The aim of this study is to evaluate the effect of using gel and solution forms of NaOCI during the chemomechanical preparation of the root canals on postoperative pain at different time intervals. 114 patients with mandibular molar teeth and symptomatic irreversible pulpitis were included in the study. All patients were divided into two groups based on the irrigant used during root canal preparation (n=57): Group 1, 5.25% NaOCI, Group 2, 5.25% NaOCI gel. All groups were filled with gutta-percha and AH Plus root canal sealer using single-cone technique. VAS scale (1-10) was used for postoperative pain assessment. After endodontic treatment, all patients were asked to record their postoperative pain levels at the 6th, 24th, 48th, 72nd hours, and 1 week later. The data were analyzed using Chi-Squared, Independent Samples T, Cochran Q and Friedman tests. Statistically significant difference was not found between the distributions of pain levels at different times according to the groups (p>0.050). A statistically significant difference was observed between the distributions of pain levels measured at different times in the solution group (p<0.001). A statistically significant difference was found between the distributions of pain levels measured at different times in the gel group (p<0.001). In both groups, highest postoperative pain levels occurred in the first 6 hours. Pain levels of the gel group as 38,5% mild, 17.3% moderate, 5.8% severe and pain levels of the solution group were obtained as 46.2% mild, 26.9% moderate, 9.6% severe at the 6th hour. The use of the gel form of NaOCI during the chemomechanical preparation of the root canals showed similar postoperative pain when compared to the solution form. When it is extruded from apical to periradicular tissues during root canal treatment, it damages endothelial cells and fibroblasts, facial nerve palsy, allergic reaction and necrosis may develop.7 In a retrospective study conducted by members of the American Association of Endodontists, 42% of clinicians reported that using NaOCI causes postoperative pain or serious complications at least once a year.8 That’s why, researchers are in search of a more biocompatible irrigant.Sodium hypochlorite (NaOCI) is the most widely used irrigation solution during root canal treatment.10 Studies have reported that the solution and gel forms of NaOCI have a similar effect on dentin. In the study of Zand, et al.10 (2010) evaluating the smear layer removal activity of the solution and gel forms of NaOCI, and the study of Garcia, et al.9 (2013) evaluating the effects of both forms on dentin microhardness, it has been reported that they have similar effects.It has been suggested currently that the use of the gel form of NaOCI is a potential option.The effect of the gel form of NaOCI on postoperative pain has not been studied; therefore, this study compared the effects of using gel and solution forms of 5.25% NaOCI in mandibular molar teeth with symptomatic irreversible pulpitis on postoperative pain. The null hypothesis was that there would be no difference between the gel and solution forms of NaOCI.Ethical approval for the study was obtained from the Institutional Review Board and the Ethics Committee of the University. In this clinical trial, Consolidated Standards of Reporting Trials guidelines were followed    and theThe inclusion criteria were as follows:Healthy individuals aged 18-45 without any systemic disease;Mandibular molar teeth that were diagnosed with symptomatic irreversible pulpitis that showed prolonged response in the tooth even after the removal of the thermal and electric pulp test;11 (1971) method, with two canals in the mesial root and a single canal in the distal root;Teeth with all root canals inclined up to 25° according to SchneiderPatients with preoperative pain scores between moderate and severe  according to the VAS scale.The exclusion criteria were the following:Patients having taken analgesics or anti-inflammatory drugs in the past 12 hours;Pregnant and lactating patients;Teeth with radiologically proven periapical lesion;Teeth that are too damaged to apply rubber dam;Teeth with resorption, radiological evidence of calcification or open apices;Patients with traumatic malocclusion;Patients without occlusal contact.114 patients were randomized into 2 groups based on the irrigation type during root canal preparation, using a computer program (available at www.randomizer.org). Each group was randomly and equally divided. The allocation ratio was 1:1. In the study, patients were not informed about the division and they were blinded. However, the clinicians could not be blinded due to the nature of the study.Root canal treatments of all patients were performed in a single session. Dental anesthesia was achieved using local anesthetic solution  containing 4% articaine and 1:200000 epinephrine for inferior alveolar nerve blockade. After rubber dam isolation, endodontic access cavity was prepared using high-speed burs . The working length (WL) was determined using apex locator  and confirmed to be 0.5-1 mm shorter than the “radiographic apex” by periapical radiographs. The root canals were mechanically prepared using ProTaper Next  up to X3. All ProTaper Next files were used with an endodontic engine  at the torque and speed values recommended by the manufacturer. After reaching the WL with size-15 K-type hand file, shaping was continued with brushing motion until the canal length was achieved with X1, X2 and X3 files, respectively. The files were withdrawn at the point where resistance was met before torsional overload occurred and the work continued after the apical opening was checked with size-10 K-type hand file. All patients were divided into two groups based on irrigant used during root canal preparation (n = 57): Group 1, 5.25% NaOCI solution , Group 2, 5.25% Chloraxid gel.Group 1 (NaOCI solution): The root canals were irrigated with 5 mL of 5.25% NaOCI.Group 2 (NaOCI gel): Gel form of 5.25% NaOCI  was used. After covering the root canal files with NaOCI gel, they were placed in the root canal. During instrumentation canals were irrigated with 5 mL saline.The irrigation procedure in all groups was performed with a NaviTip irrigation needle , placed 2 mm short of the working length. Once the shaping of the root canals was completed, according to the final irrigation procedure, all canals were irrigated with 5 mL of 17% EDTA solution , 5 mL of 5.25% NaOCI solution and 5 mL of saline, respectively. Root canals were dried with absorbent paper points . All groups were filled with gutta-percha  and AH Plus Sealer  root canal paste in the same session using the single-cone technique. After the quality of obturation was ensured with radiographs, coronal seal was provided with glass ionomer cement . The teeth was restored with composite resin  and, then, occlusal contacts was checked and relieved where necessary. Each patient was prescribed 400 mg of Ibuprofen and was instructed to take it every 8 hours when felt too severe and extremely unbearable pain to perform his daily activities.Visual analogue scale (VAS) was used for postoperative pain assessment. After endodontic treatment, all patients were given a detailed form to record their postoperative pain levels at the 6th, 24th, 48th, 72nd hours, and 1 week later. VAS assessment in this form was explained to the patients in detail, and they were asked to mark on the form the pain they felt at the 6th, 24th, 48th, 72nd hours, and 1 week later. One week after the treatment, patients were called by phone. The pain scores that the patients marked on the pain assessment form were learned and recorded in the patient file. According to the values recorded on the VAS, the pain levels were classified as no pain (0), mild pain (1-3), moderate pain (4-6) and severe pain (7-10).The data were analyzed by using IBM SPSS V23. The compatibility of the quantitative data to normal distribution was examined with the Kolmogorov Smirnov test. Chi-square test was conducted to compare categorical variables according to groups. Independent two sample t-test was performed for normally distributed data in comparison of quantitative variables according to between the two groups. Cochran Q test and Friedman test were used to examine the changes of categorical parameters within the group according to three or more time. Analysis results were presented as mean and standard deviation for quantitative data and as frequency (percentage) for categorical data. A p value of <0.05 was considered statistically significant.Of the 114 patients who participated in the study, 3 were not included in the analysis, as the instrument was broken in the root canal during root shaping (2 from the solution group and 1 from the gel group) and 7 were not accessible by phone (3 from the solution group and 4 from the gel group)   . DemogrStatistically significant difference was not observed between the groups according to distributions of pain levels at different times (p>0.05)   . A stat13 Sodium hypochlorite is the most commonly used irrigant during root canal treatment. However, its cytotoxic effects when extruded into periapical tissues are clinically worrying.9 Currently, it has been reported that the use of the gel form rather than the solution form of NaOCI is similarly effective, so the clinical use of the former may be an appropriate alternative to the latter.14The success of endodontic treatment depends on expanding and shaping the root canals, disinfecting and filling them fluid-tight. However, adequate disinfection cannot be achieved with mechanical preparation because of the complex anatomy of the root canals. Debris produced by the instruments during root canal treatment and the unshaped areas left untouched by the canal files affect the success of root canal treatment negatively by acting as a reservoir for microorganisms. Therefore, irrigation solutions should be used during and after the mechanical preparation of the root canals.15 single-session and multi-session treatment procedures,2 different irrigation concentrations16 and different irrigation activation systems.5 Topçuoğlu, et al.17 (2017)reported that the level of pain felt by the patients was higher than that of the patients in the manual file group compared to the Nair, et al.18 (2018) evaluated the effect of K-Files, Kedo-S and MTwo files on postoperative pain, they found the least pain scores in the MTwo group. Saba, et al.19 (2018) reported no difference in the effects of 2% chlorhexidine and 5.25% sodium hypochlorite solutions on postoperative pain. Farzaneh, et al.20 (2018) reported that 2.5% NaOCI solution showed lower pain levels in their studies, in which they evaluated the effect of 5.25% NaOCI and 2.5% NaOCI solution on postoperative pain. Moreover, Mostafa, et al.21 (2020) also reported that the 1.3% NaOCI solution showed lower pain levels than 5.25% NaOCI. Topçuoğlu, Topçuoğlu and Arslan22 (2018) reported in another study that apical positive irrigation (NaviTip) caused more pain than negative apical pressure irrigation system (EndoVac). To our knowledge, the effects of NaOCI’s solution and gel forms on postoperative pain have not been evaluated in any study performed to date. Therefore, the effect of NaOCI’s solution and gel forms on postoperative pain was compared in this study, and the null hypothesis was accepted.Many studies on postoperative pain levels exists in literature. Most of these studies have focused on different file systems,Although no statistically significant difference was found between the distribution of postoperative pain levels of the gel and solution forms of NaOCI (p>0.05), at all times evaluated , less pain has been observed in the gel group compared to the solution group. As the results show, it can be said that the gel form of NaOCI has a positive effect since its use during the chemomechanical preparation of the root canals caused lower levels of postoperative pain in patients.24 Therefore, reducing the apical extrusion of debris and solution can reduce the degree of postoperative pain after endodontic treatment. Many studies in the literature evaluating the effect of irrigation techniques on the amount of apical extrusion of debris and irrigation solution exists, and these studies report that more debris is extruded with conventional needle irrigation.27 In addition, many studies in the literature evaluate the effect of irrigation activation techniques on postoperative pain. In these studies, higher levels of postoperative pain were reported in the treatments performed using conventional needles compared to sonic, ultrasonic and laser irrigation, and postoperative pain levels were associated with the amount of debris extrusion.28 Although a lack of evidence is present, we think that lower postoperative pain levels with the use of the gel form of NaOCI in our study may be associated with the amount of apical debris extrusion, and this is in line with studies present in the literature. Further clinical studies are needed to evaluate the effect of the gel form of NaOCI on debris extrusion.Extrusion of dentin particles, necrotic pulp tissue and microorganisms from apical foramen to periapical tissues during chemomechanical preparation of root canals may increase postoperative pain by triggering an inflammatory reaction.10 (2010) They reported that no difference between NaOCI solution and gel forms was observed in terms of smear removal efficiency. Abu Hasna, et al.29 (2020) also reported that no difference was found in their studies evaluating the effect on Enterococcus faecalis and Escherichia coli . Further studies evaluating the smear removal, disinfection and debris extrusion efficiency of NaOCI gel and solution forms are needed.Although the gel form of NaOCI is advantageous to reduce postoperative pain, it is a concern whether the gel form of NaOCI is as effective as the smear removal and disinfection efficiency as the solution form. A limited number of studies focus on this subject in the literature review. Zand, et al.16In our study, a statistically significant difference is present between the distributions of pain levels measured at different times in the gel group (p<0.001). Pain levels of the gel group were obtained as 38,5% mild, 17.3% moderate, 5.8% severe at the 6th hour, 32.7% mild, 7.7% moderate, 3.8% severe at the 24th hour, 25% mild, 3.8% moderate, 1.9% severe at the 48th hour, 13.5% mild, 1.9% severe at the 72nd hour, 5.8% mild 1 week later. A statistically significant difference was observed between the distributions of pain levels measured at different times in the solution group (p<0.001). Pain levels of the solution group were obtained as 46.2% mild, 26.9% moderate, 9.6% severe at the 6th hour, 38.5% mild, 19.2% moderate, 1.9% severe at the 24th hour, 36.5% mild, 5.8% moderate, 1.9% severe at the 48th hour, 17.3% mild, 3.8% moderate at the 72nd hour, 5.8% mild and 1.9% moderate 1 week later. In both groups, highest postoperative pain levels occurred in the first 6 hours, with decrease observed at the following 24th, 48th, 72nd hours and the end of 1 week. The results obtained in this study are consistent with other studies in the literature evaluating postoperative pain periods.30 (2012) reported more pain in the mandibular region than in the maxillary region, while Arias, et al.31 (2009) noted higher incidence of postoperative pain in mandibular molar teeth. This variability in pain may be due to the difference of canal configurations of teeth and their anatomy in the apical third. In this study, mandibular molar teeth were used regarding the studies in the literature.26Studies in the literature report that tooth type in different regions affects postoperative pain. Ali, et al.2 In previous studies evaluating postoperative pain observed after endodontic treatment, the VAS scale was used because it is simple, valid and reliable.16 VAS scale consists of numerical values. This makes it easier for patients to interpret and record their pain perceptions.1 In this study, the VAS scale was used to evaluate postoperative pain. Limitation of the present study was the blinding of endodontist was not possible due to the use of solution and gel form of NaOCI.The painless treatment and post-treatment process provides patients with comfort and physicians with prestige. Therefore, pain research has become increasingly important in all health disciplines in recent years. However, concerns regarding the scientific communication of the sensation of pain exists. Because the sensation of pain is completely relative, varying from person to person.One of the limitations of this study is that the patients refused to come to the control sessions because root canal treatment was completed in one session. Therefore, pain levels were collected by phone calls. Although the clinicians could not be blinded due to the nature of the study, the researcher who made the phone calls could be blinded about the method of treatment.Within the limitations of the study, using gel or solution forms of NaOCI during chemomechanical preparation of root canals, resulted in similar postoperative pain. For both formulations, pain level decreased over time.


Addiction to opiates and synthetic opioids poses a major threat to public health worldwide, with pharmaceutical opioids prescribed to manage pain constituting the main problem. To counteract this threat, suitable pain management strategies should be implemented in health care. Monitoring pain management seems to be feasible using telemedicine with a certain degree of resource intensity and digitization. As a communication channel for this type of monitoring, SMS appears to be a valid alternative.The aim of this systematic literature review was to (1) provide information on the state of research regarding postoperative pain management via SMS, (2) establish a basic understanding of SMS-based pain management, and (3) provide insight into the feasibility of these management strategies. The research question was as follows: Is postoperative pain management feasible and effective utilizing SMS?A systematic literature review was performed mainly following the PRISMA guidelines and another guide on performing a systematic literature review for information systems–related research. A search string was developed based on the objectives and research question, and eight databases were searched.P<.001).The initial search resulted in 2083 records, which could be narrowed down by applying various exclusion criteria. Thereby, 11 articles were identified as relevant, which were accordingly analyzed and evaluated by full-text screening. In all articles, pain management interventions were performed using SMS communication between health care professionals and patients or their legal guardians. A prospective approach was predominantly chosen as the study design (91%) with the leading research objective of determining the intervention’s feasibility (73%). The primary reason for sending SMS messages was to monitor patients (64%). Overall, the use of SMS improved adherence, acceptance, and satisfaction regarding postoperative pain management. With an average response rate of approximately 89.5% (SD 3.8%), the reliability of SMS as a communication and monitoring tool was further emphasized. This response rate is significantly higher than that for email interventions (66.63%, This study provides a comprehensive picture of the current status on postoperative pain management by SMS. Communication via SMS was beneficial in all interventions, even preoperative. Six SMS interventions could be certified by the respective institutional review board and three were Health Insurance Portability and Accountability Act–compliant. Therefore, the results of this study could be leveraged to address the opioid epidemic. Overall, the research question could be confirmed. Future research should extend this systematic literature review regarding preoperative pain management. Based on these findings, a pre- and postoperative communication model should be developed to address the opioid epidemic effectively. Globally, the increasing use of opiates and synthetic opioids poses a major threat to public health ,2. In 20Almost every aspect of these pain management strategies, and the efficiency and quality of health care rely on effective communication ,14. PoorMobile health, delivered through mobile instant messaging apps or SMS texting, has particular potential in this regard. SMS is utilized more frequently , as SMS To address the ongoing opioid epidemic, pain management combined with SMS as a communication medium appears to be very viable, whereby the postoperative phase seems to be unusually decisive. Therefore, the aim of this study was to structure the current state of the literature regarding postoperative pain management via SMS. To our knowledge, there is currently no specific literature review on SMS-based pain management and no synthesized results. Accordingly, this study examined the following research question: Is postoperative pain management feasible and effective utilizing SMS? By answering the research question through a systematic literature review, a conceptual framework for future research is provided.To gain a valid answer to the research question, the paper is structured as follows. In the Methods, we describe the process of performing the systematic literature review, along with a detailed description of the specific selection and exclusion criteria. The results of the selected literature are compiled accordingly in the Results. The Discussion explains the principal insights from the included studies, along with the limitations of this review. Finally, we provide recommendations for action based on the conclusions, and highlight research gaps for researchers, clinicians, and other health care professionals.The goal of this literature review was to provide comprehensive insight into postoperative management via SMS. The review should (1) provide information on the state of research, (2) establish a basic understanding of SMS-based pain management, and (3) provide deep insight into the feasibility of these management strategies. To ensure completeness and transparency, a systematic literature review process was followed in all stages of the study. The methodology is mainly based on the PRISMA  guidelines  and a guIn consideration of the research question, a search string was designed using Boolean operators  for the selection of relevant literature. Various keywords connected the decisive aspects regarding text messages, postoperative care, and pain management. The conclusive search string is documented in the protocol  and is cThe initial search in the eight databases resulted in 2083 matches. The screening process narrowed down this result by applying a variety of exclusion criteria. Initially, only articles that were published in academic journals or conferences were considered. Further, all non-English articles were excluded. By applying these two criteria, 1305 articles were already excluded. Next, all duplicates were identified by DOI or title alignment and deleted for the next steps (n=143). The remaining 635 articles were screened by title, abstract, and keywords for their relevance to the research question. Accordingly, the papers needed to describe and analyze pain management, and to clearly emphasize postoperative care and SMS. Articles that interpreted abbreviations such as SMS differently or focused on issues not relevant to the review were further excluded. During this screening process, a total of 382 articles could be identified as irrelevant, as these articles neither focused on pain management, postoperative treatment, nor SMS. Only two of these three issues were addressed in 73 articles and one of the three was addressed in 163 articles. As a result of this process, 618 articles were classified as irrelevant, leaving a total of 17 articles eligible for further review.Full-text screening was performed to comprehensively analyze the remaining 17 articles, and an additional 7 articles were excluded due to thematic deviations or the secondary research method. Based on the remaining 10 articles, a forward and backward search was executed. The backward search revealed no new articles. The forward search resulted in a total of 64 matches for the eight databases. After applying the exclusion criteria, one additional article could be included for analysis, leaving 11 articles in the final pool for review  28,31].,31.28,31Telemedicine and e-Health [Of the 635 articles analyzed in the screening process, 554 (87.2%) were published in the last 5 years, since 2014. This reflects the increasing relevance of digitalized postoperative pain management in recent years. Correspondingly, this is apparent in the final pool of 11 articles, with 45% (n=5) published in 2018 and 36% (n=4) published in 2019. Three articles were published in the journal e-Health -34, reprTen of these 11 (91%) studies adopted a prospective design to investigate postoperative pain management in conjunction with SMS. Patients were grouped as cohorts, and investigated for pain and similar outcomes. One study was a nonblinded randomized control trial . The maiOverall, 4195 patients were supported by a pain management system tailored to the surgery performed and to the patients’ characteristics such as age or physical condition. The number of study participants ranged from 21 to 3049, with a mean of 381 participants and a median of 85. To select these patients, the researchers applied various selection criteria. For instance, 9 of the 11 (82%) research teams excluded patients without a mobile phone, 6 (55%) excluded patients who could not communicate via SMS, and 5 (45%) excluded patients with a language barrier. At the beginning of the intervention, the sex and age, and other demographic data of all participants were determined in 8 of 11 (73%) studies. The percentage of female participants ranged between 33% and 100%. The intervention was directed at adult patients with a mean age between 30.7 and 59.4 years in 6 of 8 (75%) studies. The other 2 studies analyzed pain management in children between 6.1 and 8.2 years of age . The eduNine of the 11 studies used automated pain management systems for their interventions and the other 2 studies did not provide any relevant information on this aspect ,41. For Whether the goal of the intervention was for patient monitoring or to analyze the adherence to pain management, the studies defined different timeframes. With 60 intervention days, one study was distinctly longer than the others  and can For 7 of the 11 (64%) studies, the message blocks’ primary outcome was the monitoring of the postsurgical pain level of the investigated patients. However, 3 of the 11 (27%) studies focused primarily on adherence to the treatment ,35,41, aFour out of the 11 36%) interventions sent additional reminders to patients, and 4 interventions (36%) also sent alerts to patients and physicians . Patient% interveP<.001) [All studies identified a positive effect of SMS on pain management, thereby indirectly providing various recommendations for action. First, 7 interventions measured response rates, each with concrete results. Overall, between 8 and approximately 400 messages were sent to patients or legal guardians. With an average response rate of approximately 89.5% (SD 3.8%), the reliability of SMS as a communication and monitoring tool is evident, especially in comparison to conventional communication methods . One stuP<.001) . Howeverr=0.972, P<.001) [Further, the response rate was confirmed to decrease steadily over the intervention duration, and the majority of unanswered messages occurred within the last postoperative days ,37,38. T P<.001) . All int P<.001) ,33. Six  P<.001) ,33,40 (TSMS-based pain management is highly applicable and efficient for postoperative communication between health care professionals and patients or legal guardians. Furthermore, alarms and reminders via SMS can improve and maintain communication, while supporting patients or their legal guardians. This support function is desirable for effective pain management . Three oSMS technology was associated with positive results for all studies. The ubiquity of SMS makes it a cost-effective and straightforward method for pain management that is valid and less intrusive ,38,40,42Furthermore, the use of SMS can prevent potential bias, and ensure the consistency and timeliness of messaging to patients ,35,37,42SMS-based pain management allows for simple pre- and postoperative extensions such as easily integrable and more specific questions about the operation and possible symptoms. In addition, reminders and alerts can be triggered automatically by SMS systems. Nevertheless, the response rate was confirmed to decrease steadily over the intervention duration, and the majority of unanswered SMS messages occurred within the last postoperative days ,37,38. TThis study is subject to various limitations. First, only a basic quality analysis of the identified studies was applied. A more detailed analysis could clarify whether the final pool is rigorous, relevant, and credible. However, demand for high-quality research approaches such as randomized control studies is identified, as only one study was a nonblinded randomized control trial . Second,This study provides a comprehensive review of the current status of the literature on postoperative pain management by SMS. SMS utilization as a communication channel appeared to be favorable and feasible in pain management in the postoperative phase. According to three studies, SMS also seems to be useful for preoperative pain management, especially for additional information on medication or schedules, or as reminders. SMS resulted in excellent patient response rates, better adherence to pain treatment, higher patient satisfaction, and less medication intake. Six SMS interventions were certified by the respective IRBs and three were HIPAA-compliant. This indicates that SMS is capable of meeting health care requirements and is suitable for a health care–specific application. All of these benefits could be leveraged to address the opioid epidemic directly, effectively, and efficiently. The ability to create efficient pain management via SMS ensures comprehensive monitoring and communication. Key drivers of the opioid epidemic, such as medication abuse, shifted patient expectations, inadequate medical education, or inadequate guidelines, could be adequately addressed. In conclusion, the research question could be confirmed: SMS is effective, very well-suited, and feasible for postoperative pain management.Future research should extend this systematic literature review regarding preoperative pain management. Based on this, a pre- and postoperative communication model should be developed to address the opioid epidemic effectively. This model should be generally applicable and adaptable to the individual clinical situation.


The overall incidence of delirium was 21%; the rate was lower in the RNB group than in the control group . The average pain score at 6 h postoperatively was lower in the RNB group than in the control group . There was no significant difference in the pain score at 12, 24, and 48 h postoperatively, amount of opioids consumed for 2 postoperative days, and time from injury to wheelchair ambulation. We recommend RNB as a standard procedure for elderly patients with hip fracture due to lower delirium incidence and more effective analgesia in the early postoperative period.Postoperative delirium is common in elderly patients with hip fracture. Pain is a major risk factor for delirium, and regional nerve blocks (RNBs) effectively control pain in hip fractures. This study aimed to evaluate the effect of RNB on delirium after hip surgery in elderly patients. This retrospective comparative study was performed in a single institution, and the data were collected from medical records between March 2018 and April 2021. Patients aged ≥60 years who underwent proximal femoral fracture surgery were included, while those with previous psychiatric illness and cognitive impairment were excluded. Two hundred and fifty-two patients were enrolled and divided into an RNB or a control group according to RNB use. Delirium was assessed as the primary outcome and postoperative pain score, pain medication consumption, and rehabilitation assessment as the secondary outcomes. Between the RNB ( Osteoporotic hip fracture is a major health problem because it is associated with high mortality, morbidity, and costs . AlthougPostoperative delirium is one of the most common complications in elderly patients with hip fracture and could result in cognitive impairment, short-term functional impairment, and increased mortality . The knoFor this reason, comprehensive pain protocols have been suggested for elderly patients with hip fracture; these include evidence-based block use, timely repeated pain assessment, and multidisciplinary orthogeriatric care . RegionaThis retrospective comparative study was performed in a single institution and approved by our institutional review board. The data were collected from medical records between March 2018 and April 2021. The inclusion criteria were as follows: (1) age of ≥60 years and (2) surgical treatment of proximal femoral fracture, which was defined as a femoral neck fracture, an intertrochanteric femoral fracture (AO/OTA 31) , and a sGeneral or spinal anesthesia was performed according to the patients’ overall health status, and RNB use was left to the discretion of the anesthesiologist. Under ultrasound guidance, a single shot of RNB, including fascia iliaca compartment block (FICB) , lumbar The patients with femoral neck fracture underwent bipolar hemiarthroplasty or internal fixation with multiple screws, while those with intertrochanteric and subtrochanteric fractures underwent intramedullary nailing. After surgery, intravenous patient-controlled analgesia (PCA) was applied in all patients. On the day of surgery, intravenous acetaminophen 1 g once a day was administered unless the patient had a contraindication. If the weight of the patient was less than 50 kg, the dose of acetaminophen was controlled at 15 mg/kg. The day after surgery, oral pain medications included a tramadol 37.5 mg/acetaminophen 325 mg tablet given twice daily and tapentadol 100 mg given twice daily. Rescue analgesia during postoperative period was intravenous tramadol 50 mg or hydromorphone 0.5 or 1.0 mg. Periarticular injection was not performed. We encouraged wheelchair ambulation as soon as possible from the day after surgery, and tolerable weight-bearing ambulation started on 2 days postoperatively.Demographic data were collected from the patients’ medical records, including age, sex, body mass index (BMI), age-adjusted Charlson comorbidity index (ACCI), Koval score before injury, injury mechanism, anesthesia method, fracture type, time from injury to surgery, time from admission to surgery, and type of surgery. The Charlson comorbidity index (CCI) was calculated by adding the coefficient assigned to comorbidities when injured. The ACCI was calculated by adding 1 point for each decade after the age of 40 years to the CCI value . Falls fDelirium was recorded and defined using the confusion assessment method on any postoperative day or night of their hospital stay following surgery as the primary outcome . PostopeThe primary and secondary outcomes were compared between the RNB and control groups. A subgroup analysis for incidence of postoperative delirium between general and spinal anesthesia was performed. A subgroup analysis between FICB, LPB, and PENG block was performed to evaluate the differences between the blocks.A multivariable analysis was performed to assess which variables were associated with incidence of delirium and clinically significant parameters were included in the model such as age, gender, CCI, RNB, and anesthesia type ,22,23. Np-values of <0.05 using SPSS version 23.0 .Categorical variables  were analyzed using the chi-square or Fisher’s exact test. Continuous variables  were analyzed using an independent t-test or the Mann–Whitney test. The Shapiro–Wilk test was used to check if the data distribution was normal. The Kruskal–Wallis test was used when compare more than two continuous variables. A logistic regression analysis was conducted for multivariable analysis. All continuous data are described as means and standard deviations. Statistical significance was accepted for The RNB group consisted of 129 patients, while the control group consisted of 123 patients. The baseline characteristics of the two study groups are presented in p = 0.027). There were no nerve block-related complications, including falls within 48 h after surgery and nerve injury.The overall incidence of delirium was 21%; the rate in the RNB group was lower than that in the control group  (p = 0.432), 24 , and 48  hours postoperatively. There was also no significant difference in the amount of opioids consumed for 2 postoperative days  and time from injury to wheelchair ambulation .The average pain score at 6 h postoperatively in the RNB group was lower than that in the control group  . There wIn the subgroup analysis between general and spinal anesthesia, there was no significant difference in the incidence of postoperative delirium . In the In the multivariable analysis, age and RNB were significantly associated with the incidence of postoperative delirium . There wIn this study, RNB reduced the incidence of delirium. It is widely accepted that pain reduction is important for the prevention of delirium , and we The results of RNB and delirium in patients with hip fracture are inconsistent. RNB was reported to be associated with less postoperative analgesia, a lower incidence of delirium, and shorter inpatient stay ,25. In cOpioids are useful in reducing pain after surgery but have limitations regarding side effects and drug poisoning . ElderlyBased on the results reported by Marino et al., who demonstrated that continuous lumbar plexus block provided pain reduction during physical therapy , we expeIn clinical practice, we usually perform LPB after induction of general anesthesia because it should be conducted in the lateral decubitus position. In contrast, FICB is usually performed before induction of spinal anesthesia because it could be conducted in the supine position, which could reduce pain for positioning of spinal anesthesia. Since LPB and FICB could block both anterior innervations of the hip joint and some surgical incision site, similar pain reduction and delirium prevention could be expected in both blocks . In our There could be concerns regarding anesthesia method. Previous studies showed controversial results. Choi et al. reported general anesthesia was an independent predictor of immediate delirium . In contFalls and procedure-related nerve injuries are important complications of RNB in patients with hip fracture ,36; in oThere were some limitations in this study. First, our study had a selection bias in relation to the retrospectively evaluated characteristics. RNB use was decided by the anesthesiologists, and there was no clear criterion. Future prospective studies with randomization are needed. Second, the types of nerve block used varied. FICB, LSPB, and PENG block were used herein, which might have confounded the results. Third, the severity of delirium was not considered. Some patients only demonstrated temporary inattention; however, other patients demonstrated irritability that needed restraint. We classified these demonstrations as delirium. Subgroup analyses according to the severity of delirium will be helpful in the evaluation of the effects of RNB. Despite these limitations, our study provided evidence that RNB can reduce the incidence of delirium, and we believe that its use can help improve the prognosis of elderly patients with hip fracture.RNB reduced the occurrence of delirium in elderly patients with hip fracture and relieved acute pain after surgery without complications. Therefore, we recommend RNB as a standard procedure for elderly patients with hip fracture due to lower delirium incidence and more effective analgesia in the early postoperative period.


Background: Chronic pain is one of the most widely recognized, disabling, and expensive health problems in Canada. Interdisciplinary multimodal pain management is effective in helping chronic pain patients lessen symptoms and reclaim functionality, but most patients lack access to such treatments.Aim: The aim of this study was to describe the development and implementation of a publicly funded and patient-centered model of care in the community.Methods: The study was set in the Pain & Wellness Centre (PWC) in Vaughan, the only community-based chronic pain clinic in Ontario funded by the Ontario Ministry of Health and Long-Term Care (MOHLTC) as a demonstration project of a template for similar future community clinics. The study is descriptive, including a brief review of the Ontario comprehensive pain strategy framework and an overview of the PWC and the process involved in the development of an interdisciplinary pain program (IDP), based on the biopsychosocial model of chronic pain management.Results: During a 2.5-year period, the PWC has offered 1055 new patient medical consultations and 1921 follow-up visits and admitted 242 patients in the IDP program (demonstrating significant success in patient outcomes at the 3-month exit from the program). It established robust outcomes research, organized educational programs for pain trainees, and cultivated a collaborative relationship with the Toronto Academic Pain Medicine (TAPMI) network and the community at large.Conclusions: This demonstration program has shown the feasibility and applicability of the principles of the MOHLTC comprehensive pain strategy, providing an effective, evidence-based, and accountable approach to chronic pain diagnosis and management in the community. Chronic pain can arise from conditions of muscles, bones, or ligaments , damage of the nervous system , disease or damage of viscera , or a combination. However, there may also be no clear cause. Generally, chronic pain (most often identified as chronic noncancer pain or CNCP) arises from a multiplicity of heterogeneous and overlapping pain conditions together with influences from psychosocial and environmental factors. Systemic and constitutional problems , often accompany chronic pain and add to disability and impaired quality of life.2 Among people living in private households, 16% of those aged 18 to 64 and 27% of seniors reported chronic pain. The prevalence is greater (up to 38%) for seniors living in long-term health care institutions.3 Women, older individuals, and those with low educational attainment are more likely to report chronic pain.6 Chronic pain is often associated with dependency in activities of daily living  and instrumental activities of daily living .7 People reporting chronic pain are more likely to use medications and be multiple medication users.3 The burden of chronic pain is expected to increase as Canada’s population is aging. Statistics Canada8 reported that the proportion of the senior population (aged 65 and older) grew from 8% to 14% between 1971 and 2010, and the proportion of seniors is expected to represent between 23% and 25% of the total population in 2036.Studies of chronic pain in Canada have found that it is a commonly reported condition.9Another major issue in Canada relating to chronic pain is the opioid epidemic. Opioid-related deaths in Ontario increased by 285% between 1995 and 2015, from 14 opioid-related deaths per million population in 1991 to 53 per million in 2015.10 Chronic pain is often associated with other diseases and is therefore inadequately recorded, both in clinical records and in the administrative coding that is used as a source for epidemiological studies. Undertreated or inappropriately treated chronic pain results in financial burden borne by both the patients and their families and the public health care system. Chronic pain includes various groups of diagnoses and syndromes; therefore, treatment options vary. Treatment of chronic pain needs highly specialized and variable approaches .11 In Ontario , many of these treatment options are paid by third-party payers, extended health benefits, or, for those patients who have none of these options, out of pocket. The publicly funded health care system in Ontario  covers medical consultations, laboratory tests, and imaging in general, though injections are the only diagnostic/treatment modality paid by OHIP, resulting in substantial costs to the provincial health care budget. In particular, in Ontario, medical clinics in the community that only provide interventions (injections) are estimated to cost the system approximately $80M yearly, with 6% of patients seen repeatedly over a period of years accounting for 41% of the injection expenditure, totaling $215M for the period 2005–2012, based on OHIP data.12 Overall, the costs of chronic pain to Ontario (including Toronto) have been estimated to be more than 2.1 billion a year in direct health care costs and $13 billion per year in productivity costs related to job losses and sick days.13The current system for chronic pain care in Canada leaves numerous patients misdiagnosed, improperly treated or undertreated, and living with poor quality of life.24. The working group pointed to a large number of problems in the province, including lack of: recognition of the magnitude of chronic pain; availability or access to treatment modalities and services; oversight, standardization, and unified policies; inadequate education for both health care providers and patients; strategies for prevention of chronicity; accountability and outcome measures; supports for primary care; and sustainable financing for providers and services. Details of the findings of the working group are outlined in Given the increasing burden of chronic pain coupled with the opioid epidemic, in January 2011 the Ontario Ministry of Health and Long-Term Care (MOHLTC) created a Chronic Pain Working Group, which included members from MOHLTC, the Ontario Medical Association, and the College of Physicians and Surgeons of Ontario. In November 2011, this group produced a white paper reporting on the current state of services available and provided recommendations for future actionThe working group subsequently determined the essential elements that would define and support a comprehensive pain system in the province, summarized in 15 vital principles (pillars). The pillars stressed the need for a governance or oversight body for pain policies and services; a patient-centered and primary care–focused approach; interdisciplinary care in the context of a chronic disease management framework; timely and stepped-up care in the care continuum; consistent, accountable, and measurable care with continuous quality improvement; application of evidence-based treatment approaches and measures for prevention of pain and pain chronicity; education for providers and patients; provisions for data information; and provisions for appropriate and sustainable funding. The 15 pillars of the Ontario comprehensive pain strategy are reported in Starting in 2014, MOHLTC provided $18M in base funding to support interdisciplinary chronic pain management across five pediatric hospitals, 13 adult hospitals, and one community chronic pain clinic in the province of Ontario. The funding exclusively supported teams of allied health professionals and administrative support staff to allow more patients to access the biopsychosocial model of care.This funding is coupled with other key initiatives supporting chronic pain care across the lines of the Ontario comprehensive chronic pain strategy framework, such as the creation of pediatric and adult advisory boards to develop a networked system with a common information registry and standard models of care; Project ECHO , which connects primary care providers from across Ontario with each other and with interdisciplinary pain specialist teams via weekly videoconferencing sessions; integrating patients from the provincial committee level to each individual chronic pain clinic; creating new quality standards by Health Quality Ontario; developing Inter-professional Spine Assessment and Education Clinics (low back pain centers), which started in 2013 and expanded by 2017; continuing with a Narcotics Monitoring System; publicly funding shingles vaccines for people between 65 and 70 years of age (announced in 2016); and promoting an opioid strategy (announced in 2016) that includes chronic pain management as a key component of the strategy .The current article reports on the Pain & Wellness Centre (PWC) in Vaughan, the only community-based chronic pain clinic funded by the MOHLTC funding envelope.2 and 3.7 million patients, north of Highway 401). The PWC was funded in 2016 by MOHLTC under the premises that it was a demonstration project and, if successful, could serve as a template for other publicly funded community-based clinics. Once MOHLTC direct funding became available to this clinic, the mission expanded beyond medical management and taxpayer-funded interdisciplinary pain management to include education and research, based on the pillars of the 2011 framework of the Ontario comprehensive pain strategy.The PWC was founded privately by the primary author, a specialist in physical medicine and rehabilitation and professor at the University of Toronto, Faculty of Medicine, with 37 years of experience currently in pain medicine. The PWC started delivering services in the fall of 2014, including medical consultations  and rehabilitative multimodal interventions . The PWC mission from its inception was to provide chronic pain consultations and interdisciplinary chronic pain management in the regions of York, Durham, Peel, Dufferin, and Simcoe  to and from the specialized services of the Toronto hospital-based academic pain clinics and other community-based specialized clinics.provide community-based chronic pain education to medical and other health science trainees (academic learners), practicing physicians (lifelong learners). and the local public .research chronic pain in a community setting with a focus on interdisciplinary pain treatment outcomes and pragmatic studies.2 of space. The facility includes reception areas, medical and administrative offices, treatment rooms, a meditation loft, a board room, staff cafeteria and kitchen facilities, a 1200 ft2 fully equipped gym, and its own parking lot. It operates as a paperless facility with an electronic medical records system safeguarded by a cloud-based company. The PWC offers medical consultations and management (funded by OHIP), is accessible to community referrals for treatment of patients funded by third parties , and reports directly to MOHLTC, which funds interdisciplinary pain services and support staff.The PWC is a free-standing two-story, three-level facility in the city of Vaughan, 45 km north of Toronto central, wheelchair accessible, and occupying 6400 ftCurrently the PWC staff consists of two physicians , one psychologist and one psychotherapist, a mindfulness meditation facilitator, two naturopathic doctors (NDs), a holistic dietician, two massage therapists, four chiropractors, a community resource facilitator (community navigator), two information technology/management staff, four reception staff, one or two research staff, and a physician assistant. Several rotating trainees such as University of Toronto pain fellows, Royal College pain medicine subspecialty residents, as well as physical medicine and family medicine residents, and chiropractic interns obtain education at the PWC. All of our chiropractors are strength trainers and have additional training and expertise in advanced soft tissue therapy techniques, medical acupuncture, concussion management, and athletic sports injuries. Additionally, all are trained as physician assistants for chronic pain consultations. The massage staff has additional training in lymphatic drainage, and two of the staff are certified life coaches. The NDs and holistic dietitian place emphasis on nutrition, weight management, and life choices. The mindfulness meditation program is offered in a small-group format over an 11-week period, 2 h per week. For patients unable to attend these classes, customized programs are offered with one-to-one mindfulness sessions.The PWC staff is offered access to PWC-funded continuous health education, including presentations and attendance at our annual Canadian Pain Conference meetings.14 Once the referral is deemed adequate, it immediately receives a classification based on distance from the PWC (more or less than 50 km from the facility) and complexity . Given our short wait list of 1 to 4 weeks, patients are called shortly after an adequate referral is received and an appointment is given. Automated voice messages are left at the patient’s phone as a reminder 48 h prior to the appointment.Medical consultation requests for assessment and treatment are faxed to the PWC and reviewed by medical and administrative staff within 48 h of receipt to ascertain basic information . Referrals that lack information are faxed back to referring physicians requesting missing information. Rejected referrals comprise 20% to 40% of referrals, based on internal statistics, with 60% or more returning with additional information.All patients  receive a 2-h consultation with a physician or a physician in conjunction with a physician assistant , pain fellow, or resident. In addition to history and thorough neuromusculoskeletal evaluation, patients complete validated batteries such as the Brief Pain Inventory (BPI), the Patient Health Questionnaire, the General Anxiety Disorder Questionnaire (GAD-7), and the Rivermead Concussion Scale as proxy measurements for pain interference, depression, anxiety, and multiple systemic and constitutional problems, respectively. In general, about 25% to 28% of referred patients are deemed very complex , 50% are of medium complexity, and 22% to 25% are deemed fairly simple .Once the patient is seen at the PWC, the physicians may (1) provide single consultation with recommendations for investigations and treatment to a referring physician; (2) order additional investigations and/or initiate/alter pharmacotherapy and arrange for follow-up at the PWC; (3) deem the patient a candidate for the PWC interdisciplinary pain program (IDP) funded by MOHLTC; or (4) refer to external sources/services such as interventions (nerve blocks and infusions), spinal stimulators, surgery , medical cannabis, etc. The IDP path can also be accessed once requested investigations are completed or pharmacotherapy  is deemed to be at least partially effective. The patient flow is shown in Despite our original goal to serve five local regions, referrals with request for consultation are now received from across the entire province of Ontario  as far as Sudbury, North Bay, Hamilton, London, Ottawa, Niagara, St. Catharines, etc. Given the very long waiting lists of the downtown academic hospitals, as well as the expertise of our team, we felt compelled to at least offer consulting services to those remote area referrals and advice to referring physicians.Since MOHLTC funding began as of April 1, 2016, the clinic has medically assessed 1055 new patients and provided 1921 medical follow-up visits in 30 months.Distance from the PWC no more than 50 km to allow for frequent attendance .Inability to afford treatment.Good working knowledge of English because poor English precludes participation in cognitive behavioral therapy (CBT), mindfulness, and nutritional counseling .Not experiencing major untreated psychopathology or life crisis.High levels of motivation and commitment.Condition that we feel can be treated in our center.Availability to attend the PWC two to three times a week for a minimum of 2 h at a time for a period of 3 to 4 months.Patients are deemed candidates for IDP if they fulfill the following criteria:These criteria were a lot more lenient at the beginning of our program. However, we experienced very high drop-out rates from patients who drove long distances (particularly those who lived in snowbelts north of the Greater Toronto Area), patients with very low functionality and established widespread pain, and patients in major life crises such as being in the midst of an acrimonious divorce, custodial battle, etc., obliging us to narrow our admission criteria.Approximately 75% to 80% of all patients referred for consultation live within a 50-km radius of the PWC. Of those, 20% to 25% fulfill our eligibility criteria and are offered admission to the IDP.Once the patient is determined to be a candidate for IDP, he or she participates in a 2-h intake interview with administrative staff, which includes the completion of an explicit consent form , a tour of the facility, explanations about the services that he or she will receive and take-home explanatory pamphlets. Patients are informed repeatedly by the treating physicians and during consent completion that two or three unjustified no-shows or cancellations may result in program termination. Additionally, at the same intake interview, patients see a research staff to complete a detailed demographic questionnaire and a battery of validated questionnaires, namely, the Pain Catastrophizing Scale; Pain Self-Efficacy Scale; Chronic Pain Acceptance Questionnaire; Tampa Scale for Kinesiophobia; GAD; Centre for Epidemiological Studies–Depression Scale; and BPI. All data are collected electronically and overseen by our staff at the time of the intake interview (our previous method of providing the questionnaires in paper format resulted in faulty and missing data). We also have a significant population of patients who are not sufficiently computer literate to do it on their own on tablets. Nevertheless, we hope to be able to provide direct tablet access to those who are computer literate in the future.IDP patients are then provided a detailed schedule agreed upon by themselves and an administrative staff for a 3-month period. Each patient receives a minimum of three and up to six services, attending twice a week for a minimum of 2 h. Most patients also attend an 11-week mindfulness group course that includes no more than eight participants. The first appointment with each service provider is devoted to education, outlining specific goals and objectives agreed upon between the provider and the patient and initiating therapeutic intervention. Manual and exercise rehabilitation is the cornerstone of our IDP, passive therapies are used to facilitate introduction to exercise in our gym, and patients are provided with home exercise programs that they review with their chiropractors. Types and frequency of services as well as a typical full-service IDP schedule are shown in Interdisciplinary communication between members of the treating team is intense and frequent and includes formal IDP rounds where selected patients are discussed with all providers and physicians, internal speedy communication using Slack , access to all electronic medical records that must be uploaded by each provider within 48 h, and “informal knock on the door” (“open door policy”).Upon discharge (exit) from the program, patients complete questionnaires  plus Global Impression of Change scales. These questionnaires are provided again at 6 and 12 months postdischarge from the IDP. During their participation in the program, patients are reviewed periodically as needed by the medical staff; medical follow-up appointments are made as well at 6 and 12 months after completion of the program to assess progress and address any problems, with the patient’s evolution and progress documented and communicated at each medical appointment to his or her referring physician. Patients can be granted additional hours of treatment service based on the recommendation of their treating team, particularly for support during return to work, when changing jobs, or when some unexpected issue arises . Patients who miss two to three sessions without a justified reason are seen by the medical staff to discuss the reasons for their absenteeism, and those who continue to miss sessions are dismissed from the program or fail to return on their own.15 It is clearly explained in the IDP consent form with the following verbatim statement: “I understand that I am part of the team and that I must take an active role in regaining control of my pain and my life. I understand that each member of the pain team will work closely with me to set specific goals, provide tools and techniques that I can use on my own and monitor my progress.” It invites therapeutic balance and highlights the centrality of an informed person choosing relevant strategies.A key aim of our program is a move toward a holistic and coordinated model. Patient-centered care is central and relationship based.Since our funding began as of April 1, 2016, we have admitted  242 patients to the IDP program and offered 13 977 h of treatments by allied health providers. Of those 242 patients, 37 (16%) dropped out (preliminary data were presented as a poster at the 2018 Canadian Pain Society meeting), 36 completed only our demographic questionnaire, outcome exit data exist for 123 patients, and the rest are still in treatment. Overall, it is estimated that each IDP patient receives 60 to 85 h of primarily one-to-one treatments.The PWC is recognized by the University of Toronto Pain Medicine as a site of compulsory rotation for all pain medicine residents, who have obtained a Royal College of Physicians and Surgeons (RCPS) certification in a number of specialties such as anesthesia or physical medicine and pursue a further 2-year residency training in noninterventional pain management and further RCPS certification in the subspecialty of pain medicine.Additionally, the PWC shares pain fellows with the Toronto Rehabilitation Institute (TRI) and serves as a site of elective rotation of physical medicine residents during their “pain block.” University of Toronto family practice residents and Canadian Memorial Chiropractic College residents and interns approach us directly for pain electives. The PWC frequently hosts teams of practicing physicians and allied health professionals for half-day visits on-site to observe our operations. We further provide continuous health education sessions for the local physicians and occasional lectures to the public (patients and families).In regard to research, we employ a senior research associate, assisted by students for data synthesis and analysis and some of our administrative staff for data collection, access to the research ethics board of the University of Toronto, organization of our research studies (retrospective and prospective), and grant submissions. Our data are mined partially through our electronic medical records system and primarily through separate databases maintained by our administrative and research staff. The PWC output in regard to clinical services, education, and research/accountability metrics is shown in The PWC has formed alliances with local facilities as follows: an x-ray facility that performs the majority of our radiological investigations in a timely manner; a neurologist for all of our electrophysiological testing; an interventional facility for all of our interventions and infusions; and a compounding pharmacy for our compound prescriptions.Additionally, the PWC has forged close liaisons with a large multispecialty community-based facility for exchange, referral, and investigations of patients with suspected inflammatory and autoimmune disorders. We have also established links with a specific nearby medical cannabis clinic, where we refer eligible patients.We have further created the unique position of a community resource facilitator who collected ledgers of community resources that may be available to our patients for navigation of services . She also works one on one with those patients who require assistance in initiating community supports and/or resources. Additionally, our community resource facilitator is charged with visiting family health teams and individual practices to inform and educate them in regard to our services, our criteria for proper referrals, and asking for early referrals of pain patients, so that chronicity can be curtailed.The director of the PWC and senior author has served as chair of a not-for-profit patient organization (ACTION Ontario) since 2005 and continues to be formally involved in the publication of their newsletters, connecting PWC patients with patient members of ACTION, reaching out to ACTION members and PWC patients for guidance relating to clinic and MOHLTC initiatives, and integrating patients’ input into the PWC’s operations.The PWC is associated bidirectionally with Toronto Academic Pain Medicine Institute (TAPMI)-associated hospitals  in regard to education of our trainees (described earlier).In terms of clinical services, the PWC refers a number of our patients to TAPMI-associated hospitals for interventions, spinal stimulators, total joint replacements, etc.; accepts to the IDP certain referrals of patients from TAPMI; and selected PWC patients are admitted to the TRI/University Health Network inpatient beds for interdisciplinary investigations under TRI staff. Inpatient TRI rounds are attended by PWC medical staff via video teleconferencing.16 reported on outcome data of 47 patients who had exited our program at 3 months, indicating substantial improvement in several validated scales , with 83% of the participants much/very much improved in Global Impressions of Change. In regard to demographics characteristics, the male : female ratio was 1:2 (P < 0.5); mean age 47 ± 18 years (18–85 years); Canadian-born patients constituted 65% (P < 0.05); 44% were employed; 30% consumed marijuana over the past year; and one third had received multiple injections in the past. In 50% of patients, pain originated from motor vehicle accident, work, and sports injuries. Mean pain ratings and pain duration were 6.1 ± 1.6 and 5 ± 6 years, respectively.An abstract presented at the Canadian Pain Society meetingA follow-up abstract has been submitted and accepted for presentation to the upcoming Canadian Pain Society 2019 meeting with a larger cohort of 121 patients treated through the PWC IDP. These data show that the much/very much improved rate on Global Impressions of Change continues to stand at 79% at the 3-month exit point and preliminary data at 6 and 12 months continue to demonstrate high levels of sustained success. The poster to be presented at the April 2019 meeting will include a more comprehensive analysis of changes from the point of entry to the point of 3-month exit, as well as longer term outcome data.So far, our data have or are being presented in 11 posters and several oral presentations, in four local meetings, in three national conferences, and in one international conference, and we are in the process of submitting several papers for peer-reviewed publications.In subsequent papers we plan to report on our results including (but not limited to) characteristics of responders and nonresponders to our IDP, costs of the IDP program, return to work/school and other outcomes, opioid consumption of new patients referred to the center, morphine-equivalent dose in subgroups , cannabis past and current use, opioid use and cannabis use in the subset of patients treated in our IDP, etc.The PWC expects to continue its work offering consultation services and interdisciplinary pain management in eligible chronic pain patients in the community.In the current year we expect to submit/publish in peer-reviewed journals the observed outcomes from our IDP, as well as the results of cross-sectional descriptive studies that describe the community populations that attend our center.The PWC director will continue to participate actively in MOHLTC committees and initiatives to assist the MOHLTC adult and pediatric networks.The PWC aims to forge further links with community primary care and specialist groups to promote evidence-based chronic pain diagnosis and management.Furthermore, the PWC is interested in designing and participating in pragmatic community-based studies in issues that matter .This brief overview of the 2.5 years of operation of the first Ontario community-based pain clinic supported by public funds confirms that the PWC model fulfills nearly all of the principles of the Ontario comprehensive pain strategy. It is interdisciplinary and multimodal; patient centered; primary care focused; operating within the chronic disease management framework; providing evidence-based and stepped-up care; accountable to MOHLTC in regard to the services paid by taxpayer’s funds and the outcomes of these services; consistent; providing access to prevention and early intervention; providing education for both patients and health providers; showing continuous quality improvement; supporting data information exchange and research; and offering reasonable access to the care continuum. Additionally, it provides navigation of the complex health care system to patients with chronic pain in our community with chronic pain, and it integrates patient input in important matters.None of the above could have materialized if it were not for sustainable funding provided by MOHLTC. Ultimately and inevitably, funding influences service delivery, because many patients cannot afford the necessary interdisciplinary  services. The described patient-centered PWC model for chronic pain does improve engagement with the individual with chronic pain and offers a viable model of pain care delivery in the community. In this context, PWC has fulfilled the expectation of MOHLTC for providing a model and a template for similar community-based and publicly funded pain clinics.24. Despite the fact that there are now new, well-trained graduate physicians, RCPS certified in multimodal interdisciplinary pain medicine, the FFS model will make non-intervention-based medical chronic pain care delivery unsustainable, because chronic complex pain patients require lengthy consultations and longitudinal care. Hybrid models of medical remuneration  are necessary.However, a major gap remains in the present PWC funding model regarding the FFS remuneration of pain physicians, because the model strictly provides funding only for nonmedical services. Since the 2011 Ontario Comprehensive Chronic Pain Strategy Report, the Royal College of Physicians and Surgeons of Canada has recognized the subspecialty of pain medicineA further word of caution: Intense interdisciplinary pain management is not suitable for every patient with chronic pain because public funding is not unlimited. Our selection criteria that place emphasis on patient motivation and commitment are very important in stratifying patients and selecting those who are more likely to improve and capitalize on the interdisciplinary resources of pain management provided to them through public funds. Less resource-intense programs such as group self-management education, group classes (like Tai Chi), web resources, etc., may fill the gap for some patients. Detailed medical consultations can assist with diagnosis, provide proper pharmacology, and offer advice to referring physicians, as well as initiate entry to our IDP for eligible patients, while judicious and careful use of interventions, spinal stimulators, and surgeries can also have their place in well selected chronic pain patients.19 Analysis of literature highlights four common dimensions in patient-centered care: biopsychosocial perspective; patient as person; sharing power and responsibility; and therapeutic alliance.20 Patient-centered care identifies with understanding of the illness or pain condition from the person’s point of view and seeing the person as a whole instead of as fragmented parts.21 An approach that is centered on the individual does not imply an individual’s unrestricted freedom of choice; rather, decision making is shared.Based on our experience and that of the literature, the gap between effort and progress in chronic pain care in general can be bridged through more effective engagement of patients in care processes and care goals. The solution lies in a truly patient-centered approach that engages the patient as the agent through which health care is delivered and by which health is achieved. There is no doubt that various jurisdictions, organizations, and health care systems are interested in moving toward a more person‐centered approach as systems rethink the way in which pain care is provided.22Looking at the larger picture, chronic pain management remains a provincial jurisdiction with gross inconsistencies and differences between provinces. Despite the Ontario comprehensive strategy and the progress obtained in Ontario through public funding, much remains to be done. There are continuous gaps in Ontario  in the health system, limiting availability and access to chronic pain programs and services. No single institution in Canada is charged with organizing the numerous aspects of pain management; there is no system for coordinating action, sharing learning, and distributing best practices to policymakers, health professionals, patients, and the network at large; and planning and care are fragmented, prompting a superfluous duplication of efforts and resulting in inefficient use of resources. This was highlighted recently in the evidence brief from the 2017 McMaster Forum, calling for the development of a national pain strategy.23 The prevalent paradigm in Canadian pain medicine is under pressure, the need for evolution is clear, and the pivotal issue is eloquently stated in the McMaster’s evidence brief:Though health care remains under provincial jurisdiction, the need for a national pain strategy is indeed pressing.While there may be significant costs associated with preventing and managing chronic pain , failing to do so using evidence-based approaches may incur even greater costs. The money being spent to address the recent rise in illicit opioid-related morbidity and mortality is to some degree an example of such greater costs .


Postoperative pain is the most common complaint in patients who underwent orthopedic surgery. Regarding with the severity of pain, orthopedic patients suffered more than non-orthopedic patients in the immediate post-operative period. Therefore, pain management is crucial for better patient outcome. Lumbar plexus (LB) and three -in-one (3IN1) nerve blocks have been routinely practiced as pain management techniques in the study area but the analgesic efficacy was not studied yet. Thus, this study was aimed to compare the analgesic efficacy of the LBP versus 3IN1B as postoperative pain management after thigh orthopedic surgery under spinal anesthesia.An institutional-based prospective cohort study was conducted from October 10, 2020 to March 30, 2021 at the University comprehensive specialized hospital. Non-probability convenient sampling was used to select participants in both groups. The time to first analgesic request, severity of pain and total analgesia consumption within the first postoperative 24 h were measured.The mean and standard deviation to seek the first analgesia request time was 11. 55 ± 2. 82hr and 13. 35 ± 2. 58hr (p- 0.07) in patients who received LPB and 3IN1B respectively. Pain severity at rest and on movement was also comparable. The total tramadol consumption was 67. 65 ± 27. 20 mg and 70. 59 ± 37. 19 mg (p- 0.71), while total Diclofenac consumption was 63. 23 ± 45. 74 mg and 44. 88 ± 34. 72 mg (p-0.07) in LPB and 3IN1B groups respectively.The study showed that there was no significant difference in the time to first analgesia request, postoperative pain, both at rest and movement and total analgesic consumption, between the LPB and 3IN1B. •Orthopedic patients suffered more than non-orthopedic patients in the immediate post-operative period.•Nerve blocks provide effective analgesic options.•There are controversies comparing the efficacy of lumbar plexus and three in one femoral nerve block.•Lumbar plexus and three in one nerve blocks have comparable time to seek 1st analgesia.•Lumbar plexus and three in one nerve blocks have comparable pain severity and comparable analgesic consumption. Therefo surgery ,4. Suboptal stay .limb pain management, specifically the thigh orthopedic pain management, including epidural, posterior and anterior lumbar plexus block and multimodal analgesia [There are many options of lower nalgesia . But optnalgesia ,10.The LPB and 3IN1B were first introduced by Winnie . The LPBhave routinely practiced pain management techniques for most of lower limb orthopedic surgery such as open reduction and internal fixation (ORIF), wiring of knee fractures, intramedullary nailing, Sequestrectomy, screw as well as plating femoral fractures [There are still different controversies comparing the efficacy of single shot LPB and 3IN1B for lower limb orthopedic surgery . Furtherractures ,19. Due In addition, Practice of regional anesthesia and analgesia is relatively low in Ethiopia ,21. Stud22.1Institutional based prospective cohort study was conducted from October 10, 2020 to March 30, 2021 at the University comprehensive specialized hospital. Ethical issue was approved and obtained from college of medicine and health science ethical review committee. The article has been registered with unique identifying number (UIN) of researchregistry7288. The study has been reported in line with the STROCSS criteria . Informe2.2Adult Patients with elective thigh orthopedic surgery operated under spinal anesthesia, post-operative LPB or 3IN1B, age between 18 and 60 years, ASA Ⅰ and ASA Ⅱ were included. While patients with loss of consciousness, psychiatric patients, unable to communicate and understand, patients who were sedated and given further analgesia in the intraoperative time, spinal anesthesia other than bupivacaine, multiple trauma, patients with chronic pain or chronic pain analgesia usage and hospital discharge before 24hr were also excluded in this study.2.3In a study done regarding, LPB vs. 3IN1B with bupivacaine, the mean duration of analgesia (mean ± SD) was 20.6 ± 5.7 and 15.8 ± 6.4 respectively . AssuminAssuming none response rate as 15%, final sample size for each 39.1 = 40.80.α Level of significance 0.05 which is 1.96,P Power of 90% = 1.28SD 1 Standard deviation of analgesia in LPB block groupSD2 Standard deviation of analgesia in 3IN1B block groupμ1 Mean for the first time analgesia request in LPB block groupμ2 Mean for first time analgesia request in 3IN1B groupTherefore, the total sample size was 2.4Non-probability convenient sampling was conducted to select participants in both groups. Odd or even numbering method was used to allocate the study participants in either group. We took a proportional number of participants in LPB and 3IN1B (40 in each group) until the required calculated sample size of 80 was fulfilled.2.5Time to first analgesia request, the severity of postoperative pain with and without movement and total analgesia consumption were the outcome variables of the study. Whereas, sociodemographic variables , ASA status, type of surgery, duration of surgery, duration of sensory recovery after spinal anesthesia, postoperative analgesia, and volume of spinal anesthesia were independent variables in this study.2.6Before spinal anesthesia, standard monitoring such as pulse oximetry, electrocardiography (ECG) and noninvasive blood pressure (NIBP) were attached and spinal anesthesia was given with aseptic technique. After the operation, either LBP or 3in1B was done by the responsible anesthetist.the lateral position with the side to be blocked up and lumbar spine flexed during LPB. Landmarks was the point of intersection between a line joining the upper border of the iliac crest and posterior superior iliac spine (PSIS). At this point the non-insulated needle was inserted perpendicular to the skin. If bone is contacted (transverse process) withdraw and redirected caudally with maximum of 20 mm until sustained contraction of the femoral quadriceps muscle at 0.5 mA. After gaining this contraction, single shot 30 ml of 0.25% bupivacaine was administered. While, the 3IN1B was also performed using the land mark of 1.5 cm below the inguinal ligament and 1.5 cm lateral to the femoral artery after putting the patient supine position. The needle was inserted perpendicular to the skin and after obtaining sustained contraction of femoral quadriceps muscle at 0.5 mA, single shot 30 ml of 0.25% bupivacaine was given.Regarding the technique of blocks, the clients were in The clients were informed to ask pain killer while they started to feel pain at any time, so that the assigned nurses could manage. This time was recorded as the first request of analgesia. Intravenous tramadol and intramuscular Diclofenac were administered in both groups of patients feeling moderate to severe post-operative pain.The time to first analgesic request in the first 24hr was the primary outcome while, the postoperative pain severity and the total analgesic consumption were the secondary outcomes. Severity of pain was assessed with numerical rating scale in which patients were asked to rate their pain on a scale of 0–10, in line with no pain, mild pain, moderate pain, and worst pain experienced.The Pain was assessed by data collectors at postoperative 2 h, 4 h, 6 h, 8 h, 12 h, and 24 h in post-anesthesia care unit and orthopedic ward or any ward where they were admitted to.The data were collected by two trained anesthetists with the questioner prepared in English version and translated into Amharic language . The investigators of the study couldn't decide about the type of block given to the patient, but the responsible anesthetist can choose the type of nerve block according to her/his preference. The investigators stayed inside the operating room and observed the type of nerve block done by the responsible anesthetist and put specific codes on the patient chart. The type of nerve block was not stated clearly on the patient chart except the specific code. Therefore, the data collectors were blinded to the types of nerve block done for each patient.2.7After completion of the data collection, entered into Epi-data software for checking and cleaning of errors. Then, transferred into SPSS .t-test, and then the result was presented as mean ± SD (standard deviation). Whereas, non-normally distributed variables were analyzed by Mann–Whitney U test and the result was expressed as median with (interquartile range). The comparisons of categorical parameters were analyzed using the chi-square test and Fisher's exact test as required and expressed in numbers and percentage. Finally, P value < 0.05 was considered as statistically significant.. Analysis was done by using SPSS version 20 statistical package. Shapiro–Wilk normality test was used to check the normality of the data. In this study, normally distributed data were analyzed using Student's independent 33.1A total of 80 participants were enrolled in this study. Of those, 40 patients were receiving LPB while the other 40 patients were given 3IN1B. The mean age of the patients was (mean ± SD) 27. 40 ± 9. 45 years (age range 18–55). The demographic characteristics of the participants  and surgical duration were comparable between the two groups. In this study, 77% of the 3IN1B group and 82% of the LPB were males . In addiRegarding the hemodynamic status, there was a statistically significant difference in mean arterial pressure (MAP) at 2hr, 4hr, and 6hr , but pulType of operation and type of block is seen in .Table 4SThe mean and standard deviation for the 1st request of analgesia was 11. 55 ± 2. 82 in LPB group and 13. 35 ± 2. 60 in the 3IN1B group  . On the The study showed that there was no statistically significant difference in postoperative pain score between the two study groups in both at rest and with movement , Table 74In this prospective cohort study, both single shot LPB and 3IN1B were comparable in the mean time to 1st request of analgesia, postoperative pain score both at movement and at rest and total analgesic consumption for the first 24hr after thigh orthopedic surgery. The result of this study was comparable with different studies done previously ,15,24. TThis finding was also different from the previous study concluding that femoral nerve block has no effect compared with LPB after total hip arthroplasty . The reaStudy done by S. Ponnambalam Namasivayam and his colleagues regarding LPB versus 3IN1B for post orthopedic surgery, lower limb pain management stated that both blocks were similar analgesic efficacy. The mean 1st analgesia request time was 9.10 (±1.52) in 3IN1B and 9.90 (±1.21) in LPB , which wAnother study conducted by Mohammed Abid Ziyauddin Chauhan regarding LPB vs.3IN1B concluded that single shot lumbar plexus block and 3IN1B had effective postoperative analgesia for lower limb orthopedic surgery and the 1st request time was 12.56 ± 3.91 and 11.83 ± 3.84  which waIn contrast to our findings, the study done by Imbelloni and his colleagues comparing psoas compartment block with inguinal paravascular block found that psoas compartment block was more effective regarding time to 1st analgesia request, total analgesia consumption and pain reduction quality . The meaA study done by Christopher J et al. to compare spinal anesthesia, LPB, and general anesthesia for knee arthroscopy surgery stated that the overall resource utilization was significantly decreased including total analgesia consumption, inra-operation and postoperative patient condition, duration of stay in post-anesthesia care unit and satisfaction with pain management in patients who underwent spinal anesthesia and LPB .Lumborum (QLB) vs. Fascia Iliac block (FIB) for postoperative pain management of hip arthroplasty supports the current study result, which stated that there was a significant drop of blood pressure in QLB compared to FIB in the post block time, but had comparable analgesic efficacy [The results of our study showed that there was a significant difference regarding the mean arterial pressure until 8hr post-regional block between LBP and 3IN1B. The reason might be LPB has a unilateral sympathetic block . This waefficacy .a fractured femur and there was significant pain relief and total morphine consumption in 3IN1B group compared with IV morphine [Taherzadeh and his colleagues compared 3IN1B vs. intravenous morphine for pain management with morphine .Another study done regarding lower limb block with intrathecal bupivacaine with and without adjuvant, the result showed that addition of dexmedtomidine prolonged postoperative analgesia compared to bupivacaine with or without clonidine. However, compared with the lumbar plexus and three -in-one nerve blocks, single shot intrathecal bupivacaine with and without adjuvant may have a short time to 1st analgesia request . Single 5homogeneous comparable groups. Not assessed regarding, Pre-operative pain, pre-operation analgesic medication, small sample size, complications related to blocks and shorter duration of postoperative follow-up. There was also covid 19 during data collection period which might affect the quality of information provided by participants.The study is observational, Patients were not randomly allocated even though there were 6The study showed that there was no statistically significant difference between LPB and 3IN1B in the time to 1st request of analgesia, postoperative pain score at each time point both at rest and movement and total analgesic consumption.Therefore, according to the current study, we recommended to use either LPB or 3IN1B for effective pain control after thigh orthopedic surgery. We also suggest further studies with longer postoperative follow-up involving the above-mentioned limitations.University of Gondar college of medicine and health science.University of Gondar college of medicine and health science.Authors' contributions this work was carried out in collaboration among all authors. HA (Habtu Adane) contributed to the conception and design of the study, acquired; analyzed and interpreted the data drafted and revised the manuscript. AT (Abraham Tarekegn) and YA (Yonas Admasu) participate in reviewing the design and methods of data collection, interpretation and preparation of the manuscript. All authors participate in preparation and critical review of the manuscripts. In addition, all authors read and approved the manuscript.Researchregistry7288https://www.researchregistry.com/browse-the-registry#home/Habtu Adane Aytolign.Written informed consent was obtained from every study participant after a clear explanation of the purpose of their participation and not harmed by participants. Anyone who was not willing to participate in the study was informed that he or she would have the full right not to participate or stop at any time.Not commissioned, externally peer-reviewed.All data generated or analyzed during this study are included in this article and found on reasonable base.The authors declare that there is no conflict of interest.


Dental patients often experience the fear of pain induced by injectable anesthesia. This study aimed to investigate the impact of hypnosis on relieving the pain of injected dental infiltration anesthesia.This single‐blind clinical trial was conducted on 32 healthy volunteers to assess the pain perception in mucosal injection. The visual analog scale was applied for the measurement of one‐sided pain intensity in the maxilla without hypnosis. When hypnosis was implemented, the same procedure was performed on the other side of the maxilla reversely within one session.p = 0.05).Hypnosis implementation significantly decreased the intensity of the perceived pain before anesthesia injection (Hypnosis before the injection of dental infiltration anesthesia could decrease the pain intensity caused by the injection. Therefore, hypnosis therapy is recommended as an effective approach to pain control for anesthesia injection. Local anesthesia injection is speculated to be a stimuli that causes anxiety in dental patients . As a tested psychological intervention, hypnosis effectually decreases the pain and discomfort caused by needles in dental patients  of A, who underwent infiltration injection in the first session without hypnosis , and B, who underwent hypnosis in the first session, followed by injection (infiltration injection in the second session without hypnosis) , treatment contraindications  and low IQ  were the exclusion criteria of the present study. In the ASA classification, ASA I refers to healthy status, and ASA II is indicative of mild‐to‐moderate systemic diseases due to surgeries or other pathological processes that are properly controlled medically. Our patients fell under the ASA I category , gauge 27, and 2% lidocaine (xylocaine) for anesthesia; notably, lidocaine contained epinephrine . The depth of the needle point, direction of the needle bevel, temperature of the carpool fluid, and speed of the anesthetic injection were the same.2.1.2After the injection, pain relief was measured using the visual analog scale (VAS) Aitken, , which i2.1.3Patient selection was based on the inclusion and exclusion criteria, and the number of the treatment sessions was determined in accordance with the protocol. The potential benefits and drawbacks of the research project were fully explained to the subjects as the project involved human models. The subjects who were willing to participants provided their written informed consent and were allowed to withdraw from the study at any given time.Hypnosis was carried out in one treatment session to decrease the patients' pain using the indirect hypnosis techniques, pain transfer, dissociate, telescope, and distraction techniques through several stages, such as the preparation of the patients for hypnosis, hypnosis, deepening techniques, therapeutic hypnosis, and termination. We applied the hypnosis technique proposed by Erickson as appropriate for dental patients . The injected anesthesia targeted the desired region of the teeth, so that the patients could touch the tooth and soft tissue with their finger. Following that, dental infiltration anesthesia was injected to the region requiring restoration , and appropriate post‐hypnosis empathy was also provided, in addition to the previous presentations of the hand and tooth anesthesia removal. The restoration continued until reaching the state of pre‐hypnosis. In another session on the symmetrical side of the jaw, injection was performed without hypnosis. Notably, the selection of the patients and sides to receive injection with or without hypnosis was completely random.2.1.4t‐test was also applied to address the analytical objectives of the research considering the significance level of 0.05.SPSS version 20 was used for data analysis, and the demographic variables were expressed as mean, standard deviation, frequency, and percentage. Independent 2.1.5http://irct.ir/).The Ethics Committee of Kurdistan University of Medical Sciences, Iran approved the protocol of this research project (IRB No. REC.IR.MUK 1397/18). The patients had a companion during all the stages in the medical department, and a clinical psychologist performed the hypnosis session, a dentist was responsible for the injections and treatments, a supervisor (pediatric dentistry) was in charge of data recording, and a statistical consultant performed the data analysis. This study has been registered in the Iranian Registry for Clinical Trials . Based on the VAS, the mean pain control with and without hypnotherapy was 1.81 ± 1.39 and 5.03 ± 1.93, respectively  of the subjects is presented in Table  Figures  and 3. At = −2.12; p = 0.04) . This is consistent with the previous studies in this regard, which have demonstrated that pain intensity based on the VAS could significantly reduce from 7.1 to 4 following hypnotherapy as also confirmed in another investigation  by 43.3% in the experimental group after hypnosis , another limitation was the small sample size as many patients were unwilling to partake in the intervention. Finally, there might have been bias affecting the obtained results, which was resolved by the random selection of the participants.5Hypnosis could effectively decrease the perceived pain induced by dentistry injection into the maxillary buccal mucosa, and hypnotherapy is recommended as a reliable and beneficial measure in dentistry. Notably, the success rate of hypnotherapy largely depends on the hypnosis level of the patients.None declared.