Sex moderates the association between quantitative sensory testing and acute and chronic pain after total knee/hip arthroplasty.

OBJECTIVES: Acute postsurgical pain (APSP) may persist over time and become chronic. Research on predictors for APSP and chronic postsurgical pain (CPSP) has produced inconsistent results. This observational study aimed to analyze psychological and psychophysical variables associated with APSP and CPSP after total knee or hip arthroplasty, and to explore the role of sex. METHODS: Assessments were conducted before surgery, 48 h, and 3 months postsurgery, including questionnaires (sociodemographic, pain related, and psychological) and quantitative sensory testing (QST). Hierarchical linear regression models analyzed potential predictors of APSP and CPSP, and moderation analyses evaluated the role of sex. RESULTS: The study included 63 participants undergoing total knee (34, 54%) or hip (29, 46%) arthroplasty. Thirty-one (49.2%) were female and 32 (50.8%) were male. APSP (48 h) was associated with impaired conditioned pain modulation (CPM) (ß = 0.301, p = 0.019). CPSP (3 months) was associated with being female (ß = 0.282, p = 0.029), longer presurgical pain duration (ß = 0.353, p = 0.006), knee arthroplasty (ß = -0.312, p = 0.015), higher APSP intensity (ß = 373, p = 0.004), and impaired CPM (ß = 0.126, p = 0.004). In multivariate analysis, these clinical variables were significant predictors of CPSP, unlike sex, and CPM (adj. R 2 = 0.349). Moderation analyses showed that wind-up ratio (WUR) was a significant predictor of APSP in men (WUR × sex: b = -1.373, p = 0.046) and CPM was a significant predictor of CPSP in women (CPM × sex: b = 1.625, p = 0.016). CONCLUSIONS: Specific QST parameters could identify patients at risk for high-intensity APSP and CPSP, with sex as a moderator. This has important clinical implications for patient care, paving the way for developing tailored preventive pain management strategies.

Predictive value of quantitative sensory testing for acute and chronic postsurgical pain after total joint arthroplasty: a systematic review.

ABSTRACT: Quantitative sensory testing (QST) can be useful to identify high-risk patients for the development of chronic postsurgical pain. This systematic review aims to assess if presurgical sensory sensitivity measured using QST is associated with acute and chronic postsurgical pain after total joint arthroplasty. A systematic search was performed in September 2020 in PubMed, EMBASE, Web of Science, and Scopus, using terms related to total joint arthroplasty and QST. Prospective studies were included if they reported an association between presurgical QST and postsurgical pain in adults with osteoarthritis undergoing primary unilateral total joint arthroplasty. From 2994 identified studies, 18 met the inclusion criteria (1869 patients). Total knee arthroplasty was the most common surgery (16 studies), and pressure pain threshold was the most common test (11 studies), followed by dynamic measures (9 studies). Postsurgical pain was assessed at acute (5 studies), subacute (2 studies), and chronic (13 studies) time points. Risk of bias was assessed using the Quality in Prognosis Studies tool and evaluated as low to moderate in most domains. Fourteen studies reported at least one statistically significant association between QST and pain (acute: 4 studies, subacute: 1 study, and chronic: 9 studies). Pressure pain threshold was associated with postsurgical pain in 6 studies (of 11, 55%), heat pain threshold in 2 studies (of 6, 33%), conditioned pain modulation in 1 study (of 6, 17%), and temporal summation of pain in 5 studies (of 8, 63%). The predictive role of presurgical QST for postarthroplasty pain remains unclear, mainly because of heterogeneous methodologies and inconsistent results.

Effectiveness of hypnosis for pain and health-related quality-of-life among people with hemophilia: Three-month outcomes of a randomized controlled pilot trial.

BACKGROUND AND PURPOSE: Pain is a common condition among people with hemophilia (PWH), negatively impacting quality of life. However, effective treatment remains a challenge. This two-arm, parallel randomized controlled pilot trial aimed to examine the three-month effects of hypnosis intervention on clinical and psychosocial variables, and on the inflammatory profile of PWH. MATERIALS AND METHODS: The study was conducted between January and October 2018, in a Reference Center for Congenital Coagulopathies. Adult (age ≥18) patients were randomized to experimental group (EG) or control group (CG). The EG received four weekly hypnosis sessions plus treatment-as-usual, and the CG maintained treatment-as-usual only. Outcomes were evaluated at one week and three months post-intervention and included pain, joint status, health-related quality of life (HRQoL), emotional state and inflammatory profile (leukocytes, C-reactive protein, cytokines). The randomization sequence was computer-generated, and allocation was concealed until enrolment. The outcome assessor was blind to allocation, but blinding of the participants was not possible due to the differences in procedure. RESULTS: Twenty patients were randomized to EG (n = 10; 8 analyzed) or CG (n = 10; 10 analyzed). Two-way mixed ANOVA showed significant time × group interactions on pain interference with normal work and with relations with other people, and on perception of health status. The EG significantly improved in pain interference with normal work and perception of health status. There was no report of harm. CONCLUSION: Hypnosis may be a promising intervention to manage hemophilia-related pain and promote HRQoL, with benefits lasting up to three months.

Haemophilia A: health and economic burden of a rare disease in Portugal.

BACKGROUND: Haemophilia A is a hereditary bleeding disorder, which has been considered rare and chronic. The burden of this disease in Portugal remains unknown. The aim of this study was to estimate the annualized cost and health burden of haemophilia A in Portugal. METHODS: Data were extracted from a Portuguese expert panel, from official data and national literature. Annual costs were calculated from the perspective of the society including direct and indirect costs. Unitary costs were extracted from 2017 national official sources and are expressed in euros. Health burden was expressed in disability adjusted life years (DALYs) based on incidence and quality of life questionnaires. Estimates are presented for the overall population and stratified by severity, age group (< 18 years vs. adults) and inhibitor status. RESULTS: The yearly average cost per patient is estimated to range from €39,654/patient without inhibitors and €302,189/patient with inhibitors, representing a 7.6 fold difference. Amongst patients without inhibitors, the annual average cost was €401 in mild, €5327 in moderate and €85,805 in severe disease. Average cost per child and adult is €72,287 and €51,737, respectively. Direct costs represent approximately 95% of all costs, of which almost the totality accounts for clotting factor replacement therapy and bypassing agents. The total annual cost of haemophilia A for the Portuguese society was estimated to be €42,66 million, one third of which was related to the treatment of patients with inhibitors. It is estimated that haemophilia A is responsible for 3878 DALYs in Portugal (497 DALYs in mild, 524 DALYs in moderate, 2031 DALYs in severe patients without inhibitors and 784 DALYs in patients with inhibitors) for the cohort of 2017 (750 patients) or 5.2 DALY/patient during lifetime. CONCLUSIONS: Despite being rare, the economic and health burden of haemophilia A is remarkable. The main cost driver is clotting factor replacement therapy. Moreover, haemophilia A is more costly in children than in adults and rises exponentially with disease severity.

A new measure to assess pain in people with haemophilia: The Multidimensional Haemophilia Pain Questionnaire (MHPQ).

People with haemophilia (PWH) experience acute pain during joint bleeds and might develop chronic pain due to joint degeneration. However, there is a lack of standardized measures to comprehensively assess pain in PWH. This study aimed to develop a multidimensional questionnaire for haemophilia-related pain, the Multidimensional Haemophilia Pain Questionnaire (MHPQ), and to present initial validation data among adults.The questionnaire distinguishes between acute/chronic pain and queries about pain locations, duration, frequency, triggering factors, intensity, interference, strategies, specialists for pain management and satisfaction with treatment. An initial version was tested with 16 patients to ensure item comprehensibility and face validity. The final version was answered by 104 adults, with 82 (78.8%) reporting haemophilia-related pain in the previous year (mean age = 43.17; SD = 13.00). The non-response analysis revealed good item acceptability. Exploratory and confirmatory factor analysis (EFA/CFA), reliability (internal consistency, test-retest, inter-item and item-total correlations) and convergent validity were analysed for the intensity and interference dimensions of the questionnaire. A combined EFA with these two constructs supported a 2-factor structure distinguishing intensity (α = 0.88) from interference items (α = 0.91). CFA was tested for the interference dimension, demonstrating suitability for this sample. Item-total correlations were >0.30 on both dimensions and most inter-item correlations were <0.70. Test-retest reliability (n = 42) was good for intensity (r = 0.88) and interference (r = 0.73), and convergent validity was confirmed for most hypotheses (r>0.30).This questionnaire is a comprehensible tool, achieving a thorough assessment of relevant pain dimensions. The MHPQ can help guide treatment recommendations by highlighting relevant topics and contributing to more effective, integrated treatments.

Psychological factors predict an unfavorable pain trajectory after hysterectomy: a prospective cohort study on chronic postsurgical pain.

Chronic postsurgical pain (CPSP) is a well-recognized potential complication with negative personal, social, and health care consequences. However, limited data exist on CPSP and on the course of pain over time after hysterectomy. Using data from a prospective cohort study on a consecutive sample assessed at 4 time points, presurgery (T1), 48 hours (T2), 4 months (T3), and 5 years postsurgery (T4), we sought to examine women's PSP trajectories using assessments of pain at T3 and T4. In addition, this study aimed to investigate presurgical and postsurgical risk factors associated with an unfavourable pain trajectory (PT). Based on pain data collected at T3 and T4, 3 distinct trajectories of PSP emerged: no CPSP (PT1; n = 88), prolonged PSP (PT2; n = 53), and CPSP (PT3; n = 29). Moreover, reported CPSP prevalence at 5 years was 17.1%. Multinomial logistic regression models controlling for age, presurgical pain, and type of hysterectomy tested for baseline and acute postsurgical predictive variables. Membership in PT2 and PT3 was predicted by presurgical anxiety (odds ratio [OR] = 1.131, P = 0.015; OR = 1.175, P = 0.009, respectively), emotional representation of the surgical disease (OR = 1.155, P = 0.034; OR = 1.213, P = 0.020, respectively), and pain catastrophizing (OR = 1.079, P = 0.043; OR = 1.143, P = 0.001, respectively). Furthermore, acute PSP intensity and frequency determined membership of women in PT3 (OR = 1.211, P = 0.033; OR = 3.000, P = 0.029, respectively), and postsurgical anxiety (OR = 1.182, P = 0.026) also played a key predictive role. This study identified factors that can be easily screened before and after surgery and are amenable to change through carefully designed timely and tailored interventions for women at risk of an unfavorable PSP trajectory posthysterectomy.

A comparison of predictors and intensity of acute postsurgical pain in patients undergoing total hip and knee arthroplasty.

BACKGROUND: Acute pain is an expected result after surgery. Nevertheless, when not appropriately controlled, acute pain has a very negative impact on individual clinical outcomes, impairing healing and recovery, and has clear consequences on health care system costs. Augmenting knowledge on predictors and potentially modifiable determinants of acute postsurgical pain can facilitate early identification of and intervention in patients at risk. However, only a few studies have examined and compared acute pain after total hip arthroplasty (THA) and total knee arthroplasty (TKA). The aim of this study was to compare THA and TKA in acute postsurgical pain intensity and its predictors. METHODS: A consecutive sample of 124 patients with osteoarthritis (64 undergoing THA and 60 TKA) was assessed 24 hours before (T1) and 48 hours after (T2) surgery. Demographic, clinical, and psychological factors were assessed at T1, and acute postsurgical pain experience was examined at T2. Additionally, the same hierarchical regression analysis was performed separately for each arthroplasty type. RESULTS: TKA patients reported higher levels of acute postsurgical pain compared with THA (t=8.490, p=0.004, d=0.527, 95% confidence interval, 0.196-0.878). In the final THA predictive model, presurgical pain was the only variable approaching significant results (t[57]=1.746, ß=0.254, p=0.086). In the final TKA predictive model, optimism was the only predictor of pain (t[51]=-2.518, ß=-0.339, p=0.015), with emotional representation (t[51]=1.895, ß=0.254, p=0.064) presenting a trend toward significance. CONCLUSION: The current study is the first examining THA and TKA differences on acute postsurgical pain intensity and its predictors using a multivariate approach. Results from this study could prove useful for the design of distinct interventions targeting acute postsurgical pain management depending on whether the site of arthroplasty is the hip or the knee. Finally, the current results also support the argument that these two surgeries, at least with regard to acute pain, should be approached separately.

Predictors of Acute Postsurgical Pain After Inguinal Hernioplasty.

Acute postsurgical pain (APSP) is a common and anticipated problem after surgery with detrimental consequences if not appropriately managed. This study examined the independent and joint contribution of presurgical demographic, clinical, and psychological variables as predictors of APSP intensity, evaluated using an 11-point numeric rating scale, after inguinal hernioplasty, one of the most performed surgeries worldwide. In a prospective observational cohort study, a consecutive sample of 135 men undergoing hernioplasty was assessed before and 48 hours after surgery. When adjusted for depression, helplessness, and magnification scores, a multiple hierarchical regression analysis revealed that younger age (ß = -.247, P < .005), previous chronic pain (ß = .175, P < .05), presurgical anxiety (ß = .235, P < .05), and the rumination component of pain catastrophizing (ß = .222, P < .05) were significant predictors of APSP intensity. The integrative predictive model found in this study revealed the simultaneous influence that demographic, clinical, and psychological factors have on APSP after inguinal hernioplasty. Therefore, these results improve knowledge on APSP predictors after inguinal hernioplasty and highlight potential modifiable intervention targets, such as anxiety and pain catastrophizing (rumination), for the design of interventions focused on APSP prevention and management. Hence, taken together, these findings lend support for the inclusion of presurgical screening and psychological interventions among surgical patients at risk for higher APSP intensity. PERSPECTIVE: This study found that, when adjusted for depression, helplessness, and magnification scores, the variables younger age, previous chronic pain, presurgical anxiety, and the rumination component of pain catastrophizing are significant predictors of APSP intensity after inguinal hernioplasty. These findings improve knowledge on APSP and highlight potential modifiable intervention targets for the design of interventions focused on APSP prevention and management.

Correction: Validation of the Surgical Fear Questionnaire in Adult Patients Waiting for Elective Surgery.

[This corrects the article DOI: 10.1371/journal.pone.0100225.].

Differential predictors of acute post-surgical pain intensity after abdominal hysterectomy and major joint arthroplasty.

BACKGROUND: Psychological factors have a significant role in post-surgical pain, and their study can inform pain management. PURPOSE: The aims of this study are to identify psychological predictors of post-surgical pain following abdominal hysterectomy (AH) and major joint arthroplasty (MJA) and to investigate differential predictors by type of surgery. METHOD: One hundred forty-two women undergoing AH and 110 patients undergoing MJA were assessed 24 h before (T1) and 48 h after (T2) surgery. RESULTS: A predictive post-surgical pain model was found for AH and MJA yielding pre-surgical pain experience and pain catastrophizing as significant predictors and a significant interaction of pre-surgical optimism and surgery type. Separate regression models by surgery type showed that pre-surgical optimism was the best predictor of post-surgical pain after MJA, but not after AH. CONCLUSIONS: Findings highlight the relevance of psychological predictors for both surgeries and the value of targeting specific psychological factors by surgery type in order to effectively manage acute post-surgical pain.

Validation of the surgical fear questionnaire in adult patients waiting for elective surgery.

OBJECTIVES: Because existing instruments for assessing surgical fear seem either too general or too limited, the Surgical Fear Questionnaire (SFQ) was developed. The aim of this study is to assess the validity and reliability of the SFQ. METHODS: Based on existing literature and expert consultation the ten-item SFQ was composed. Data on the SFQ were obtained from 5 prospective studies (N = 3233) in inpatient or day surgery patients. These data were used for exploratory factor analysis (EFA), confirmatory factor analysis (CFA), reliability analysis and validity analysis. RESULTS: EFA in Study 1 and 2 revealed a two-factor structure with one factor associated with fear of the short-term consequences of surgery (SFQ-s, item 1-4) and the other factor with fear of the long-term consequences of surgery (SFQ-l, item 5-10). However, in both studies two items of the SFQ-l had low factor loadings. Therefore in Study 3 and 4 the 2-factor structure was tested and confirmed by CFA in an eight-item version of the SFQ. Across all studies significant correlations of the SFQ with pain catastrophizing, state anxiety, and preoperative pain intensity indicated good convergent validity. Internal consistency (Cronbach's alpha) was between 0.765-0.920 (SFQ-total), 0.766-0.877 (SFQ-s), and 0.628-0.899 (SFQ-l). The SFQ proved to be sensitive to detect differences based on age, sex, education level, employment status and preoperative pain intensity. DISCUSSION: The SFQ is a valid and reliable eight-item index of surgical fear consisting of two subscales: fear of the short-term consequences of surgery and fear of the long-term consequences.

Persistent pain after total knee or hip arthroplasty: differential study of prevalence, nature, and impact.

This study compares the incidence, nature, and impact of persistent post-surgical pain after total knee arthroplasty (TKA) and total hip arthroplasty (THA) and investigates differences between these procedures, with the focus on potential presurgical and post-surgical issues that could be related to the distinct persistent post-surgical pain outcomes between these two groups. A consecutive sample of 92 patients was assessed prospectively 24 hours before, 48 hours, and 4-6 months after surgery. The data show that TKA patients had a higher likelihood of developing persistent post-surgical pain, of reporting higher pain levels, and of using more neuropathic descriptors when classifying their pain. In addition, TKA patients more often reported interference from pain on functional domains, including general activity, walking ability, and normal work. Demographic factors, like gender and age, along with presurgical clinical factors like disease onset, existence of medical comorbidities, and other pain problems, may have contributed to these differences, whereas baseline psychologic factors and functionality levels did not seem to exert an influence. Heightened acute post-surgical pain experience among TKA patients could also be related to distinct outcomes for persistent post-surgical pain. Future prospective studies should therefore collect TKA and THA samples wherein patients are homogeneous for demographic and presurgical clinical issues. Overall, these findings contribute to a small but growing body of literature documenting persistent post-surgical pain after major arthroplasty, conducted in different countries and across different health care settings.

Risk factors for moderate and severe persistent pain in patients undergoing total knee and hip arthroplasty: a prospective predictive study.

Persistent post-surgical pain (PPSP) is a major clinical problem with significant individual, social and health care costs. The aim of this study was to examine the joint role of demographic, clinical and psychological risk factors in the development of moderate and severe PPSP after Total Knee and Hip Arthroplasty (TKA and THA, respectively). This was a prospective study wherein a consecutive sample of 92 patients were assessed 24 hours before (T1), 48 hours after (T2) and 4-6 months (T3) after surgery. Hierarchical logistic regression analyses were performed to identify predictors of moderate and severe levels of PPSP. Four to six months after TKA and THA, 54 patients (58.7%) reported none or mild pain (Numerical Rating Scale: NRS ≤ 3), whereas 38 (41.3%) reported moderate to severe pain (NRS >3). In the final multivariate hierarchical logistic regression analyses, illness representations concerning the condition leading to surgery (osteoarthritis), such as a chronic timeline perception of the disease, emerged as a significant predictor of PPSP. Additionally, post-surgical anxiety also showed a predictive role in the development of PPSP. Pre-surgical pain was the most significant clinical predictive factor and, as expected, undergoing TKA was associated with greater odds of PPSP development than THA. The findings on PPSP predictors after major joint arthroplasties can guide clinical practice in terms of considering cognitive and emotional factors, together with clinical factors, in planning acute pain management before and after surgery.

Predictors of acute postsurgical pain and anxiety following primary total hip and knee arthroplasty.

UNLABELLED: This study aims to examine the joint role of demographic, clinical, and psychological variables as predictors of acute postsurgical pain and anxiety in patients undergoing total knee arthroplasty and total hip arthroplasty. A consecutive sample of 124 patients was assessed 24 hours before (T1) and 48 hours after (T2) surgery. Demographic, clinical, and psychological factors were assessed at T1 and several postsurgical pain issues, anxiety, and analgesic consumption were evaluated at T2. Hierarchical linear regression analyses were performed to identify predictors of acute pain and anxiety following surgery. In the final multivariate model, presurgical optimism emerged as the main significant predictor of postsurgical pain intensity. Presurgical optimism also had a significant role in the prediction of postsurgical anxiety, together with presurgical anxiety level and emotional representation of the condition leading to surgery (osteoarthritis). A significant positive correlation between postsurgical anxiety and acute pain was also confirmed. The present study enhances our understanding of predictors of acute pain and anxiety following total knee arthroplasty and total hip arthroplasty by showing the relevance of psychological factors, over and above other potential clinical predictors. These findings could be used to develop targeted interventions aimed at acute postsurgical pain and anxiety management following major joint arthroplasties. PERSPECTIVE: This article reveals the significant influence of psychological factors on the prediction of acute pain and anxiety 48 hours after primary total hip and knee arthroplasty. These results could prove useful for the design of interventions aimed at postsurgical pain and anxiety management.

Critérios mínimos para credenciamento de centros formadoresde especialistas em Alergia e Imunologia Clínica: propostaelaborada pelas oficinas de discussão realizadas nos CongressosBrasileiros de Alergia e Imunopatologia de 2010 e 2011 / Minimum criteria for accreditation of specialty training centers in Allergyand Clinical Immunology: proposal prepared by discussion workshopsheld in 2010 and 2011 Brazilian Congresses of Allergy and Immunopathology

Em resposta às necessidades da Comissão de Títulode Especialista, a Diretoria de Ensino e Credenciamentode Serviços realizou pesquisa sobre os serviços brasileirosenvolvidos na capacitação e treinamento de especialistasem Alergologia e Imunologia Clínica no ano de 2010 cujosresultados foram publicados recentemente1. Este estudo tevecomo base outros realizados pela World Allergy Organization(WAO) ao estabelecer os critérios mínimos para a formaçãode um especialista em Alergologia e Imunologia2-4 e tevepor objetivo a busca sobre o perfil do serviço que reunisseas condições mínimas para ser credenciado como apto paraoferecer tal capacitação na especialidade, tomando-se comobase os requisitos mínimos para admissão dos especializandos,os critérios de seleção, o tipo de treinamento, o tempo idealde treinamento, bem como o seu modo de certificação.

Risk factors for persistent postsurgical pain in women undergoing hysterectomy due to benign causes: a prospective predictive study.

UNLABELLED: Persistent postsurgical pain (PPSP) is a major clinical problem with significant individual, social, and healthcare costs. The aim of this study was to examine the role of demographic, clinical, and psychological risk factors in the development of PPSP after hysterectomy due to benign disorders. In a prospective study, a consecutive sample of 186 women was assessed 24 hours before surgery (T1), 48 hours after surgery (T2), and 4 months after surgery (T3). Regression analyses were performed to identify predictors of PPSP. Four months after hysterectomy, 93 (50%) participants reported experiencing pain (numerical rating scale >0). Age, pain due to other causes, and type of hysterectomy emerged as significant predictive factors. Baseline presurgical psychological predictors identified were anxiety, emotional illness representation of the condition leading to surgery, and pain catastrophizing. Among the identified psychological predictors, emotional illness representation emerged as the strongest. Acute postsurgical pain frequency and postsurgical anxiety also revealed a predictive role in PPSP development. These results increase the knowledge on PPSP predictors and point healthcare professionals toward specific intervention targets such as anxiety (presurgical and postsurgical), pain catastrophizing, emotional illness representations, and acute pain control after surgery. PERSPECTIVE: This study found that presurgical anxiety, emotional illness representations, and pain catastrophizing are risk factors for PPSP 4 months after hysterectomy, over and above age and clinical variables. These findings improve knowledge on PPSP and highlight potential intervention targets for healthcare professionals.

The mediating role of pain catastrophizing in the relationship between presurgical anxiety and acute postsurgical pain after hysterectomy.

The aim of this study was to examine the joint role of demographic, clinical, and psychological variables as predictors of acute postsurgical pain in women undergoing hysterectomy due to benign disorders. A consecutive sample of 203 women was assessed 24 hours before (T1) and 48 hours after (T2) surgery. Baseline pain and predictors were assessed at T1 and postsurgical pain and analgesic consumption at T2. Several factors distinguished women who had no or mild pain after surgery from those who had moderate to severe pain, with the latter being younger, having more presurgical pain, and showing a less favorable psychological profile. Younger age (odds ratio [OR]=0.90, P<.001), presurgical pain (OR=2.50, P <.05), pain due to other causes (OR=4.39, P=.001), and pain catastrophizing (OR=3.37, P=.001) emerged as the main predictors of pain severity at T2 in multivariate logistic regression. This was confirmed in hierarchical linear regression (ß=-0.187, P<.05; ß=0.146, P<.05; ß=0.136, P<.05; ß=0.245, P<.01, respectively). Presurgical anxiety also predicted pain intensity at T2. Findings revealed an integrative heuristic model that accounts for the joint influence of demographic, clinical, and psychological factors on postsurgical pain intensity and severity. In further mediation analysis, pain catastrophizing emerged as a full mediator between presurgical anxiety and postsurgical pain intensity. The potential clinical implications for understanding, evaluating, and intervening in postsurgical pain are discussed.