Effects of Preoperative Exercises on Reducing Postlaparoscopic Operation Pain in Adults

Effects of Preoperative Exercises on Reducing Postlaparoscopic Operation Pain in Adults | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effects of Preoperative Exercises on Reducing Postlaparoscopic Operation Pain in Adults Hong-Wun Chen, Li-An Liao, Chih-Han Chan, Wui-Chiu Mui This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6497422/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background : Preoperative exercise and physical activity (PA) are strongly recommended in prehabilitation for enhanced recovery after surgery. However, the evidence of the effect of preoperative PA on postoperative pain remains inconclusive. Therefore, the aim of this study was to explore the hypoalgesic effects of preoperative PA on postlaparoscopic operation pain in adults. Methods: A total of 1600 participants who underwentdifferent types of laparoscopic operations and information on the incidence and severity of pain and other suffering of each patient were periodically recorded at 1, 4, 7, 10 and 24 hours after the operation. The patient’s pain level was rated via a numeric rating scale ranging from 1 (no pain at all) to 5 (excruciating pain). Among the participants, 460 underwent 6 to 8 weeks of preoperative PA at moderate or vigorous intensity. The latent growth models were constructed via structural equation modeling to estimate and select the model that best fit the pain scores collected. Results : Three unconditional growth models fit the data. Among the fitted models, the quadratic model was the best at fitting the trajectory pain scores and was adapted to assess the pain scores after recovery. The results from the quadratic growth model revealed that pain scores were significantly lower than those of non-PA controls for patients who had performed 6 to 8 weeks of preoperative PA at moderate or vigorous intensity. Conclusion : Preoperative moderate-to-vigorous intensity PAs reduce postoperative pain in adults within 24 hours after various types of laparoscopic operations. Physical activity Laparoscopic operation Postoperative pain Prehabilitation Enhanced recovery after surgery Figures Figure 1 Figure 2 Background Despite millions of surgeries performed every year around the world, postoperative pain remains prevalent and is often addressed with inadequate or suboptimal treatments. 1 Despite the increasing knowledge of the mechanisms of incisional inflammation, transmission of nociception signals, and peripheral and central sensitization, 2 and in addition to the current advancements in pharmacology, pharmaceutics, techniques and equipment, the US Institute of Medicine revealed that 80% of patients receiving surgery have reported postoperative pain, 3 , 4 with 88% of them at moderate, severe, or extreme levels. 5 Many studies have aimed to address how to reduce postoperative pain. For example, pain can be managed through analgesic medications, but nearly 80% of patients experience some adverse effects. 6 Additionally, many clinicians face uncertainty about optimizing the use of analgesics, as pain is inherently influenced by individualized factors. 7 In addition to the use of analgesic medications, some studies have suggested that physical activity can prevent pain and alleviate it after injury. 8 Therefore, assessing patients’ health status before surgery and implementing exercise programs to enhance their overall health and physical fitness may help reduce postoperative discomfort and facilitate faster recovery. 9 Enhanced recovery after surgery (ERAS) is an evidence-based, patient-centered, multidisciplinary team approach for the optimization of surgical recovery. 10 , 11 A standard ERAS protocol consisting of preoperative, intraoperative, and postoperative guidelines that help improve patient outcomes, reduce complications, and accelerate patient recovery is a prevalent policy that combines evidence-based perioperative care to accelerate surgical recovery. 12 , 13 Anesthesiologists are involved in many perioperative ERAS elements of patients in terms of evaluation and implementation, e.g., prehabilitation, perioperative multimodal pain management and multimodal antiemetic prophylaxis against postoperative nausea and vomiting (PONV). Prehabilitation is a preoperative approach that prepares patients in advance of elective surgery with conditioning exercises and other interventions to optimize their health. 9 Greater ischemic pain tolerance is well documented after combined moderate- and vigorous-intensity aerobic exercise for healthy individuals 14 , 15 , and acute physical exercise also has hypoalgesic effects. 16 , 17 Physical activity (PA) has an important protective role in the prevention and management of a variety of comorbid health conditions prevalent in older individuals but also has a protective effect against long-term disability and frailty. 18 , 19 PA is also a key element of evidence-based chronic pain management. 20 , 21 In a longitudinal study, lower levels of PA were associated with pain progression in adults aged over 50 years. 22 Recent studies revealed that perioperative PA was associated with improved quality of life and a reduction in the development of postoperative pain. 23 – 26 However, the optimal prescription of perioperative PAs (e.g., type, dose, intensity, and volume) has not been well established. Hayashi et al. 23 conducted a systematic review and meta-analysis to investigate the effects of preoperative exercise on postoperative pain. Among the 28 included studies, the evidence remained inconclusive. For example, the impact of preoperative exercise on postoperative pain might vary across different postoperative time points. However, their conclusions support the use of preoperative exercise to improve pain outcomes following total knee arthroplasty. Therefore, more research is needed to clarify the effects of preoperative exercise on postoperative pain. To enhance the evidence of the hypoalgesic effects of preoperative PA on postoperative pain, this study investigated the relationship between preoperative moderate-to-vigorous-intensity PA and postoperative pain in different types of laparoscopic operations. The results can further our knowledge of the effects of preoperative exercise on postoperative pain. Methods Trial Design and Patients A single-center, prospective control trial (PA patients vs non-PA patients) was conducted at the Ditmanson Medical Foundation, Chia-Yi Christian Hospital, Taiwan. This study was approved by the Ditmanson Medical Foundation Chia-Yi Christian Hospital Ethics Committee. The approval number is CYCHIRB-104042. Participants were enrolled in the study from January 7, 2018, to December 31, 2022. This study aimed to explore the beneficial effects of preoperative PA for 6 to 8 weeks on postoperative pain in patients. The recommendations of the American College of Sport Medicine 27,28 include the use of the World Health Organization 29 for adults to divide enrolled patients into a moderate-intensity group (30–60 min d-1 ( 150 min wk-1)) and a vigorous-intensity group (20–60 min d-1 ( 75 min wk-1)). The severity of postoperative pain was measured prospectively at 1, 4, 7, 10 and 24 hours after surgery. The operations were performed under general anesthesia (GA) with endotracheal intubation. The GA procedures were discussed and decided upon by anesthesiologists together with patients/caregivers at the Pre-Anesthesia Consultation Clinic. The American Society of Anesthesiologists physical status scoring system was used for risk stratification, 30 which includes approaches such as Apfel’s preventive strategy for PONV prophylaxis31,32 and perioperative multimodal pain management in addition to other appropriate elements in ERAS. PONV was defined as nausea, vomiting or retching within 24 hours of surgery. Vomiting and retching were combined into one single item in the statistical analysis. The regimens of perioperative pain management are as follows: (1) Perioperative oral and/or parenteral opioids (2) Perioperative oral and/or parenteral nonopioids (3) Single injection of different types of echo-guided regional analgesia with 0.3 ml/kg 0.167–0.25% levobupivacaine or bupivacaine combined with 2.5 mcg/ml epinephrine postoperatively in the operating room or in the postanaesthesia care unit (PACU) (4) Patient-controlled intravenous (IV) analgesia with fentanyl 0.005 mg/ml together with droperidol 0.0156 mg/ml or only morphine 0.5 mg/ml. (5) Patient-controlled epidural analgesia (fentanyl 0.0013 mg/ml with 0.6 mg/ml bupivacaine or fentanyl 0.0013 mg/ml with 0.6 mg/ml levobupivacaine). (1), (4), and (5) represent the opioid groups, and (2), (3) represent the nonopioid groups. Oral and/or parenteral nonopioids were given postoperatively only when patients complained of pain. All the enrolled patients/caregivers were given written informed consent forms to sign appropriately in the PACU after receiving a detailed description of the study by one of the three well-trained research nurses (or data collectors). Upon obtaining patients’ written informed consent, baseline biopsychosocial characteristics such as sex, age, height, body weight, allergy, addiction and chronic disease history, use of any drugs, number of PONV predictors of Apfel’s simplified risk score (i.e., female sex, history of motion sickness or PONV, nonsmoking, and the use of postoperative opioids), 30,31 and PA intensities were recorded. The methods section has been updated to include a description of the pain measurement scale used, as proposed by Bistolfi et al. 33 The patient’s pain level was assessed via a numeric rating scale, a single-item tool that directly asks the patient about their current perceived pain intensity. Responses were recorded on a 1–10 numeric rating scale. In addition, scores of satisfaction on the Life Scale 34 and the Perceived Stress Scale 35 were also recorded to determine the effects of life satisfaction, perceived life stress and other baseline biopsychosocial characteristics related to postoperative pain. Specifically, the first and/or the second operations on routine elective surgical schedules from Monday to Friday were arranged to prevent patients from sleeping at night, especially when our data collection fell between 7 and 10 hours after surgery. The first operations began at 8:00 AM, working on an 8-hour/day shift schedule, and the research data were collected during the first hour before leaving the PACU and at 4, 7, 10, and 24 hours after the operation in the wards. Enrolled patients aged greater than or equal to 18 years were scheduled to undergo various laparoscopic operations expected to last greater than or equal to 60 minutes under endotracheal intubation (GA). Patients were excluded from the trial for the following conditions: (1) patients later transferred to the intensive care unit (ICU) after surgery; (2) patients whose ASA physical status was ≥4, poorly controlled diabetic mellitus (DM) (HA1c 9, prolonged QTc (male 0.45 sec, female 0.47 sec); (3) patients who were allergic to any opioids (e.g., morphine, fentanyl, pethidine and others); nonopioids (e.g., selective or nonselective NSAIDs and acetaminophen); dexamethasone, granisetron, droperidol, metoclopramide; (4) deaf or unable to speak/understand Taiwanese or Mandarin; and (5) patients who failed to recall or were uncertain about how many days/times they had spent doing moderate or vigorous PA during the study period (recent 6--8 weeks). Anesthesia All patients were asked to fast solid foods for 6 hours, while the intake of clear water and carbohydrates was allowed up to 2 hours before GA induction. Both the PA and non-PA groups received the same anesthetic technique without preanesthetic sedatives in the morning of the operation. GA was induced with thiamylal sodium or propofol and/or midazolam plus fentanyl IV. The airway was secured with endotracheal intubation via an IV muscle relaxant (rocuronium or cisatracurium) followed by maintenance doses. The GA was maintained with oxygen, air, and sevoflurane or desflurane corrected for age and carefully titrated and monitored to depth via an anesthesia depth monitor (Entropy EasyFit Sensor: M1174413, GE Healthcare Finland Oy). This ensured the control of normal sPO2, EKG, blood pressure, heart rate and anesthesia depth. Routine antibiotics were administered IV within 60 minutes prior to the skin incisions were made. Body temperatures were maintained within the normal range by a heating blanket, a convectively active warming device and continuous measurements of core temperature. Perioperative fluid management was balanced between crystalloids and colloids. Residual muscle paralysis was reversed by neostigmine and atropine. Neuromuscular function was assessed with a peripheral nerve stimulator (ECG Leadwire Set: 2106390-002, GE Healthcare Finland Oy), and objective measurement of the train-of-four ratio was performed to determine the best timing for extubation. Patients were then transferred to the PACU with stable hemodynamics. Patients stayed there for 60 minutes, with the first hour of research data collected before being transferred back to their wards. One of our data collectors recorded the following data for each patient at 1, 4, 7, 10, and 24 hours postoperatively: incidence and severity of postoperative nausea, vomiting and retching (using a Likert 5-point scale), pain (using a Likert 5-point scale), dosages of opioids and nonopioids according to the multimodal pain management programs mentioned above, metoclopramide given and other body discomforts. A multimodal approach to PONV was implemented for each patient according to Apfel’s preventive strategy (i.e., the number of antiemetics given was related to the PONV risk factors for patients). 30,31 The antiemetics used were dexamethasone, droperidol and granisetron. When postoperative PONV had occurred, metoclopramide was administered IV every 4 hours as needed. Statistical analysis The data were analyzed via SPSS Version 25.0 and Mplus Version 8.2. Data on demographics, pain scores, PONV frequency and severity or suffering were analyzed via descriptive statistics and frequency distributions. Latent growth models (LGMs) were constructed through structural equation modeling via maximum likelihood estimation. 36 Three unconditional growth models were examined to fit the pain score pattern from the pain score data collected from patients: (1) a linear model with the slope factor fixed at 0, 1, 2, 3, and 4; (2) a quadratic model with the linear slope factor fixed at 0, 1, 2, 3, and 4 and the quadratic slope factor fixed at 0, 1, 4, 9, and 16; and (3) an unspecified curve model with the slope factor loadings at the following settings: (a) wave 1 set to 0; (b) wave 2 set to 1; (c) waves 3, 4, and 5 allowed free estimation.37 Upon obtaining the best-fit model for the pattern, the predictive variables of PA, 9 time-invariant covariates and 15 time-varying covariates, were introduced. The 9 time-invariant covariates were control variables of intercept and slope factors. The 15 time-varying covariates were repeated as exogenous predictors of the pain scores. The pain scores in each wave were assigned three covariates. The predictor, 9 time-invariant variables, 15 time-variant covariates and all variables were allowed to correlate with one another in the model. The performance of model fitting was evaluated via the following goodness-of-fit indices: the χ 2 statistic, root mean square error of approximation (RMSEA), comparative fit index (CFI), standardized root mean square residual (SRMR), Akaike information criterion (AIC), and Bayesian information criterion (BIC). An RMSEA of 0.0 indicates a model with an exact fit 37, and an RMSEA of 0.08 and preferably 0.05 were adopted to indicate good model fit. A CFI 0.90 or preferably 0.95 was adopted to indicate good fitting models. 38 An SRMR 0.05 indicated a good-fitting model, and values as high as 0.08 were considered acceptable 39,40 . AIC and BIC are useful for model selection but do not provide absolute measurements of model fit. The best-fit model had the smallest AIC and BIC values. Results Initially, 2162 laparoscopic surgery patients participated in the study, 562 of whom were excluded because of the following conditions: slept during any of the five waves of data collection (111 patients), refused to answer questions (52 patients), experienced severe nausea or vomiting (144 patients), or experienced severe pain (255 patients). In the end, 1600 patients completed 5 data collections as required in our study. According to Moshagen & Musch, 41 a sample size of 1000 in structural modeling is robust for parameter estimation. These patients underwent different types of laparoscopic surgeries: (a) gynecology and/or oncology (325 patients); (b) genitourinary (424 patients); (c) gastrointestinal (466 patients); and (d) colorectal surgeries (385 patients). The numbers of patients performing moderate- and vigorous-intensity physical activities are shown in Table 1 , and patient stratification followed the recommendations of the American College of Sports Medicine (ACSM) 27 , 28 and the World Health Organization (WHO). 29 Table 1 Numbers of patients who participated in different kinds of moderate and vigorous intensities of physical activity (PA). * Moderate Intensity physical activity (3-5.9 METs) Number of patients Vigorous Intensity physical activity (6–10 METs) Number of patients Walking (2.5-4.0 mph) 38 Fast walking (≥ 4.5 mph) 45 Aerobic dancing, low impact 11 Running, 5.0–6.0 mph 40 Gardening, lawn work, general 6 Climbing briskly up a hill (Vigorous effort) 9 Farming (light to moderate effort) 21 Soccer (causal, general and competitive) 20 Kicking Jianzi 17 Jogging, general 40 Active involvement in games and sports with children 12 Swimming, leisurely, not laps 6 Table tennis, Ping-Pong 16 Swimming, breaststroke, sidestroke 16 General building task 11 Tennis, singles, general 16 Weightlifting (free weight), light to moderate effort 7 Weightlifting (free weight), powerlifting, vigorous effort 10 Swinging arms, hands and squatting (QI Gong) 29 Heavy shoveling/Digging 6 Tai-Chi 48 Bicycling, 10-15.9 mph 6 Gymnastics, general 10 Jogging on a mini-trampoline 5 Calisthenics, light or moderate effort 15 * PA intensity was defined as 3–10 metabolic equivalents (METs) for our patients, since the general public is nonathletics with PA levels usually < 11 METs. Patient characteristics The descriptive statistics of the patients in terms of their characteristics, pain scores, and use of analgesics (opioids or nonopioids) for the 5 assessment periods are shown in Table 2 . Among the 1600 patients, 30.063% were women. The mean BMI was 25.363 (SD = 4.905, range = 14.648–58.582). The mean age was 46.123 years (SD = 15.683, range = 18–92). A history of PONV was found in 20.689% of the patients. Almost half (50.250%) had experienced motion sickness. A smoking habit was found in 7.625% of them. Most (87.500%) patients had received metoclopramide in the wards. The mean life satisfaction score was 4.613 (SD = 1.272, range: 1–7). The mean level of life pressure was 2.557 (SD = .554, range: 1–5). Only 28.750% of our patients had taken moderate-to-vigorous intensity PA on a weekly basis over the period of 6–8 weeks. The means of the perceptions of pain scores at each wave were 5.480 (SD = 1.976, range = 1–10) at wave 1, 5.118 (SD = 1.838, range = 1–10) at wave 2, 4.698 (SD = 1.768, range = 1–10) at wave 3, 4.374 (SD = 1.658, range = 1–10) at wave 4, and 4.278 (SD = 1.534, range = 1–10) at wave 5. A substantial proportion of patients did not take any form of analgesics (82.937%, 46.125%, 50.186%, 58.875%, and 44.375% at waves 1, 2, 3, 4, and 5, respectively). The average frequencies of vomiting and nausea at waves 1, 2, 3, 4, and 5 were 0.281 (SD = 0.677, range: 0–7), 0.455 (SD = 1.344, range: 0–18), 0.459 (SD = 1.412, range: 0–16), 0.300 (SD = 1.043, range: 0–12), and 0.169 (SD = 0.795, range: 0–16), respectively. Table 2 Descriptive data on patient characteristics, pain scores, and analgesic (opioids or nonopioids) use for the 5 assessment periods. Characteristics Patients (N = 1600) Sex (women; man) 481: 1119 BMI 25.363 (4.905) range: 14.648–58.582 Age 46.123 (15.683) range: 18–92 History of PONV (yes: no) 331: 1269 Motion sick (yes: no) 804: 796 Smoking (yes: no) 122: 1478 Anti-emetic drugs (yes: no) 1400: 200 Life satisfaction 4.613 (1.272) range: 1–7 Perceived stress scores 2.557 (0.554) range: 1–5 Physical activities (yes: no) 460: 1140 Pain scores at wave 1 5.480 (1.976) range: 1–10 Pain scores at wave 2 5.118 (1.838) range: 1–10 Pain scores at wave 3 4.698 (1.768) range: 1–10 Pain scores at wave 4 4.374 (1.658) range: 1–10 Pain scores at wave 5 4.278 (1.534) range: 1–10 Analgesics taking at wave 1 (a:b:c) 1327: 27: 246 Analgesics taking at wave 2 (a:b:c) 738: 503: 359 Analgesics taking at wave 3 (a:b:c) 803: 439: 358 Analgesics taking at wave 4 (a:b:c) 942: 352: 306 Analgesics taking at wave 5 (a:b:c) 710: 477: 413 Frequency of vomiting and nausea at wave 1 0.281 (0.677) range: 0–7 Frequency of vomiting and nausea at wave 2 0.455 (1.344) range: 0–18 Frequency of vomiting and nausea at wave 3 0.459 (1.412) range: 0–16 Frequency of vomiting and nausea at wave 4 0.300 (1.043) range: 0–12 Frequency of vomiting and nausea at wave 5 0.169 (0.795) range: 0–16 Note: a: no analgesics taken, b: nonopioid groups; c: opioid groups; the value in parentheses is the standard deviation. Unconditional Growth Model The unconditional linear LGM, quadratic LGM, and unspecified parameter LGM were fitted for the pain scores of 1600 operated patients. The results are presented in Table 3 . The fit indices of the linear model were χ 2 (df) = 104.370(10), p < 0.001, RMSEA = 0.077, CFI = 0.959, SRMR = 0.040, AIC = 18,354.500 and BIC = 18,354.280. The intercept factor was significantly positive (mean = 2.698, p < .001), indicating that the pain scores were significantly different from 0 at baseline. The linear slope was significantly negative (mean = -0.150, p < 0.001), indicating that the instantaneous rate of change was significant at the initial stage. All variances of the initial statuses and linear slopes were statistically significant at α = 0.001, indicating large individual variations in the initial status and slope of the pain scores. The fit indices of the quadratic model were χ 2 (df) = 21.346(6), p = 0.002, RMSEA = 0.040, CFI = 0.993, SRMR = 0.018, AIC = 18,279.473 and BIC = 18,354.761. The intercept factor was significantly positive (mean = 2.755, p < 0.001), indicating that the pain scores were different from 0 at baseline. The linear slope was significantly negative (mean = -0.253, p < 0.001), indicating that there was a significant instantaneous rate of change. The quadratic slope was significantly positive (mean = 0.024, p < .001), reflecting an accelerated rate of increase in the curvature per unit change in time. All variances of the initial statuses, linear slope, and quadratic slope were statistically significant at α = 0.001, indicating individual variations in the initial status, linear slope, and quadratic slope of the pain scores. The fit indices of the unspecified parameter model were χ 2 (df) = 47.664(7), p < 0.001, RMSEA = 0.060, CFI = 0.982, SRMR = 0.028, AIC = 18,303.791 and BIC = 18,373.702. The intercept factor was positive and significant (mean = 2.725, p < 0.001), indicating that pain scores were significantly different from 0 at baseline. The unspecified slope was negative and significant (mean = -0.151, p < 0.001). All the variances of the initial statuses and unspecified slopes were statistically significant at α = 0.001, indicating large individual variations in the initial status and unspecified slopes of the pain scores. On the basis of the above findings, the quadratic model was selected as the best-fit model for describing the trajectory of pain scores. All the fit indices supported this choice as the best model. In addition, the AIC and BIC of the quadratic model were the lowest fitted models. Therefore, the temporal trajectory of pain scores was well explained by the intercept factor, linear slope and quadratic slope. Table 3 Summary of estimates for the unconditional growth model Linear model Quadratic model Unspecified curve model Factor means Intercept 2.698 *** 2.755 *** 2.725 *** Linear − .150 *** − .253 *** − .151 *** quadratic .024 *** Factor variances Intercept .489 *** .602 *** .514 *** Linear .020 *** .198 *** .020 ** Quadratic .010 *** Factor covariances Intercept with linear -0.054 *** -0.177 *** − .059 *** Intercept with quadratic 0.025 *** Linear with quadratic -0.041 *** Fit indices χ 2 (df) 104.37(10) 21.346(6) 47.664(7) P value < .001 .002 < .001 RMSEA .077 .040 .060 CFI .959 .993 .982 SRMR .040 .018 .028 AIC 18354.50 18279.473 18303.791 BIC 18408.28 18354.761 18373.702 Note: **p < 0.01; ***p < 0.001 Predictors of PA After the best analytical model was chosen, the PA variable was introduced to predict its intercept factor, linear slope, and quadratic slope. The 9 time-invariant covariates (drug group, sex, age, BMI, history of PONV, motion sickness, smoking, life satisfaction, and perceived life stress) were added to serve as control variables for the intercept factor, linear slope, and quadratic slope. The 15 time-variant covariates (i.e., the analgesics taken at waves 1 to 5 and the frequency of vomiting and nausea at waves 1 to 5) were added to the model to control for pain perceptions at each wave (Fig. 1 ). The conditional model showed an excellent fit to the data (χ 2 (df) = 152.619 (86), p < 0.001, RMSEA = 0.022, CFI = 0.976, SRMR = 0.033, AIC = 17,947.735, BIC = 18,264.758). Here, PA was negatively and significantly associated with the intercept (b = -0.579, p < 0.001) (Table 4 ), positively and significantly associated with the linear slope (b = 0.157, p < 0.001) (Table 4 ), and negatively and significantly associated with the quadratic slope (b = -0.031, p < 0.001) (Table 4 ). The results indicated that the pain scores of those who had \(\:\ge\:\) 150 hours of moderate PA/week or \(\:\ge\:\) 75 hours of vigorous PA/week for at least 6–8 weeks before the operation were significantly lower than those of non-PA patients. The mean pain score for PA patients tended to increase, and the growth function decreased over time. Two other time-invariant covariates and time-variant covariates were used as control variables; hence, no further explanations were needed for them. The summaries of the control variables are presented in Tables 4 and 5 . Table 4 Summary of estimates for time-invariant covariates Intercept Linear slope Quadratic slope Time-invariant covariates Drug control group .084 − .071 .022 Sex − .053 .099* − .020* Age − .001 .001 < .001 BMI .001 .003 < .001 History of PONV .062 − .068 .015 Motion sickness .039 − .036 .007 Smoking .080 − .127 + a .037* Life satisfaction score − .043* .043** − .01** Perceived stress score .017 − .081* .015 + b Exercise − .579*** .157*** -0.031*** Note: * p < 0.05, **p < 0.01, ***p < 0.001. +a = .087, +b = .085 Table 5 Summary of estimates for time-variant covariates. Pain_1 Pain_2 Pain_3 Pain_4 Pain_5 Time-variant covariates Contrast: No use of analgesic Nonopioids at wave 1 − .274 + c Opioids at wave 1 .353 *** Frequency of vomiting and nausea at wave 1 .121 *** Nonopioids at wave 2 .048 Opioids at wave 2 .192 *** Frequency of vomiting and nausea at wave 2 .054 *** Nonopioids at wave 3 .0.39 Opioids at wave 3 .154 *** Frequency of vomiting and nausea at wave 3 .018 Nonopioids at wave 4 − .024 Opioids at wave 4 .245*** Frequency of vomiting and nausea at wave 4 .045** Nonopioids at wave 5 .070* Opioids at wave 5 .312*** Frequency of vomiting and nausea at wave 5 .070*** Note: **p < 0.01; ***p < 0.001; +c = 0.081. To better visualize the effects of moderate- and vigorous-intensity PAs compared with those of controls, the curve disparity between the two groups was plotted. In Fig. 2 , all control variables were fixed as constants. The values of non-PA were set to 0 for all waves, and the values of PA were set to 1 for all waves. The estimated curve formula was − 0.579 + 0.157(PA) -0.031 (PA) 2 . Figure 2 shows lower pain scores in the PA group (i.e., 0.597 less) than in the non-PA group at wave 1. With time, the difference between these two groups progressively decreased (to 0.453 less at wave 2, 0.389 less at wave 3, 0.387 less at wave 4, and the gap increased to 0.447 less at wave 5). Discussion Preoperative multimodal prehabilitation programs generally include exercise, nutritional optimization, and counseling components for biopsychosocial well-being and are believed to play important roles in reducing postoperative complications, improving functional capacity and reducing the length of hospital stay in patients with lung cancer, 42 colorectal cancer 43 , 44 and major abdominal surgery. 45 There is increasing evidence that preoperative exercise therapy in various surgical specialties is effective and well tolerated. 46 Future improvements in standards of care and optimal preoperative preparation should focus not only on the surgical team/hospital organization but also on incorporating the active involvement of patients. Inadequate control of acute postoperative pain remains a widespread, unresolved health-care problem that is accompanied by an array of negative consequences. 1 – 4 Moreover, early postoperative pain appears to trigger persistent postsurgical pain that may last for months after surgery in a good portion of patients. 47 Nevertheless, acute postoperative pain represents a clinical challenge that has not yet been well addressed. 1 To prevent such progression of postoperative pain from acute to chronic, more aggressive analgesics, anesthetics and other measures were used to reduce the incidence and intensity of acute pain immediately after different types of surgery. The goal of this study was to assess the associations between preoperative PA and postoperative pain for different types of laparoscopic surgery. The results indicated that preoperative PA was associated with a reduction in postoperative pain over a wide range of laparoscopic surgeries. This result is in line with the findings of Hayashi et al. in 2023. 23 Their study performed a meta-analysis on the postoperative pain reduction associated with total knee arthroplasty (TKA) in preoperative PA patients from 23 research articles. The studies concluded that preoperative exercise reduced pain in patients who underwent TKA within 2 months, and moderate pain reduction was observed 3 to 5 months after TKA. This study is the first to characterize trajectory changes at different postoperative time points (1, 4, 7, 10, and 24 hours) via a latent curve model for comparing postoperative pain between PA patients and non-PA patients after controlling for confounding biopsychosocial variables such as life satisfaction and life stress. Specifically, patients who performed moderate-to-vigorous-intensity PA preoperatively showed greater pain tolerance than controls at all postoperative time points. Similarly, the quadratic curve of the pain scores was significantly different. At 1 and 4 hours after the operation, pain perception in the PA group was lower than that at 7 and 10 hours. These phenomena could be due to the decline in the effects of the GA/analgesic drugs, which lingered to cover the periods of 1 and 4 hours after the operation. Further comprehensive research is needed to explain this phenomenon. The key findings suggest the implementation of PA in multimodal prehabilitation programs in ERAS protocols for laparoscopic surgery patients, which may significantly reduce postoperative pain suffering and the side effects of analgesics. Logistical considerations and the degree of patient adherence represent barriers to effective prehabilitation programs. Barriers include those patients not able to attend physical training sessions or not willing to follow the procedures of the programs due to language restrictions, psychological disorders, lack of traffic facilities, training institutions, qualified sport physicians, physiotherapists, dietitians, geographical obstructions, patient lifestyles (inactivity, obesity, dietary patterns, and smoking behavior), and cultural taboo. These factors are particularly important in low- and middle-income regions or developing countries because of financial considerations, inadequate institutions and cost effectiveness. Therefore, the study suggests that 6 to 8 weeks of preoperative moderate-to-vigorous intensity PA for patients to perform at home or in some nearby environment that they enjoy is more pragmatic than receiving exercise and PA programs (such as achieving the prescribed METs*min*wk-1, lactate threshold test, peak oxygen uptake estimation, which requires skilled technicians, expensive equipment, and is time consuming—all of which are usually impractical) to improve preoperative cardiopulmonary physiologic reserve and reduce laparoscopic postoperative pain (our new and unique key finding). Certain limitations should be taken into account in the findings: Owing to its nature, this study was performed nonblinded and focused only on different types of laparoscopic operations. Patients who were < 18 y/o, had an ASA physical status ≥ 4, had poorly controlled DM, had prolonged QTc, and were transferred to the ICU postoperatively were excluded. Further research is necessary to include these patients to consolidate this finding. It is unclear whether PA intensity 10 METs alone for 6–8 weeks preoperatively has the same effects. Future research is needed to more accurately delineate the optimal prescription of preoperative PAs (e.g., type, dose, intensity, and volume) for specific types of laparoscopic operations and other types of nonlaparoscopic operations. Conclusions This study revealed that patients with 6–8 weeks of preoperative moderate-intensity physical activity had less postoperative pain than non-PA patients did. Moreover, this study is the first to characterize the trajectory changes at different postoperative time points (1, 4, 7, 10, and 24 hours) in a latent curve model to compare the degree of postoperative pain between patients who underwent preoperative moderate-to-vigorous intensity PA and non-PA patients. The results revealed that preoperative PA patients had greater pain tolerance than non-PA patients did at all 24-hour postoperative time points. There is no one-size-fits-all standard protocol for preoperative pain management. This study revealed that preoperative moderate-intensity physical activity may help reduce postoperative pain. Therefore, a physician should first assess a patient’s physical and mental health conditions to determine whether the patient is suitable for engaging in moderate-intensity exercise. If deemed suitable, the specific type of exercise can then be discussed. Common preoperative exercises include aerobic exercises and strength training, with the intensity tailored to the patient’s current physical fitness level. Engaging in such exercises for 6 to 8 weeks can help improve physical fitness. Additionally, patients may choose to exercise at home or in a nearby safe exercise facility. Abbreviations ACSM: American College of Sports Medicine AIC: Akaike information criterion ASA: American Society of Anesthesiologists BIC: Bayesian information criterion BMI: body mass index CFI: comparative fit index DM: diabetes mellitus ERAS: enhanced recovery after surgery GA: general anesthesia ICU: intensive care unit LGM: Latent growth model PA: physical activity PACU: postanesthesia care unit PONV: postoperative nausea and vomiting RMSEA: root mean square error of approximation SD: standard deviation SRMR: standardized root mean square residual TKA: knee arthroplasty Declarations Ethics approval and consent to participate This study with an informed consent form was approved by the Institutional Board of Ditmanson Medical Foundation Chia-Yi Christian Hospital. The approval number is CYCH-IRB -10402. Human Ethics and Consent to Participate The human ethics was approved by the Institutional Board of Ditmanson Medical Foundation Chia-Yi Christian Hospital. The approval number is CYCH-IRB -10402. All participants agreed to participate in the study and signed the informed consent form. Clinical Trial Number Not applicable. Consent for publication Not applicable. Availability of data and materials The data can be obtained upon request from the corresponding author. Competing interests The authors declare that they have no conflicts of interest. Funding The study received no funding. Authors' contributions Hong-Wun Chen and Wui-Chiu Mui : Conceptualization, statistical analysis, and writing – review & editing of the manuscript. Li-An Liao and Chih-Han Chan : Participated in the study design, critical review, and data collection. All authors provided final approval for publication of the manuscript and are responsible for the integrity of the study. Acknowledgments All participants in the study were highly appreciated. References Paladini A, Rawal N, Coca Martinez M, Trifa M, Montero A, Pergolizzi Jr J, et al. 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Cutoff criteria for fit indices in covariance structure analysis: Conventional criteria versus new alternatives. Struct Equ Modeling. 1999;6(1):1-55. doi:10.1080/10705519909540118. Diamantopoulos A, Siguaw JA. Introducing LISREL: A guide for the uninitiated. Thousand Oaks, CA: Sage; 2000. Thakkar JJ. Structural equation modeling: Application for research and practice. Springer; 2020. Moshagen M, Musch J. Sample size requirements of the robust weighted least squares estimator. Methodology. 2014;10(2):60-70. doi:10.1027/1614-2241/a000068. Steffens D, Beckenkamp PR, Hancock M, Solomon M, Young J. Preoperative exercise halves the postoperative complication rate in patients with lung cancer: A systematic review of the effect of exercise on complications, length of stay and quality of life in patients with cancer. Br J Sports Med. 2018;52(5):344-352. doi:10.1136/bjsports-2017-098032. Li C, Carli F, Lee L, Charlebois P, Stein B, Liberman AS, et al. Impact of a trimodal prehabilitation program on functional recovery after colorectal cancer surgery: A pilot study. Surg Endosc. 2013;27(4):1072-1082. doi:10.1007/s00464-012-2560-5. Rooijen SV, Carli F, Dalton S, Thomas G, Bojesen R, Guen ML, et al. Multimodal prehabilitation in colorectal cancer patients to improve functional capacity and reduce postoperative complications: the first international randomized controlled trial for multimodal prehabilitation. BMC Cancer. 2019;19(1):98. doi:10.1186/s12885-018-5232-6. Barberan-Garcia A, Ubré M, Roca J, Lacy AM, Burgos F, Risco R, et al. Personalized prehabilitation in high-risk patients undergoing elective major abdominal surgery: A randomized blinded controlled trial. Ann Surg. 2018;267(1):50-56. doi:10.1097/SLA.0000000000002293. Topal B, Smelt HJM, Van Helden EV, Celik A, Verseveld M, Smeenk F, et al. Utility of preoperative exercise therapy in reducing postoperative morbidity after surgery: A clinical overview of current evidence. Expert Rev Cardiovasc Ther. 2019;17(6):395-412. doi:10.1080/14779072.2019.1625771. Richebé P, Capdevila X, Rivat C. Persistent postsurgical pain: Pathophysiology and preventative pharmacologic considerations. Anesthesiology. 2018;129(3):590-607. doi:10.1097/ALN.0000000000002238. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6497422","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":453829713,"identity":"9c76d25c-9048-4279-b493-2cf9a7dc3089","order_by":0,"name":"Hong-Wun Chen","email":"","orcid":"","institution":"Chaoyang University of Technology","correspondingAuthor":false,"prefix":"","firstName":"Hong-Wun","middleName":"","lastName":"Chen","suffix":""},{"id":453829714,"identity":"408eba8c-41c6-4cfc-be14-4b597393f216","order_by":1,"name":"Li-An Liao","email":"","orcid":"","institution":"Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Li-An","middleName":"","lastName":"Liao","suffix":""},{"id":453829715,"identity":"66ec16ef-1024-4c52-8180-910d820267b8","order_by":2,"name":"Chih-Han Chan","email":"","orcid":"","institution":"Nanhua University","correspondingAuthor":false,"prefix":"","firstName":"Chih-Han","middleName":"","lastName":"Chan","suffix":""},{"id":453829716,"identity":"64388014-306f-435a-94b5-4baee564e52a","order_by":3,"name":"Wui-Chiu Mui","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAt0lEQVRIiWNgGAWjYPACCTkGBh4StRiTrIUhsYFoLQbHTyc+utlmkb7h+NmDDz4w2MnpNhDSciZ3s3Fum0TuhjN5yYYzGJKNzQ4Q0nIgd5s0WMuBHDNpHoYDidsIajn/dvtvoJZ0g/NviNVyI3cbM1BLgsENYm2RvPF2s3TOOQnDmTfeGBvOMCDCL3znczd+zimrk+c7n2P44EOFnRxBLQoHUBgGBJSDgHwDOmMUjIJRMApGAToAAHjsRSq20HQ1AAAAAElFTkSuQmCC","orcid":"","institution":"Ditmanson Medical Foundation ChiaYi Christian Hospital","correspondingAuthor":true,"prefix":"","firstName":"Wui-Chiu","middleName":"","lastName":"Mui","suffix":""}],"badges":[],"createdAt":"2025-04-21 15:38:25","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6497422/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6497422/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82581629,"identity":"d7416811-9807-4030-a765-d5620defd7f5","added_by":"auto","created_at":"2025-05-13 06:38:53","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":119357,"visible":true,"origin":"","legend":"\u003cp\u003eConditional quadratic model of the study\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6497422/v1/5e283ffe08520edf9efd5d08.jpg"},{"id":82581572,"identity":"7f3824de-99d8-4158-8206-b3929ab6dc95","added_by":"auto","created_at":"2025-05-13 06:38:52","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":27147,"visible":true,"origin":"","legend":"\u003cp\u003eDifferences in the estimated pain scores on the quadratic curve between the physical activity and nonphysical activity groups\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6497422/v1/0f57e00fa115f4d813a23de8.jpg"},{"id":83026019,"identity":"9004d1a2-a9c0-4656-815d-03381344fc91","added_by":"auto","created_at":"2025-05-19 08:24:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1076742,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6497422/v1/c81dad29-0cde-46cc-8c00-85d60768517f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eEffects of Preoperative Exercises on Reducing Postlaparoscopic Operation Pain in Adults\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eDespite millions of surgeries performed every year around the world, postoperative pain remains prevalent and is often addressed with inadequate or suboptimal treatments.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Despite the increasing knowledge of the mechanisms of incisional inflammation, transmission of nociception signals, and peripheral and central sensitization,\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e and in addition to the current advancements in pharmacology, pharmaceutics, techniques and equipment, the US Institute of Medicine revealed that 80% of patients receiving surgery have reported postoperative pain,\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e with 88% of them at moderate, severe, or extreme levels.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Many studies have aimed to address how to reduce postoperative pain. For example, pain can be managed through analgesic medications, but nearly 80% of patients experience some adverse effects.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Additionally, many clinicians face uncertainty about optimizing the use of analgesics, as pain is inherently influenced by individualized factors.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e In addition to the use of analgesic medications, some studies have suggested that physical activity can prevent pain and alleviate it after injury.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Therefore, assessing patients\u0026rsquo; health status before surgery and implementing exercise programs to enhance their overall health and physical fitness may help reduce postoperative discomfort and facilitate faster recovery.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eEnhanced recovery after surgery (ERAS) is an evidence-based, patient-centered, multidisciplinary team approach for the optimization of surgical recovery.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e A standard ERAS protocol consisting of preoperative, intraoperative, and postoperative guidelines that help improve patient outcomes, reduce complications, and accelerate patient recovery is a prevalent policy that combines evidence-based perioperative care to accelerate surgical recovery.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Anesthesiologists are involved in many perioperative ERAS elements of patients in terms of evaluation and implementation, e.g., prehabilitation, perioperative multimodal pain management and multimodal antiemetic prophylaxis against postoperative nausea and vomiting (PONV).\u003c/p\u003e \u003cp\u003ePrehabilitation is a preoperative approach that prepares patients in advance of elective surgery with conditioning exercises and other interventions to optimize their health.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Greater ischemic pain tolerance is well documented after combined moderate- and vigorous-intensity aerobic exercise for healthy individuals\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003c/sup\u003e and acute physical exercise also has hypoalgesic effects.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Physical activity (PA) has an important protective role in the prevention and management of a variety of comorbid health conditions prevalent in older individuals but also has a protective effect against long-term disability and frailty.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e PA is also a key element of evidence-based chronic pain management.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e In a longitudinal study, lower levels of PA were associated with pain progression in adults aged over 50 years.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e Recent studies revealed that perioperative PA was associated with improved quality of life and a reduction in the development of postoperative pain.\u003csup\u003e\u003cspan additionalcitationids=\"CR24 CR25\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e However, the optimal prescription of perioperative PAs (e.g., type, dose, intensity, and volume) has not been well established. Hayashi et al.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e conducted a systematic review and meta-analysis to investigate the effects of preoperative exercise on postoperative pain. Among the 28 included studies, the evidence remained inconclusive. For example, the impact of preoperative exercise on postoperative pain might vary across different postoperative time points. However, their conclusions support the use of preoperative exercise to improve pain outcomes following total knee arthroplasty. Therefore, more research is needed to clarify the effects of preoperative exercise on postoperative pain. To enhance the evidence of the hypoalgesic effects of preoperative PA on postoperative pain, this study investigated the relationship between preoperative moderate-to-vigorous-intensity PA and postoperative pain in different types of laparoscopic operations. The results can further our knowledge of the effects of preoperative exercise on postoperative pain.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eTrial Design and Patients\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA single-center, prospective control trial (PA patients vs non-PA patients) was conducted at the Ditmanson Medical Foundation, Chia-Yi Christian Hospital, Taiwan. This study was approved by the Ditmanson Medical Foundation Chia-Yi Christian Hospital Ethics Committee. The approval number is CYCHIRB-104042. Participants were enrolled in the study from January 7, 2018, to December 31, 2022.\u003c/p\u003e\n\u003cp\u003eThis study aimed to explore the beneficial effects of preoperative PA for 6 to 8 weeks on postoperative pain in patients. The recommendations of the American College of Sport Medicine\u003csup\u003e27,28\u0026nbsp;\u003c/sup\u003einclude the use of the World Health Organization\u003csup\u003e29\u003c/sup\u003e for adults to divide enrolled patients into a moderate-intensity group (30–60 min\u003cimg width=\"3\" height=\"15\" src=\"data:image/png;base64,R0lGODlhBQAXAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAAACgAFAAUAhAAAAFlZiltailpZinMdHXEeHXciImdmnmZmiGTG/2XE/2TE/27M/3Tg/4EiIbuIZsKKWcKKWsCKWd2eZv//xv//xP//zP//4AECAwECAwECAwECAwECAwECAwECAwECAwUTIAABAVBFhaBck3M0FVAMC2DbIQA7\" alt=\"image\"\u003ed-1 (\u003cimg width=\"10\" height=\"15\" src=\"data:image/png;base64,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\" alt=\"image\"\u003e150 min\u003cimg width=\"3\" height=\"15\" src=\"data:image/png;base64,R0lGODlhBQAXAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAAACgAFAAUAhAAAAFlZiltailpZinMdHXEeHXciImdmnmZmiGTG/2XE/2TE/27M/3Tg/4EiIbuIZsKKWcKKWsCKWd2eZv//xv//xP//zP//4AECAwECAwECAwECAwECAwECAwECAwECAwUTIAABAVBFhaBck3M0FVAMC2DbIQA7\" alt=\"image\"\u003ewk-1)) and a vigorous-intensity group (20–60 min\u003cimg width=\"3\" height=\"15\" src=\"data:image/png;base64,R0lGODlhBQAXAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAAACgAFAAUAhAAAAFlZiltailpZinMdHXEeHXciImdmnmZmiGTG/2XE/2TE/27M/3Tg/4EiIbuIZsKKWcKKWsCKWd2eZv//xv//xP//zP//4AECAwECAwECAwECAwECAwECAwECAwECAwUTIAABAVBFhaBck3M0FVAMC2DbIQA7\" alt=\"image\"\u003ed-1 (\u003cimg width=\"10\" height=\"15\" src=\"data:image/png;base64,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\" alt=\"image\"\u003e75 min\u003cimg width=\"3\" height=\"15\" src=\"data:image/png;base64,R0lGODlhBQAXAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAAACgAFAAUAhAAAAFlZiltailpZinMdHXEeHXciImdmnmZmiGTG/2XE/2TE/27M/3Tg/4EiIbuIZsKKWcKKWsCKWd2eZv//xv//xP//zP//4AECAwECAwECAwECAwECAwECAwECAwECAwUTIAABAVBFhaBck3M0FVAMC2DbIQA7\" alt=\"image\"\u003ewk-1)). The severity of postoperative pain was measured prospectively at 1, 4, 7, 10 and 24 hours after surgery. The operations were performed under general anesthesia (GA) with endotracheal intubation. The GA procedures were discussed and decided upon by anesthesiologists together with patients/caregivers at the Pre-Anesthesia Consultation Clinic. The American Society of Anesthesiologists physical status scoring system was used for risk stratification,\u003csup\u003e30\u003c/sup\u003e which includes approaches such as Apfel’s preventive strategy for PONV \u003csup\u003eprophylaxis31,32 and\u003c/sup\u003e perioperative multimodal pain management in addition to other appropriate elements in ERAS. PONV was defined as nausea, vomiting or retching within 24 hours of surgery. Vomiting and retching were combined into one single item in the statistical analysis.\u003c/p\u003e\n\u003cp\u003eThe regimens of perioperative pain management are as follows:\u003c/p\u003e\n\u003cp\u003e(1) Perioperative oral and/or parenteral opioids\u003c/p\u003e\n\u003cp\u003e(2) Perioperative oral and/or parenteral nonopioids\u003c/p\u003e\n\u003cp\u003e(3) Single injection of different types of echo-guided regional analgesia with 0.3 ml/kg 0.167–0.25% levobupivacaine or bupivacaine combined with 2.5 mcg/ml epinephrine postoperatively in the operating room or in the postanaesthesia care unit (PACU)\u003c/p\u003e\n\u003cp\u003e(4) Patient-controlled intravenous (IV) analgesia with fentanyl 0.005 mg/ml together with droperidol 0.0156 mg/ml or only morphine 0.5 mg/ml.\u003c/p\u003e\n\u003cp\u003e(5) Patient-controlled epidural analgesia (fentanyl 0.0013 mg/ml with 0.6 mg/ml bupivacaine or fentanyl 0.0013 mg/ml with 0.6 mg/ml levobupivacaine).\u003c/p\u003e\n\u003cp\u003e(1), (4), and (5) represent the opioid groups, and (2), (3) represent the nonopioid groups.\u003c/p\u003e\n\u003cp\u003eOral and/or parenteral nonopioids were given postoperatively only when patients complained of pain.\u003c/p\u003e\n\u003cp\u003eAll the enrolled patients/caregivers were given written informed consent forms to sign appropriately in the PACU after receiving a detailed description of the study by one of the three well-trained research nurses (or data collectors).\u003c/p\u003e\n\u003cp\u003eUpon obtaining patients’ written informed consent, baseline biopsychosocial characteristics such as sex, age, height, body weight, allergy, addiction and chronic disease history, use of any drugs, number of PONV predictors of Apfel’s simplified risk score (i.e., female sex, history of motion sickness or PONV, nonsmoking, and the use of postoperative opioids),\u003csup\u003e30,31\u003c/sup\u003e and PA intensities were recorded. The methods section has been updated to include a description of the pain measurement scale used, as proposed by Bistolfi et al.\u003csup\u003e33\u003c/sup\u003e The patient’s pain level was assessed via a numeric rating scale, a single-item tool that directly asks the patient about their current perceived pain intensity. Responses were recorded on a 1–10 numeric rating scale. In addition, scores of satisfaction on the Life Scale\u003csup\u003e34\u003c/sup\u003e and the Perceived Stress Scale\u003csup\u003e35\u003c/sup\u003e were also recorded to determine the effects of life satisfaction, perceived life stress and other baseline biopsychosocial characteristics related to postoperative pain.\u003c/p\u003e\n\u003cp\u003eSpecifically, the first and/or the second operations on routine elective surgical schedules from Monday to Friday were arranged to prevent patients from sleeping at night, especially when our data collection fell between 7 and 10 hours after surgery. The first operations began at 8:00 AM, working on an 8-hour/day shift schedule, and the research data were collected during the first hour before leaving the PACU and at 4, 7, 10, and 24 hours after the operation in the wards.\u003c/p\u003e\n\u003cp\u003eEnrolled patients aged greater than or equal to 18 years were scheduled to undergo various laparoscopic operations expected to last greater than or equal to 60 minutes under endotracheal intubation (GA). Patients were excluded from the trial for the following conditions: (1) patients later transferred to the intensive care unit (ICU) after surgery; (2) patients whose ASA physical status was ≥4, poorly controlled diabetic mellitus (DM) (HA1c \u003cimg width=\"10\" height=\"15\" src=\"data:image/png;base64,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\" alt=\"image\"\u003e9, prolonged QTc (male \u003cimg width=\"10\" height=\"15\" src=\"data:image/png;base64,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\" alt=\"image\"\u003e0.45 sec, female \u003cimg width=\"10\" height=\"15\" src=\"data:image/png;base64,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\" alt=\"image\"\u003e0.47 sec); (3) patients who were allergic to any opioids (e.g., morphine, fentanyl, pethidine and others); nonopioids (e.g., selective or nonselective NSAIDs and acetaminophen); dexamethasone, granisetron, droperidol, metoclopramide; (4) deaf or unable to speak/understand Taiwanese or Mandarin; and (5) patients who failed to recall or were uncertain about how many days/times they had spent doing moderate or vigorous PA during the study period (recent 6--8 weeks).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnesthesia\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients were\u0026nbsp;asked to\u0026nbsp;fast solid foods for 6 hours, while the intake of clear water and carbohydrates was allowed up to 2 hours before GA induction. Both the PA and non-PA groups received the same anesthetic technique without preanesthetic sedatives\u0026nbsp;in\u0026nbsp;the morning of the operation. GA was induced with thiamylal sodium or propofol and/or midazolam plus fentanyl IV. The airway was secured with endotracheal intubation via an IV muscle relaxant (rocuronium or cisatracurium) followed by maintenance doses. The GA was maintained with\u0026nbsp;oxygen, air, and sevoflurane or desflurane corrected for age and carefully titrated and monitored to depth via an anesthesia depth monitor (Entropy EasyFit Sensor: M1174413, GE Healthcare Finland Oy). This ensured the control of normal sPO2, EKG, blood pressure, heart rate and anesthesia depth. Routine antibiotics were administered IV within 60 minutes\u0026nbsp;prior to the skin incisions were made. Body temperatures were maintained within the normal range by a heating blanket, a convectively active warming device and continuous measurements of core temperature. Perioperative fluid management was balanced between crystalloids and colloids. Residual muscle paralysis was reversed by neostigmine and atropine. Neuromuscular function was assessed with a peripheral nerve stimulator (ECG Leadwire Set: 2106390-002, GE Healthcare Finland Oy), and objective measurement of the train-of-four ratio was performed to determine the best timing for extubation. Patients were then transferred to the PACU with stable hemodynamics. Patients stayed there for 60 minutes, with the first hour of research data collected before being transferred back to their wards.\u003c/p\u003e\n\u003cp\u003eOne of our data collectors recorded the following data for each patient at 1, 4, 7, 10, and 24 hours postoperatively: incidence and severity of postoperative nausea, vomiting and retching (using\u0026nbsp;a\u0026nbsp;Likert 5-point\u0026nbsp;scale), pain (using\u0026nbsp;a\u0026nbsp;Likert 5-point\u0026nbsp;scale), dosages of opioids and nonopioids according to the multimodal pain management programs mentioned above, metoclopramide given and other body discomforts.\u003c/p\u003e\n\u003cp\u003eA multimodal approach to PONV was implemented for each patient according to Apfel’s preventive strategy (i.e., the number of antiemetics given was related to the PONV risk factors for patients).\u003csup\u003e30,31\u003c/sup\u003e The antiemetics used were dexamethasone, droperidol and granisetron. When postoperative PONV had occurred, metoclopramide was administered IV every 4 hours as needed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data were analyzed via SPSS Version 25.0 and Mplus Version 8.2. Data on demographics, pain scores, PONV frequency and severity or suffering were analyzed via descriptive statistics and frequency distributions.\u003c/p\u003e\n\u003cp\u003eLatent growth models (LGMs) were constructed through structural equation modeling via maximum likelihood estimation.\u003csup\u003e36\u003c/sup\u003e Three unconditional growth models\u0026nbsp;were\u0026nbsp;examined\u0026nbsp;to fit the pain score pattern from the pain score data collected from patients: (1) a linear model with the slope factor fixed at 0,\u0026nbsp;1, 2, 3, and 4; (2) a quadratic model with the linear slope factor fixed at 0, 1, 2, 3, and 4 and the quadratic slope factor fixed at 0, 1, 4, 9, and 16; and (3) an unspecified curve model with the slope factor loadings at the following settings: (a) wave 1 set to 0; (b) wave 2 set to 1; (c) waves 3, 4, and 5 allowed\u0026nbsp;free estimation.37 Upon obtaining the best-fit model for the pattern,\u0026nbsp;the predictive variables of PA, 9 time-invariant covariates and 15 time-varying covariates,\u0026nbsp;were introduced. The 9 time-invariant covariates were control variables of intercept and slope factors. The 15 time-varying covariates were repeated as exogenous predictors of the pain scores. The pain scores in each wave were assigned three covariates.\u0026nbsp;The predictor, 9 time-invariant variables, 15 time-variant covariates and all variables were allowed to correlate with one another\u0026nbsp;in the model.\u003c/p\u003e\n\u003cp\u003eThe performance of model fitting was evaluated via the following goodness-of-fit indices: the χ\u003csup\u003e2\u003c/sup\u003e statistic, root mean square error of approximation (RMSEA), comparative fit index (CFI), standardized root mean square residual (SRMR), Akaike information criterion (AIC), and Bayesian information criterion (BIC). An RMSEA of 0.0 indicates a model with an exact fit\u003csup\u003e37,\u003c/sup\u003e and an RMSEA of\u0026nbsp;\u003cimg width=\"12\" height=\"24\" src=\"data:image/png;base64,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\" alt=\"image\"\u003e0.08 and preferably\u0026nbsp;\u003cimg width=\"12\" height=\"24\" src=\"data:image/png;base64,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\" alt=\"image\"\u003e0.05\u0026nbsp;were\u0026nbsp;adopted to indicate good model fit. A CFI\u0026nbsp;\u003cimg width=\"12\" height=\"24\" src=\"data:image/png;base64,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\" alt=\"image\"\u003e0.90 or preferably\u0026nbsp;\u003cimg width=\"12\" height=\"24\" src=\"data:image/png;base64,R0lGODlhEgAkAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAAACwASABIAhwAAAAAAAAEKFBEAAA0UHAgAAAAADAAAFQoAAAABFhYCAAACFhMVOBMMLx8hOwA3agQufB88dwAmfwAudwAqcwArcxJNegBIgzIUADkfBSMiNCkrLjstQiVMcjVXkTdgh0QAAFACAFYxDUg2JFpOQFVKQFBKUERRZktVc0pZcUpjelV8mGIdEmM7FG4iAG4hAHMrAGNLLX9qa25xdmZ8g3uRqWyHvHem2XGizW6i1W+i1W6i1Gyr4Wq3+4VNTJNzToB8Zol5coCOmoGFiJGSsZ6mmpyvppulqIypwIu704ms1Y+z4YDI95PB85nI/4LC6L+CRr2LTrSHWbGXe7WQaLafmqKViK6birygdKuurKO03qC8wrnK77rh4MBdKsh/JsVoPMR0TsaCN8SAO9KQdNSeadGiatSibsGmk8C/qci50NTAqdzTu9XZzNfVw8bQ0dHAwNDa/tXm28jq99bz9dX//93//87//9T9/9n1//+AO/+VVfWmdeK6lOu4k+a9p//Vm+LGqvjPpv/mnf/gqP/qv//urv//3f/xzP//2/f//+T//+L//+/1/+r//+n///Ho/+H/////7v//6+v/////6v///wECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwi5AAEIHEiwIEE3AOgYXAjgUKA/VU4A4MGQIB8ALDSsQCIEwIOKA62smTJCQIckXUACIAQAA4AhaYAAgACgkco+UURwQFFDCxeVAH6goULCw41HKlvICDLDxhKGAwBcwRKjQQQAcQwiEiQlAwEVW4ws3AMghIkjWYrQ+ADgDkMyPhxYwIEnEkg2cNQMtAQyEYA8QAmaAVAAQADDiA8fpgDA0aQyLxAEmEy5coIKOigBOANAQeLPhys0DggAOw==\" alt=\"image\"\u003e0.95\u0026nbsp;was\u0026nbsp;adopted to indicate good fitting models.\u003csup\u003e38\u003c/sup\u003e An SRMR\u0026nbsp;\u003cimg width=\"12\" height=\"24\" src=\"data:image/png;base64,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\" alt=\"image\"\u003e0.05 indicated a good-fitting model, and values as high as 0.08 were considered acceptable\u003csup\u003e39,40\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eAIC and BIC are useful for model selection but do not provide absolute measurements of model fit. The best-fit model had the smallest AIC and BIC values.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eInitially, 2162 laparoscopic surgery patients participated in the study, 562 of whom were excluded because of the following conditions: slept during any of the five waves of data collection (111 patients), refused to answer questions (52 patients), experienced severe nausea or vomiting (144 patients), or experienced severe pain (255 patients). In the end, 1600 patients completed 5 data collections as required in our study. According to Moshagen \u0026amp; Musch,\u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e a sample size of 1000 in structural modeling is robust for parameter estimation.\u003c/p\u003e \u003cp\u003eThese patients underwent different types of laparoscopic surgeries: (a) gynecology and/or oncology (325 patients); (b) genitourinary (424 patients); (c) gastrointestinal (466 patients); and (d) colorectal surgeries (385 patients).\u003c/p\u003e \u003cp\u003eThe numbers of patients performing moderate- and vigorous-intensity physical activities are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, and patient stratification followed the recommendations of the American College of Sports Medicine (ACSM) \u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e and the World Health Organization (WHO).\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eNumbers of patients who participated in different kinds of moderate and vigorous intensities of physical activity (PA). *\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate Intensity physical activity (3-5.9 METs)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of patients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVigorous Intensity physical activity (6\u0026ndash;10 METs)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNumber of patients\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWalking (2.5-4.0 mph)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFast walking (\u0026ge;\u0026thinsp;4.5 mph)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAerobic dancing, low impact\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRunning, 5.0\u0026ndash;6.0 mph\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGardening, lawn work, general\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClimbing briskly up a hill (Vigorous effort)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFarming (light to moderate effort)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSoccer (causal, general and competitive)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKicking Jianzi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eJogging, general\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eActive involvement in games and sports with children\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSwimming, leisurely, not laps\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTable tennis, Ping-Pong\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSwimming, breaststroke, sidestroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral building task\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTennis, singles, general\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeightlifting (free weight), light to moderate effort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWeightlifting (free weight), powerlifting, vigorous effort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSwinging arms, hands and squatting (QI Gong)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHeavy shoveling/Digging\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTai-Chi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBicycling, 10-15.9 mph\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGymnastics, general\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJogging on a mini-trampoline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCalisthenics, light or moderate effort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e* PA intensity was defined as 3\u0026ndash;10 metabolic equivalents (METs) for our patients, since the general public is nonathletics with PA levels usually\u0026thinsp;\u0026lt;\u0026thinsp;11 METs.\u003c/p\u003e\n\u003ch3\u003ePatient characteristics\u003c/h3\u003e\n\u003cp\u003eThe descriptive statistics of the patients in terms of their characteristics, pain scores, and use of analgesics (opioids or nonopioids) for the 5 assessment periods are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eAmong the 1600 patients, 30.063% were women. The mean BMI was 25.363 (SD\u0026thinsp;=\u0026thinsp;4.905, range\u0026thinsp;=\u0026thinsp;14.648\u0026ndash;58.582). The mean age was 46.123 years (SD\u0026thinsp;=\u0026thinsp;15.683, range\u0026thinsp;=\u0026thinsp;18\u0026ndash;92). A history of PONV was found in 20.689% of the patients. Almost half (50.250%) had experienced motion sickness. A smoking habit was found in 7.625% of them. Most (87.500%) patients had received metoclopramide in the wards. The mean life satisfaction score was 4.613 (SD\u0026thinsp;=\u0026thinsp;1.272, range: 1\u0026ndash;7). The mean level of life pressure was 2.557 (SD\u0026thinsp;=\u0026thinsp;.554, range: 1\u0026ndash;5). Only 28.750% of our patients had taken moderate-to-vigorous intensity PA on a weekly basis over the period of 6\u0026ndash;8 weeks. The means of the perceptions of pain scores at each wave were 5.480 (SD\u0026thinsp;=\u0026thinsp;1.976, range\u0026thinsp;=\u0026thinsp;1\u0026ndash;10) at wave 1, 5.118 (SD\u0026thinsp;=\u0026thinsp;1.838, range\u0026thinsp;=\u0026thinsp;1\u0026ndash;10) at wave 2, 4.698 (SD\u0026thinsp;=\u0026thinsp;1.768, range\u0026thinsp;=\u0026thinsp;1\u0026ndash;10) at wave 3, 4.374 (SD\u0026thinsp;=\u0026thinsp;1.658, range\u0026thinsp;=\u0026thinsp;1\u0026ndash;10) at wave 4, and 4.278 (SD\u0026thinsp;=\u0026thinsp;1.534, range\u0026thinsp;=\u0026thinsp;1\u0026ndash;10) at wave 5.\u003c/p\u003e \u003cp\u003eA substantial proportion of patients did not take any form of analgesics (82.937%, 46.125%, 50.186%, 58.875%, and 44.375% at waves 1, 2, 3, 4, and 5, respectively). The average frequencies of vomiting and nausea at waves 1, 2, 3, 4, and 5 were 0.281 (SD\u0026thinsp;=\u0026thinsp;0.677, range: 0\u0026ndash;7), 0.455 (SD\u0026thinsp;=\u0026thinsp;1.344, range: 0\u0026ndash;18), 0.459 (SD\u0026thinsp;=\u0026thinsp;1.412, range: 0\u0026ndash;16), 0.300 (SD\u0026thinsp;=\u0026thinsp;1.043, range: 0\u0026ndash;12), and 0.169 (SD\u0026thinsp;=\u0026thinsp;0.795, range: 0\u0026ndash;16), respectively.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive data on patient characteristics, pain scores, and analgesic (opioids or nonopioids) use for the 5 assessment periods.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatients (N\u0026thinsp;=\u0026thinsp;1600)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex (women; man)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e481: 1119\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.363 (4.905) range: 14.648\u0026ndash;58.582\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46.123 (15.683) range: 18\u0026ndash;92\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistory of PONV (yes: no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e331: 1269\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMotion sick (yes: no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e804: 796\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking (yes: no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e122: 1478\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnti-emetic drugs (yes: no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1400: 200\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLife satisfaction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.613 (1.272) range: 1\u0026ndash;7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceived stress scores\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.557 (0.554) range: 1\u0026ndash;5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysical activities (yes: no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e460: 1140\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain scores at wave 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.480 (1.976) range: 1\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain scores at wave 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.118 (1.838) range: 1\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain scores at wave 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.698 (1.768) range: 1\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain scores at wave 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.374 (1.658) range: 1\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain scores at wave 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.278 (1.534) range: 1\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnalgesics taking at wave 1 (a:b:c)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1327: 27: 246\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnalgesics taking at wave 2 (a:b:c)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e738: 503: 359\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnalgesics taking at wave 3 (a:b:c)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e803: 439: 358\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnalgesics taking at wave 4 (a:b:c)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e942: 352: 306\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnalgesics taking at wave 5 (a:b:c)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e710: 477: 413\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFrequency of vomiting and nausea at wave 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.281 (0.677) range: 0\u0026ndash;7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFrequency of vomiting and nausea at wave 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.455 (1.344) range: 0\u0026ndash;18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFrequency of vomiting and nausea at wave 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.459 (1.412) range: 0\u0026ndash;16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFrequency of vomiting and nausea at wave 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.300 (1.043) range: 0\u0026ndash;12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFrequency of vomiting and nausea at wave 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.169 (0.795) range: 0\u0026ndash;16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eNote: a: no analgesics taken, b: nonopioid groups; c: opioid groups; the value in parentheses is the standard deviation.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eUnconditional Growth Model\u003c/h2\u003e \u003cp\u003eThe unconditional linear LGM, quadratic LGM, and unspecified parameter LGM were fitted for the pain scores of 1600 operated patients. The results are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The fit indices of the linear model were χ\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e (df)\u0026thinsp;=\u0026thinsp;104.370(10), p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, RMSEA\u0026thinsp;=\u0026thinsp;0.077, CFI\u0026thinsp;=\u0026thinsp;0.959, SRMR\u0026thinsp;=\u0026thinsp;0.040, AIC\u0026thinsp;=\u0026thinsp;18,354.500 and BIC\u0026thinsp;=\u0026thinsp;18,354.280. The intercept factor was significantly positive (mean\u0026thinsp;=\u0026thinsp;2.698, p\u0026thinsp;\u0026lt;\u0026thinsp;.001), indicating that the pain scores were significantly different from 0 at baseline. The linear slope was significantly negative (mean = -0.150, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating that the instantaneous rate of change was significant at the initial stage. All variances of the initial statuses and linear slopes were statistically significant at α\u0026thinsp;=\u0026thinsp;0.001, indicating large individual variations in the initial status and slope of the pain scores.\u003c/p\u003e \u003cp\u003eThe fit indices of the quadratic model were χ\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e (df)\u0026thinsp;=\u0026thinsp;21.346(6), p\u0026thinsp;=\u0026thinsp;0.002, RMSEA\u0026thinsp;=\u0026thinsp;0.040, CFI\u0026thinsp;=\u0026thinsp;0.993, SRMR\u0026thinsp;=\u0026thinsp;0.018, AIC\u0026thinsp;=\u0026thinsp;18,279.473 and BIC\u0026thinsp;=\u0026thinsp;18,354.761. The intercept factor was significantly positive (mean\u0026thinsp;=\u0026thinsp;2.755, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating that the pain scores were different from 0 at baseline. The linear slope was significantly negative (mean = -0.253, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating that there was a significant instantaneous rate of change. The quadratic slope was significantly positive (mean\u0026thinsp;=\u0026thinsp;0.024, p\u0026thinsp;\u0026lt;\u0026thinsp;.001), reflecting an accelerated rate of increase in the curvature per unit change in time. All variances of the initial statuses, linear slope, and quadratic slope were statistically significant at α\u0026thinsp;=\u0026thinsp;0.001, indicating individual variations in the initial status, linear slope, and quadratic slope of the pain scores.\u003c/p\u003e \u003cp\u003eThe fit indices of the unspecified parameter model were χ\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e (df)\u0026thinsp;=\u0026thinsp;47.664(7), p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, RMSEA\u0026thinsp;=\u0026thinsp;0.060, CFI\u0026thinsp;=\u0026thinsp;0.982, SRMR\u0026thinsp;=\u0026thinsp;0.028, AIC\u0026thinsp;=\u0026thinsp;18,303.791 and BIC\u0026thinsp;=\u0026thinsp;18,373.702. The intercept factor was positive and significant (mean\u0026thinsp;=\u0026thinsp;2.725, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating that pain scores were significantly different from 0 at baseline. The unspecified slope was negative and significant (mean = -0.151, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). All the variances of the initial statuses and unspecified slopes were statistically significant at α\u0026thinsp;=\u0026thinsp;0.001, indicating large individual variations in the initial status and unspecified slopes of the pain scores.\u003c/p\u003e \u003cp\u003eOn the basis of the above findings, the quadratic model was selected as the best-fit model for describing the trajectory of pain scores. All the fit indices supported this choice as the best model. In addition, the AIC and BIC of the quadratic model were the lowest fitted models. Therefore, the temporal trajectory of pain scores was well explained by the intercept factor, linear slope and quadratic slope.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of estimates for the unconditional growth model\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLinear model\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuadratic model\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUnspecified curve model\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFactor means\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntercept\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.698\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.755\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.725\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLinear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.150\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.253\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.151\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003equadratic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.024\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFactor variances\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntercept\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.489\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.602\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.514\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLinear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.020\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.198\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.020\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuadratic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.010\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFactor covariances\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntercept with linear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.054\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.177\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.059\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntercept with quadratic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.025\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLinear with quadratic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.041\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFit indices\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eχ\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e (df)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e104.37(10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21.346(6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e47.664(7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRMSEA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.077\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.040\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.060\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCFI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.959\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.993\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.982\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSRMR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.040\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.028\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAIC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18354.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18279.473\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18303.791\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBIC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18408.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18354.761\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18373.702\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eNote: **p\u0026thinsp;\u0026lt;\u0026thinsp;0.01; ***p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePredictors of PA\u003c/h3\u003e\n\u003cp\u003eAfter the best analytical model was chosen, the PA variable was introduced to predict its intercept factor, linear slope, and quadratic slope. The 9 time-invariant covariates (drug group, sex, age, BMI, history of PONV, motion sickness, smoking, life satisfaction, and perceived life stress) were added to serve as control variables for the intercept factor, linear slope, and quadratic slope. The 15 time-variant covariates (i.e., the analgesics taken at waves 1 to 5 and the frequency of vomiting and nausea at waves 1 to 5) were added to the model to control for pain perceptions at each wave (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe conditional model showed an excellent fit to the data (χ\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e (df)\u0026thinsp;=\u0026thinsp;152.619 (86), p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, RMSEA\u0026thinsp;=\u0026thinsp;0.022, CFI\u0026thinsp;=\u0026thinsp;0.976, SRMR\u0026thinsp;=\u0026thinsp;0.033, AIC\u0026thinsp;=\u0026thinsp;17,947.735, BIC\u0026thinsp;=\u0026thinsp;18,264.758). Here, PA was negatively and significantly associated with the intercept (b = -0.579, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e), positively and significantly associated with the linear slope (b\u0026thinsp;=\u0026thinsp;0.157, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e), and negatively and significantly associated with the quadratic slope (b = -0.031, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The results indicated that the pain scores of those who had \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\ge\\:\\)\u003c/span\u003e\u003c/span\u003e150 hours of moderate PA/week or \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\ge\\:\\)\u003c/span\u003e\u003c/span\u003e75 hours of vigorous PA/week for at least 6\u0026ndash;8 weeks before the operation were significantly lower than those of non-PA patients. The mean pain score for PA patients tended to increase, and the growth function decreased over time. Two other time-invariant covariates and time-variant covariates were used as control variables; hence, no further explanations were needed for them. The summaries of the control variables are presented in Tables\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e and \u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of estimates for time-invariant covariates\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntercept\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLinear slope\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQuadratic slope\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime-invariant covariates\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDrug control group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.084\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.071\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.022\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.053\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.099*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.020*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistory of PONV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.062\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.068\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.015\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMotion sickness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.039\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.036\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.007\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.080\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.127\u003csup\u003e+\u0026thinsp;a\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.037*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLife satisfaction score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.043*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.043**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.01**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceived stress score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.081*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.015\u003csup\u003e+\u0026thinsp;b\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExercise\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.579***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.157***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.031***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eNote: * p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, **p\u0026thinsp;\u0026lt;\u0026thinsp;0.01, ***p\u0026thinsp;\u0026lt;\u0026thinsp;0.001. +a\u0026thinsp;=\u0026thinsp;.087, +b\u0026thinsp;=\u0026thinsp;.085\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of estimates for time-variant covariates.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePain_1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePain_2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePain_3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePain_4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePain_5\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime-variant covariates\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContrast:\u003c/p\u003e \u003cp\u003eNo use of analgesic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNonopioids at wave 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.274\u003csup\u003e+\u0026thinsp;c\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOpioids at wave 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.353\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFrequency of vomiting and nausea at wave 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.121\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNonopioids at wave 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.048\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOpioids at wave 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.192\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFrequency of vomiting and nausea at wave 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.054\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNonopioids at wave 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e.0.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOpioids at wave 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.154\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFrequency of vomiting and nausea at wave 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNonopioids at wave 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOpioids at wave 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.245***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFrequency of vomiting and nausea at wave 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.045**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNonopioids at wave 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.070*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOpioids at wave 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.312***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFrequency of vomiting and nausea at wave 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.070***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eNote: **p\u0026thinsp;\u0026lt;\u0026thinsp;0.01; ***p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; +c\u0026thinsp;=\u0026thinsp;0.081.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTo better visualize the effects of moderate- and vigorous-intensity PAs compared with those of controls, the curve disparity between the two groups was plotted. In Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, all control variables were fixed as constants. The values of non-PA were set to 0 for all waves, and the values of PA were set to 1 for all waves. The estimated curve formula was \u0026minus;\u0026thinsp;0.579\u0026thinsp;+\u0026thinsp;0.157(PA) -0.031 (PA)\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Figure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows lower pain scores in the PA group (i.e., 0.597 less) than in the non-PA group at wave 1. With time, the difference between these two groups progressively decreased (to 0.453 less at wave 2, 0.389 less at wave 3, 0.387 less at wave 4, and the gap increased to 0.447 less at wave 5).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePreoperative multimodal prehabilitation programs generally include exercise, nutritional optimization, and counseling components for biopsychosocial well-being and are believed to play important roles in reducing postoperative complications, improving functional capacity and reducing the length of hospital stay in patients with lung cancer,\u003csup\u003e\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e colorectal cancer\u003csup\u003e\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e,\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u003c/sup\u003e and major abdominal surgery.\u003csup\u003e\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThere is increasing evidence that preoperative exercise therapy in various surgical specialties is effective and well tolerated.\u003csup\u003e\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u003c/sup\u003e Future improvements in standards of care and optimal preoperative preparation should focus not only on the surgical team/hospital organization but also on incorporating the active involvement of patients.\u003c/p\u003e \u003cp\u003eInadequate control of acute postoperative pain remains a widespread, unresolved health-care problem that is accompanied by an array of negative consequences.\u003csup\u003e\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Moreover, early postoperative pain appears to trigger persistent postsurgical pain that may last for months after surgery in a good portion of patients.\u003csup\u003e\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u003c/sup\u003e Nevertheless, acute postoperative pain represents a clinical challenge that has not yet been well addressed.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eTo prevent such progression of postoperative pain from acute to chronic, more aggressive analgesics, anesthetics and other measures were used to reduce the incidence and intensity of acute pain immediately after different types of surgery.\u003c/p\u003e \u003cp\u003eThe goal of this study was to assess the associations between preoperative PA and postoperative pain for different types of laparoscopic surgery. The results indicated that preoperative PA was associated with a reduction in postoperative pain over a wide range of laparoscopic surgeries. This result is in line with the findings of Hayashi et al. in 2023.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e Their study performed a meta-analysis on the postoperative pain reduction associated with total knee arthroplasty (TKA) in preoperative PA patients from 23 research articles. The studies concluded that preoperative exercise reduced pain in patients who underwent TKA within 2 months, and moderate pain reduction was observed 3 to 5 months after TKA.\u003c/p\u003e \u003cp\u003eThis study is the first to characterize trajectory changes at different postoperative time points (1, 4, 7, 10, and 24 hours) via a latent curve model for comparing postoperative pain between PA patients and non-PA patients after controlling for confounding biopsychosocial variables such as life satisfaction and life stress. Specifically, patients who performed moderate-to-vigorous-intensity PA preoperatively showed greater pain tolerance than controls at all postoperative time points. Similarly, the quadratic curve of the pain scores was significantly different. At 1 and 4 hours after the operation, pain perception in the PA group was lower than that at 7 and 10 hours. These phenomena could be due to the decline in the effects of the GA/analgesic drugs, which lingered to cover the periods of 1 and 4 hours after the operation. Further comprehensive research is needed to explain this phenomenon.\u003c/p\u003e \u003cp\u003eThe key findings suggest the implementation of PA in multimodal prehabilitation programs in ERAS protocols for laparoscopic surgery patients, which may significantly reduce postoperative pain suffering and the side effects of analgesics.\u003c/p\u003e \u003cp\u003eLogistical considerations and the degree of patient adherence represent barriers to effective prehabilitation programs. Barriers include those patients not able to attend physical training sessions or not willing to follow the procedures of the programs due to language restrictions, psychological disorders, lack of traffic facilities, training institutions, qualified sport physicians, physiotherapists, dietitians, geographical obstructions, patient lifestyles (inactivity, obesity, dietary patterns, and smoking behavior), and cultural taboo. These factors are particularly important in low- and middle-income regions or developing countries because of financial considerations, inadequate institutions and cost effectiveness. Therefore, the study suggests that 6 to 8 weeks of preoperative moderate-to-vigorous intensity PA for patients to perform at home or in some nearby environment that they enjoy is more pragmatic than receiving exercise and PA programs (such as achieving the prescribed METs*min*wk-1, lactate threshold test, peak oxygen uptake estimation, which requires skilled technicians, expensive equipment, and is time consuming\u0026mdash;all of which are usually impractical) to improve preoperative cardiopulmonary physiologic reserve and reduce laparoscopic postoperative pain (our new and unique key finding).\u003c/p\u003e \u003cp\u003eCertain limitations should be taken into account in the findings:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eOwing to its nature, this study was performed nonblinded and focused only on different types of laparoscopic operations.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePatients who were \u0026lt;\u0026thinsp;18 y/o, had an ASA physical status\u0026thinsp;\u0026ge;\u0026thinsp;4, had poorly controlled DM, had prolonged QTc, and were transferred to the ICU postoperatively were excluded. Further research is necessary to include these patients to consolidate this finding.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eIt is unclear whether PA intensity\u0026thinsp;\u0026lt;\u0026thinsp;3 or \u0026gt;\u0026thinsp;10 METs alone for 6\u0026ndash;8 weeks preoperatively has the same effects. Future research is needed to more accurately delineate the optimal prescription of preoperative PAs (e.g., type, dose, intensity, and volume) for specific types of laparoscopic operations and other types of nonlaparoscopic operations.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study revealed that patients with 6\u0026ndash;8 weeks of preoperative moderate-intensity physical activity had less postoperative pain than non-PA patients did. Moreover, this study is the first to characterize the trajectory changes at different postoperative time points (1, 4, 7, 10, and 24 hours) in a latent curve model to compare the degree of postoperative pain between patients who underwent preoperative moderate-to-vigorous intensity PA and non-PA patients. The results revealed that preoperative PA patients had greater pain tolerance than non-PA patients did at all 24-hour postoperative time points. There is no one-size-fits-all standard protocol for preoperative pain management. This study revealed that preoperative moderate-intensity physical activity may help reduce postoperative pain. Therefore, a physician should first assess a patient\u0026rsquo;s physical and mental health conditions to determine whether the patient is suitable for engaging in moderate-intensity exercise. If deemed suitable, the specific type of exercise can then be discussed. Common preoperative exercises include aerobic exercises and strength training, with the intensity tailored to the patient\u0026rsquo;s current physical fitness level. Engaging in such exercises for 6 to 8 weeks can help improve physical fitness. Additionally, patients may choose to exercise at home or in a nearby safe exercise facility.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eACSM: \u0026nbsp;American College of Sports Medicine\u003c/p\u003e\n\u003cp\u003eAIC:\u0026nbsp;Akaike information criterion\u003c/p\u003e\n\u003cp\u003eASA: American Society of Anesthesiologists\u003c/p\u003e\n\u003cp\u003eBIC:\u0026nbsp;Bayesian information criterion\u003c/p\u003e\n\u003cp\u003eBMI: body mass index\u003c/p\u003e\n\u003cp\u003eCFI:\u0026nbsp;comparative fit index\u003c/p\u003e\n\u003cp\u003eDM: diabetes mellitus\u003c/p\u003e\n\u003cp\u003eERAS: enhanced recovery after surgery\u003c/p\u003e\n\u003cp\u003eGA: general anesthesia\u003c/p\u003e\n\u003cp\u003eICU: intensive care unit\u003c/p\u003e\n\u003cp\u003eLGM:\u0026nbsp;Latent growth model\u003c/p\u003e\n\u003cp\u003ePA: physical activity\u003c/p\u003e\n\u003cp\u003ePACU: postanesthesia care unit\u003c/p\u003e\n\u003cp\u003ePONV: postoperative nausea and vomiting\u003c/p\u003e\n\u003cp\u003eRMSEA:\u0026nbsp;root mean square error of approximation\u003c/p\u003e\n\u003cp\u003eSD: standard deviation\u003c/p\u003e\n\u003cp\u003eSRMR:\u0026nbsp;standardized root mean square residual\u003c/p\u003e\n\u003cp\u003eTKA: knee arthroplasty\u003c/p\u003e"},{"header":"Declarations","content":"\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThis study with an informed consent form was approved by the Institutional Board of Ditmanson Medical Foundation Chia-Yi Christian Hospital. The approval number is CYCH-IRB -10402.\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe human ethics was approved by the Institutional Board of Ditmanson Medical Foundation Chia-Yi Christian Hospital. The approval number is CYCH-IRB -10402. All participants agreed to participate in the study and signed the informed consent form.\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eClinical Trial Number\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe data can be obtained upon request from the corresponding author.\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe authors declare that they have no conflicts of interest.\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe study received no funding.\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eHong-Wun Chen\u003c/strong\u003e and \u003cstrong\u003eWui-Chiu Mui\u003c/strong\u003e: Conceptualization,\u0026nbsp;statistical analysis, and writing – review \u0026amp; editing of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLi-An Liao\u003c/strong\u003e and \u003cstrong\u003eChih-Han Chan\u003c/strong\u003e: Participated in the study design, critical review, and data collection.\u003c/p\u003e\n\u003cp\u003eAll authors provided final approval for publication of the manuscript and are responsible for the integrity of the study.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eAll participants in the study were highly appreciated.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePaladini A, Rawal N, Coca Martinez M, Trifa M, Montero A, Pergolizzi Jr J, et al. Advances in the management of acute postsurgical pain: A review. Cureus. 2023;15(8):e42974. doi:10.7759/cureus.42974.\u003c/li\u003e\n\u003cli\u003ePogatzki-Zahna EM, Segelckea D, Schugb SA. Postoperative pain\u0026mdash;from mechanisms to treatment. PAIN Reports. 2017;9:e588. doi:10.1097/PR9.0000000000000588.\u003c/li\u003e\n\u003cli\u003eInstitute of Medicine. Relieving pain in America: A blueprint for transforming prevention, care, education, and research. Washington: National Academies Press; 2011.\u003c/li\u003e\n\u003cli\u003eGan TJ, Habib AS, Miller TE, White W, Apfelbaum JL. Incidence, patient satisfaction, and perceptions of postsurgical pain: results from a US national survey. Curr Med Res Opin. 2014;30(1):149-160. doi:10.1185/03007995.2013.860019.\u003c/li\u003e\n\u003cli\u003eGan TJ. Poorly controlled postoperative pain: Prevalence, consequences, and prevention. J Pain Res. 2017;10:2287-2298. doi:10.2147/JPR.S144066.\u003c/li\u003e\n\u003cli\u003eKehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: Risk factors and prevention. Lancet. 2006;367:1618-1625. doi:10.1016/S0140-6736(06)68700-X.\u003c/li\u003e\n\u003cli\u003eLandmark T, Romundstad P, Borchgrevink PC, Kaasa S, Dale O. Associations between recreational exercise and chronic pain in the general population: evidence from the HUNT 3 study. Pain. 2011;152(10):2241-2247. doi:10.1016/j.pain.2011.04.029.\u003c/li\u003e\n\u003cli\u003eLandmark T, Romundstad PR, Borchgrevink PC, Kaasa S, Dale O. Longitudinal associations between exercise and pain in the general population\u0026mdash;the HUNT pain study. PLoS One. 2013;8:e65279. doi:10.1371/journal.pone.0065279.\u003c/li\u003e\n\u003cli\u003eHadlandsmyth K, Zimmerman MB, Wajid R, Sluka KA. Longitudinal postoperative course of pain and dysfunction following total knee arthroplasty. 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Anesthesiology. 2018;129(3):590-607. doi:10.1097/ALN.0000000000002238.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Physical activity, Laparoscopic operation, Postoperative pain, Prehabilitation, Enhanced recovery after surgery","lastPublishedDoi":"10.21203/rs.3.rs-6497422/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6497422/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Preoperative exercise and physical activity (PA) are strongly recommended in prehabilitation for enhanced recovery after surgery. However, the evidence of the effect of preoperative PA on postoperative pain remains inconclusive. Therefore, the aim of this study was to explore the hypoalgesic effects of preoperative PA on postlaparoscopic operation pain in adults.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: A total of \u003c/strong\u003e1600 participants who underwentdifferent types of laparoscopic operations and information on the incidence and severity of pain and other suffering of each patient were periodically recorded at 1, 4, 7, 10 and 24 hours after the operation. The patient’s pain level was rated via a numeric rating scale ranging from 1 (no pain at all) to 5 (excruciating pain). Among the participants, 460 underwent 6 to 8 weeks of preoperative PA at moderate or vigorous intensity. The latent growth models were constructed via structural equation modeling to estimate and select the model that best fit the pain scores collected.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Three unconditional growth models fit the data. Among the fitted models, the quadratic model was the best at fitting the trajectory pain scores and was adapted to assess the pain scores after recovery. The results from the quadratic growth model revealed that pain scores were significantly lower than those of non-PA controls for patients who had performed 6 to 8 weeks of preoperative PA at moderate or vigorous intensity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: Preoperative moderate-to-vigorous intensity PAs reduce postoperative pain in adults within 24 hours after various types of laparoscopic operations.\u003c/p\u003e","manuscriptTitle":"Effects of Preoperative Exercises on Reducing Postlaparoscopic Operation Pain in Adults","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-13 06:38:15","doi":"10.21203/rs.3.rs-6497422/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"57826c6b-069c-463f-be96-cf86066e40b9","owner":[],"postedDate":"May 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-05-19T08:23:43+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-13 06:38:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6497422","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6497422","identity":"rs-6497422","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}