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PubMed2026

Pain outcomes of pediatric circumcision patients following administration of pre-operative ketorolac: A randomized clinical trial.

INTRODUCTION: Circumcision is a common surgical intervention, and pain is the most common complaint. Poorly managed pain can increase morbidity and reduce patient and parent satisfaction. Ketorolac, a non-steroidal anti-inflammatory drug (NSAID), provides analgesia and may be effective in reducing pain after circumcision in pediatric patients. STUDY OBJECTIVES: The primary objective was to determine the effect of pre-operative intravenous ketorolac versus normal saline placebo on parental perception of postoperative pain at 24 h. We also explored the effect of ketorolac on postoperative pain scores, incidence of bleeding, incidence of vomiting, and analgesic use. MATERIALS AND METHODS: A prospective, randomized, single-blinded trial was conducted at a single tertiary children's hospital. Patients aged 1-17 presenting for circumcision were included and randomized to either normal saline injectate or ketorolac (0.5 mg/kg, maximum 30 mg). Postoperative delirium and pain scores were recorded in the post-anesthetic care unit. Parents completed the parents' postoperative pain measure (PPPM) at 24 h. The CONSORT criteria and checklist were used to guide reporting of this randomized controlled trial. RESULTS: A total of 100 participants were included. 50 participants were in each group. Mean (SD) PPPM score 24 h after normal saline and ketorolac was 6.1 (3.4) and 5.5 (3.3), respectively for a mean difference of -0.55 points [95% CI: -1.9 to 0.83; p = 0.427]. The mean (95% CI) fixed effect size of ketorolac on post anesthetic care unit reported Face, Leg, Activity, Cry, Consolability score was -0.17 (-0.77 to 0.43, p = 0.585) points, while the mean (95% CI) effect size of ketorolac on numerical rating scale was -1.2 (-2.2 to -0.18, p = 0.026) points. DISCUSSION: Pre-operative intravenous ketorolac, compared to normal saline placebo, did not result in a difference in parental perception of postoperative pain at 24 h after circumcision surgery. As part of exploratory analyses, those receiving ketorolac had modestly lower mean immediate postoperative pain scores, likely not of clinical importance. Ketorolac has often been avoided due to concerns of increased bleeding risk, however it is important to consider that there is no substantial evidence to support this. This is the first study to our knowledge evaluating the effect of ketorolac in pediatric circumcision patients. While the PPPM score is a family centered outcome, it is an indirect measurement of pediatric pain. CONCLUSIONS: Pre-operative intravenous ketorolac was not associated with lower parental reported pain scores at 24 h compared to normal saline placebo after pediatric circumcision surgery. CLINICAL TRIAL REGISTRATION: NCT02973958.

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PubMed2026

Cost-effectiveness analysis of a virtually administered pain coping skills training intervention in women with breast cancer in underserved areas.

OBJECTIVES: Women with cancer who live in medically underserved areas could benefit from behavioral pain interventions, but access is limited. A randomized trial reported that a 4-session virtual program incorporating pain coping skills training (mPCST) was effective in improving pain outcomes compared to an attention-control condition. We performed a cost-effectiveness analysis of mPCST vs. control. METHODS: Data on medical resource use, therapist time, and participants' attendance at intervention sessions and time associated with travel and using a mobile app were collected. The 5-level EuroQol 5-Dimension (EQ-5D-5L), a preference-weighted measure of health-related quality of life (HRQOL), was administered at baseline, after the intervention period, and 3 and 6 months later. Medicare payments were used to value medical resource use and therapist time to deliver mPCST. Patient time was valued using the average US wage. RESULTS: Medical resource utilization was similar for both groups, but hospitalizations trended higher in the mPCST group. EQ-5D-5L preference weights were higher by an average of 0.066 (p = 0.04) with mPCST across the follow-up period, representing an incremental gain of 0.04 quality-adjusted life years (QALYs) (95% CI: 0.00-0.08). When including the base-case cost of mPCST of \$500 vs. \$0 for the control group, the incremental cost-effectiveness ratio (ICER) was \$12,725 per QALY (95% CI: 5,566-69,343). Including the value of patient time added \$303 to mPCST costs resulting in an ICER of \$20,438 per QALY (95% CI: 9,051-111,403). SIGNIFICANCE OF RESULTS: mPCST is a cost-effective program that improves HRQOL for women with cancer living in medically underserved areas.

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PubMed2026

Endoscopic Ultrasound-Guided Versus Transjugular Portal Pressure Measurements: Systematic Review and Meta-Analysis.

PURPOSE: Published reviews of endoscopic ultrasound-guided portal pressure gradient (EUS-PPG) have emphasized feasibility and safety. We performed a systematic review and meta-analysis specifically to evaluate how closely EUS-based portal pressure measurements track invasive comparator measurements in prospective paired studies and to summarize agreement, technical success, and adverse events. METHODS: We searched major databases through January 2026 for prospective cohorts reporting same-patient EUS-based portal pressure measurement and invasive hemodynamic measurements. Correlations were pooled with random-effects models and analyzed separately for studies comparing EUS-PPG with hepatic venous pressure gradient (HVPG) and studies comparing EUS-based portal measurements with direct portal venous pressure. Agreement and threshold discordance were summarized descriptively. RESULTS: Six prospective cohorts (127 attempted procedures) were included. In studies using HVPG as the comparator, the pooled correlation was 0.82 (95% CI, 0.72-0.89; I2 = 0%). In studies comparing EUS-based portal measurements with direct portal venous pressure, the pooled correlation was 0.86 (95% CI, 0.72-0.93; I2 = 16.9%). Technical success was 95.3%. EUS-PPG-attributed adverse events occurred in 2.4% of procedures, with no procedure-related deaths. Agreement data were limited. Reported limits of agreement were wide (approximately - 6 to + 7 mmHg), and discrepancies of 5 mmHg or greater occurred in 4 of 30 paired measurements. CONCLUSIONS: EUS-based portal pressure measurement is feasible and shows a strong association with invasive hemodynamic comparators, but the evidence base remains small (six cohorts, 127 attempted procedures). Further study will be necessary to establish patient-level agreement, procedural reproducibility, EUS-specific clinically significant portal hypertension thresholds, and whether HVPG-based decision thresholds can be transferred to EUS-derived measurements.

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PubMed2026

Impact of education protocols and physiotherapeutic management in improving pain, symptoms, activities of daily living, and quality of life in patients with knee osteoarthritis: A systematic review and meta-analysis.

BACKGROUND: Knee osteoarthritis is a debilitating condition of the knee joint and the major cause of disability globally, with an increased economic burden on healthcare. Patient education (PE) has emerged as a primary care treatment approach in chronic conditions. This review aims to evaluate the effectiveness of PE along with exercise in reducing pain, alleviating symptoms, improving activities of daily living, and promoting quality of life among individuals with knee osteoarthritis. METHOD: A systematic search was conducted across three electronic databases, PubMed, Cochrane Library, and PEDro. The search was limited to between 2020 and 2025, and included only randomized controlled trials. The Cochrane Risk of Bias Tool and the PEDro Scale were used to evaluate the methodological evidence. Statistical synthesis was analysed using mean differences (MDs) with 95% confidence intervals (CIs) under a random-effects model. RESULTS: Eight trials were included, of which four studies evaluated the four Knee Injury and Osteoarthritis Outcome Score (KOOS) domains, and three studies evaluated the Visual Analogue Scale (VAS) and KOOS activities of daily living domain in patients with knee osteoarthritis. For the meta-analysis, we assessed all five domains of the KOOS scale and VAS. Statistical analysis of the studies showed a significant reduction in pain (VAS) for the PE along with exercise group (MD = -3.28, 95% CI (-4.85; -1.70), and I2 = 69.6%), but there was no significant improvement in the domains of the KOOS scale. CONCLUSION: The study highlights the importance of PE along with exercise in reducing pain. It might not be more effective when compared with exercise therapy as a standalone intervention in improving ADLs, QoL, and symptoms, but it has demonstrated some degree of effectiveness. It additionally promotes self-management and self-efficacy as a physiotherapeutic rehabilitation treatment intervention.

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PubMed2026

Patient expectations assessed before randomisation and after the first treatment session, and their associations with pain outcome at 3 months in patients with tennis elbow: a secondary analysis of a randomised controlled feasibility trial in Norwegian secondary care.

OBJECTIVE: To evaluate patients' expectations of pain improvement before randomisation (T1) and after the first treatment (T2), and to examine how expectations at these two time points were associated with pain outcome measured at 3 months (T3). DESIGN: Exploratory secondary analyses of a three-arm, randomised controlled feasibility trial in patients with tennis elbow comparing heavy slow resistance training, shock wave therapy and advice (1:1:1). SETTING: Outpatient clinic at Oslo University Hospital. PARTICIPANTS: Adults with lateral epicondylalgia, commonly known as tennis elbow. MAIN OUTCOME MEASURES: Expected pain was rated on a Numeric Rating Scale (NRS, 0-10) at T1 and T2. Present pain (NRS, 0-10) was reported at 3 months (T3). Changes in expectations from T1 to T2 were summarised descriptively. Univariable linear regressions assessed associations between T3 pain and expectations at T1 and T2, treatment group and baseline factors. Explained variance was quantified by R2. Multivariable models including demographics and baseline pain were evaluated via adjusted R2. RESULTS: Fifty-four participants were included. In the shock wave group, nine (47%) came to expect greater improvement from T1 to T2; by contrast, in the advice group, seven (41%) expected less improvement. Expectations at T1 were not associated with T3 pain, whereas expectations at T2 were positively associated with T3 pain (b=0.61, 95% CI 0.33 to 0.89, p<0.01, R2=0.27), suggesting that higher expected pain at T2 was associated with higher reported pain at T3. Adding education and baseline pain increased explained variance modestly (R2 from 0.27 to 0.32). CONCLUSION: In this study, expectations measured after randomisation and one treatment session were associated with pain at 3 months for patients with tennis elbow. Larger, prospectively designed studies should investigate how postrandomisation expectations relate to clinical outcomes in non-blinded musculoskeletal trials. TRIAL REGISTRATION NUMBER: NCT04803825.

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PubMed2026

The musculoskeletal pain literacy questionnaire (MSK-PLq) - Part 1: Development of a preliminary version through a systematic review and Delphi consensus.

OBJECTIVE: Chronic musculoskeletal (MSK) pain is a leading cause of disability worldwide, and self-management is a first-line approach recommended by international clinical guidelines. Access to evidence-based information that enhances health literacy may support patients' engagement in their self-management and treatment decision-making, potentially reducing disease burden and pain. However, no tool currently exists to assess health literacy specifically in MSK pain. This study aimed to develop and describe the preliminary version of a knowledge-based questionnaire to evaluate MSK pain literacy, the Musculoskeletal Pain-Literacy questionnaire (MSK-PLq). METHODS: A systematic literature review identified existing health literacy instruments and generated a preliminary list of domains. A two-round Delphi study with 22 panellists (19 experts and three people living with chronic MSK pain), followed by consensus meetings, was used to refine domains and items (≥70% agreement). Readability was assessed using the Flesch Reading Ease (FRE) score and three stakeholders were consulted to review the questionnaire for comprehensibility, clarity, and face validity. RESULTS: Six domains were retained (Understand, Access, Appraise, Apply, Digital, Beliefs), comprising 20 items in the preliminary version of MSK-PLq. Readability was acceptable (mean FRE 74, indicating fairly easy reading), and subject feedback supported the questionnaire's clarity and face validity. CONCLUSIONS: The preliminary version of the MSK-PLq is proposed as the first knowledge-based tool to assess functional, interactive, and critical aspects of MSK pain literacy. It may have applications in clinical practice, research, education, and digital health, by informing tailored patient education and supporting self-management strategies, although further psychometric validation is required.

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PubMed2026

Cryostick pre-cooling reduces pain during intra-articular knee injections: a randomized, contralateral-controlled trial.

BACKGROUND: Intra-articular knee injections are essential for osteoarthritis management but often limited by "needle phobia" and procedural pain. The cryostick, a high-thermal-conductivity device, is a potential analgesic; however, evidence regarding its efficacy in reducing pain and bleeding is limited. The purpose of the study was to evaluate whether cryostick application reduces procedural pain, reduces bleeding, and improves patient satisfaction during intra-articular knee injections. METHODS: This randomized, contralateral-controlled trial included 50 patients (100 knees) with bilateral knee osteoarthritis. One knee received a 20-s cryostick protocol (-20°C) immediately before injection; the contralateral knee received a standard injection. Primary outcome was pain intensity (100-mm VAS) during needle penetration and at 5-min post-injection. Secondary outcomes included bleeding area (mm2) and satisfaction (1-5 Likert scale). RESULTS: Cryostick application significantly reduced pain during needle penetration (Mean Difference [MD] -24.8 mm; 95% CI -29.9 to -19.7; P < 0.001) and at 5-min post-injection (MD -20.8 mm; 95% CI -26.8 to -14.8; P < 0.001). The Number Needed to Treat (NNT) to achieve the Minimal Clinically Important Difference (13 mm) was 1.28 (95% CI 1.15-1.54) during penetration and 1.79 (95% CI 1.45-2.36) at 5-min post-injection. The bleeding area was significantly smaller with cryostick (MD -4.82 mm2; P = 0.014). Patients reported significantly higher satisfaction scores with the cryostick (4.10 vs 2.96; P < 0.001). CONCLUSIONS: A 20-s cryostick application is a safe, well-tolerated, and effective adjunct for attenuating pain and bleeding during knee injections. This technically simple approach requires minimal complexity, offering an efficient, non-pharmacological tool to enhance patient comfort.

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PubMed2026

Analyzing the impact of subcutaneous injection needle, device, and administration characteristics on patient pain, anxiety, and safety: a systematic literature review.

The subcutaneous (SC) injection route is a commonly used and important method for therapeutic delivery of a wide range of compounds, and needle characteristics have a significant influence on patient pain, anxiety, safety, and other outcomes. This systematic review evaluates the evidence on how needle-specific characteristics (e.g. gauge, length, tip design, wall thickness, concealment) and administration- or device-related factors can affect patient-reported outcomes and clinical safety indicators during and following SC injections. A comprehensive search was conducted in MEDLINE, PubMed, Embase, and ClinicalTrials.gov in June 2024. Studies were included if they assessed the relationship between needle characteristics and pain, anxiety, safety, or related outcomes in individuals receiving SC injections. A dual-reviewer process was used for study selection, data extraction, and quality assessment. Sixty-two studies met inclusion criteria. Evidence consistently indicated that thinner and shorter needles reduced patient-reported pain and adverse events such as bruising and bleeding. Tapered and lubricated needles, hidden or retractable needle designs, and use of autoinjectors or prefilled syringes also contributed to reduced anxiety and improved user satisfaction. However, results were heterogeneous, and many studies lacked sufficient power or single-variable evaluation of individual needle parameters, limiting definitive conclusions. Needle characteristics significantly influence patient experience and safety with SC delivery. While both clinical evidence and practical experience clearly favor thinner, shorter, and concealed needles, further standardized, high-quality research is needed to isolate and quantify the specific contributions of individual needle characteristics to optimize injection practices and support patient-centered device design.

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PubMed2026

Patient-reported outcomes in pediatric regional anesthesia trials: current use and limitations.

PURPOSE OF REVIEW: This review examines the current use and limitations of patient-reported outcome measures (PROMs) in pediatric regional anesthesia research. Despite the increasing emphasis on patient-centered outcomes, existing pediatric outcome assessment frameworks may inadequately capture the pain experience and interference with daily living. RECENT FINDINGS: Across 17 identified randomized controlled trials and 15 ongoing studies, PROM use remains highly variable, with consistent reliance on observational pain scales such as the Face, Legs, Activity, Cry, and Consolability scale and limited incorporation of standardized, longitudinal health-related quality-of-life measures. SUMMARY: Current pediatric PROM frameworks remain fragmented, limiting comprehensive evaluation of recovery. Greater standardization and incorporation of developmentally appropriate, longitudinal outcome measures are needed to better align clinical research with meaningful patient-centered endpoints and to improve assessment of functional and psychosocial recovery.

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PubMed2026

Yoga MAT: A factorial randomized study using the Multiphase Optimization Strategy to develop a multicomponent yoga intervention for people with chronic pain taking medications for opioid use disorder.

BACKGROUND: People taking medications for opioid use disorder (MOUD) commonly experience chronic pain. Yoga interventions show promise for decreasing pain-related disability in other populations. More time spent in yoga practice may improve pain-related outcomes. METHODS: The Multiphase Optimization Strategy (MOST) provided the framework for developing an optimized yoga intervention package. In a 2x2x2x2 factorial experiment, we evaluated four candidate intervention components which, when added to a weekly yoga class, might increase yoga engagement. The primary outcome was minutes per week of yoga practice (classes and other yoga practice) over the 12-week intervention period. We sought to determine which combination of intervention components was associated with the most yoga practice for people with chronic pain taking buprenorphine or methadone as MOUD. RESULTS: We enrolled 192 adults. There was a significant main effect for Component "B" (having two private sessions with a yoga teachers; IRR = 1.10, 90%CI 1.02; 1.18), and a synergistic interaction between Components "B" and "D" (D was financial incentives for attending class; IRR = 1.11, 90%CI 1.02; 1.19). This combination of these two components (without other potential components) was associated with the second highest model-predicted mean minutes of yoga per week (157.1min; 90% CI = 120.1-194.0) which was only 4min less than the combination including all four components. CONCLUSIONS: We identified a combination of intervention components as the optimized intervention. A next step will be to test the effect of this optimized intervention on pain and substance use outcomes in a randomized controlled clinical trial.

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PubMed2026

Comparative effectiveness and safety of pharmacological interventions for sleep outcomes in chronic non-cancer pain: a systematic review and network meta-analysis.

Sleep disturbances are highly prevalent among individuals with chronic non-cancer pain and are associated with worse pain severity and poorer prognosis. The comparative trade-offs between the effectiveness and safety of available pharmacotherapies for sleep outcomes in this population remain poorly defined. Ninety-eight RCTs involving 28,920 participants (mean age 53.2 years, 71.2% female) were included. Moderate-certainty evidence demonstrated that melatonin significantly improved sleep quality compared with placebo (standardized mean difference [SMD] = -0.60, 95%CI: -0.98, -0.22). Ten agents (e.g., amitriptyline, oxycodone, gabapentin, pregabalin, duloxetine) also showed statistically significant improvements in subjective sleep quality (SMD = -0.24 to -1.07), but most effects were supported by low-certainty evidence and were accompanied by an increased risk of adverse events (odds ratio [OR] = 1.90 to 37.00). Conversely, melatonin was not associated with an increased risk (OR = 0.88, 95%CI: 0.19, 3.94). Our findings indicate that melatonin shows promise as a safe, adjunctive option for improving sleep quality in this population, but larger, condition-specific trials are warranted to confirm these effects. Other pharmacological agents are limited by lower-certainty and unfavorable safety profiles. These results should be interpreted cautiously given limited direct comparisons, heterogeneous chronic pain populations, the high proportion of trials at high risk of bias, and the predominance of subjective sleep outcomes.

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PubMed2026

Efficacy and Safety of Elagolix Versus Dienogest for Treatment of Moderate-to-Severe Endometriosis Pain: A Phase III, Multicentric, Double-Blind, Active-Controlled, Non-Inferiority Study.

OBJECTIVE: To compare the efficacy, safety and tolerability of elagolix with dienogest in women with moderate-to-severe endometriosis-associated pain. DESIGN: A multicentre, double-blind, double-dummy, randomised, parallel-group, active-controlled, non-inferiority phase III study. SETTING: Nineteen clinical centres across India. STUDY POPULATION: Women (18-49 years) diagnosed with endometriosis and experiencing moderate-to-severe pain. METHODS: Participants were randomised (1:1) to receive oral elagolix (150 mg once daily) or dienogest (2 mg once daily) for 24 weeks. OUTCOME MEASURES: The primary outcome was change in endometriosis-related pain (Numeric Rating Scale [NRS]) from baseline to Day 85. Secondary outcomes included changes in NRS (Day 169), dysmenorrhoea, non-menstrual pelvic pain (NMPP) scores (Days 85 and 169), rescue medication use, patient global impression of change (PGIC), adverse events and bone mineral density. RESULTS: Of 340 patients screened, 230 were randomised (115 per group). At Day 85, both arms showed similar reductions in NRS pain scores with a treatment difference of 0.04 (95% CI: -0.3, 0.37) [p = 0.9747] demonstrating non-inferiority as upper 95% CI was below pre-specified margin of 1.5. At Day 169, both arms showed comparable improvements in overall pain, dysmenorrhoea and NMPP from baseline (p = 0.9372, p = 0.8884, and p = 0.9616, respectively). Rescue medication use and PGIC were comparable between treatment arms. Adverse event incidence was similar (elagolix: 14.8%; dienogest: 19.1%), with no serious TEAEs or discontinuations. No significant bone mineral density changes were observed. CONCLUSIONS: Elagolix demonstrated non-inferiority to dienogest with an acceptable safety and tolerability profile, supporting its use in managing endometriosis-associated pain. TRIAL REGISTRATION: ClinicalTrials.gov identifier: CTRI/2023/01/049292.

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PubMed2026

[Clinical efficacy and safety of electroacupuncture at the motor area for Parkinson's disease with musculoskeletal pain: a randomized controlled trial].

OBJECTIVE: To observe the clinical efficacy and safety of electroacupuncture (EA) at the motor area for Parkinson's disease (PD) with musculoskeletal pain. METHODS: Fifty-eight patients with PD accompanied by musculoskeletal pain were randomly assigned to an EA group (29 cases, 1 case dropped out) and a sham EA group (29 cases, 1 case dropped out). The EA group was treated with EA at the motor area contralateral to the painful side (for bilateral pain, the left motor area was selected), using disperse-dense wave (2 Hz/20 Hz), with a current intensity of 1-2 mA, and needles were retained for 30 min. The sham EA group was treated with sham EA at non-acupoint area located 5-20 mm posterior to the motor area contralateral to the painful side. The connection mode was the same as that in the EA group, but no electrical current was delivered, and the needles were retained for 30 min. Both groups were treated once daily for 5 consecutive days. Visual analogue scale (VAS) for pain, unified Parkinson's disease rating scale part Ⅲ (UPDRS-Ⅲ), 24-item Hamilton depression rating scale (HAMD-24), Hamilton anxiety rating scale (HAMA), and 39-item Parkinson's disease questionnaire (PDQ-39) scores were evaluated before treatment, immediately after treatment, and at 2 and 4 weeks after treatment completion in the two groups. Safety was also assessed in the two groups. RESULTS: In both groups, VAS scores for pain after treatment and at 2 and 4 weeks after treatment completion were lower than those before treatment (P<0.01, P<0.05). VAS scores for pain in the EA group were lower than those in the sham EA group after treatment and at 2 and 4 weeks after treatment completion (P<0.05). In the EA group, UPDRS-Ⅲ, HAMD-24, HAMA, and PDQ-39 scores after treatment and at 2 and 4 weeks after treatment completion were lower than those before treatment (P<0.05, P<0.01). In the sham EA group, there were no statistically significant differences in UPDRS-Ⅲ, HAMD-24, HAMA, and PDQ-39 scores at any post-treatment time point compared with those before treatment (P>0.05). There were no statistically significant differences in UPDRS-Ⅲ, HAMD-24, HAMA, and PDQ-39 scores between the two groups at any post-treatment time point (P>0.05). No serious adverse events occurred during the trial. CONCLUSION: EA at the motor area could reduce pain intensity in patients with PD accompanied by musculoskeletal pain, and improve pain-related motor symptoms, emotional status, and quality of life, with a favorable safety profile.

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PubMed2026

A flipped classroom approach compared with low-interactive online learning for pediatric pain management knowledge and instructional motivation in nursing students: A randomized controlled study.

AIM: This study aimed to compare a flipped classroom approach with low-interactive online learning in terms of nursing students' questionnaire-assessed pediatric pain management knowledge and instructional motivation. BACKGROUND: Pain management in children is a critical and multidimensional nursing responsibility. However, limited curricular time and opportunities for applied learning may restrict nursing students' preparedness in this area. Structured and interactive instructional formats, such as the flipped classroom, may support knowledge acquisition and motivation in pediatric nursing education. METHODS: This study employed a parallel-group randomized controlled trial design with a 1:1 allocation ratio. Eighty-eight third-year prelicensure nursing students were randomized to either the flipped classroom group (n = 44) or the low-interactive online learning group (n = 44). Due to attrition (2 intervention, 2 control), analyses included 42 participants per group (n = 84 in total). Data were collected between February and July 2022 using the Pediatric Pain Management Knowledge Scale for Nursing Students and the Instructional Materials Motivation Survey. This study was prospectively registered at ClinicalTrials.gov (Identifier: NCT07129044). RESULTS: At baseline, the groups were comparable in terms of knowledge and learning motivation. Following the intervention, the flipped classroom group demonstrated greater improvements in questionnaire-assessed pediatric pain management knowledge and instructional motivation than the low-interactive online learning group. Although scores declined from post-test to the three-month follow-up, they remained above baseline in the flipped classroom group. CONCLUSIONS: Within the context of this course, the flipped classroom approach was associated with greater improvement in questionnaire-assessed pediatric pain management knowledge and instructional motivation than low-interactive online learning. The findings should be interpreted as proximal educational outcomes rather than evidence of improved clinical competence or durable long-term effectiveness. Further studies using objective performance-based outcomes and longer follow-up periods are needed.

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PubMed2026

Nociception-guided opioid administration within multimodal analgesia for laparoscopic endometriosis surgery: a randomized controlled trial.

Women with endometriosis are at increased risk of severe postoperative pain due to nociceptive sensitization. While multimodal analgesia reduces opioid use, the added value of objective nociception monitoring remains unclear. This study evaluated whether NOL®-guided opioid titration improves perioperative outcomes within a standardized multimodal regimen. In this prospective, randomized, single-blinded trial, premenopausal women undergoing laparoscopic surgery for suspected endometriosis or adenomyosis were assigned to NOL®-guided analgesia or standard care based on clinical assessment. All patients received a standardized multimodal protocol. The primary outcome was total perioperative opioid consumption. Secondary outcomes included postoperative pain scores (NRS) and PACU length of stay. Exploratory analyses assessed the association between preoperative pain (Mankoski Pain Scale, MPS) and postoperative outcomes. A total of 111 patients were analyzed (NOL®: n = 54; control: n = 57). Total perioperative opioid consumption did not differ significantly between groups (adjusted mean difference = 14 μg for Fentanyl and 52 μg for Remifentanil; p = 0.8). Surgery duration was an independent predictor of opioid use (p < 0.001) and PACU length of stay (p = 0.01), whereas treatment group had no significant effect. Postoperative pain scores were comparable between groups at all time points. NOL®-derived metrics were not associated with opioid consumption or pain. Higher preoperative MPS scores independently predicted higher pain scores in the late PACU phase. NOL®-guided opioid titration did not reduce perioperative opioid consumption or improve early postoperative outcomes compared with standard multimodal analgesia in women undergoing laparoscopic surgery for endometriosis.

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PubMed2026

Do adherence-focused interventions in low back pain have an impact on rehabilitation outcomes? A systematic review with meta-analysis.

BACKGROUND: Low back pain (LBP) is the leading cause of disability worldwide. Exercise-based interventions are effective, but adherence remains suboptimal. This systematic review and meta-analysis evaluated the effectiveness of strategies designed to enhance adherence to exercise-based interventions in individuals with LBP in terms of adherence as well as pain and functionality. METHODS: Randomized controlled trials including adults with non-specific LBP were eligible if they compared exercise-based interventions incorporating adherence-enhancing strategies versus exercise alone or usual care. Primary outcome was adherence; secondary outcomes were pain and functionality. Searches were conducted in PubMed, Embase, Web of Science, Cochrane Library, CINAHL, Scopus, and PEDro up to May 2026. Two reviewers independently screened studies, extracted data, and assessed risk of bias using the Cochrane RoB 2 tool. Random-effects meta-analyses were performed using standardized mean differences. Certainty of evidence was evaluated using the GRADE approach. RESULTS: Fourteen randomized controlled trials including 1233 participants were included. Risk of bias was low in six studies, with the remainder showing some concerns or high risk. For adherence outcomes, evidence showed no clear effect of adherence-enhancing strategies on either device-measured physical activity (SMD = 0.21, 95% CI -0.01 to 0.43; 3 trials, 320 participants; moderate-certainty evidence) or questionnaire-based adherence (SMD = 0.33, 95% CI -0.23 to 0.89; 4 trials, 377 participants; very low-certainty evidence). For pain and functionality, moderate certainty of evidence indicated small improvements favoring intervention groups in the medium term. CONCLUSIONS: Strategies to enhance adherence to exercise in LBP show uncertain effects on adherence but may provide small improvements in clinical outcomes in the medium term. Higher-quality trials are needed to strengthen the evidence base.

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PubMed2026

Analgesic effect of premixed nitrous oxide in postoperative rehabilitation for ankle fractures: a randomized controlled trial.

INTRODUCTION: The global incidence of ankle fractures is on the rise, effective postoperative rehabilitation is a crucial aspect of surgical management. However, the occurrence of severe pain during the rehabilitation continues to pose a substantial clinical challenge. METHODS: The study utilizes a dual-arm, single-center, double-blind, randomized controlled trial design. A total of 100 participants were enrolled. Participants included patients experiencing acute pain (self-reported pain score ≥4) who underwent postoperative rehabilitation for ankle fractures. Participants undergoing rehabilitation training were randomized to receive either 65% nitrous oxide or 100% oxygen. The primary outcome measured was the pain score, while secondary outcomes encompassed anxiety scores, physiological indices, side effects, patient and therapist satisfaction, acceptance, and residual pain. RESULTS: Pain scores were found to be significantly lower in the nitrous oxide group than in the oxygen group (T1: median difference -3.0, [95% CI -3.4 to -2.6]; p < 0.001; T2: median difference -2.0, [95% CI -2.8 to -1.2]; p < 0.001). Compared with the oxygen group, both therapists (p < 0.001) and participants (p < 0.001) in the nitrous oxide group reported significantly higher satisfaction levels. Acceptance rate showed significant intergroup differences (p < 0.001). No severe adverse effects were observed in either group. Anxiety scores between the two groups did not show a significant difference (p = 0.31, η2 = 0.027). CONCLUSION: The safety and analgesic profile of nitrous oxide renders it a suitable option for pain management in postoperative ankle fractures rehabilitation, thus providing a safe and easily manageable alternative to the current available strategies. CLINICAL TRIAL REGISTRATION: We have registered at https://www.chictr.org.cn and the registration number is: ChiCTR2400089379.

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PubMed2026

Clinical outcomes of fusion vs excision in the treatment of painful type II accessory naviculars: A matched cohort study.

BACKGROUND: For painful Type II accessory naviculars, whether to remove or fuse them remains unclear based on the current literature. This study aimed to investigate the clinical outcomes of fusion versus excision in treating painful type II accessory naviculars. METHODS: This retrospective comparative study included and followed 54 eligible patients (from May 2017 to March 2023). After 1:1 propensity score matching (PSM), 34 patients (17 fusion versus 17 excision) were analyzed. Outcomes included Visual Analog Scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) midfoot score, Tegner score, complication rates, and radiographic measurements. Receiver operating characteristic (ROC) curve analysis was performed to identify the appropriate accessory navicular size cutoff for predicting nonunion following fusion. RESULTS: The mean follow-up was 35.0 ± 9.9 months. The fusion and excision groups showed significant and comparable VAS and AOFAS score improvements (p < .001). The fusion group had a higher complication rate (41.2% vs. 5.9%, p = .039), primarily nonunion and persistent pain. ROC curve analysis identified 50.3 mm² as the cutoff for nonunion risk; sizes < 50.3 mm² predicted high nonunion likelihood. CONCLUSIONS: Both fusion and excision are effective treatments for painful type II accessory naviculars, demonstrating acceptable pain and functional improvement during midterm follow-up. However, the lower complication rate along with relatively superior functional recovery favors the excision technique. For accessory naviculars smaller than 50.3 mm2, excision may be a better choice. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Humans↗