mg of meperidine was injected intravenously for patients with a VAS score of >3. Therefore, in this study, 30 mL of 0.3% ropivacaine was administered to both sides, thereby not only achieving the analgesic effect but also prolonging the analgesic time. The maximum amount of ropivacaine was not exceeded. Another study reported that TAPB was performed by utilizing anatomical landmarks for better analgesia in lower parts of the abdomen; however, using this block method has a higher risk of complications such as nerve and organ damage.Various analyses have shown that TAPB is an effective tool to counter postoperative pain in terms of reducing the total dose of opioids but only when spinal morphine is not used. In this study, we also conducted bilateral TAPB under ultrasound guidance for patients undergoing cesarean section without complications and with definite effects. No significant difference was found between the groups in pain scores recorded at regular time intervals both at rest and during movement. Few side effects were noted in the TAPB group, whereas 1 patient vomited, 1 was sedated slightly, and 3 were nauseated in the PCIA group. Patient satisfaction in the TAPB group was significantly higher than that in the PCIA group, likely resulting from more effective pain control by TAPB after cesarean section.,16 In addition, TAPB was better accepted because it was more convenient for patients.Because of the use of ultrasound in blocks, truncal blocks can be simply performed with a low frequency of side effects.Overall, the present study showed that compared with traditional PCIA, ultrasound-guided TAPB, as a local analgesic mode, exhibits fewer side effects and threats to patient health and vastly improves patient satisfaction. It is a better strategy for pain control after cesarean section in clinical practice, especially in pregnant woman, and greatly improves the quality of life.Conceptualization: Yuanchao Gao, Huan Zhang.Data curation: Yuanchao Gao, Mengzhuo Guo, Chunyuan Du, Haijing Zhang.Formal analysis: Yuanchao Gao, Mengzhuo Guo, Chunyuan Du.Investigation: Yuanchao Gao, Chunyuan Du.Writing – original draft: Yuanchao Gao.Writing – review & editing: Huan Zhang.