BRAZILIAN JOURNAL OF PAINBRAZILIAN JOURNAL OF PAINBRAZILIAN JOURNAL OF PAINBrJPBrJPBrJP

capa brjp 2018.indd 1 08/05/2018 18:29:44

Vol. 02 No 02 Apr/May/Jun. 2019

ISSN 2595-3192

ANÚNCIO

Volumen 2 – nº 2April to June, 2019

Trimestral Publication

SOCIEDADE BRASILEIRA PARA O ESTUDO DA DOR

DIRECTORY Biennium 2018-2019

PresidentEduardo Grossmann

Vice-PresidentPaulo Renato Barreiros da Fonseca

Scientific DirectorJosé Oswaldo de Oliveira Junior

Administrative DirectorDirce Maria Navas Perissinotti

TreasurerJuliana Barcellos de Souza

SecretaryJanaina Vall

Av. Conselheiro Rodrigues Alves, 937 Cj. 2 – Vila Mariana

04014-012 São Paulo, SPPhone: (55) 11 5904-2881/3959

www.dor.org.brE-mail: dor@dor.org.br

Quotations of Brazilian Journal of Pain shall be abbreviated to BrJP.

BrJP is not responsible whatosever by opinions.

Advertisements published in this edition do nogenerate conflict of interests.

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Publication edited and produced byMWS Design – Phone: (055) 11 3399-3038

Journalist In ChargeMarcelo Sassine - Mtb 22.869

Art EditorAnete Salviano

CONTENTS

EDITORIALThe adequate use of opioids and the position of the Latin American Federation of Associations for the Study of Pain ___________________________________________99Durval Campos Kraychete, João Batista Santos Garcia

ORIGINAL ARTICLESComparison of the pain pressure threshold on the pelvic floor in women with and without primary dysmenorrhea ____________________________________________101Victória dos Santos Guarda Lima, Guilherme Tavares de Arruda, Cyntia Scher Strelow, Michele Adriane Froelich, Michele Forgiarini Saccol, Melissa Medeiros Braz

Prevalence and factors associated with chronic neuropathic pain in workers of a Brazilian public university ________________________________________________________105Igor Garcia Barreto, Katia Nunes Sá

Pain assessment in critical patients using the Behavioral Pain Scale _______________112Laudice Santos Oliveira, Maiara Pimentel Macedo, Stefany Ariadley Martins da Silva, Ana Paula de Freitas Oliveira, Victor Santana Santos

Low back pain, anthropometric indexes and range of motion of rural workers ______117Patrik Nepomuceno, Luíza Müller Schmidt, Marcelo Henrique Glänzel, Miriam Beatrís Reckziegel, Hildegard Hedwig Pohl, Éboni Marília Reuter

Sleep alterations in patients with the human immunodeficiency virus and chronic pain __123Glória Pinto Soares de Aguiar, Jairo Alberto Dussán-Sarria, Andressa de Souza

Comparative analysis between three forms of application of transcutaneous electrical nerve stimulation and its effect in college students with non-specific low back pain __132Carla Maria Verruch, Andersom Ricardo Fréz, Gladson Ricardo Flor Bertolini

Pain in children with cerebral palsy in the postoperative: perception of parents and health professionals __________________________________________________________137Aline Cristina da Silva Fornelli, Jessica Borges de Oliveira Lopes, Daniela Fernandes Lima Meirelles, José Baldocchi Pontin, Márcia de Almeida Lima

Non-pharmacological measures for pain relief in venipuncture in newborns: description of behavioral and physiological responses ___________________________________142Priscila Pereira de Souza Gomes, Ana Paola de Araújo Lopes, Maria Solange Nogueira dos Santos, Silvania Moreira de Abreu Façanha, Ana Valeska Siebra e Silva, Edna Maria Camelo Chaves

Use of non-invasive neuromodulation in the treatment of pain in temporomandibular dysfunction: preliminary study ____________________________________________147Tatyanne dos Santos Falcão Silva, Melyssa Kellyane Cavalcanti Galdino, Suellen Mary Marinho dos Santos Andrade, Luciana Barbosa Sousa de Lucena, Renata Emanuela Lyra de Brito Aranha, Evelyn Thais de Almeida Rodrigues

Self-reported musculoskeletal disorders by the nursing team in a university hospital __155Edilson Gonçalves Maciel Júnior, Francis Trombini-Souza, Paula Adreatta Maduro, Fabrício Olinda Souza Mesquita, Tarcísio Fulgêncio Alves da Silva

Analysis of pain and free cortisol of newborns in intensive therapy with therapeutic procedures ____________________________________________________________159Cibele Thomé da Cruz Rebelato, Eniva Miladi Fernandes Stumm

Submitted to articles online:https://www.gnpapers.com.br/brjp/default.asp

SCIENTIFIC EDITORDurval Campos Kraychete

Federal University of Bahia, Salvador, BA – Brazil.

CO-EDITORSÂngela Maria Sousa

University of São Paulo, São Paulo, SP – Brazil. Dirce Maria Navas Perissinotti

University of São Paulo, São Paulo, SP – Brazil. Eduardo Grossmann

Federal University of Rio Grande do Sul, Porto Alegre, RS – Brazil.Irimar de Paula Posso

University of São Paulo, São Paulo, SP – Brazil. Janaina Vall

Federal University of Ceara, Fortaleza, CE – Brazil.José Aparecido da Silva

University of São Paulo, Ribeirão Preto, SP - Brazil.José Oswaldo Oliveira Júnior

University of São Paulo, São Paulo, SP – Brazil. Juliana Barcellos de Souza

Federal University of Santa Catarina, Florianópolis, SC – Brazil.Lia Rachel Chaves do Amaral Pelloso

Federal University of Mato Grosso, Cuiabá, MT, Brazil.Maria Belén Salazar Posso

Christian University Foundation, Pindamonhangaba, SP – Brazil.Sandra Caires Serrano

Pontifícia Universidade Católica de Campinas, São Paulo, SP – Brazil.Telma Regina Mariotto Zakka

University of São Paulo, São Paulo, SP – Brazil.

EDITORIAL COUNCILAbrahão Fontes Baptista

Federal University of Pernambuco, Recife, PE – Brazil.Alexandre Annes Henriques

General Hospital of Porto Alegre, Porto Alegre, RS – Brazil.Fábio Henrique de Gobbi Porto

University of Sao Paulo, São Paulo, SP - Brazil.Guilherme Antônio Moreira de Barros

School of Medicine of Botucatu, Botucatu, SP – Brazil.Hazem Adel Ashmawi

University of São Paulo, São Paulo, SP – Brazil.Ismar Lima Cavalcanti

University Iguacu, Rio de Janeiro, RJ – Brazil.Jamir Sardá Junior

University of Vale do Itajaí, Itajaí, SC – Brazil.João Batista Santos Garcia

Federal University of Maranhão, São Luiz, MA – Brazil.José Geraldo Speciali

University of São Paulo, Ribeirão Preto – Brazil.José Tadeu Tesseroli de Siqueira

University of São Paulo, São Paulo, SP – Brazil.Josimari Melo de Santana

Federal University of Sergipe, Aracaju, SE – Brazil.Juliane de Macedo Antunes

National Institute of Traumatology and Orthopedics, Rio de Janeiro, RJ – Brazil.Karina Gramani Say

Federal University of São Carlos, São Carlos, SP - Brazil.Kátia Nunes Sá

Bahia School of Medicine and Public Health, Salvador, BA – Brazil.Manoel Jacobsen Teixeira

University of Sao Paulo, São Paulo, SP - Brazil.Mauro Brito de Almeida

Federal University of Pará, Belém, PA - Brazil.Miriam Seligman de Menezes

Federal University of Santa Maria, Santa Maria, RS – Brazil.Mirlane Guimarães de Melo Cardoso

Federal University of Amazonas, Manaus, AM – Brazil.Onofre Alves Neto

Federal University of Goiás, Goiânia, GO – Brazil.Oscar Cesar Pires

University of Taubaté, Taubaté, SP - Brazil.Paulo Cesar Rodrigues Conti

School of Dentistry of Bauru, Bauru, SP – Brazil.Renato Leonardo de Freitas

University of Sao Paulo, Ribeirão Preto, SP – Brazil.Rosana Maria Tristão

Federal University of Brasilia, Brasilia, DF - Brazil.Silvia Regina Dowgan Tesseroli de Siqueira

University of Sao Paulo, Sao Paulo, SP – Brazil.Vania Maria de Araújo Giaretta

University of Taubaté, Taubaté - SP. Brazil.Walter Lisboa de Oliveira

Federal University of Sergipe, Aracaju, SE – Brazil.

INTERNATIONAL BOARDAllen Finley

Dalhousie University, Halifax – Canada.Antoon De Laat

Catholic University of Leuven – Belgium.Gary M. Heir

Medicine and Dentistry University of New Jersey, New Jersey- EUA.Jeftrey P. Okeson

Kentucky University, Lexington- EUA.José Manoel Castro Lopes

University of Porto, Porto – Portugal.Lee Dongchul

Department of Anesthesiology and Pain MedicineGuwol – Dong Mamdong-gu, Incheon – Korea.

Mark JensenWashington University, Washington – USA.

Ricardo Plancarte SánchezNational Institute of Cancerology, Mexico – Mexico

EDITORIAL COORDINATIONEvanilde Bronholi de Andrade

REVIEW ARTICLESConheceDOR: the development of a board game for modern pain education for patients with musculoskeletal pain ________________________________________________166Juliana Carvalho de Paiva Valentim, Ney Armando Meziat-Filho, Leandro Calazans Nogueira, Felipe J. Jandre Reis

Pregnancy-related lumbosacral pain ________________________________________176Fábio Farias de Aragão

Effects of the hyaluronic acid infiltration in the treatment of internal temporomandibular joint disorders __________________________________________________________182Liliane Emilia Alexandre de Oliveira, Jandenilson Alves Brígido, Aline Dantas Diógenes Saldanha

Hydrotherapy and crenotherapy in the treatment of pain: integrative review ________187Juliane de Macedo Antunes, Donizete Vago Daher, Vania Maria de Araújo Giaretta, Maria Fernanda Muniz Ferrari, Maria Belén Salazar Posso

CASES REPORTSInterventional analgesic block in a dog with cauda equina syndrome. Case report ____199Rodrigo Mencalha, Camila de Souza Generoso, Daniel Sacchi de Souza

Orofacial manifestations of chikungunya infection. Case report _________________204Ana Paula Varela Brown Martins, Juliana Stugisnki-Barbosa, Paulo Cesar Rodrigues Conti

LETTER TO THE EDITORAnalgesic effect of the interferential current in chronic low back pain management ___208Ricardo Vieira Teles Filho

INSTRUCTIONS TO AUTHORS __________________________________________209

99

The adequate consumption of opioids in developing countries is still a significant challenge as it can bring about the reflection on the issues involving the correct treatment of acute and chronic pain. The literature is classic in reporting that physicians find it difficult to prescribe opioids, and the patient to accept therapy, for fear of adverse effects or addiction. On the other hand, opioids, a gold standard in the treatment of cancer pain and other types of moderate or severe pain, have insufficient availability and access to the patient, either because of the cost or the health surveillance public policy. The poor education on the subject of pain in undergraduate and postgrad-uate courses in medical schools, the restrictive government policies for the purchase and distribution of opioids, the need for registra-tion to acquire specific prescriptions, fear of addiction, and the use of opioids for illicit purposes, as well as cultural attitudes towards pain contribute to what the scientific community calls opiophobia1-5. This refers to the opioid crisis that developed countries face6. Paradoxically, this crisis deals precisely with the consequences of prolonged and indiscriminate use of opioids in developed countries, since there has been an increase in the number of reports of death and addiction related to these drugs. In Latin America, however, the incidence of abuse is around 1%7. In fact, in our region, cocaine and marijuana are the substances that lead to problems of abuse. In this way, we are facing a new paradigm, where the look and the critical reading of the opiophobia must be differentiated and related to the global geographic and economic context. It suffices to say that the daily average dose of opioids consumption for statistical purposes is 150 (S-DDD). This dose is below the recommended by the literature, reflecting how much we have to improve to achieve optimal pain treatment8. Also, the global consumption of opioids is higher in developed countries, and 75% of the world population in underdeveloped or developing countries do not receive any painkillers proportionally to the intensity of pain9. Therefore, the Latin American Federation of Associations for the Study of Pain (FEDELAT), in its current management, gathered in São Paulo opinion leaders and representatives from several Latin American countries to publish a position on the measures necessary to reverse this situation and the impact of opiophobia in developing countries. This paper10 to be published in the Pain Reports (already accepted for publication and in press) addresses the necessary measures to correct this problem, which include: 1) continuous education - promoting the training of professionals on the safe use of opioids, based on protocols and scientific evidence. The training can be with meetings with experts and educational materials on the institutional web platforms; 2) public policies -creating awareness among the leaders about the need to de-velop specific programs for the treatment of pain and national scientific recommendations for the use of opioids, facilitating the access and the prescription of these drugs correctly; 3) creation of an electronic prescription – allowing the registration of the opioid prescription, the patient’s disease, the dose, the duration of the prescription, the pharmacy that provided the medicine and the monitoring of risks; 4) statistics -promoting the registration of hospital and outpatient use and distribution of opioids; 5) multidisciplinary care - encouraging the creation of clinics involving other health professionals who ensure the assessment, diagnosis, treatment and the appropriate follow-up of cancer or non-cancer patients; 6) jointly work of organizations - involving national and international institutions to promote joint actions that include continuous education, publication of recommendations and incentives to clinical and experimental research around the theme of opioids; 7) conflict of interest – avoiding the undue influence of entities that have profit in the engagement and bid of opioids to establish the most ethic relationship possible with the prescribers. Therefore, we can conclude that we must contribute unconditionally for the legitimation of the proper treatment of pain in Brazil and the correct prescription of opioids, monitoring and treating the adverse effects, stratifying the risks and fighting the opiophobia, offering, with sympathy, the relief of pain to the suffering patient.

Durval Campos KraycheteUniversidade Federal da Bahia, Salvador, BA, Brasil

https://orcid.org/0000-0001-6561-6584E-mail: dkt@terra.com.br

João Batista Santos GarciaUniversidade Federal do Maranhão, São Luís, MA, Brasil.

https://orcid.org/0000-0002-3597-6471E-mail: jbgarcia@uol.com.br

The adequate use of opioids and the position of the Latin American Federation of Associations for the Study of PainUso adequado de opioide e a posição da Federação Latino Americana de Associações para o Estudo da Dor

© Sociedade Brasileira para o Estudo da Dor

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DOI 10.5935/2595-0118.20190018

EDITORIAL

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Kraychete DC and Garcia JBBrJP. São Paulo, 2019 apr-jun;2(2):99-100

REFERENCES

1. Hastie BA, Gilson AM, Maurer MA, Cleary JF. An examination of global and re-gional opioid consumption trends 1980-2011. J Pain Palliat Care Pharmacother. 2014;28(3):259-75.

2. Cleary J, Simha N, Panieri A, Scholten W, Radbruch L, Torode J, et al. Formulary availability and regulatory barriers to accessibility of opioids for cancer pain in India: a report from the Global Opioid Policy Initiative (GOPI). Ann Oncol. 2013;24(Suppl 11):xi33-40.

3. Javier FO, Irawan C, Mansor MB, Sriraj W, Tan KH, Thinh DH. Cancer pain man-agement insights and reality in Southeast Asia: expert perspectives from six countries. J Glob Oncol. 2016;2(4):235-43.

4. O’Brien T, Christrup LL, Drewes AM, Fallon MT, Kress HG, McQuay HJ, et al. European Pain Federation position paper on appropriate opioid use in chronic pain management. Eur J Pain. 2017;21(1):3-19.

5. Ahmedzai SH, Bautista MJ, Bouzid K, Gibson R, Gumara Y, Hassan AA, et al. Op-timizing cancer pain management in resource-limited settings. CAncer Pain manage-ment in Resource-limited settings (CAPER) Working Group.. Support Care Cancer. 2018;21. [Epub ahead of print).

6. Barnett ML, Gray J, Zink A, Jena AB. Coupling Policymaking with Evaluation - The Case of the Opioid Crisis. N Engl J Med. 2017;377(24):2307-9.

7. Gobierno Nacional de la República de Colombia: Ministerio de Justicia y del Derecho - Observatorio de Drogas de Colombia y el Ministerio de Salud y Protección Social, Oficina de las Naciones Unidas contra la Droga y el Delito - UNODC -, Comisión Interamericana para el Control del Abuso de Drogas - CICAD -, Organización de los Estados Americanos - OEA -, Embajada de los Estados Unidos en Colombia - INL -.Estudio nacional de consumo de sustancias psicoactivas en Colombia pp. 63-65, 2013 www.odc.gov.co.

8. International Narcotics Control Board (2015) Availability of internationally con-trolled drugs: ensuring adequate access for medical and scientific purposes, indis-pensable, adequately available and not unduly restricted. https://www.incb.org/documents/Publications/AnnualReports/AR2015/English/Supplement-AR15_avail-ability_ English.pdf. Accessed 6 November 2017.

9. Knaul FM, Farmer PE, Krakauer E, De Lima L, Bhadelia A, Jiang Kwete X, et al. Alleviating the access abyss in palliative care and pain relief an imperative of universal health coverage: the Lancet Commission report. Lancet. 2018;391(10128):1391-454.

10. Garcia JBS, Lopez MPG, Barros GAM, et al. Latin American Pain Federation po-sition paper on appropriate opioid use in pain management. Pain Reports. 2019 [In Press].

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ABSTRACT

BACKGROUND AND OBJECTIVES: Primary dysmenor-rhea is characterized as menstruation with painful conditions in women with no associated pathologies, whose pain sites are classically investigated in the abdomen. However, it is known that the pelvic floor can also be compromised by primary dys-menorrhea and can be a source of hyperactivity of this muscula-ture. The objective of this study was to compare the pain pressure threshold in the pelvic floor of women with and without primary dysmenorrhea. METHODS: An observational, quantitative and cross-sectional study was conducted with young women. The sample consisted of 20 women divided into two groups: with primary dysmen-orrhea (n=10) and without primary dysmenorrhea (n=10). The Adapted Assessment Questionnaire was applied for the data col-lection on the characteristics of the menstrual cycle followed by an evaluation of the pressure threshold of the pelvic floor of the participants using the Microfet 2 HHD manual dynamometer. RESULTS: There was no significant difference in pressure pain threshold between the groups on the left side (p=0.156) and right side (p=0.198) of the pelvic floor. CONCLUSION: In this women sample, the occurrence or non-occurrence of primary dysmenorrhea was not associated with an increase in the pain pressure threshold of the pelvic floor.Keywords: Dysmenorrhea, Pelvic floor, Women.

Comparison of the pain pressure threshold on the pelvic floor in women with and without primary dysmenorrheaComparação do limiar pressórico de dor no assoalho pélvico em mulheres com e sem dismenorreia primária

Victória dos Santos Guarda Lima1, Guilherme Tavares de Arruda1, Cyntia Scher Strelow1, Michele Adriane Froelich1, Michele Forgiarini Saccol1, Melissa Medeiros Braz1

Victória dos Santos Guarda Lima - https://orcid.org/0000-0002-7268-6078; Guilherme Tavares de Arruda - https://orcid.org/0000-0001-5994-3247; Cyntia Scher Strelow - https://orcid.org/0000-0003-1585-4458; Michele Adriane Froelich - https://orcid.org/0000-0001-8747-7650; Michele Forgiarini Saccol - https://orcid.org/0000-0002-7894-690X; Melissa Medeiros Braz - https://orcid.org/0000-0002-9138-0656.

1. Universidade Federal de Santa Maria, Departamento de Fisioterapia e Reabilitação, Santa Maria, RS, Brasil.

Submitted on November 11, 2018.Accepted for publication on February 19, 2019.Conflict of interests: none – Sponsoring sources: none.

Correspondence to:Av. Roraima nº 1000, Cidade Universitária - Bairro Camobi97105-970 Santa Maria, RS, Brasil.E-mail: gui_tavares007@hotmail.com

© Sociedade Brasileira para o Estudo da Dor

RESUMO

JUSTIFICATIVA E OBJETIVOS: A dismenorreia primária é caracterizada como uma menstruação com quadros álgicos em mulheres sem doenças associadas, cujos pontos de dor são in-vestigados classicamente no abdômen. Entretanto, sabe-se que o assoalho pélvico também pode ser comprometido pela disme-norreia primária e pode ser fonte de hiperatividade dessa muscu-latura. O objetivo deste estudo foi comparar o limiar pressórico de dor no assoalho pélvico de mulheres com e sem dismenorreia primária. MÉTODOS: Foi realizado um estudo observacional, com abor-dagem quantitativa e de caráter transversal com mulheres jovens. A amostra constituiu de 20 mulheres divididas em dois grupos: com dismenorreia primária (n=10) e sem dismenorreia primária (n=10). O Questionário Adaptado de Avaliação foi aplicado para a coleta dos dados sobre as características do ciclo menstrual, se-guido de uma avaliação do limiar pressórico do assoalho pélvico das participantes com o dinamômetro manual Microfet 2 HHD. RESULTADOS: Não houve diferença significativa no limiar de dor à pressão entre os grupos no lado esquerdo (p=0,156) e lado direito (p=0,198) do assoalho pélvico. CONCLUSÃO: Nesta amostra de mulheres, a ocorrência ou não de dismenorreia primária não foi associada ao aumento do limiar pressórico de dor do assoalho pélvico.Descritores: Diafragma pélvico, Dismenorreia, Mulheres.

INTRODUCTION

Primary dysmenorrhea (PD) is characterized by menstruation with painful periods in women with no lesions in the pelvic or-gans. It is also considered as a gynecological dysfunction that man-ifests with pain in the lower abdomen, which may radiate to the paravertebral region and thighs. It usually begins in adolescence and is accompanied by nausea, vomiting, and diarrhea, varying in intensity according to the commitment in daily activities1,2.The most accepted theories to explain the pain in women with PD are the production and excess release of prostaglandins during menstruation through the endometrium, which would cause uterine hypercontractility, hypoxia, and ischemia3,4. More frequently, the abdominal region is investigated in wom-en with PD. However, current research considers the hypothe-sis that, during the menstrual cycle, the hormonal variations of these women may be related to the pain sensitization mecha-

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nisms of the central nervous system (CNS), making the pelvic floor (PF) more sensitized during the entire menstrual cycle5,6.A recent study6 demonstrated hyperalgesia during the menstrual cycle of women with PD, especially in the deep tissues, as evi-dence of the presence of central sensitization. The pain thresh-olds for pressure, heat and electricity are reduced in the abdom-inal, paravertebral and limb regions in the menstrual phase in patients with PD6. However, research is still incipient in relation to painful PF sites in women with PD.Central sensitization may be associated with pain in the PF of women with PD, by the passage of nociceptive stimuli through the facilitation of the CNS, which generates tension and hyper-activity in the pelvic floor muscles (PFM). These pelvic struc-tures, when affected, can result in cognitive, sexual, behavioral and emotional dysfunctions. In addition, this impairment may be associated with urinary incontinence7 in the future.It is of fundamental importance to have a better knowledge of the painful places to be able to intervene on them. Physiotherapy has resources for pain relief and many other ways of minimizing the effects of pain in PF have been studied. The objective of this study was to compare the pain pressure threshold in the pelvic floor of women with and without PD. METHODS

An observational cross-sectional study with a quantitative approach was carried out with university students from a Higher Education Institution of the south of Brazil, from March to June 2018.The sample consisted of young women divided into two groups: with PD (G1) and without PD (G2). The study included wom-en between the ages of 18 and 35, with and without complaints of PD, nulligans and users of oral contraceptives (OC) in a non-continuous way. Women with a diagnosis of secondary dys-menorrhea or who presented, at the time of data collection, some diagnosed gynecological pathology were excluded. The sample calculation was performed using G-Power software 3.1.9.2, based on the results of a pilot study with 10 women di-vided into two groups. It was estimated a sample of 8 individuals

in each group to achieve a level of significance (alpha) of 5% (p<0.05) and power (beta) of 80%.The data collection occurred during the menstrual cycle at a painless time between the second and third week of OC use. The instruments used to collect the data were the Adapted Questionnaire according to the criteria of Lefebvre et al.8, which includes information such as personal characteristics, gynecological history and characteristics of PD; and an algom-eter, Microfet 2 HHD (Hoggan Health, United States) manual dynamometer, for evaluation of the pressure threshold of pain, the point where the pain starts. All measurements of the dyna-mometer were expressed in kg/cm3. The protocol for evalua-tion of pain points was based on the Molins-Cubero et al.9. For the PFM evaluation (levator ani and coccygeal), the patient was asked to stay in the lithotomy position, with the support of the lower members and relaxed PFM, locating the points located bilaterally in the pelvis (Figure 1).The participant was shown how algometry would be performed on the adductor muscle of the thumb, after which she was asked to speak the word “pain” when she felt a painful stimulus in the PF for three repetitions. For the PF evaluation, the algometer was positioned perpendicularly at each of the demarcated points, increasing the pressure at a constant rate (1kg/s), without abrupt variations. Measurements were made three times consecutively at each point, on the right side, and the left side, with a 30-sec-ond interval between each repetition, considering the average between these measurements. Participants were examined by a single researcher to maintain data collection consistency.The research began after approval of the Institutional Research Ethics Committee under Opinion number 2.384.714 in 2017.

Statistical analysesAll variables were analyzed for normality using the Kolmogor-ov-Smirnov test so that the variables that presented Gaussian distribution were submitted to parametric tests, and those that did not were analyzed through non-parametric tests. Parametric data were presented in mean±SD and non-parametric variables in median and interquartile range. Statistical differences between

Figure 1. Representation of the two assessed points in algometry9,10.

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BrJP. São Paulo, 2019 abr-jun;2(2):101-4

groups were analyzed using Student’s t-test or the Mann-Whit-ney test. Values of p<0.05 were considered statistically signifi-cant, using a 95% confidence interval. All statistical analysis was performed using GraphPad Prism® software, version 6.0 for Win-dows (GraphPad Software, San Diego, CA). RESULTS

Twenty-four young women were evaluated. Under the eligibili-ty criteria, the sample consisted of 20 women divided into two groups: G1 (n=10) and G2 (n=10). The flowchart with the inclu-sion and exclusion criteria is shown in figure 2.Table 1 presents data on the groups’ characterization of body mass index (BMI), age at menarche, bleeding time and blood flow. Table 1. Characterization of young women

G1 G2 p-value

Age (years) 21.0 ± 0.3 22.5 ± 0.4 0.015*

Body mass index (kg/m²) 23.1 ± 0.9 22.1 ± 0.8 0.449

Menarca (years) 12.7 ± 0.5 12.8 ± 0.4 0.878

Bleeding time (days) 3.0 (2.0-3.0) 2.5 (2.0-3.0) 0.449

Menstrual flow (grade) 2 (2.0-3.0) 2 (1.75-2.0) 0.232

Light 1 (10%) 2 (20%)

Moderate 6 (60%) 8 (80%)

IntenseFamily history of PD

2 (30%)7 (70%)

00

G1 = with primary dysmenorrhea; G2 = without primary dysmenorrhea; PD = primary dysmenorrhea. Data expressed as mean±SD, median, interquartile ran-ge and percentage. *p<0.05.

Table 2 presents the results of the pain pressure threshold in the groups during the period outside the menstrual bleeding. There was no statistically significant difference between groups. Table 2. Pressure pain threshold of young women

Pressure threshold G1 G2 p-value

Right side 2.4 ± 0.2 2.8 ± 0.2 0.156

Left side 2.5 ± 0.2 2.9 ± 0.3 0.198

G1 = with primary dysmenorrhea; G2 = without primary dysmenorrhea; Data expressed as mean±SD. *p<0.05.

DISCUSSION

In this study, we sought to compare the pain pressure threshold in the PF of women with and without PD. The participants of the G1 were younger than those of G2, and no difference was observed between the PF pain pressure threshold between the groups. Thus, despite the occurrence of pain during the menstru-al period, the PF of the G1 did not present pain sensitization at the central level, and it is possible to influence the use of OC in response to noxious stimuli.Vincent et al.11, when comparing pain tolerance among wom-en with and without PD who were not users of OC, found that the former showed higher responses to noxious stimu-lation, not only at the moment of pain but throughout the cycle. This suggests that women have central sensitization to pain related to the chronicity of pain. In the present study, the time of complaint of PD was not investigated and, con-sidering that the patients did not present chronic pain, this may have contributed to the non-occurrence of central sensi-tization, in addition to the results that were similar between the two groups.The evaluation of the pressure pain threshold in the low-er limb muscles and trunk of young women with PD and non-users of OC has already been demonstrated. Alfieri et al.12 observed a reduction in the pain tolerance values at the follicular phase of the menstrual cycle, suggesting that pain tolerance is negatively influenced by the follicular phase of the cycle. Although the mechanisms remain unclear, female hormones interact with the nociceptive processes at multiple CNS and peripheral levels, and hormonal variations are as-sociated with variations in the pain experience. However, in another study, no difference in pain sensitivity was observed during the menstrual cycle phases, suggesting that there was no consensus in the studies regarding pressure tolerance to pressure in PD patients5.For women who do not use OC, there is a fluctuation in pres-sure tolerance, which is lower in the menstrual phase. How-ever, for women using OC, the threshold seems to remain the same at different stages of the cycle13. It has already been shown that women who used OC presented a lower variation in the

Figure 2. Flowchart of inclusion and exclusion criteria

2 did not use oral contraceptives

Group with primary dysmenorrhea (n=10)

1 did not respond to all assessment tools

24 females evaluated

20 women analyzed

1 was in continuous use of oral hormonal contraceptives

Group without primary dysmenorrhea (n=10)

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pressure pain threshold compared to those who did not use this medication14. Similarly, another study15 examined the in-fluence of the menstrual cycle in women with symptoms of temporomandibular joint dysfunction and found that women who have used OC, with or without PD, showed higher tol-erance to pain when subjected to algometry. Comparing OC and non-OC users, the difference in pain tolerance was ob-served throughout the cycle only in women who did not use OC, which could indicate that the hormonal variation along the cycle may influence the perception of pain. Women who use OC showed no significant variations in the perception of pain during the menstrual cycle, since hormonal variation is small, which lessens the effects of the same cycle, suggesting that the OC can modulate pain.It should be emphasized that no studies were found that eval-uated the PF pressure threshold in women with and without PD. In the present study, in relation to the values found in the non-menstrual phase, it was observed that the PF pain threshold values were lower than those of the studies evaluating the abdo-men and anteroposterior iliac spines16. In addition, no reference values were found for women in this age group for comparison.Sherman et al.17 observed a variation in pain intensity at differ-ent stages of the menstrual cycle, but not at the blood pressure threshold. However, another study18 concluded that both the PD and the phase of the cycle might influence the pain threshold. Thus, it is assumed that the differences between the studies may relate to the different tissues evaluated and the type of stimulus that was given, so that there was little difference in the effect of the menstrual cycle on the response to pain by specific stimuli, except for electrical stimulation15.In the literature, PD charts are related to family history. Lopes13 analyzed 48 women with PD and found that 70% had a fami-ly history of menstrual cramps. Likewise, the present study, in which 70% of the women with PD reported having relatives with menstrual cramps, corroborates the findings of another study19, in which women who had mothers with PD had a better chance of developing PD.This study was the first to evaluate the pressure pain threshold in the PF algometry. Moreover, it stands out for evaluating women users of OC that, as previously described, can influence the sen-sation of pain throughout the cycle.

CONCLUSION

Apparently, the presence of primary dysmenorrhea does not in-fluence the pressure pain threshold in the pelvic floor of young women using oral contraceptives. REFERENCES

1. Tozun M, Unsal A, Ayranci U, Arslan G. Prevalence of disordered eating and its im-pact on quality of life among a group of college students in a province of west Turkey. Salud Publica Mex. 2010;52(3):190-8.

2. Araujo LM, Bastos WT, Silva JMN, Ventura PL. Diminuição da dor em mulheres com dismenorreia primária, tratadas pelo método Pilates. Rev Dor. 2012;13(2):119-23.

3. Kannan P, Claydon LS. Some physiotherapy treatments may relieve menstrual pain in women with primary dysmenorrhea: a systematic review. J Physiother. 2014;60(1):13-21.

4. Yu YP, Ma LX, Ma YX, Ma YX, Liu YQ, Xie JP, et al. Immediate effect of acupuncture at Sanyinjiao (SP6) and Xuanzhong (GB39) on uterine arterial blood flow in primary dysmenorrhea. J Altern Complement Med. 2010;16(10):1073-8.

5. Iacovides S, Avidon I, Baker FC. What we know about primary dysmenorrhea today: a critical review. Hum Reprod Update. 2015;21(6):762-78.

6. Terzi R, Terzi H, Kale A. [Evaluating the relation of premenstrual syndrome and primary dys-menorrhea in women diagnosed with fibromyalgia]. Rev Bras Reumatol. 2015;55(4):334-9.

7. Hoffman D. Central and peripheral pain generators in women with chronic pelvic pain: patient centered assessment and treatment. Curr Rheumatol Rev. 2015;11(2):146-66.

8. Lefebvre G, Pinsonneault O, Antao V, Black A, Burnett M, Feldman K, et al. Primary dysmenorrhea consensus guideline. J Obstet Gynaecol Can. 2005;27(12):1117-46. English, French.

9. Molins-Cubero S, Rodríguez-Blanco C, Oliva-Pascual-Vaca A, Heredia-Rizo AM, Boscá--Gandía JJ, Ricard F. Changes in pain perception after pelvis manipulation in women with primary dysmenorrhea: a randomized controlled trial. Pain Med. 2014;15(9):1455-63.

10. Travell JG, Simons DG. Dor e Disfunção Miofascial - Manual dos pontos-gatilho. 2. ed. Porto Alegre: Artmed Editora; 2006.

11. Vincent K, Warnaby C, Stagg CJ, Moore J, Kennedy S, Tracey I. Dysmenorrhoea is as-sociated with central changes in otherwise healthy women. Pain. 2011;152(9):1966-75.

12. Alfieri FM, Bernardo KM, Pinto YS, Silva NC, Portes LA. Pain tolerance and cardio-respiratory fitness in women with dysmenorrhea. Rev Dor. 2017;18(4):311-5.

13. Lopes KN. Avaliação dos limiares sensitivo e doloroso em mulheres com dismenorreia primária moderada ou grave [Dissertação]. Ribeirão Preto: Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto; 2016.

14. Dao TT, Knight K, Ton-That V. Modulation of myofascial pain by the reproductive hormones: a preliminary report. J Prosthet Dent. 1998;79(6):663-70.

15. Lobato VL, Bauru O. Influência do ciclo menstrual nas alterações de limiar de dor a pressão. Dissertação de Mestrado FOB. 2007.

16. Stallbaum JH, Silva FS, Saccol MF, Braz MM. Controle postural de mulheres com dismenorreia primária em dois momentos do ciclo menstrual. Fisioter Pesqui. 2018;25(1):74-81.

17. Sherman JJ, LeResche L, Mancl LA, Huggins K, Sage JC, Dworkin SF. Cyclic effects on experimental pain response in women with temporomandibular disorders. J Oro-fac Pain. 2005;19(2):133-43.

18. Giamberardino MA, Berkley KJ, Iezzi S, de Bigontina P, Vecchiet L. Pain threshold variations in somatic wall tissues as a function of menstrual cycle, segmental site and tissue depth in non-dysmenorrheic women, dysmenorrheic women and men. Pain. 1997;71(2):187-97.

19. Yanez N, Bautista-Roa SJ, Ruiz-Sternberg JE, Ruiz-Sternberg AM. Prevalencia y fac-tores asociados a dismenorrea en estudiantes de ciencias de la salud. Rev Cienc Salud. 2010;8(3):37-48.

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ABSTRACT

BACKGROUND AND OBJECTIVES: Although it is a public health problem, the prevalence of chronic pain, especially in work-ers, is underestimated. The present study aims to estimate the prev-alence of chronic pain and chronic neuropathic pain in workers of a federal public institution and to identify the associated factors.METHODS: A cross-sectional study conducted in a stratified random sample of civil servants of a federal higher education in-stitution, between October 2017 and March 2018. Standardized questionnaires involving sociodemographic characteristics and life habits were applied. For those with chronic pain (duration equal to or greater than three months), a questionnaire with pain characteristics was also applied, including a body map, the visu-al analog scale, and the neuropathic pain questionnaire Doleur Neuropathic 4. The prevalence of chronic pain was estimated, and the Poisson model was used to test the associations between variables (5% of alpha).RESULTS: In a sample of 108 active civil servants, chronic pain was found in 50% of the sample (95% CI=40.6-59.4) and chronic neuropathic pain in 12% (CI 95%=6.9-19.2). No asso-ciations were found between chronic pain and sociodemograph-ic characteristics or life habits. An independent association was confirmed between the frequency of pain and neuropathic pain, where continuous pain in relation to the occasional pain showed a prevalence ratio of 5.17 (CI95% CI=1.69-15.79, p=0.004).CONCLUSION: Chronic pain had a high prevalence in the in-stitution, being continuous in workers with neuropathic pain. The severity of this type of pain requires urgent actions for its control.Keywords: Chronic pain, Pain measurement, Risk factors.

Prevalence and factors associated with chronic neuropathic pain in workers of a Brazilian public universityPrevalência e fatores associados à dor neuropática crônica em trabalhadores de uma universidade pública brasileira

Igor Garcia Barreto1, Katia Nunes Sá2

Igor Garcia Barreto - https://orcid.org/0000-0003-3674-2826;Katia Nunes Sá - https://orcid.org/0000-0002-0255-4379.

1. Universidade Federal do Recôncavo da Bahia, Cruz das Almas, BA, Brasil.2. Escola Bahiana de Medicina e Saúde Pública, Salvador, BA, Brasil.

Submitted on December 11, 2018.Accepted for publication on March 20, 2019.Conflict of interests: none – Sponsoring sources: none.

Correspondence to: Pró-Reitoria de Gestão de PessoasRua Rui Barbosa, 71044380-000 Cruz das Almas, BA, Brasil.E-mail: igbarreto2@gmail.com

© Sociedade Brasileira para o Estudo da Dor

RESUMO

JUSTIFICATIVA E OBJETIVOS: Embora seja um problema de saúde pública, a prevalência de dor crônica, especialmente em trabalhadores, é subestimada. O presente estudo teve o objeti-vo de estimar a prevalência de dor crônica e de dor neuropática crônica em trabalhadores de uma instituição pública federal e identificar os fatores associados.MÉTODOS: Estudo de corte transversal conduzido em amostra aleatória estratificada de servidores de uma instituição de ensino superior federal, entre outubro de 2017 e março de 2018. Foram aplicados questionários padronizados envolvendo características sociodemográficas e hábitos de vida. Para os que tinham dor crô-nica (duração igual ou maior que três meses), foram também aplicados um questionário de características dolorosas, envolven-do um mapa corporal, a escala visual analógica e o questionário de dor neuropática Doleur Neuropathic 4. A prevalência de dor crônica foi estimada e o modelo de Poisson utilizado para testar as associações entre as variáveis (alfa de 5%).RESULTADOS: Em uma amostra de 108 servidores ativos, a dor crônica foi encontrada em 50% da amostra (IC95%=40,6-59,4), sendo 12% (IC95%=6,9-19,2) com características neuro-páticas. Não foram encontradas associações entre dor crônica e características sociodemográficas ou hábitos de vida. Foi confir-mada a associação independente entre a frequência de dor e dor neuropática, onde a dor contínua em relação à ocasional apresen-tou razão de prevalência de 5,17 (IC95%=1,69-15,79; p=0,004).CONCLUSÃO: A dor crônica apresentou elevada prevalência na instituição, sendo contínua em trabalhadores com dor neuropática. A gravidade desse tipo de dor exige ações urgentes para seu controle.Descritores: Dor crônica, Fatores de risco, Mensuração da dor.

INTRODUCTION

According to the International Association for the Study of Pain (IASP), chronic pain (CP) is the one that lasts longer than the ex-pected period for tissue healing. The threshold of three months has been recognized as the most convenient for non-malignant pain1. CP causes great damage for the individual, such as reduction of quality of life (QoL) and psychiatric disorders, including anxiety2, insomnia3, and depression4. It also creates an enormous burden on society, since it causes considerable damage to the health care systems and is associated with significant losses of productivity5,6.In the United States alone, CP affects around 100 million adults, which is higher than the total of heart disease, cancer, and diabe-

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DOI 10.5935/2595-0118.20190020

ORIGINAL ARTICLE

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tes combined5. In addition to its high frequency, it also presents a low annual recovery rate, since 79% of the affected individuals still have the symptoms even after four years7. On a global scale, CP has reached epidemic proportions due to the increasing prev-alence over the years8. In developed countries, its prevalence is estimated between 26.4 and 51.3%7-10, while in Brazil, between 28.1 and 42%11-13. Due to its subjective nature, CP varies ac-cording to psychosocial, cultural and sociodemographic factors, which is why tracking and identification of associated factors be-come relevant.CP can be classified as nociceptive or neuropathic. Neuropath-ic pain arises from injury or nervous system dysfunction14, and it is associated with more intense pain, in addition to being more difficult to treat15,16. Chronic neuropathic pain (CNP) causes more significant QoL impairment, mood disorders and difficulties in daily life activities17. Its treatment is very differ-ent from the effective treatment for nociceptive pain, being of utmost importance its differentiation. The careful evaluation of CP, especially the CNP, is vital to address more effective mea-sures for its control.Despite the high social cost and magnitude of the problem, with the involvement of a significant portion of the population on productive age, few studies have been conducted in Brazil to check the prevalence of CP in work environments. In this con-text, back pain is a recurrent complaint18,19. When it comes to workers of the public sector, the damage caused by CP affects the whole society directly, since they pay the costs.The present study aimed to estimate the prevalence of CP and CNP, as well as to check the factors associated with this disease in a population of workers of a higher education federal institution.

METHODS

A cross-sectional study conducted at the Federal University of Recôncavo da Bahia (UFRB), at its campuses located in the cities of Cruz das Almas, Santo Antônio de Jesus, Amargosa, Cachoe-ira, Santo Amaro and Feira de Santana (Bahia-Brazil) between October 2017 and March 2018.The active workers of UFRB were eligible for the study. Accord-ing to data from March 2017, there were 1,496 active workers, of these 781 teachers and 715 administrative technicians. The exclusion criteria were pregnancy, workers at gestation leave, workers away for personal reasons, for health reasons, provided that the cause was not the CP and training, with a scheduled date for the end of the respective leaves after 30 days after the ex-pected date to conclude the data collection. Employees working out of their main workplace and with difficulties to answer the questionnaires were also excluded. Workers who were away from their activities for less than the study period, such as in the case of leave, short leave or holidays, were interviewed after 30 days of returning to work.The stratified random sample was performed with the Micro-soft Excel® software using the following procedure: a) the list of all workers was divided by position (teachers or administrative technicians), b) the command “= random ( ) “ was used to gen-erate a random number assigned to each worker, c) the lists were

sorted in ascending order based on the random number, d) the list was then followed strictly until the sample calculation was reached within each category. The stratification was performed due to significant wage and socio-cultural differences between these categories. With an estimated prevalence of CP of 41.4%, as found in a study conducted in Salvador12, a sample was calcu-lated by WinPepi, version 11.65, with a 95% confidence interval (CI) and an acceptable difference of 9%, of 56 teachers and 52 administrative technicians.The participants selected were invited to the study via institu-tional email or telephone contact. For those who indicated an intention to participate, individual face-to-face interviews were scheduled with a single investigator, a labor physician who per-formed the collection in a standardized manner.First, a questionnaire was applied involving sociodemographic information and lifestyle. In the end, individuals were asked about the presence of pain and, if so, how long they have had the problem. The minimum duration of three months was used as the classification criteria for CP. Participants with CP then answered a questionnaire about pain characteristics, with a body map to identify the sites with the worst pain, a visual analog scale, ranging from “zero”, without pain, to “10”, the worst pain possible, in addition to questions about the frequency of pain and if they have had any treatment for it.The Doleur Neuropathic 4 (DN-4) questionnaire was used to differentiate the type of pain between neuropathic or nocicep-tive, which was validated for Brazilian Portuguese, showing good validity and reliability21. The participants answered two ques-tions, involving seven pain symptoms. Each item had “yes” or “no” answers. Each “no” answer received a “zero” score, and each “yes” received a “1”. Participants with a score greater than or equal to 3 were classified as neuropathic pain. When using this strategy, the instrument has a sensitivity of 81.6% and specificity of 85.7% in the detection of neuropathic pain20.The Human Research Ethics Committees of the Escola Baiana de Medicina e Saúde Pública (Medicine and Pub-lic Health Care School of Bahia), and Universidade Federal do Recôncavo da Bahia (Federal University of the Recôn-cavo of Bahia), approved the present study under numbers 69348117.8.0000.5544 and 69348117.8.3001.0056, respec-tively. All the workers had the signatures collected in the Free and Informed Consent Form (FICT).

Statistical analysis All data were tabulated and analyzed by Stata for Windows version 13.0 (StataCorp LP, College Station, TX, USA). The variables were presented descriptively in absolute numbers and proportions, and their prevalence were estimated by the num-ber of affected individuals divided by the number of individuals exposed. Two analyses were performed after the descriptive sta-tistic. The first one had as independent variables: age, gender, marital status, skin color, position, physical activities, smoking, alcoholism, education level and distance between the cities of residence and work, being the dependent variable the presence or not of CP. The second analysis used as independent variables, the time since the beginning of the pain symptoms, their intensity,

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location, frequency and if the patient was receiving any treat-ment for control. The type of pain (nociceptive or neuropathic) was the dependent variable.The variable marital status was categorized as single, married, do-mestic partnership, divorced or widowed. The color of the skin was classified according to the criteria of the Brazilian Institute of Geography and Statistics (IBGE) as white, black, brown, yellow and indigenous, the latter category being excluded due to lack of representatives. For physical activity, the guidelines of the Amer-ican College of Sports Medicine (ACSM) were used, defining as active individuals those who performed 30 minutes or more of physical activity (PA) with moderate intensity at least 5 days per week or 20 minutes of vigorous PA at least 3 days per week. The others were classified as sedentary21.The educational level was categorized into 5 levels (high school or below, higher education, postgraduate, masters, doctorate or higher). The alcohol consumption was determined as moderate or excessive if the consumption was higher than weekly or in the presence of drunkenness. Less frequent use classified respondents as non-consumers. For smoking, the workers were divided into nonsmokers, former smokers, and current smokers. The location of the pain was categorized according to the segments of the body in the head and neck, lumbar spine, lower limbs, and upper limbs. The numerical variables were analyzed in their original form.A high prevalence of the study outcome was expected due to pre-vious population-based studies of CP. For this reason, the estimate of the prevalence ratio (PR) obtained by the Odds Ratio (OR) in logistic regression models became inadequate. Due to this prob-lem, the Poisson regression with the sandwich estimator of the variance22 was used in the present study, since this model presents estimates of the PR and its CI95% similar to those obtained by the Mantel-Haenszel procedure, even with the use of more than one confounding variable and continuous covariates23.

An initial univariate analysis was performed in the two statistical analyzes cited. The variables that had a p<0.2 were selected to enter the multivariate model. Through the “Backward” elimi-nation process, the least significant variables were successively excluded until a p<0.1 in the remnants was reached, which was used as the threshold for inclusion of the variables in the final multivariate model. Analysis with p<0.05 was considered statis-tically significant.

RESULTS

Figure 1 shows the flowchart of the data collection.As noted, 108 participants completed the questionnaires and were included in the study. The sociodemographic characteris-tics and lifestyle of the interviewed workers are shown in table 1.The workers in the sample had a mean age of 42.4±10.7 years. The majority of them were male (62%), married or in a do-mestic relationship (60.2%). Regarding skin color, brown was the predominant (48.6%), while white was 31.4%, black 17.1% and yellow 2.9% of the sample. Teachers accounted for 51.9% of the participants, followed by lower level tech-nicians, 32.4% and higher level, 15.7%. In terms of educa-tional level, the majority of the workers had a Ph.D. (39.8%), followed by postgraduate or specialization (20.4%), master’s degree (18.5%), higher education (13.9%) and high school or lower (7.4%).Regarding life habits, the sample was predominantly composed of sedentary individuals (52.3%), non-smokers (81.6%) and non-consumers of alcoholic beverage (75.5%). The distance be-tween the city of residence and work had a median of zero and an interquartile range (IQR) of zero in the quartile of 25% and of 117.5 in the quartile of 75%, indicating that most people live in the same city where they work.

Figure 1. Data collection flowcharta list generated with data from October/2017; b the command “= random ()” from the software Microsoft Excel was used to generate a random number associated with each worker. The lists of workers were then sorted in ascending order to obtain a random sequence; c Training refers to the long-term absence of service for a master’s, doctorate or postdoctoral degree.

1525 workers subject to stratification a

54 guests

2 (3.7%) excluded1 (1.8) Training c

1 (1.8) Exercise out of workplace

52 Administrative Technicians completed the questionnaire

712 Administrative Technicians generated by random list b

813 Teachersgenerated by random list b

78 guests

22 (28.2%) excluded9 (11.5) Training c

13 (16.7) did not respond to the invitation

56 Teachers completed the questionnaire

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Of the 108 participants, 54 were positively tracked for CP, result-ing in a prevalence of 50% (CI95%=40.6-59.4). The pain time had a median of 28.5 months (IQI: 16.5-61.0), and the pain intensity had a mean of 5.55±1.76. Low back pain was the ma-jor cause of CP in the sample, affecting 22 individuals (41.5%),

Table 1. Sociodemographic profile and lifestyle of the UFRB workers sample

Variables Total (n = 108)

Age (years)

Mean±SD 42.4±10.7

Gender

Male (n and %) 67 (62)

Female (n and %) 41 (38)

Marital status

Single (n and %) 36 (33.3)

Married or domestic part (n and %) 65 (60.2)

Divorced or widowed (n and %) 7 (6.5)

Skin color a

White (n and %) 33 (31.4)

Black (n and %) 18 (17.1)

Brown (n and %) 51 (48.6)

Yellow (n and %) 3 (2.9)

Position

Teacher (n and %) 56 (51.9)

Higher education technician (n and %) 17 (15.7)

high school or less educational technician (n and %)

35 (32.4)

Physical activity

Active (n and %) 51 (47.7)

Sedentary (n and %) 56 (52.3)

Smoking

Yes (n and %) 6 (5.8)

No (n and %) 84 (81.6)

Ex-smoker (n and %) 13 (12.6)

Alcohol consumption

No (n and %) 80 (75.5)

Moderate or excessive (n and %) 26 (24.5)

Education level

High school or lower (n and %) 8 (7.4)

Higher education (n and %) 15 (13.9)

Postgraduate or specialization (n and %) 22 (20.4)

Master’s degree (n and %) 20 (18.5)

Ph.D. (n and %) 43 (39.8)

Distance between the city of residence and work in km

Median (IQI) 0 (0-117.5)SD = standard deviation; IQI = interquartile interval; a the “indigenous” category was excluded due to lack of representatives.

followed by pain in the upper limbs present in 13 (24.5%), lower limbs in 11 (20.8%) and head and neck pain in 7 (13.2%). The pain was occasional in 31 people (57.4%), and the majority of the workers (66.7%) were not receiving any treatment for it. Re-garding the type of pain, 41 individuals (75.9%) had nociceptive pain characteristics, while only 13 had neuropathic pain. This data allows the calculation of the prevalence of CP with neu-ropathic characteristics of 12% (95% CI = 6.9-19.2) (Table 2).An analysis was performed involving possible factors associated with the presence of CP in the worker’s sample, using the Poisson model with a robust estimator of the variance. In the univariate analysis, no statistically significant associations were found among the variables. Of the possible factors associated with CP in the sample, only the gender reached the pre-specified threshold of p <0.2 for multivariate analysis, justifying its non-performance (Table 3).A second analysis was performed to test possible associations be-tween the pain characteristics and the probability of having CP with neuropathic characteristics. In the univariate analysis, it was observed that the time, intensity and frequency of pain variables reached the thresholds of p <0.2 and entered the initial multivar-iate model (Table 4).After the Backward elimination procedure, only the variable pain frequency remained significant enough to enter the final model, where a p=0.004 was observed. When analyzing the factors, it was noted that this association was due to a PR of 5.17 (95% CI = 1.69-15.79) for ongoing pain in relation to the occasional pain (Table 5).

Table 2. Characterization of pain among chronic pain patients in the UFRB workers sample

Variables Total (n=54)

Time of pain (in months)

Median (IQI) 28.5 (16.5-61.0)

Pain intensity

Mean±SD 5.55±1.76

Location of pain (n and %) ä

Head and neck 7 (13.2)

Lumbar spine 22 (41.5)

Upper limbs 13 (24.5)

Lower limbs 11 (20.8)

Pain frequency (n and %)

Occasional 31 (57.4)

Daily 17 (31.5)

Continuous 6 (11.1)

Treatment for pain (n and %)

Yes 18 (33.3)

No 36 (66.7)

Type of pain (n and %)

Nociceptive 41 (75.9)

Neuropathic 13 (24.1)

SD = standard deviation; IQI = interquartile interval; a there were no participants with thoracic spine pain.

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Table 3. Univariate analysis of the factors associated with chronic pain among UFRB workers (n=108)

Variables Chronic pain Gross PR (CI95%) b p-value

Age 0.74

Mean±SD 42±11 1 (0,98-1,01) c

Gender 0.16 d

Male (%) 30 (27.8) 1

Female (%) 24 (22.2) 1.31 (0.89-1.90)

Marital status 0.87

Single (%) 17 (15.7) 1.65 (0.44-6.14)

Married or domestic part. (%) 35 (32.4) 1.88 (0.52-6.81)

Divorced or widowed (%) 2 (1.19) 1

Skin color a 0.39

White (%) 18 (17.1) 1.63 (0.22-11.91)

Black (%) 10 (9.5) 1.67 (0.22-12.38)

Brown (%) 24 (22.9) 1.41 (0.19-10.24)

Yellow (%) 1 (0.9) 1

Position 0.23

Teacher (%) 25 (23.2) 0.78 (0.52-1.18)

Higher education technician (%) 9 (8.3) 0.93 (0.54-1.60)

High school educational technician or lower (%) 20 (18.5) 1

Physical activity 0.78

Active (%) 26 (24.3) 1.06 (0.72-1.55)

Sedentary 27 (25.2) 1

Smoking 0.44

Yes (%) 3 (2.9) 0.81 (0.50-1.33)

No (%) 42 (40.8) 0.81 (0.30-2.17)

Ex-smoker 8 (7.8) 1

Alcohol consumption 0.66

No (%) 41 (38.7) 1.11 (0.69-1.78)

Moderate or excessive (%) 12 (11.3) 1

Education level 0.22

High school or lower (%) 3 (2.8) 0.90 (0.32-2.48)

Higher education (%) 10 (9.2) 1.60 (0.95-2.66)

Postgraduate or specialization (%) 14 (13.0) 1.52 (0.94-2.46)

Master’s degree (%) 9 (8.3) 1.07 (0.58-1.98)

Ph.D. (%) 18 (16.7) 1

Distance between the city of residence and work in km 0.98

Median (IQI) 61.6 (106.6) 1 (1-1) c

SD = standard deviation; IQI = interquartile interval; PR = prevalence ratio; a the category “indigenous” was excluded due to lack of representatives; b PR calculated by Poisson regression with robust estimator; c these values represent the PR of the increment of one unit in the independent variabled multivariate analysis was not performed because only the variable “gender” had reached the pre-defined threshold of p<0.2.

Table 4. Analysis of factors associated with neuropathic pain among patients with chronic pain in the sample (n=54)

Variables a Neuropathic n (%) Nociceptive n (%) Univariate - p a

Gross PR (IC95%)

Time of pain (in months) p=0.16

Median (IQI) 24 (14.5-56) 30 (17.5-75) 0.99 (0.98-1.00)

Location of painb p=0.84

Head and neck 3 (25.0) 4 (9.8) 2.36 (0.47-11.75)

Lumbar spine 1 (8.3) 21 (51.2) 0.25 (0.23-2.65)

Upper limbs 6 (50.0) 7 (17.1) 2.54 (0.59-10.82)

Lower limbs 2 (16.7) 9 (22.0) 1Continue...

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Barreto IG and Sá KNBrJP. São Paulo, 2019 abr-jun;2(2):105-11

DISCUSSION

CP has reached alarming proportions, becoming a priority con-cern for the health care systems. By reaching a significant por-tion of the working-age population, it has negative impacts on employers. Despite this, there is a scarceness of studies that track the prevalence of CP, especially in labor environments in Brazil. The present sample showed a high prevalence was found, placing the institution and the federation in a situation of economic vul-nerability and workers in social risks related to the loss of health.A 50% prevalence of CP was found among active public workers of the institution. This result exceeds most of the previous studies. Three population-based studies conducted in Brazil found prevalence of 28.1% in São Paulo11, 41.4% in Salvador12 and 42% in São Luís13. Considering a work envi-ronment, a study conducted by Kreling, da Cruz e Pimenta24 found an even higher prevalence of 61.4% among employees of a state university in Paraná. However, that study did not screen for CNP. It is noteworthy that the prevalence of CP is so high in educational institutions. In a study conducted among tobacco farmers, whose mechanical risk is high, they found a prevalence of 8.4% of pain in the lumbar spine18, a result much lower than the one found in the present study, which estimated 20.4% prevalence of pain in this body area. In other countries, prevalences were always lower and ranged from 19.6% to 43.5% in Libya25, Morocco26, France20, and the United Kingdom8. These differences can be justified by the cut-off point for the stratification of CP, varying between three and six months, and by the different economic, social and cultural conditions involved.

CNP had a prevalence of 12% in the sample. This value is wor-risome, mainly because this type of pain is related to a worse prognosis and has greater interference in the life of the individu-als affected compared to those who only have nociceptive pain17. A similar result was found in a population-based study in São Luís that found a prevalence of CNP of 10%13. However, that study included the elderly and retirees, indicating that the prev-alence of CNP in the current study is even more serious because it affects explicitly active workers. At the global level, the preva-lence of neuropathic pain is 3.9% in Libya25, 6.9% in France20, 8.1% in Canada27, from 8.2 to 8.9 % in the United Kingdom8

and 10.6% in Morocco26. The variation in the outcome found in these studies can be explained by the use of different scales to diagnose the type of pain. In Brazil, the high incidence of CNP is alarming, which requires urgent measures.In the present study, no differences were found between the sociodemographic factors or lifestyle and the presence of CP. In the literature, there are differences among the predictors for CP, but most of the studies state that its prevalence is higher in females and increases with age8,11-13,26. The size of the sample may have been insufficient to find significance in these associations since the study was not designed to evaluate these outcomes specifically.The individuals with CNP had a higher prevalence of contin-uous pain compared to occasional pain. Previous studies have shown that pain characteristics vary significantly among peo-ple with nociceptive and neuropathic pain20,26. Similarly, it was found in these studies a more intense pain and a longer time since the onset of the symptoms and the location in the limbs among those with CNP. These were also the findings of the study conducted by De Moraes Vieira et al. 13, with the addi-tional finding of a higher daily and continuous pain frequency among patients with CNP. The higher frequency of pain among those with CNP suggests a more significant impairment of dai-ly activities, which further affects the ability to work, leads to early retirement and increases the direct and indirect costs for the whole society.The present study sought a rigorous methodology to get an ac-curate estimate of the prevalence of CP and CNP among work-ers of a federal institution, using a stratified random sampling and appropriate robust statistical models. It also applied the

Table 4. Analysis of factors associated with neuropathic pain among patients with chronic pain in the sample (n = 54) – continuation

Variables a Neuropathic n (%) Nociceptive n (%) Univariate - p a

Gross PR (IC95%)

Pain intensity p=0.02

Mean±SD 6.5±1.7 5.2±1.7 1.42 (1.05-1.91)

Pain frequency p=0.004

Continuous 4 (30.8) 2 (4,9) 5.17 (1.69-15.79)

Daily 5 (38.5) 12 (29.3) 2.28 (0.68-7.56)

Occasional 4 (30.8) 27 (65.9) 1

Treatment for pain p=0.66

No 8 (61.5) 28 (68.3) 0.80 (0.30-2.14)

Yes 5 (38.5) 13 (31.7) 1SD = standard deviation; IQI = interquartile interval; PR = prevalence ratio; a Poisson Robust model; b there were no participants with thoracic spine pain.

Table 5. Multivariate analysis of factors associated with neuropathic pain (n=54)

Variables Adjusted PR a

(CI95%)p-value

Pain frequency 0.004

Continuous 5.17 (1.69-15.79)

Daily 2.28 (0.68-7.56)

Occasional 1a Robust Poisson model. The time and intensity of pain variables were succes-sively excluded.

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instrument that presented the best results for the tracking of neuropathic pain20,26-28. However, the study faced difficulties in getting answers from teachers. Even reaching the calculation of the sample and applying adequate techniques for randomization, the high refusal in this group of workers may have led, to some degree, to a selection bias. The fact that the present study was conducted with a particular population of workers, and the find-ing of the prevalence of CP and CNP was higher than most of the previous studies, suggests an association with being a public worker. This association was not tested since a comparison group of non-public workers was not used. However, it can serve as the basis for future studies on this subject. The cross-sectional design did not allow to establish causal or trend inferences. However, as an exploratory study, it provides relevant data for longitudinal studies, socio-educational interventions in occupational health and public health policies. CONCLUSION

In conclusion, the 50%prevalence of CP and 12% of CNP was found among the employees of a higher education institution located in the countryside of the state of Bahia, Brazil. No asso-ciations were found between sociodemographic characteristics or lifestyle and the presence of CP. Continuous pain was more prev-alent among people with CNP. The study broadens the knowl-edge about the epidemiology of pain in the workplace, showing the higher prevalence of CNP found so far, both in national and international studies.

ACKNOWLEDGMENTS

To the participants for the time and collaboration in the study, as well as to the entire team of the Pro-Rectory of People Man-agement of the Federal University of the Recôncavo da Bahia for the support and provision of the necessary data for this study. REFERENCES

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16. Vissers KC. The clinical challenge of chronic neuropathic pain. Disabil Rehabil. 2006;28(6):343-9.

17. Alves MI. Compreender a Dor Neuropática Crónica. 2009.18. Meucci RD, Fassa AG, Faria NM, Fiori NS. Chronic low back pain among tobacco

farmers in southern Brazil. Int J Occup Environ Health. 2015;21(1):66-73.19. Höfelmann DA, Blank N. [Self-rated health among industrial workers in Southern

Brazil]. Rev Saude Publica. 2007;41(5):777-87. Portuguese.20. Bouhassira D, Lantéri-Minet M, Attal N, Laurent B, Touboul C. Prevalence of

chronic pain with neuropathic characteristics in the general population. Pain. 2008;136(3):380-7.

21. de Lima DF, Levy RB, Luiz Odo C. Recommendations for physical activity and health: consensus, controversies, and ambiguities]. Rev Panam Salud Publica. 2014;36(3):164-70. Portuguese.

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23. Coutinho LM, Scazufca M, Menezes PR. [Methods for estimating prevalence ratios cross-sectional studies]. Rev Saude Publica. 2008;42(6):992-8. English, Portuguese.

24. Kreling MC, da Cruz DA, Pimenta CA. [Prevalence of chronic pain in adult workers]. Rev Bras Enferm. 2006;59(4):509-13. Portuguese.

25. Elzahaf RA, Johnson MI, Tashani OA. The epidemiology of chronic pain in Libya: a cross-sectional telephone survey. BMC Public Health. 2016;16(1):776.

26. Harifi G, Amine M, Ait Ouazar M, Boujemaoui A, Ouilki I, Rekkab I, et al. Preva-lence of chronic pain with neuropathic characteristics in the Moroccan general popu-lation: a national survey. Pain Med. 2013;14(2):287-92.

27. VanDenKerkhof EG, Mann EG, Torrance N, Smith BH, Johnson A, Gilron I. An epidemiological study of neuropathic pain symptoms in Canadian adults. Pain Res Manag. 2016;2016:9815750.

28. Bouhassira D, Attal N, Alchaar H, Boureau F, Brochet B, Bruxelle J, et al. Compari-son of pain syndromes associated with nervous or somatic lesions and development of a new neuropathic pain diagnostic questionnaire (DN4). Pain. 2005;114(1-2):29-36.

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ABSTRACT

BACKGROUND AND OBJECTIVES: The sensation of pain is essential for life, and its assessment in critical non-contacting patients can be performed using validated scales. The Behavioral Pain Scale is a highly accurate tool that has been widely used in this group of patients. This study aimed to describe and charac-terize pain and the use of analgesia in the emergency or intensive care service.METHODS: This was a cross-sectional study with a quantita-tive approach with 67 critically ill patients unable to verbalize their pain perception, who were hospitalized in the emergency service or Intensive Care Units of a public hospital in Vitória da Conquista, Bahia from April to July 2017. Clinical and epide-miological data were collected using the medical record and then applied to the Behavioral Pain Scale for pain assessment. RESULTS: There was a predominance of male patients (47/70.1%). Three groups were identified based on the use of sedatives and analgesics: patients taking sedatives and analgesics combined, only analgesia, and those without any sedation or an-algesia. We observed ascending Behavioral Pain Scale scores in all groups during tracheal suction, but the same did not occur with the physiological parameters. CONCLUSION: The study proposes the adoption of pain assess-ment scales in critical patients, such as the Behavioral Pain Scale, as well as the use of protocols for analgesia management, and con-sequently improve the quality of care and patient’s recovery.Keywords: Emergency medical services, Intensive Care Units, Pain, Pain management, Pain measurement.

Pain assessment in critical patients using the Behavioral Pain Scale Avaliação da dor em pacientes críticos por meio da Escala Comportamental de Dor

Laudice Santos Oliveira1, Maiara Pimentel Macedo1, Stefany Ariadley Martins da Silva1, Ana Paula de Freitas Oliveira1, Victor Santana Santos2

Laudice Santos Oliveira - https://orcid.org/0000-0002-8747-4625;Maiara Pimentel Macedo - https://orcid.org/0000-0002-0611-6034;Stefany Ariadley Martins da Silva - https://orcid.org/0000-0001-9637-4485;Ana Paula de Freitas Oliveira - https://orcid.org/0000-0002-7410-1563;Victor Santana Santos - https://orcid.org/0000-0003-0194-7397.

1. Universidade Federal da Bahia, Instituto Multidisciplinar em Saúde-Campus Anísio Teix-eira, Departamento de Enfermagem, Vitória da Conquista, BA, Brasil. 2. Universidade Federal de Alagoas, Departamento de Enfermagem, Arapiraca, AL, Brasil.

Submitted on May 10, 2018.Accepted for publication on February 19, 2019.Conflict of interests: none – Sponsoring sources: none.

Correspondence to: Rua Hormindo Barros, 58, Quadra 17, Lote 58 – Bairro Candeias 45.029-094 Vitória da Conquista, BA, Brasil.E-mail: enf.lais@gmail.com

© Sociedade Brasileira para o Estudo da Dor

RESUMO

JUSTIFICATIVA E OBJETIVOS: A sensação de dor é essencial para a vida. Sua avaliação em pacientes críticos não contatantes pode ser realizada por meio de escalas validadas. A Behavioral Pain Scale é um instrumento de aplicação, com elevada acurácia, e que tem sido amplamente utilizada neste grupo de pacientes. Este estudo objetivou descrever e caracterizar a dor e o uso de analgesia no serviço de urgência e cuidados intensivos.MÉTODOS: Trata-se de um estudo transversal com abordagem quantitativa, realizado com 67 pacientes críticos impossibilitados de verbalizar a percepção de dor, os quais estavam hospitalizados na área vermelha do pronto-socorro ou nas Unidades de Terapia Intensiva de um hospital público de referência em Vitória da Con-quista, Bahia no período de abril a julho de 2017. Dados clínicos e epidemiológicos foram coletados utilizando-se o prontuário e em seguida foi aplicada a Behavioral Pain Scale para avaliação da dor. RESULTADOS: Houve predomínio de pacientes do sexo mas-culino (47/70,1%). Foram identificados três grupos com base no uso de sedativos e analgésicos: pacientes em uso de sedoanal-gesia, uso apenas de analgesia, e os que estavam sem sedação ou analgesia. Visualizou-se ascensão dos escores da Behavioral Pain Scale em todos os grupos durante a aspiração traqueal, porém o mesmo não aconteceu com os parâmetros fisiológicos. CONCLUSÃO: O estudo apresentou como proposta a adoção de escalas de avaliação da dor no paciente crítico, como a Beha-vioral Pain Scale, bem como uso de protocolos de analgesia e manuseio, melhorando assim a qualidade da assistência prestada e a recuperação do paciente.Descritores: Dor, Manuseio da dor, Mensuração da dor, Pronto--Socorro, Unidade de Terapia Intensiva.

INTRODUCTION

The sensation of pain is essential for life. Its perception is the re-sult of multidimensional and personal experiences in the face of the various stimuli that result or not in tissue injury1. Therefore, the protocols of care recommend the evaluation of pain by health professionals during the assistance. In individuals who verbalized and have preserved cognition, pain measurement can be more easily reported because the individual is able to describe the pain he/she feels2. However, in critically ill patients who are under ad-verse conditions that prevent them from verbalizing the presence or absence of pain3,4 either by changes in the level of conscious-ness, the effects of sedative agents and/or the use of mechanical ventilation5, the measurement of pain can only be indirect.

DOI 10.5935/2595-0118.20190021

ORIGINAL ARTICLE

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Some studies report that the observation of changes in physio-logical parameters may be a quick and simple method to infer pain6-8. However, the use of physiological data alone is debat-able, since several factors such as fear, anxiety and psychological stressors can influence this measurement6,7,9. Also, the absence of changes in the vital signs does not necessarily indicate the ab-sence of pain10.As the inability to report pain does not deny its existence and does not discard the right to adequate treatment11, when it is impossible to obtain the patient’s self-report about the pain it is recommended to use observational scales12 that are based on the individual’s physiological parameters and body expressions. Among the available scales to measure the pain in non-respon-sive patients, the most used by the health services is the Behav-ioral Pain Scale (BPS) because it is highly accurate and easy to apply to patients with severe pain13,14.Knowing the level of pain of patients, whether critical or not, is essential to optimize comfort and minimize suffering15. In ad-dition, effective and adequate pain control is associated with a reduction in mechanical ventilation time, shorter patient length of stay, and lower morbidity and mortality rates in intensive care units (ICU)16. However, despite these benefits, pain assessment has been performed inadequately (or not performed) in some health services that provide care to critical patients, making it difficult to manage pain in these patients adequately17,18. Given the above, the present study aimed to evaluate the pain and the use of analgesia in critically ill patients admitted to the emergency and intensive care services of a public reference insti-tution in southwest Bahia.

METHODS

This is a cross-sectional and descriptive study with a quantita-tive approach, referring to critically ill patients admitted to the red area of the emergency room or to one of the two ICUs of a public reference hospital in Vitória da Conquista, Bahia, Brazil, between April and July 2017. This hospital is located 519 km from the capital, Salvador, and it is a reference for 73 smaller cities with a population of approxi-mately 1.7 million inhabitants19. The sampling was non-probabilistic due to adequacy, with an estimated sample size of about 60 – 65 patients. The calculation was based on an accuracy of 0.95±0.05 of the Cronbach’s alpha coefficient for a scale with three subscales.All critical patients admitted during the study period, older than 18 years of age, of both genders, using mechanical ventilation, sedated and unarticulated, who were unable to report pain, and with a maximum stay time of 48h were included. Patients in neurological protection, quadriplegic, who had received a neuro-muscular blocker, who had peripheral neuropathy or suspicion of brain death, were excluded. These exclusion criteria were used not to include patients whose diseases or drugs could compro-mise the expression of pain behaviors.After the written consent was signed by a responsible family member, duly trained research assistants, using the previously prepared data collection instrument, obtained the clinical and

demographic data from the patient’s medical records. The demo-graphic information included age and gender. The clinical data included prior comorbidities, diagnosis, pharmacological pre-scription (use of analgesics and continuous infusion sedatives, given at regular intervals or if necessary). In addition, the infor-mation on the neurological assessment of each patient was ob-tained using the Glasgow Coma Scale, FOUR (Full Outline of Unresponsiveness), and the Richmond Agitation Sedation Scale (RASS), which are routinely used by professionals who work in the field of study. The research assistants also collected information on the vi-tal signs of each patient using a multimodal monitor during three moments of the study: at rest, during eye cleansing (EC) with gauze moistened in saline (considered a non-painful procedure) performed by the nursing technician and during the tracheal suction (TS) (considered a painful procedure)20 performed by the assistant physiotherapist. These procedures are already part of the patient care routine, so no additional procedure is required.Simultaneously, the researchers applied the BPS validated in Brazil by Morete et al.14 (Table 1). The BPS has a total of 12 descriptors, distributed in 3 items (1. Facial expression, 2. Upper limbs, 3. Adaptation to mechanical ventilation)7,14 with results varying from 3 (absence of pain) to 12 (unbear-able pain)13. A score >3 indicates the presence of pain and ≥5 indicates significant pain21.

Table 1. The Brazilian version of the Behavioral Pain Scale

Items Description Score

Facial expression RelaxedPartially contracted (e.g., lowering eyelid)Completely contracted (eyes clo-sed)Facial contortion

1234

Movement of the upper limbs

No motionPartial motionFull motion with finger flexionPermanently contracted

1234

Comfort with the mechanical ventila-tion

TolerantCough, but tolerant of mechanical ventilation most of the timeFighting with the fanNo ventilation control

12

34

The present study complies with the provisions of Resolution 466/12 and was approved by the Human Research Ethics Committee of the Multidisciplinary Health Institute, Anísio Teixeira Campus of the Federal University of Bahia under CAAE 65835917.6.0000.5556.

Statistical analysisAll information obtained was coded and inserted into a data-base. Then, we performed an exploratory analysis of the data through the calculation of absolute and percentage simple fre-quencies for the categorical variables. The normal distribution of the data set was checked using the Kolmogorov-Smirnov test. The ANOVA test was used to check the fluctuation of the

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RESULTS

Sixty-seven patients were included in the study. Each of them was evaluated in three moments: a) at rest, b) eye cleansing (EC) and c) tracheal suction (TS); totaling 201 observations (67 pa-tients versus three observations each). Patients were predomi-nantly male (47/70.1%), with a median age of 56 years (IIQ: 36-74), urban residents (51/76.1%), with reports of pre-existing comorbidity (41/61.2%). Most patients had a clinical diagnosis (49/73.1%), followed by trauma (18/26.9%) (Table 2).After collection, three groups of patients were identified based on the use of sedatives and analgesics: G1, patients undergoing sedation and analgesia; G2, only using analgesia; and G3, with-out sedation or analgesia. The majority of the patients were using analgesia associated with sedation (31/46.3%), and midazolam and fentanyl were the most commonly used drugs. Patients undergoing sedation and analgesia were evaluated by RASS and had an average score of -4.5±1.29. Eighteen (26.9%) were using analgesia alone, with fentanyl and dipyrone being the most prescribed analgesics. For these individuals, the neurological evaluation was performed us-ing the FOUR scale in 28 patients with a mean of 6.2±3.63; and Glasgow coma scale in six patients with a mean of 4.3±2.16. Sixteen patients (23.9%) were without analgesia or sedation. Of the 201 observations, in 70 (34.8%) patients had a score of ≥5 on BPS (Table 2).Table 3 shows the variation of the physiological parameters in the three evaluation moments for the three groups identified. Variation was observed in the three evaluation groups in all the physiological parameters with the interventions, except in temperature. Table 4 shows the variation of the BPS scores. In all three groups of patients, a significant fluctuation was observed in all scores on the scale, especially between at rest and tracheal suction.

Table 2. Demographic and clinical data of the patients included in the study. Vitória da Conquista, April to July/2017

Categorical variables n (%)

Gender, male 47 (70.1)

Area, urban 51 (76.1)

Diagnostic classification

Clinical 49 (73.1)

Trauma 18 (26.9)

Comorbidity

Yes 41 (61.2)

Pharmacological scheme

Prescribed sedation and analgesia

Group 1 31 (46.3)

Group 2 18 (26.9)

Group 3 16 (23.9)

Pain assessment

BPS ≥5* 70 (34.8)

BPS ≥5 (During TS) ** 61 (91)

Numerical variables Mean (SD)

Age, median (IQI) FOUR

56 (36-74)6.2±3.63

Coma Glasgow scale 4.3±2.16

RASS -4.5±1.29BPS = Behavioral Pain Scale; TS = tracheal suction; FOUR = Full Outline of Unres-ponsiveness; RASS = Richmond Agitation Sedation Scale; IQI = interquartile inter-val; Group 1 = sedation and analgesia; Group 2 = analgesia; Group 3 = no sedation or analgesia. Categorical data presented quantitatively and percentage, numerical data on average and standard deviation. * 201 observations, ** 67 observations.

Table 3. Variation of the physiological parameters in the three moments of evaluation with the Behavioral Pain Scale in patients hospitalized in a regional hospital of Vitória da Conquista, Bahia, Brazil, 2017

Groups Parameters Mean±SD p-value*

At rest Eye cleansing Tracheal suction

Group 1 HR (bpm) 88.7 (26.6) 89.9 (26.4) 104 (29.1) <0.001

RR (irpm) 15.7 (3.8) 15.6 (3.9) 20.4 (7.4) <0.001

SpO2 in% 97.3 (4.0) 97.3 (3.8) 95.0 (4.9) <0.001

SBP (mmHg) 122.3 (29.4) 122.3 (28.9) 139.8 (38.5) <0.001

DBP (mmHg) 67.3 (15.4) 67.7 (14.8) 80.1 (18.7) <0.001

MAP (mmHg) 83.2 (20.8) 86.4 (16.9) 101.3 (24.2) <0.001

Temperature °C 35.9 (1.2) 35.9 (1.2) 35.9 (1.2) 0.846

Group 2 HR (bpm) 90.9 (21.7) 91.2 (22.3) 104.4 (20.1) <0.001

RR (irpm) 16.1 (4.5) 16.4 (4.7) 25.2 (9.2) <0.001

SpO2 in% 97.7 (2.5) 97.8 (2.6) 95.3 (3.6) <0.001

SBP (mmHg) 121.2 (27.8) 123.8 (25.5) 141.8 (30.8) <0.001

DBP (mmHg) 63.6 (12.5) 64.8 (11.6) 77.9 (11.8) <0.001

MAP (mmHg) 82.5 (17.2) 84.6 (15.4) 101.7 (17.9) <0.001

Temperature oC 35.7 (1.1) 35.7 (1.1) 35.7 (1.1) 0.717Continue...

parameters within the same group between the three moments of measurement of the values. The level of significance of the analysis was 5% (p<0.05). The data were analyzed using the SPSS software version 20.0.

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DISCUSSION

Pain control, even in critically unarticulated patients, is vital. However, despite the technological advances in the care of criti-cal patients in emergency or intensive care units, pain assessment and its proper management have been poorly addressed. This study found that even for patients undergoing analgesia and se-dation, there was variation in the physiological parameters and BPS scores when they underwent painful procedures, especially TS, a routine technique in hospital units. This implies flaws in the process of pain assessment and the adequacy of analgesia in patients in intensive care.This ineffective control of pain is the result of a series of factors indicated in literature such as choosing an inadequate method of pain measurement, insufficient professional training or improper management of the pain without scientific evidence9,17,22,23. In addition, the resistance to change the routine of many profes-sionals is also an important cause of inadequacies in the control of the pain in critical patients17.

Table 3. Variation of the physiological parameters in the three moments of evaluation with the Behavioral Pain Scale in patients hospitalized in a regional hospital of Vitória da Conquista, Bahia, Brazil, 2017 – continuation

Groups Parameters Mean±SD p-value*

At rest Eye cleansing Tracheal suction

Group 3 HR (bpm) 87.2 (26.5) 91.6 (16.0) 100.8 (15.4) <0.001

RR (irpm) 17.8 (6.0) 17.8 (6.2) 23.0 (7.9) <0.001

SpO2 in% 96.6 (3.2) 96.7 (3.1) 94.7 (5.4) 0.025

SBP (mmHg) 121.8 (29.4) 121.9 (29.3) 150.3 (43.5) 0,001

DBP (mmHg) 67.8 (16.3) 68.4 (16.7) 83.1 (21.8) <0.001

MAP (mmHg) 84.8 (20.0) 85.1 (19.8) 103.7 (25.7) <0.001

Temperature oC 35.6 (1.4) 35.6 (1.5) 35.5 (1.5) 0.368Group 1 = sedation and analgesia; Group 2 = analgesia; Group 3 = no sedation or analgesia; HR = heart rate; RR = respiratory rate; SpO2 = peripheral oxygen satu-ration; SBP = systolic blood pressure; DBP = diastolic blood pressure; MAP = mean arterial pressure. Data expressed as mean and standard deviation. *ANOVA test.

Table 4. Behavioral Pain Scale scores during the three times of scale application in patients hospitalized in a regional hospital, Vitória da Con-quista, Bahia, Brazil, 2017

Groups BPS Scores Mean±SD p-value*

At rest Eye cleansing Tracheal suction

Group 1 Facial expression 1.1 (0.3) 1.1 (0.4) 2.1 (0.9) <0.001

Upper limbs 1.0 (0.2) 1.0 (0.2) 2.1 (0.7) <0.001

Adaptation to mechanical ventilation 1.0 (0.1) 1.0 (0.1) 2.0 (0.3) <0.001

Total 3.1 (0.3) 3.2 (0.4) 6.2 (1.4) <0.001

Group 2 Facial expression 1.3 (0.6) 1.4 (0.6) 3.2 (1.0) <0.001

Upper limbs 1.1 (0.3) 1.1 (0.3) 2.8 (1.0) <0.001

Adaptation to mechanical ventilation 1.1 (0.2) 1.1 (0.2) 2.2 (0.6) <0.001

Total 3.4 (1.0) 3.6 (1.0) 8.2 (2.4) <0.001

Group 3 Facial expression 1.3 (0.7) 1.4 (0.7) 2.7 (0.9) <0.001

Upper limbs 1.3 (0.6) 1.3 (0.6) 2.7 (1.0) <0.001

Adaptation to mechanical ventilation 1.1 (0.2) 1.1 (0.2) 1.9 (0.4) <0.001

Total 3.7 (1.4) 3.7 (1.4) 7.3 (2.1) <0.001Group 1 = sedation and analgesia; Group 2 = analgesia; Group 3 = no sedation or analgesia; Data expressed as mean and standard deviation. * ANOVA test.

Some studies have also pointed out the lack of knowledge of the professionals about scales with considerable accuracy to as-sess pain in unarticulated patients9,24. However, since it is not possible to obtain the patient’s verbal report about his/her pain, several observational scales have been recommended12. Among them, the BPS stands out for its high accuracy, easy application and for being adapted to the Brazilian reality8,25. Like other studies conducted in Brazil6,17,25, this study showed that the BPS was adequate to evaluate pain in unarticulated pa-tients. The comparison of the scale scores at rest and during eye cleansing, considered as a non-painful procedure, showed no variation. In this study, eye cleansing simulates other situations or procedures that are performed by the professional, such as dressing changes and measure temperature, but which do not necessarily correspond to painful stimuli8,25,26. However, the re-sults showed a significant variation in the scale scores during TS – considered a painful process for the patient – and the highest scores of the instrument were observed, regardless of the form of analgesia (or absence).

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Although the change in physiological parameters is not neces-sarily an indication to assess the pain in unarticulated patients, a significant variation in heart rate, respiratory rate, oxygen satu-ration, and systemic blood pressure was observed in the present study. These results are similar to those reported in other stud-ies that analysed whether changes in BPS were accompanied by physiological changes in patients13,17. However, it is worth men-tioning that the physiological parameters can be sensitive to sev-eral factors besides the presence of pain, such as fear, anxiety and psychological stressors6,7,9 and other clinical conditions. Thus, the monitoring of physiological parameters alone as a way to assess pain has not been recommended9,12,27-32, making necessary the use of properly validated scales/instruments and with proved accuracy, such as the BPS9,33.The lowest BPS scores were found in group 1. However, even these patients showed significant variations in the scores of the pain scale, which implies that even in them the pain was being underestimated. Also, it was not possible to establish whether those in group 1 were experiencing less pain or if they were un-able to present it8, as it would be unethical to conduct research involving the manipulation of sedation or analgesia levels since the patients would be exposed to a higher possibility of feeling pain17. Indeed, from the results of this study, it can be inferred that adjustments in pain control should be performed even in individuals with sedation and analgesia, which can be obtained with an accurate assessment of the pain in these patients.Other studies show that behavioral indicators are more sensitive and present more adequate data than the hemodynamic parame-ters in the assessment of pain in critically ill patients29,33,34. How-ever, the use of observational scales should not be considered as the most reliable or the only evaluation necessary since they do not reflect the intensity or the location of the pain, and they can be masked by deep sedation or the use of blocking agents. Likewise, these instruments should not replace the self-report of pain, when possible25,34. CONCLUSION

Considering the observed aspects, we noticed an intense pain during TS, visualized by the elevation of the BPS scores in all the groups observed, confirming their responsiveness. Despite the alteration of the physiological parameters during the observation of groups 1 and 2, the same did not happen in group 3, indicat-ing that the hemodynamic alterations should not be used as valid precursors to measure the pain. REFERENCES

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22. Gélinas C, Arbour C, Michaud C, Vaillant F, Desjardins S. Implementation of the cri-tical-care pain observation tool on pain assessment/management nursing practices in an intensive care unit with nonverbal critically ill adults: a before and after study Int J Nurs Stud. 2011;48(12):1495-504.

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25. Azevedo-Santos IF, Alves IG, Cerqueira Neto ML, Badauê-Passos D, Santana-Filho VJ, Santana JM. [Validation of the Brazilian version of Behavioral Pain Scale in adult sedated and mechanically ventilated patients]. Rev Bras Anestesiol. 2017;67(3):271-7.

26. Ribeiro CJ, Bezerra DS, Lima AG, Fernandes CC, Menezes MG, Ribeiro MC. Pain du-ring tracheal aspiration in patients with traumatic brain injury undergoing mechanical ventilation. Rev Dor. 2017;18(4):332-7.

27. De Jong A, Molinari N, de Lattre S, Gniadek C, Carr J, Conseil M, et al. Decreasing severe pain and serious adverse events while moving intensive care unit patients: a prospective interventional study (the NURSE-DO project). Crit Care. 2013;17(2):R74.

28. Chen YY, Lai YH, Shun SC, Chi NH, Tsai PS, Liao YM. The Chinese Behavior Pain Scale for critically ill patients: translation and psychometric testing. Int J Nurs Stud. 2011;48(4):438-48.

29. Kapoustina O, Echegaray-Benites C, Gélinas C. Fluctuations in vital signs and behavioural responses of brain surgery patients in the Intensive Care Unit: are they valid indicators of pain? J Adv Nurs. 2014;70(11):2562-76.

30. Gélinas C, Johnston C. Pain assessment in the critically ill ventilated adult: validation of the critical-care pain observation tool and physiologic indicators. Clin J Pain. 2007;23(6):497-505.

31. Gélinas C, Arbour C. Behavioral and physiologic indicators during a nociceptive procedu-re in conscious and unconscious mechanically ventilated adults: similar or different? J Crit Care. 2009;24(4):628.e7-17.

32. Arbour C, Gélinas C. Behavioral and physiologic indicators of pain in nonverbal patients with a traumatic brain injury: an integrative review. Pain Manag Nurs. 2014;15(5):506-18.

33. Barr J, Fraser GL, Puntillo KA, Ely EW, Gélinas C, Dasta JF, et al. Clinical practice guide-lines for the management of pain, agitation, and delirium in adult ICU patients. Crit Care Med. 2013;41(1):263-306.

34. Gélinas C, Tousignant-Laflamme Y, Tanguay A, Bourgault P. Exploring the validity of the bispectral index, the critical-care pain observation tool and vital signs for the detection of pain in sedated and mechanically ventilated critically ill adults: a pilot study. Intensive Crit Care Nurs. 2011;27(1):46-52.

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ABSTRACT

BACKGROUND AND OBJECTIVES: This study is necessary considering the expressive number of rural workers that are not assisted by a health professional despite the presence of muscu-loskeletal changes such as low back pain. Thus, the objective was to check if there is a relationship among low back pain levels, anthropometric measures and range of motion of rural workers. METHODS: A cross-sectional study with rural workers that used the visual analog scale to measure low back pain. The data on body mass index, fat percentage, waist circumference, waist-hip ratio and visceral fat area were obtained, as well as the assess-ment of posterior chain range of motion. RESULTS: Fifty-five rural workers were evaluated, with a pre-dominance of women and married. Of the subjects evaluated, 37 (67.3%) reported low back pain, with an average pain of 3.4±2.7. More than half of the sample presented values of body mass index, fat percentage, waist circumference and waist-hip ratio considered undesirable. Those with pain had higher values of body mass index and visceral fat area. CONCLUSION: Rural workers with low back pain presented higher values of body mass index and visceral fat area, as well as those with an inadequate range of motion in the same region who had higher values of visceral fat area and pain. It is also possible to infer that there is an association between the values of body mass index and visceral fat area with the level of pain, just as the waist-hip ratio is associated with the levels of the range of motion.Keywords: Anthropometry, Farmers, Low back pain, Range of motion.

Low back pain, anthropometric indexes and range of motion of rural workers Dor lombar, índices antropométricos e flexibilidade em trabalhadores rurais

Patrik Nepomuceno1, Luíza Müller Schmidt1, Marcelo Henrique Glänzel1, Miriam Beatrís Reckziegel2, Hildegard Hedwig Pohl2,3, Éboni Marília Reuter1

Patrik Nepomuceno - https://orcid.org/0000-0001-8753-6200; Luíza Müller Schmidt - https://orcid.org/0000-0003-3010-0873;Marcelo Henrique Glänzel - https://orcid.org/0000-0002-0426-3321;Miriam Beatrís Reckziegel - https://orcid.org/0000-0001-5854-3153;Hildegard Hedwig Pohl - https://orcid.org/0000-0002-7545-4862;Éboni Marília Reuter - https://orcid.org/0000-0002-0470-2910.

1. Universidade de Santa Cruz do Sul, Departamento de Educação Física e Saúde, Curso de Fisioterapia, Santa Cruz do Sul, RS, Brasil. 2. Universidade de Santa Cruz do Sul, Departamento de Educação Física e Saúde, Curso de Educação Física, Santa Cruz do Sul, RS, Brasil.3. Universidade de Santa Cruz do Sul, Departamento de Educação Física e Saúde, Programa de Pós-Graduação em Promoção da Saúde, Santa Cruz do Sul, RS, Brasil.

Submitted on November 08, 2018.Accepted for publication on February 18, 2019.Conflict of interests: none – Sponsoring sources: none.

Correspondence to: Avenida Independência, 2293 – Universitário96815-900 Santa Cruz do Sul, RS, Brasil.E-mail: patrik.np@hotmail.com

© Sociedade Brasileira para o Estudo da Dor

RESUMO

JUSTIFICATIVA E OBJETIVOS: O estudo justifica-se pelo ex-pressivo contingente de trabalhadores rurais que não são acom-panhados quanto à saúde, ao mesmo tempo que apresentam al-terações musculoesqueléticas como dor lombar. Dessa forma, o objetivo foi verificar se há relação entre a dor lombar, medidas antropométricas e níveis de flexibilidade de trabalhadores rurais. MÉTODOS: Trata-se de um estudo transversal com trabalhado-res rurais que utilizou a escala analógica visual para mensurar a dor lombar. Foram obtidas as medidas de índice de massa cor-poral, percentual de gordura, circunferência da cintura, relação cintura-quadril e área de gordura visceral, além da aferição da flexibilidade de cadeia posterior. RESULTADOS: Foram avaliados 55 trabalhadores rurais, com predomínio do sexo feminino e casados. Dos sujeitos avaliados 37 (67,3%) referiram queixas de dor lombar, sendo a pontuação média de dor de 3,4±2,7. Mais da metade da amostra apresentava valores de índice de massa corporal, percentual de gordura, cir-cunferência da cintura e relação cintura-quadril classificados em categorias indesejáveis. Aqueles com dor apresentaram valores de índice de massa corporal e área de gordura visceral superiores. CONCLUSÃO: Os trabalhadores rurais com dor lombar apre-sentaram valores de índice de massa corporal e área de gordura visceral maiores, assim como aqueles com flexibilidade inadequa-da na mesma região apresentam valores maiores de área de gor-dura visceral e dor. Também é possível inferir que há associação entre os valores de índice de massa corporal e área de gordura visceral com o nível de dor, bem como a relação cintura-quadril se associa aos níveis de flexibilidade.Descritores: Agricultores, Amplitude de movimento, Antropo-metria, Dor lombar.

INTRODUCTION

Worker’s health has been highlighted in research in the area of collective health, a fact that is related to the incidence of health problems arising from work activity. However, in some popula-tions, these issues need to be addressed in-depth, as is the case of rural workers1. These workers present more health problems and diseases when compared to workers in the urban area, not to mention their difficulty in accessing health services2.Farmers often perform activities that require intense physical effort leading to frequent musculoskeletal disorders. As a con-sequence, they refer to pain and discomfort that interfere with their daily activities. Among the main discomforts identified in these workers is low back pain (LBP). LBP can occur due to

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DOI 10.5935/2595-0118.20190022

ORIGINAL ARTICLE

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several factors, such as the reduction of the flexibility of the pos-terior muscle chain related to workload and lack of actions to prevent injuries, and it may also be connected to obesity. Esti-mates indicate that from 60 to 80% of the general population will have low back pain at some point in life1.Such disorders in the spine, which are expressed in pain, lead to the impairment of work activities and postural changes. These workers may have high-intensity pain, which associated with musculoskeletal disorders cause changes in postural stability. In addition, overweight is frequent in this population, which can aggravate their condition. The physical overload during the work activity may favor the onset of LBP and decrease the flexibility of this population. Thus, it is essential to detect these changes to develop actions to prevent related disorders2.Considering that Brazil has a significant number of workers in this sector whose health needs are not monitored, it is evident the importance of knowing their illness profile. In this context, the present study is justified since it addresses the painful symptoms, referred to as common in rural work-ers, trying to identify the contributing elements associated with physical fitness. It is known that due to the characteristics of the rural work, high prevalence of LBP is common, reaching 98%, but there is still a gap to be filled by research on this subject in the population. Also, the exponential increase in non-communi-cable chronic diseases in rural areas, especially obesity, has been described1,3. Therefore, the objective was to check if there is a relationship between LBP, anthropometric measures and levels of flexibility of rural workers.

METHODS

It is a cross-sectional retrospective study4 conducted with rural workers from Santa Cruz do Sul and municipalities of the Regional Development Council of the Rio Pardo Valley (COREDE-VRP). It was considered α (two-sided) 0.05 and 80% power to estimate the statistical power. Thus, with 55 workers it was possible to reach the effect magnitude of 0.454. The sample size was calculated in the G*Power software. The sample was selected by external seminars to introduce the project, and the subjects were invited to participate in the study. The present study is part of the research “Screening of risk fac-tors related to overweight in workers of the agroindustry using new analytical and health information technologies - Phase III” developed at the University of Santa Cruz do Sul. The age of the selected subjects ranged from 18 to 65 years, who work in rural areas and who signed the Free and Informed Consent Term (FICT). The exclusion criteria were individuals who were unable to complete all the tests or who had already undergone a surgical procedure in the spine.A self-reported questionnaire on sociodemographic and life-style data was applied to characterize the sample. The workers answered questions about gender (female/male), age (in years), socioeconomic class (Brazilian Business Association criteria), marital status (married/other), domestic journey (less than 2h and more than 2h) time of activity in the area (in years), hours of work per day, number of children, predominant posture at

work (standing, sitting, alternating) and physical activity prac-tice (yes/no).LBP was measured by the visual analog scale (VAS). Individuals were informed that zero meant no pain and 10 would be the maximum pain. They referred the corresponding value looking at the scale. The results were classified as “no pain” (zero), “mild to moderate pain” (1 to 5), and “moderate to severe pain” (6 to 10)5.The data considered for the anthropometric evaluation was the total obesity indexes such as body mass index (BMI) and per-centage of fat (%G), and fat location such as waist circumference (WC), waist-hip ratio (WHR) and area of visceral fat (AVF). The weight and height were obtained in an analog scale with a stadiometer to calculate the BMI (kg/m2), being classified according to the categories of the World Health Organization6 and later dichotomized in “recommended range” and “overweight.” The %G of seven skinfolds, obtained with the Lange caliper, and all the measurements taken in the right hemisphere, and calculated by the Jackson and Pollock equation, followed by the Siri equation, was classified using the proposal by Pollock and Wilmore7. The results “excellent”, “good” and “above average” were considered “adequate”, and “average”, “below average”, “bad” and “very bad”, as “inadequate”.The WC was obtained with an anthropometric tape at the midpoint between the last rib and the iliac crest. It was classified according to Lean, Han and Morrison8 as “normal” considered to be “adequate” and “increased risk” and “high risk” as “inadequate”. The WHR was calculated by the ratio between the WC and the hip ratio, obtaining the hip circumference of the major trochanter of the femur, was classified according to Heyward9 in “low risk” as “adequate” and “moderate risk”, “high risk” and “very high risk” considered “inadequate”. The AVF was obtained by bioimpedance analysis (InBody 720®) and expressed in cm³ and classified according to Pitanga et al.10 as “normal” and “high”.The flexibility was measured in cm with the sit and reach test using a Wells Bench, with three maneuvers performed and considered the best result. It was classified according to Wells and Dillon11 as “weak”, “regular”, “medium” classified as “inadequate” and “good” and “very good” as “suitable”.This study was approved by the Ethics Committee of the institu-tion under opinion number 2.349.234/2017.

Statistical analysisThe results were presented in tables and expressed by the mean and standard deviation for numerical data, and frequency and percentage for categorical data, and analyzed by the SPSS Sta-tistics® software. The Shapiro-Wilk test was used to check data normality. Pearson’s (parametric variables) and Spearman’s tests (non-parametric variables) were used for the correlation analy-sis. The comparison of means between the groups was checked by the Student’s t-test for independent samples, and ANO-VA with Hochberg’s post-hoc GT2 (parametric variables) and Mann-Whitney and Kruskal-Wallis U (non-parametric vari-ables). For the categorical variables, the Chi-square test was used considering p<0.05.

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RESULTS

Fifty-five individuals with mean age of 48.4±12.2 years were evaluated, of which 30 (54.5%) were female, mostly married (76.4%) with children (85.5%) and C1 and C2 socioeconom-ic status (56.4%). The average years working in agriculture was 26.64±15.88 years. Regarding household chores, the majority of the sample reported less than 2h daily (72.2%), with no relation between household chores and pain. Also, no differences were observed between gender and household chores time (p=0.269), although only women have reported dedicating from 4 to 6 hours for such activities (n=5).In the comparison of sociodemographic and lifestyle variables in the groups with pain, no differences were found for gen-der, age, marital status, domestic journey, activity time, hours of work per day, number of children and practice of physical activity. However, it is possible to observe that individuals of the B socioeconomic class had more pain than those belonging to class C. In addition, individuals with higher pain intensity perform their work activities alternating between standing and sitting (Table 1).

When asked about LBP, 37 (67.3%) complained of pain in this region with a mean pain score in the VAS of 3.4±2.7. Regarding the variables evaluated, more than half of the sample had BMI values. %G, WC and WHR were classified as undesirable cate-gories (Table 2).When comparing the averages of the anthropometric variables and the flexibility of the individuals without LBP with mild to moderate and moderate to severe pain, it was identified that

Table 1. Characterization of the sample regarding sociodemographic data and lifestyle

Variables Low back pain p-value

Without pain(n=18)

Mild to moderate(n=24)

Moderate to intense(n=13)

Gender*

Female 8 (32.0) 12 (48.0) 5 (20.0) 0.793a

Male 10 (33.3) 12 (40.0) 8 (26.7)

Age** 49.89 (11.62) 46.96 (13.04) 48.92 (12.20) 0.739b

Socioeconomic class*

B 2 (9.5) 14 (66.7) 5 (23.8) 0.005a

C 15 (48.4) 8 (25.8) 8 (25.8)

Marital status*

Married 13 (31.0) 18 (42.9) 11 (26.2) 0.710a

Others 5 (38.5) 6 (46.2) 2 (15.4)

Domestic journey*

Less than 2 hours 13 (32.5) 19 (47.5) 8 (20.0) 0.516a

More than 2 hours 5 (33.3) 5 (33.3) 5 (33.3)

Time of activity** 21.17 (13.80) 29.75 (16.48) 28.46 (16.65) 0.302b

Working hours/day** 8.67 (2.50) 9.33 (2.26) 10.46 (1.85) 0.067c

Children*

Yes 15 (31.9) 21 (44.7) 11 (23.4) 0.926a

No 3 (37.5) 3 (37.5) 2 (25.0)

Number of children** 2.07 (0.88) 1.81 (0.93) 2.36 (0.81) 0.187c

Predominant posture*

Standing 15 (40.5) 17 (45.9) 5 (13.5) 0.028a

Alternating standing/sitting 3 (16.7) 7 (38.9) 8 (44.4)

Physical activity*

Yes 3 (37.5) 5 (62.5) - 0.219a

No 15 (31.9) 19 (40.4) 13 (27.7)* absolute frequency (relative frequency); ** mean±Standard deviation; a Chi-square test; b ANOVA with Hochberg post hoc GT2; c Kruskal-Wallis test.

Table 2. Characterization of subjects regarding the anthropometric and flexibility variables

Variables Adequate n (%) Inadequate n (%)

BMI 19(34.5) 36(65.5)

%G 24 (43.6) 31 (56.4)

WC 25 (45.5) 30 (54.5)

WHR 10(18.2) 45 (81.8)

AVF 29 (52.7) 26 (47.3)

SRT 32(58.2) 23 (41.8)BMI = body mass index; %G = percentage of fat; WC = waist circumfe-rence; WHR = waist-to-hip ratio; AVF = area of visceral fat; SRT = sit and reach test.

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those with pain had higher BMI and AVF values, and the values of these variables increased with the referred pain intensity. In multiple comparisons, it was identified an AVF and BMI differ-ence between the groups without pain and moderate to severe pain (p=0.031; p=0.046, respectively) (Table 3).When comparing the anthropometric and VAS values consider-ing the categories of flexibility, the individuals with inadequate levels of flexibility had higher AVF values (p=0.035) and LBP (p=0.014) (Table 4).Moreover, it was observed an association between the VAS for the lumbar region and the BMI variables (r=0.304; p=0.024) and AVF (r=0.314; p=0.020). Thus, one can infer that the high-er the BMI and AVF, the higher the referred pain score. We also identified a weak and inverse association between the WHR and the flexibility that involves the lumbar region, the higher the WHR, the lower the SRT values (r=-0.276; p=0.042).When comparing the variables for age, it was observed that there was no difference in BMI values, AVF, SRT, and VAS, indicating that age does not influence pain and flexibility. However, values of central adiposity, evaluated by WC and WHR increase pro-gressively with age, as well as total obesity by %G. In multiple comparisons, differences between 18 and 39 years and 40 and 59 years were observed for %G (p=0.025); between 40-59 and 60-65 years for WHR (p=0.015) and between 18-39 and 60-65 years for WC (p=0.026) and WHR (0.004) (Table 5).

DISCUSSION

Agriculture is characterized by heavy manual labor. Farmers need to handle a considerable amount of weight to transport their ma-terials and products. During this activity, they adopt inappropri-ate postures that can damage the tissues, especially muscles and joints which favor the onset of LBP12. LBP may be associated with radiated pain or pain in the lower limbs, especially in rural workers who spend long hours standing to do their job13. In the present study, it was observed that individuals with high pain values performed their activities alternating between standing and sitting, which may be related to an attempt to adapt to the work routine due to the pain.Although agricultural activity is considered as a risk factor for the development of LBP, its influence on the health of the worker is poorly explored, especially in the painful situations14. The pres-ent results show that both BMI and AVF are related to pain and its intensity in rural workers. It is also possible to observe that pain, AVF and WHR are associated with flexibility, which can be explained by a possible overload in the lumbar spine and changes in the center of gravity. A study by Briggs et al.15 observed that subjects with in-creased WC had significantly higher pain values (OR=2.39; CI: 1.09-5.21), a different result from the present study. However, it was also observed that subjects classified by BMI with overweight or obesity showed a higher frequency of LBP and systemic inflammation that may contribute to the aggravation of pain. In a large-scale study by Hashimoto et al.16 conducted with Jap-anese men found that the chance of LBP is greater in overweight individuals when compared to those who have desirable BMI results, highlighting the need for BMI control, both to prevent and treat LBP. A national survey in the United States17 observed that individuals with overweight or obesity, evaluated by BMI, had great chances of having LBP (OR=1.21; CI: 1.11-1.32 and OR=1.55; CI: 1.44-1.67, respectively). This survey found that white men and women were at increased risk of developing LBP. Considering the characteristics of our region, this could be a jus-tification for the high prevalence of pain observed in this study. The findings described corroborate those found in the present

Table 5. Comparison of means between age groups

Variables Ages p-value

18-39 years(n=12)

40-59 years(n=32)

60-65 years(n=11)

BMI 25.21 (3.47) 28.30 (5.77) 28.53 (5.61) 0.248a

%G 21.65 (5.66) 27.71 (7.05) 27.27 (5.75) 0.027b

WC 83.46 (11.58) 88.79 (9.95) 95.21 (10.08) 0.031b

WHR 0.82 (0.82) 0.86 (0.08) 0.94 (0.06) 0.003b

AVF 83.41 (25.38) 103.56 (43.03) 110.64 (43.56) 0.225b

SRT 28.32 (7.03) 26.87 (8.55) 23.02 (10.05) 0.308b

VAS 3.25 (2.67) 3.28 (2.78) 3.64 (2.50) 0.888a

BMI = body mass index; %G = percentage of fat; WC = waist circumference; WHR = waist-to-hip ratio; AVF = area of visceral fat; SRT = sit and reach test; VAS = visual analog scale; a Kruskal-Wallis test; b ANOVA with Hochberg post hocGT2.

Table 3. Comparison of means between groups of pain

Variables Low back pain p-value

Without pain(n=18)

Mild to mo-derate(n=24)

Moderate to intense(n=13)

BMI 25.94 (2.78) 27.18 (5.92) 30.97 (6.02) 0.035a

%G 25.26 (5.84) 25.48 (7.85) 29.26 (5.83) 0.209b

WC 86.86 (9.24) 87.85 (10.08) 93.72 (13.43) 0.182b

WHR 0.87 (0.08) 0.86 (0.08) 0.86 (0.10) 0.988b

AVF 86.91 (29.15) 98.01 (43.00) 124.24 (41.46)

0.034b

SRT 28.09 (7.83) 26.72 (9.70) 23.53 (7.26) 0.343b

BMI = body mass index; %G = percentage of fat; WC = waist circumference; WHR = waist-to-hip ratio; AVF = area of visceral fat; SRT = sit and reach test; a Kruskal-Wallis test; b ANOVA with Hochberg post-hoc GT2.

Table 4. Comparison of means between groups of flexibility

Variables Flexibility p-value

Adequate(n=32)

Inadequate(n=23)

Age 45.39 (11.16) 50.53 (12.69) 0.125b

BMI 26.40 (3.42) 29.44 (7.03) 0.162a

%G 25.60 (6.82) 27.28 (7.00) 0.378b

WC 86.90 (8.17) 91.72 (13.44) 0.136b

WHR 0.87 (0.09) 0.86 (0.08) 0.945b

AVF 90.89 (33.54) 114.06 (45.90) 0.035b

VAS 2.63 (2.47) 4.35 (2.64) 0.014a

BMI = body mass index; %G = percentage of fat; WC = waist circumference; WHR = waist-to-hip ratio; AVF = area of visceral fat; VAS = visual analog scale; a Mann-Whitney U test; b Student’s t-test.

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study. Thus, one can infer that overweight is related to the in-creased chance of developing LBP.Iizuka et al.18 analyzed the prevalence of chronic non-specif-ic LBP and related factors in middle-aged and elderly individ-uals and did not identify a relationship between BMI and the presence of pain (p=0.422). This result is the opposite of that observed in the present study and may be due to the low preva-lence of LBP (24.8%) in the sample. However, it has pointed out that smoking and the quality of life is related to LBP (p=0.021; p=0.016, respectively). The authors do not have a justification for such results.Su et al.19 studied the association between BMI and prevalence, severity and frequency of LBP. When comparing the frequency of LBP with the BMI classification, it was observed that the fre-quency is higher (p<0.05) in overweight and obesity, as well as in severe and morbid obesity (p<0.01) when compared to the group with normal weight or low weight. Therefore, these data corroborate those of this study considering that the higher the BMI and AVF, the greater the pain intensity. The authors did not identify a relationship between BMI and the severity or frequen-cy of low back pain episodes.Rahmani et al.20 used ultrasonography to check the dimensions of the multifidus muscle in adolescents with and without LBP and found an association between muscle size and BMI, and this is a possible explanation for the high prevalence of LBP in over-weight individuals observed in the present study. Besides, it was observed that all muscle measures correlate inversely with pain intensity and functional disability, suggesting that the smaller the dimensions, the greater the pain and the disability.In a study with rural workers from a region of Santa Catarina1. the prevalence of 98.3% of LBP was found with an average pain on the VAS of 5.89±2.49, being more intense in women (mean: 6.14±2.45. There was a relationship between pain and SRT (r=-0.42; p<0.01). These data are in agreement with the present re-sults considering that individuals with inadequate flexibility had higher pain values.Silva et al.21 found similar results with rural workers in the Vale do Rio Pardo. The individuals with high intensity of pain had lower levels of flexibility and considerable postural changes. LBP is common in Thai rubber farmers. Udom, Janwantanakul and Kanlayanaphotporn22 found a high prevalence of LBP (55.7%) with high intensity, identifying a relationship between BMI and pain (p=0.048) and corroborating the present study. So, it is possible to infer that BMI is an important predictor of LBP in different populations. Several studies have observed that there is an association between anthropometric markers, such as weight, BMI, WC, and LBP, confirming that the increase in fat is a risk factor for the development of LBP23,24.Workers from several sectors are exposed to the reduction of elements of physical fitness according to the work performed. Nepomuceno et al.25 analyzed the profile of industrial workers and detected prevalence of pain, reduced flexibility and anthro-pometric changes, reinforcing the results found in the present study. They also observed a tendency in the association between flexibility and the presence of pain. Therefore, flexibility may in-fluence pain.

Paz et al.26 identified that the anthropometric variables were not related to lumbar functional disability. Even so, the study sample was considered relatively healthy, which may have contributed to this result. It was highlighted that lumbar flexibility, assessed by the SRT, presented greater as-sociation with disability.Obesity can play a role not only on pain and flexibility but also in muscular endurance. Ummunah, Ibkunle and Ezeakunne27 identified an inverse relationship between BMI and hip circum-ference with the maximum sustaining time of isometric contrac-tion. That means that the higher the fat, the shorter the main-tenance time of muscle contraction, and these results may be important in explaining LBP in overweight individuals.It was considered that the sample size might have been a lim-iting factor of the study, in part due to the difficulty of access of this population historically unassisted. However, this study brings important considerations about the health of the rural population and also for the planning of actions that promote health and the prevention of diseases related to LBP. Moreover, it was found that individuals with a higher socioeconomic class had more pain. Nonetheless, the mechanisms that associate this variable with pain remain unknown.

CONCLUSION

The present study showed that rural workers with LBP had high-er BMI and AVF values, as well as those with inadequate flexi-bility in the same region had higher values of AVF and pain. It is also possible to infer that there is an association between the values of BMI and AVF with the level of pain, and WHR is asso-ciated with levels of flexibility.

ACKNOWLEDGMENTS

To Professor Tania Cristina Malezan Fleig from the Physiother-apy course of the University of Santa Cruz do Sul for the valu-able contribution in the elaboration of this research project and manuscript.

REFERENCES

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2. Befort CA, Nazir N, Perri MG. Prevalence of obesity among adults from rural and ur-ban areas of the United States: findings from NHANES (2005-2008). J Rural Health. 2012;28(4):392-7.

3. O’Sullivan D, Cunningham C, Blake C. Low back pain among Irish farmers. Occup Med. 2009;59(1):59-61.

4. Hulley SB, Cummings SR, Browner WS, Grady DG, Newman TB. Delineando a pesquisa clínica. 4ª ed. Porto Alegre: Artmed; 2015. 386p.

5. Sociedade Brasileira para Estudo da Dor [Internet]. 5º Sinal Vital. 2009. [cited 2018 May 17]. Available from: http://www.sbed.org.br/materias.php?cd_secao=65.

6. World Health Organization [Internet]. BMI classification. 2006. [cited 2018 May 17]. Available from: http://apps.who.int/bmi/index.jsp?introPage=intro_3.html.

7. Pollock M, Wilmore J. Exercícios na saúde e na doença: avaliação e prescrição para prevenção e avaliação. Rio de Janeiro: Medsi; 1993.

8. Lean ME, Han TS, Morrison CE. Waist circumference as a measure for indicating need for weight management. BMJ. 1995;311(6998):158-61.

9. Heyward VH. Avaliação Física e Prescrição de Exercício: técnicas avançadas. 6th ed. Porto Alegre: Artmed; 2013. 485p.

10. Pitanga CP, Pitanga FJ, Gabriel RE, Moreira MH. Associação entre o nível de ativi-dade física e a área de gordura visceral em mulheres pós-menopáusicas. Rev Bras Med Esporte. 2014;20(4):252-4.

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11. Wells KF, Dillon EK. The sit and reach: a test of back and leg flexibility. Res Q Exerc Sport. 1952;23:115-8.

12. Keawduangdee P, Puntumetakul R, Swangnetr M, Laohasiriwong W, Settheetham D, Yamauchi J, et al. Prevalence of low back pain and associated factors among farmers during the rice transplanting process. J Phys Ther Sci. 2015;27(7):2239-45.

13. Essien SK, Trask C, Dosman J, Bath B. Investigating the association between lower ex-tremity and low back symptoms among Saskatchewan farmers using the Standardized Nordic Questionnaire. Spine. 2017;42(19):1147-54.

14. Meucci RD, Fassa AG, Faria NM, Fiori NS. Chronic low back pain among tobacco farmers in southern Brazil. Int J Occup Environ Health. 2015;21(1):66-73.

15. Briggs MS, Givens DL, Schmitt LC, Taylor CA. Relations of C-reactive protein and obesity to the prevalence and the odds of reporting low back pain. Arch Phys Med Rehabil. 2013;94(4):745-52.

16. Hashimoto Y, Matsudaira K, Sawada SS, Gando Y, Kawakami R, Sloan RA, et al. Association between objectively measured physical activity and body mass index with low back pain: a large-scale cross-sectional study of Japanese men. BMC Public Health. 2018;18(341):1-8.

17. Peng T, Pérez A, Pettee Gabriel K. The association among overweight, obesity, and low back pain in U.S. adults: a Cross-Sectional Study of the 2015 National Health Interview Survey. J Manipulative Physiol Ther. 2018;41(4):294-303.

18. Iizuka Y, Iizuka H, Mieda T, Tsunoda D, Sasaki T, Tajika T, et al. Prevalence of chronic nonspecific low back pain and its associated factors among middle-aged and elderly people: an analysis based on data from a musculoskeletal examination in Japan. Asian Spine J. 2017;11(6):989-97.

19. Su CA, Kusin DJ, Li SQ, Ahn UM, Ahn NU. The association between body mass index and the prevalence, severity, and frequency of low back pain: data from the osteoarthritis initiative. Spine. 2018;43(12):848-52.

20. Rahmani N, Kiani A, Mohseni-Bandpei MA, Abdollahi I. Multifidus muscle size in adolescents with and without back pain using ultrasonography. J Bodyw Mov Ther. 2018;22(1):147-51.

21. Silva RK, Reckziegel MB, Burgos MS, Pohl HH. Dor lombar e sua relação com a flex-ibilidade e os desvios posturais em trabalhadores rurais de municípios da microrregião sul do Vale do Rio Pardo/RS. Fisioter Bras. 2017;18(2):130-9.

22. Udom C, Janwantanakul P, Kanlayanaphotporn R. The prevalence of low back pain and its associated factors in Thai rubber farmers. J Occup Health. 2016;58(6):534-42.

23. Brooks C, Siegler JC, Marshall PWM. Relative abdominal adiposity is associated with chron-ic low back pain: a preliminary explorative study. BMC Public Health. 2016;16(1):700-8.

24. Heuch I, Heuch I, Hagen K, Zwart JA. A comparison of anthropometric measures for assessing the association between body size and risk of chronic low back pain: the HUNT Study. PLoS One. 2015;10(10):e0151268.

25. Nepomuceno P, Braz CD, Dummel KL, Wendt D, Campos GD, Couto AN, et al. Perfil antropométrico e a relação da flexibilidade com a dor e desconforto em tra-balhadores da indústria de Santa Cruz do Sul – RS. Cinergis. 2016;17(4):313-8.

26. Paz GA, Maia MF, Santiago FL, Lima VP. Correlação entre incapacidade funcional lombar e índices da aptidão física para a saúde. Saúde em Rev. 2012;12(31):23-30.

27. Ummunah JO, Ibikunle PO, Ezeakunne AC. Relationship between isometric endur-ance of back extensor muscles and selected anthropometric indices among some Nige-rian undergraduates. J Back Musculoskelet Rehabil. 2014;27(3):291-8.

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ABSTRACT

BACKGROUND AND OBJECTIVES: In patients with chronic pain, insomnia is reported between 50 and 88% of them. It is es-sential to recognize sleep disorders to estimate its repercussions on the quality of life and to seek knowledge that supports the necessary interventions. This study aims to identify the possible factors that influence sleep quality, as well as its prevalence in these patients.METHODS: Sample consisting of 68 patients (58 women, 10 men), the mean age of 45.3±10.3 years, with a positive diagnosis of human immunodeficiency virus undergoing antiretroviral and chronic pain treatment in Porto Alegre, RS. The Pittsburgh Sleep Quality Index was used to assess the components of the scale as well as their overall score. For the classification of the type of chronic pain, the Leeds Assessment of Neuropathic Symptoms and Signs scale was used, which differentiates nociceptive and neuropathic pain. RESULTS: Patients classified with no pain, nociceptive pain and neuropathic pain. Overall score divided into good sleep, bad sleep and sleep disorder, where patients without pain accounted for 8.8%, 16.2 and 2.9% respectively. With nociceptive pain 4.4, 11.8 and 5.9%, respectively. With neuropathic pain 4.4, 23.5 and 22.1% re-spectively. Patients with neuropathic pain had the highest rates of poor sleep and sleep disorder, accounting for 50.0% and using more sleeping pills compared to the control group (p<0.05). CONCLUSION: There is a high prevalence of sleep disorders or poor sleep in patients with the human immunodeficiency virus with neuropathic pain. The importance of assessing the sleep as

Sleep alterations in patients with the human immunodeficiency virus and chronic pain Alterações do sono em pacientes vivendo com o vírus da imunodeficiência humana e dor crônica

Glória Pinto Soares de Aguiar1, Jairo Alberto Dussán-Sarria2, Andressa de Souza3

Glória Pinto Soares de Aguiar - https://orcid.org/0000-0002-5468-4730;Jairo Alberto Dussán-Sarria - https://orcid.org/0000-0002-1271-0638;Andressa de Souza - https://orcid.org/0000-0002-6608-4695.

1. Universidade La Salle, Programa de Pós-Graduação em Saúde e Desenvolvimento Hu-mano, Canoas, RS, Brasil.  2. Hospital de Clínicas de Porto Alegre, Serviço de Anestesiologia e Medicina Perioperatória, Porto Alegre, RS, Brasil.3. Universidade Federal do Rio Grande do Sul. Programa de Pós-Graduação em Ciências Biológicas: Farmacologia e Terapêutica, Porto Alegre, RS, Brasil. 

Submitted on August 01, 2018.Accepted for publication on March 18, 2019.Conflict of interests: none – Sponsoring sources: Conselho Nacional de Desenvolvimento Cientí-fico e Tecnológico - CNPq. Edital CNPQ-Universal (442479/2014-0).

Correspondence to: Av. Victor Barreto, 2288, Prédio 792010-000 Canoas, RS, Brasil. E-mail: andressasz@gmail.com

© Sociedade Brasileira para o Estudo da Dor

an essential part of the clinical assessment should be recognized and incorporated without delay by health professionals.Keywords: Chronic pain, Human immunodeficiency virus, Nursing, Sleep.

RESUMO

JUSTIFICATIVA E OBJETIVOS: Em pacientes com dor crô-nica, a insônia é relatada entre 50 e 88% deles. É fundamental reconhecer as alterações do sono para estimar suas repercussões na qualidade de vida e buscar conhecimentos que respaldem as necessárias intervenções. Este estudo buscou identificar os possí-veis fatores que influenciam a qualidade do sono, bem como suas prevalências nesses pacientes. MÉTODOS: Amostra constituída por 68 pacientes (58 mulheres e 10 homens) com idade média de 45,3±10,3 anos, diagnóstico positivo para o vírus da imunodeficiência humana em tratamento antirretroviral e dor crônica, de uma instituição em Porto Alegre, RS. O Questionário do Índice de Qualidade de Sono de Pitts-burgh foi usado para a avaliação dos componentes da escala de sono, bem como sua pontuação total. Para a classificação do tipo de dor crônica foi utilizada a escala Leeds Assessment of Neuropathic Symptoms and Signs, que diferencia dor nociceptiva e neuropática. RESULTADOS: Os pacientes foram classificados em sem dor, dor nociceptiva e dor neuropática. A pontuação global foi di-vidida em sono bom, sono ruim e distúrbio do sono, onde os pacientes sem dor representaram 8,8, 16,2 e 2,9% respectiva-mente. Com dor nociceptiva 4,4, 11,8 e 5,9% respectivamente. Com dor neuropática 4,4, 23,5 e 22,1% respectivamente. Os pacientes com dor neuropática apresentaram os maiores índices de sono ruim e distúrbio do sono, representando 50,0% e utili-zavam mais fármacos para dormir em comparação com o grupo controle (p<0,05). CONCLUSÃO: Existe elevada prevalência de distúrbios do sono ou sono ruim em pacientes portadores do vírus com dor neuro-pática. A importância da avaliação do sono como parte essencial da avaliação clínica deve ser reconhecida e incorporada sem de-mora pelos profissionais de saúde.Descritores: Dor crônica, Enfermagem, Sono, Vírus da imuno-deficiência humana.

INTRODUCTION

The human immunodeficiency virus (HIV) attacks the im-mune system destroying the defense cells, CD4+ T lympho-cytes, causing an immunosuppression picture. Immunode-

BrJP. São Paulo, 2019 apr-jun;2(2):123-31

DOI 10.5935/2595-0118.20190023

ORIGINAL ARTICLE

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ficiency is characterized by continuous viral replication and depletion of CD4+ T-lymphocytes, affecting the capacity of the immune system to defend the body from foreign or anomalous cells that invade or attack it, such as bacteria, vi-ruses, fungi, and cancer cells1.As the lymphatic system and immune responses slowly col-lapse, an HIV-infected person becomes more susceptible to opportunistic infections, getting sicker more often. This condition of susceptibility due to the lymphatic system and defective immune responses is diagnosed as Acquired Im-munodeficiency Syndrome (AIDS), characterized not by a symptom, but by a set of signs and symptoms arising from a decrease in the CD4+ T-cell lymphocyte count.AIDS is diagnosed when the T-cell count falls below 200 per microliter of blood. The CD4+ T-lymphocyte count, and the vi-ral load are important prognostic markers to monitor the infec-tion and to follow-up the disease progression in these patients1.According to the Joint United Nations Program on HIV/AIDS3, the number of people living with HIV/AIDS in the world is approximately 36.7 million. The report shows that antiretroviral therapy is providing a longer life to people with HIV. In 2015, people over the age of 50 accounted for about 17% of the adult population (15 years or older) living with HIV. In high-income countries, 31% of people living with HIV were over 50 years old3.In Brazil, from 1980 to 2016, 548,850 (65.1%) cases of AIDS in men and 293,685 (34.9%) in women were regis-tered. Over the last 10 years, AIDS detection rates in men have shown a growth trend. In 2006 the rate was 24.1 cases per 100 thousand inhabitants, reaching 27.9 in 2015, an in-crease of 15.9%4.According to the HIV/AIDS Epidemiological Bulletin of the Department of Surveillance of the Ministry of Health, pub-lished annually, in 2015 there were 39,113 new cases of HIV infection in Brazil. The city of Porto Alegre presented a rate of 74 cases for 100 thousand inhabitants, corresponding to twice the rate of the State of Rio Grande do Sul and almost four times the rate of Brazil. The AIDS detection rate in Bra-zil has stabilized in the last 10 years, with an mean of 20.7 cases per 100,000 inhabitants. The recommendation for the treatment of people with HIV, regardless of CD4 count, is in place since December 2013. In June 2016, around 18.2 mil-lion people worldwide had access to the antiretroviral treat-ment, including 910,000 children, twice the number regis-tered five years earlier4.As people with HIV become older, they are also more susceptible to the long-term adverse effects of the antiretroviral treatment, developing resistance to drugs, and requiring the treatment of comorbidities, such as tuberculosis and hepatitis C, among oth-ers, that may also interact with the antiretroviral therapy. Ongo-ing research and investments are needed to discover simpler and more tolerable treatments for HIV and comorbidities, as well as to discover a vaccine and the cure for the virus3.The use of combined antiretroviral therapy, available at the Brazilian public services since 1997, has determined a new course for the disease5. Controlling the virus replication and

the consequent improvement of patients’ immunity, AIDS has taken the characteristics of chronic disease, increasing the life expectancy of patients6. Unfortunately, even provid-ing patients with a longer life expectancy, the mechanism of action of the drugs brings chronic complications not directly related to the HIV infection, such as cardiovascular diseases, liver, renal and bone alterations, as well as neoplasms and loss of neurocognitive functions and neuropathologies1. Neurological manifestations are frequent in people with HIV, being the first manifestation of the disease in 10% of cases, and between 30 and 50% of patients will report neurological symptoms at some point in life. Peripheral neuropathies are commonly associated with HIV infections, and distal periph-eral neuropathy is the most frequent symptomatic form in 35% of the patients7,8.The neuropathic pain in HIV patients is a result of changes in the immune system, due to immunosuppression9. Immu-nosuppression makes the individual more susceptible to in-fections and malignancies, which are aggravated by the huge negative interaction of drugs used for analgesia and the an-tiretrovirals, making it difficult to treat painful symptoms in these patients, reducing their quality of life (QoL)10.Statistics show that 30% of the world’s population suffers from chronic pain11. In Brazil, this number reaches almost 60 million people, with 50% reporting serious impair to their routine. Larue, Fontaine and Colleau12 found that in the HIV/AIDS population, 30% of outpatients and 62% of hospitalized patients due to HIV reported HIV-related pain and that their severity was significantly underestimated by the physicians who cared seropositive patients. In adults with HIV, neuropathic pain is more common in men with low CD4 levels or increased viral load. In this population, 80% of patients report experiencing intense pain, which interferes with the mood, QoL and work capacity. It is known that QoL is directly related to sleep quality, among other factors.13. Sleep, characterized by the temporary suspension of the sensory and perceptive voluntary motor ac-tivity, is part of the basic needs of the human being, as well as eating and drinking, having a restorative function for the organism and the brain14. Studies have related sleep to the im-mune function, indicating that its deprivation may compro-mise this function15. Experimentally sleep-deprived subjects have decreased the NK (Natural Killer) cells activity, which is part of the innate immunity, accounting for about 10 to 20% of the circulating lymphocytes16. According to the World Health Organization17, about 40% of the world population does not sleep as desired and has some of the more than 80 sleep disorders and syndromes listed by the International Classification of Sleep Disorders (ICSD). In addition, it is known that sleep disorders are a significant impact factor in a person’s life, causing short- or long-term impairment in daily activities, social, somatic, psychological or cognitive adversities18 and according to the Brazilian Sleep Association, sleep disorders can have important repercussions on performance and social costs. Estimates of the rate of ac-cidents and deaths caused by drowsiness or fatigue vary from

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2 to 41%, with a high cost in financial and life terms involv-ing economic and health issues, such as increased hospitaliza-tions, absenteeism, traffic accidents and the development of mental disorders19.Patients with AIDS have many complaints, especially regard-ing chronic pain and adverse reactions of the antiretroviral treatment, and it is also expected to find complains related to sleep quality20.The diagnosis of sleep disorders is not so easy because most people are unaware that this is a clinical condition that can be treated. Because of this lack of knowledge, patients fail to report sleep problems, and due to the lack of knowledge of most health professionals in identifying such disorders, there is no input to a diagnosis and treatment, thus increasing the worsening of symptoms19.Since sleep is a basic human need, its preservation and main-tenance are fundamental for the individual to have a healthy life. It is important to recognize and relate these difficulties in order to seek knowledge that supports the necessary nurse interventions to improve the QoL21.Nurses, as health professionals, play a fundamental role in the promotion, prevention, and care of health problems. It is be-lieved that such an understanding is essential for the planning of decisive actions in this context22. The objective of this study was to identify the possible factors that impact sleep quality as well as the prevalence in patients with HIV.

METHODS

A cross-sectional cohort study, with a quantitative approach, conducted at a Non-Governmental Organization (NGO) in Porto Alegre/RS, where participants were included in the study according to the following inclusion criteria: confirmed diagnosis of HIV/AIDS in treatment with antiretroviral ther-apy; aged between 18 and 65 years, of both genders; and Free and Informed Consent Term (FICT) understood and signed. The exclusion criteria were active acute contagious infection (meningitis, active pulmonary tuberculosis); history of chronic diseases associated with neuropathy (diabetes, lupus, rheuma-toid arthritis); HTLV infection (Human T-cell Lymphotrophic Virus); chronic renal failure; peripheral vascular disease; use of systemic corticosteroids; cancer; severe disease that would limit the understanding of the FICT or the questionnaires.Data collection was from August to December 2015. The data were collected when the subjects had an appointment at the NGO. The interviews were in a private room, before or after the care visit.Semi-structured data collection forms were used for data collection, which included questions related to the patient’s identification, socioeconomic profile, health history, and treatment.The Pittsburgh Sleep Quality Index (PSQI-BR) questionnaire was used, an American questionnaire validated for the Portu-guese language, which characteristic is the evaluation of sleep quality in the last month23. This questionnaire has 19 ques-

tions that configure seven components of sleep evaluation: quality, latency, duration, efficiency, nocturnal disorders, use of sleeping pills and daytime sleepiness. Each component re-ceives a score ranging from zero to three so that the instru-ment’s final score can range from zero to 21. The higher the score, the worse the sleep quality, and values higher than five indicate poor quality sleep. For the classification of the chronic pain, the Leeds Assess-ment of Neuropathic Symptoms and Signs (LANSS) was used. This scale is validated in Brazil and used to differentiate nociceptive pain from neuropathic pain24.All the 68 patients who made up this sample has completed 100% of the data related to the PSQI-BR questionnaire and were evaluated in accordance with the mentioned tests.Considering that the description of the quality of sleep in patients with HIV/AIDS, evaluated for the Pittsburgh scale would be one of the most significant contributions of the present study to the scientific literature, the size of the sample was calculated on this outcome. Ferreira and Ceolim26 de-scribed that patients with HIV have a high prevalence of poor sleep quality. The effect size was 1.35 (Cohen’s D). Sample size calculation was performed with a two-tailed alpha error of 0.05, 95% power and equal sample size. The calculation of the sample size was performed by the Gpower software.According to the ethical recommendations of the Ministry of Health, the development of the study is in accordance with Resolution 466/12 - National Health Council (CNS), which deals with human research ethics25. The patients were informed about the purpose of the study and agreed to participate signed the FICT. They were also told that they could withdraw at any time, without any discontinuation of their care. At the end of the study, the institution where the study was conducted had all data available, as well as all those who might be interested. This study is part of a larger project entitled “Neurophysi-ology of Nociception and Central Sensitization in Patients with HIV Neuropathy”, coordinated by Prof. Dr. Andres-sa de Souza and collaborators, of the Graduate Program in Health and Human Development, line of Pathological Pro-cesses Research, funded by the National Council for Scientific and Technological Development - CNPq (Universal 442479 / 2014-0), with Certificate of Presentation for Ethical Ap-praisal (CAAE) number 30388114.3.0000.5307 and with the opinion of approval number 647.372. University La Salle.

Statistical analysisThe data were summarized using conventional descriptive statistics. Continuous variables were described using mean, median and standard deviation. Categorical variables were described using absolute numbers and percentages. The com-parison between the groups for the continuous variables was performed using the Kruskal-Wallis test. The comparisons be-tween the categorical variables were performed using the Chi-square test or Fisher’s Exact test, accordingly. For all analysis, the level of statistical significance for the established alpha error was a two-tailed p<0.05. Analyzes were processed using SPSS version 20.0 (SPSS, Chicago, IL).

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RESULTS

The sample consisted of 68 patients with a mean age of 45.3±10.3 years, all with a confirmed diagnosis of HIV/AIDS in treatment with antiretroviral therapy. Of the 68 patients, 15 live alone, 49 (72.0%) live with the family, that could be spouse, parents or children, and 04 (6.0%) do not fit the pre-vious ones. As for the time of schooling, the mean is 5.9 years.

Regarding the professional occupation, 27 (40.0%) are unem-ployed. The viral load is detectable in 34 (50.0%) patients. In this sample, all patients are being treated with antiretroviral therapy, and only 17 (25.0%) patients used the non-nucleoside reverse transcriptase inhibitor Efavirenz. Table 1 shows the data obtained.Regarding the perceived pain, only 31% reported no pain and the remaining 69% reported pain in the head (46%), upper limbs (41%), chest (43%) and lower limbs (43%). In this study, the patients were classified according to the LANSS scale24, which differentiates nociceptive from neu-ropathic pain. Thus, patients were subdivided into a control group (no pain, n=19), nociceptive pain (n=15), and neuro-pathic pain (n=34). The results are shown in Table 2.Regarding the usual sleep characteristics, the patients were also divided between control (no pain), nociceptive pain and neuro-pathic pain groups. The results are shown in table 3. Of the total sample, 35 (51.5%) had habitual sleep efficiency above 85%, 13 (19.1%) between 75 and 84%, 10 (14.7%) between 65 and 74% and 10 (14.7%) had sleep efficiency lower than 65%.In the sleep quality analysis, obtained with the PSQI-BR, the indexes of subjective quality, latency, duration, efficiency, dis-turbances, use of sleeping pills and daytime sleepiness are cor-related. The values of these indices are shown in table 4.According to the PSQI-BR, the following factors that cause considerable difficulties to sleep were evaluated in the sample: cough or loud snoring, taking more than 30 minutes to get to sleep, getting up to go to the bathroom, waking up in the mid-dle of the night or too early, have difficulty breathing, feel very cold, feel very hot, have bad dreams or nightmares, feel pain and other reasons, as shown in table 5. Of these factors, the following stand out especially in the neuropathic pain group; get up to go to the bathroom, 20 (29.4%) patients; take more

Table 2. Sociodemographic and clinical characteristics with a significant association with the classification of the with pain and without pain groups in patients with HIV/AIDS

Variables Characteristics Control (No pain) Nociceptive pain Neuropathic pain Total p-value

Gender Female 13 (19.1%) 13 (19.1%) 32 (47.1%) 58 (85.3%) 0.033*

Male 6 (8.8%) 2 (2.9%) 2 (2.9%) 10 (14.7%)

Age (years) # - 45.83±9.53 44.93±11.23 44.50±10.48 - 0.838*

Education (years) # - 6.94±3.37 4.93±2.67 5.78±2.90 - 0.122*

Smoking Yes 4 (6.1%) 4 (6.1%) 11 (16.7%) 19 (28.8%) 0.938*

No 12 (18.2%) 10 (15.2%) 22 (33.3%) 44 (66.7%)

Not informed 1 (1.5%) 1 (1.5%) 1 (1.5%) 3 (4.5%)

Alcohol consumption Yes 7 (10.6%) 5 (7.6%) 12 (18.2%) 24 (36.4%) 0.096*

No 8 (12.1%) 7 (10.6%) 22 (33.3%) 37 (56.1%)

Not informed 2 (3%) 3 (4.5%) 0 (0.0%) 5 (7.6%)

Viral load Detectable 8 (11.8%) 10 (14.7%) 16 (23.5%) 34 (50%) 0.138*

Undetectable 9 (13.2%) 4 (5.9%) 18 (26.5%) 31 (45.6%)

No information 2 (2.9%) 1 (1.5%) 0 (0%) 3 (4.4%)

Use of Efavirenz Yes 7 (10.3%) 3 (4.4%) 7 (10.3%) 17 (25%) 0.409*

No 12 (17.6%) 12 (17.6%) 27 (39.7%) 51 (75%)Variables expressed in absolute numbers (percentage). # variable shown as mean±SD of the mean. * Exact Fisher and Kruskal-Wallis tests. p<0.05 was considered a significant difference.

Table 1. Characterization of the sample regarding sociodemographic data and lifestyle

Variables Frequency %

Gender Male 10 14.7

Female 58 85.3

Age (years) Between 35 and 55 46 67.7

More than 55 13 19.1

Less than 35 9 13.2

Housing Living alone 15 22.0

Living with family 49 72.0

Other types of housing 4 6.0

Schooling Mean years of study 5.9

Median years of study 5

Professional work Active 14 21.0

Unemployed 27 40.0

Social allowance 25 37.0

Viral load Undetectable 31 45.6

Not informed 3 4.4

Detectable 34 50.0

Use of Efavirenz Using 17 25.0

Not using 51 75.0

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Table 5. Factors that have caused, more frequently, difficulty to fall asleep among patients without pain, nociceptive pain or neuropathic pain

Variables Occurrence Control (no pain) Nociceptive pain Neuropathic pain p-value

Cough or snore very loud Never 13 (19.1%) 9 (13.2%) 15 (22.1%) 0.592*

Less than once a week 1 (1.5%) 1 (1.5%) 1 (1.5%)

Once-twice a week 2 (2.9%) 2 (2.9%) 6 (8.8%)

3 times/week or more 3 (4.4%) 4 (4.4%) 12 (17.6%)

Take more than 30 minutes to fall asleep

Never 7 (10.3%) 4 (5.9%) 8 (11.8%) 0.647*

Less than once a week 2 (2.9%) 2 (2.9%) 1 (1.5%)

Once-twice a week 3 (4.4%) 3 (4.4%) 6 (8.8%)

3 times/week or more 7 (10.3%) 6 (8.8%) 19 (27.9%)

Get up to go to the bathroom Never 2 (2.9%) 3 (4.4%) 4 (5.9%) 0.694*

Less than once a week 1 (1.5%) 0 (0.0%) 1 (1.5%)

Once-twice a week 4 (5.9%) 1 (1.5%) 9 (13.2%)

3 times/week or more 12 (17.6%) 11 (16.2%) 20 (29.4%)Continue...

Table 3. Regarding the usual sleep characteristics, the patients were also divided into control (no pain), nociceptive pain and neuropathic pain groups

Usual sleep characteristics Control (no pain) Nociceptive pain Neuropathic pain p-value

Mean SD Median Mean SD Median Mean SD Median

Time to go to bed 23.000 1.452 23.000 22.666 2.160 22.000 23.029 1.678 23.000 0.701*

Latency (minutes) 43.421 65.448 15.000 57.400 61.719 30.000 51.323 48.073 30.000 0.218*

Wake-up time 7.105 1.696 7.000 6.933 1.944 7.000 7.088 1.896 7.000 0.820*

Sleep duration (hours) 7.111 1.449 7.000 7.400 1.993 8.000 6.650 2.281 6.000 0.225*

Usual sleep efficiency

>85% 12 (17.6%) 8 (11.8%) 15 (22.1%) 0.336#

75 to 84% 3 (4.4%) 3 (4.4%) 7 (10.3%)

65 to 74% 2 (2.9%) 0 (0.0%) 8 (11.8%)

<65% 2 (2.9%) 4 (5.9%) 4 (5.9%)

Total 19 (27.9%) 15 (22.1%) 34 (50.0%)For sleep efficiency, the variables are expressed in absolute numbers (percentage). SD of the mean; * Kruskal Wallis test. # Fisher’s Exact test; p<0.05 was considered a significant difference.

Table 4. Comparison of overall PSQI-BR score and components among patients without pain, nociceptive pain or neuropathic pain

PSQI-BR components Control (no pain) Nociceptive pain Neuropathic pain p-value

Mean SD Median Mean SD Median Mean SD Median

Subjective sleep quality 1.500 0.730 1.000 1.500 0.650 1.000 1.727 0.801 2.000 0.529*

Sleep latency 1.263 1.284 1.000 1.666 1.234 2.000 1.970 1.086 2.000 0.148*

Sleep duration 0.736 0.933 0.000 0.866 1.125 0.000 1.294 1.268 1.000 0.276*

Sleep efficiency 0.684 1.056 0.000 1.000 1.309 0.000 1.029 1.086 1.000 0.477*

Sleep disorders 1.578 0.507 2.000 2.000 0.755 2.000 1.911 0.621 2.000 0.119*

Sleeping pills 0.157 0.688 0.000 1.000 1.463 0.000 1.058 1.412 0.000 0.038*

Daytime sleepiness 0.894 0.936 1.000 0.866 0.743 1.000 1.323 1.000 1.006 0.192*

Overall score (%)

Good sleep 6 (8.8%) 3 (4.4%) 3 (4.4%) 0.059#

Poor sleep 11 (16.2%) 8 (11.8%) 16 (23.5%)

Sleep disorder 2 (2.9%) 4 (5.9%) 15 (22.1%)

Total 19 (27.9%) 15 (22.1%) 34 (50.0%) 0.059Overall sleep score, data expressed in absolute numbers (percentage). # Fisher’s Exact test; *Kruskal-Wallis test; p<0.05 was considered a significant difference.

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than 30 minutes to fall asleep and wake up in the middle of the night or too early, 19 (27.9%) patients with both factors in the last month. In the nociceptive pain group, the factors that caused the most difficulty to fall asleep were wake up in the middle of the night or too early in the morning, 12 (17.6%) patients; get up to go to the bathroom, 11 (16.2%); and take more than 30 minutes to fall asleep, 6 (8.8%) patients. All fac-tors repeated three times or more per week. Feeling the pain and having bad dreams or nightmares were also preponderant factors, with a significant difference in the study among pa-tients with neuropathic pain.

DISCUSSION

Some studies suggest that 90% of individuals with HIV have pain. Specifically, pain occurs for three main reasons: (1) HIV symptom; (2) another opportunistic disease or infection; (3) or adverse effect of the antiretroviral therapy (ART). The problem is even worse in cases of chronic pain associated with AIDS

since there is a big negative interaction among the drugs used for analgesia and the antiretrovirals, making it difficult to treat the pain symptoms in these patients26. In addition, there is a higher incidence of adverse drug effects; greater under-treat-ment of pain in AIDS (85%) than in cancer (49%), and there is a worse scale of emotional well-being when compared with any chronic disease, regardless of the disease stage, except primary depression9,27. According to the International Association for the Study of Pain (IASP), pain is “an unpleasant sensory and emotional experience associated with an existing or potential injury, or described in terms of such injury.” When named as “chronic pain,” it is characterized as continuous or recurrent pain, last-ing at least for three months, often with uncertain etiology, and does not disappear with the use of conventional thera-peutic procedures, becoming the cause of prolonged incapac-ity and disability28,29. This study confirms the data presented in the literature since almost 70% of the sample reported pain with chronicity. The interaction between antiretrovirals and

Table 5. Factors that have caused, more frequently, difficulty to fall asleep among patients without pain, nociceptive pain or neuropathic pain – continuation

Variables Occurrence Control (no pain) Nociceptive pain Neuropathic pain p-value

Waking up in the middle of the night or early morning

Never 5 (7.4%) 1 (1.5%) 2 (2.9%) 0.114*

Less than once a week 1 (1.5%) 0 (0.0%) 6 (8.8%)

Once-twice a week 5 (7.4%) 2 (2.9%) 7 (10.3%)

3 times/week or more 8 (11.8%) 12 (17.6%) 19 (27.9%)

Difficult breathing Never 14 (20.6%) 9 (13.2%) 23 (33.9%) 0.928*

Less than once a week 1 (1.5%) 2 (2.9%) 1 (1.5%)

Once-twice a week 2 (2.9%) 2 (2.9%) 6 (8.8%)

3 times/week or more 2 (2.9%) 2 (2.9%) 4 (5.9%)

Feel very cold Never 12 (17.6%) 4 (5.9%) 15 (22.1%) 0.504*

Less than once a week 1 (1.5%) 2 (2.9%) 2 (2.9%)

Once-twice a week 3 (4.4%) 4 (5.9%) 7 (10.3%)

3 times/week or more 3 (4.4%) 5 (7.4%) 10 (14.7%)

To feel very hot Never 11 (16.2%) 3 (4.4%) 15 (22.1%) 0.088*

Less than once a week 2 (2.9%) 5 (7.4%) 2 (2.9%)

Once-twice a week 4 (5.9%) 3 (4.4%) 6 (8.8%)

3 times/week or more 2 (2.9%) 4 (5.9%) 11 (16.2%)

Have bad dreams or nightmares Never 15 (22.1%) 7 (10.3%) 13 (19.1%) 0.051*

Less than once a week 1 (1.5%) 4 (5.9%) 4 (5.9%)

Once-twice a week 2 (2.9%) 3 (4.4%) 7 (10.3%)

3 times/week or more 1 (1.5%) 1 (1.5%) 10 (14.7%)

To feel pain Never 15 (22.1%) 8 (11.8%) 12 (17.6%) 0.007*

Less than once a week 0 (0.0%) 1 (1.5%) 2 (2.9%)

Once-twice a week 4 (5.9%) 2 (2.9%) 6 (8.8%)

3 times/week or more 0 (0.0%) 4 (5.9%) 14 (20%)

Other reasons Never 14 (20.5%) 9 (13.2%) 21 (30.8%) 0.668*

Less than once a week 1 (1.5%) 1 (1.5%) 0 (0.0%)

Once-twice a week 2 (2.9%) 1 (1.5%) 5 (7.4%)

3 times/week or more 2 (2.9%) 4 (5.9%) 8 (11.8%)Data expressed in absolute numbers (percentage). # Fisher’s Exact test; *Kruskal-Wallis test; p<0.05 was considered a significant difference.

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drugs, such as cigarette and alcohol, is a risky behavior that can lead to toxicity and ineffective therapy; increased morbid-ity and mortality; increased exposure to high-risk sexual ac-tivity; acceleration of the disease progression; low adherence to ART; decline in CD4+ T-cell lymphocytes and increase in viral load30. In this study, it was observed that 28.8% were smokers and 36.4% consumed alcohol, in these, neuropathic pain prevails. Some studies have related the frequency of neuropathic pain with increased viral load and low CD4 levels, which did not present significance (p=0.138) in this sample. The use of the antiretroviral Efavirenz showed no significant association be-tween the groups (p=0.409).According to the data in table 2, there was no significant as-sociation between sociodemographic and clinical characteris-tics with the control and pain groups. A significant difference was observed between the gender ratio in the neuropathic pain group, women 32 and men 2, in comparison to the others, which is explained by the number of requests for care at the NGO where the study was performed. Sleep is important to maintain the body homeostasis, and if it does not happen, the person will be subject to daytime sleep-iness, fatigue, altered mood, and periods of disorientation. It may also reduce pain resistance because the fatigue of the sympathetic central nervous system is increased, which in turn causes an increase in the use of drugs to control pain, which contributes to sleep deprivation31. Therefore, sleep is a basic human need that deserves to receive all the attention and inter-ventions from health professionals, especially the nurse32. Ac-cording to Souza and Guimarães13, the human being needs to sleep, as he needs to breathe and feed. Sleeping is not a passive act, but rather a restful and active act, so its time should be respected and the less unregulated as possible 33. The number of sleeping hours varies among people according to gender, age, and biological constitution. Women sleep 40 to 50 minutes longer than men and have greater amount of deep sleep. In relation to age, sleep decreases during life. While a newborn sleeps up to 18 hours a day, a young person needs about seven to eight hours, and an old person may be satisfied with five hours. impaired sleep and inadequate wakefulness are invaluable sources of human suffering34. The evidence indicates that deep sleep outweighs chronic pain-ful processes so that patients with more hours of sleep probably experience the symptoms with less intensity. For Vasilceac35 a night’s sleep of poor quality may increase pain sensitivity on the following day. This is evident in this sample because, on mean, the pain groups had fewer hours of sleep than the control group (no pain).The response to pain is one of the behaviors that can be altered due to changes in the sleep pattern. Patients with chronic pain have sleep fragmentation, a condition that may increase pain. A study by Edwards et al.36 investigated the relationship between sleep duration and the presence of pain complaints in the pop-ulation. They found that subjects who slept less than six hours or for nine hours or more reported pain more frequently on the following day, and those who slept for three hours or less had

an 81% increase in pain frequency over the sleep period from 6 to 9 hours, and sleeping for more than 11 hours was associated with a 137% increase in pain frequency. Several authors stress the importance of a good night’s sleep and its benefits. More-over, there is an association between poor sleep and reduction in survival. Sleep disorders are typical signs of depression, as well as of pharmacological interactions, and it is necessary to investigate to solve this problem37.Symptomatic or asymptomatic AIDS can lead to excessive day-time sleepiness (EDS) and insomnia. Studies with asymptom-atic HIV patients have shown increased slow-wave sleep, espe-cially during the second part of the night, as well as reduced sleep efficiency. As HIV progresses, sleep becomes more frag-mented, with frequent arousal, the slow-wave sleep decreases and rhythmic REM/non-REM cycles are suppressed. Insomnia and fatigue are the most common complaints, but more than 100 other disorders have been identified. Among its main cat-egories are the problems to keep a regular resting routine and unusual behaviors during sleep38. According to Cruess et al.,39 the presence of sleep disorders is of particular importance in HIV due to the already known ad-verse effects exerted by sleep deprivation on the immunity of healthy subjects and in HIV patients.When comparing the overall score between the PSQI-BR com-ponents and the control, nociceptive and neuropathic pain groups, a significant association was found among patients with neuropathic pain who used sleeping pills (p<0.05). In this study, it was observed that more than 80% of the patients had poor sleep or sleep disorders. When compared to WHO data,17 that shows that 40% of the world population have difficulties in relation to the overall quality of sleep, the sample recorded the double of that loss of quality.The Brazilian Society for the Study of Pain (SBED)40 describes that approximately 50% of patients with chronic pain report some sleep problems, such as difficulty in sleeping and awak-ening, closely associated with pain intensity. Many research-ers and clinical practice professionals are becoming aware of the importance of the relationship between changes in time or quality of sleep and the presence of chronic pain. Although the mechanisms involved in this bidirectional relationship are still unclear, a good night’s sleep can be an important tool to reduce pain complaints and improve patients’ QoL40.Studies related to sleep in patients with HIV/AIDS describe that these patients face a lot of stress during the course of the disease, including dependence, disability, fear of pain and painful death, which can lead to bad dreams and nightmares, such as presented in the sample. They also point out that pain, whether acute or chronic, associated with sleep disorders is an important public health problem, causing numerous damages, including human, occupational and labor injuries41.It is known that pain interferes with sleep, but lack of sleep can increase the perception of pain42. Although there is a clear, strong relationship between pain and sleep, the reasons to ex-plain it are unclear. The relationship between sleep and pain is bidirectional and more studies are still required. Also, both chronic pain and sleep disorders share a range of physical and

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mental health problems, such as obesity, type II diabetes, and depression. Having an interdisciplinary view is fundamental to understand the diagnosis better35. In 2017, SBED 40 recom-mended that the teams who treat patients with these symptoms should be staffed by professionals from several areas.Extended periods of rest deprivation may increase the risk of heart problems, as well as mental disorders or pain-related complaints43. The studies on the relationship between sleep and pain manifestations have intensified and confirmed their association. Individuals with chronic pain, for example, are also susceptible to severe sleep problems44. The circadian marker and the sleep homeostasis play central roles in the functions of daily life. Studies suggest that improved sleep enhances the immune function, both in cancer patients and in HIV-positive patients45.Despite the benefits of antiretroviral therapy, AIDS has a phys-ical, psychic and social impact. The nursing team seeks to im-prove its knowledge to provide individualized assistance in the different spaces where health care is provided. There is an in-creasing and continuous development towards comprehensive and personalized care, which allows nurses to plan their daily activities, enabling the development of nursing activity and valuing their knowledge46.The nursing care directed to these patients should be performed with systematized actions in order to produce positive results in the care of these patients47. To obtain a satisfactory result with the treatment of pain, it is necessary to pay attention to the complaints related to sleep, characterizing and identifying these alterations to propose the required interventions to im-prove the QoL of these patients48.

CONCLUSION

There is a high prevalence of sleep disorders or poor sleep in HIV patients with neuropathic pain. There was also a higher number of patients with normal sleep efficiency in the neuropathic pain group, which may be related to the greater use of sleeping pills, practically the double of the other groups.

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20. Oliveira RM, Silva LM, Pereira ML, Gomes JM, Figueiredo SV, Almeida PC. Dor e analgesia em pacientes com síndrome da imunodeficiência adquirida. Rev Dor. 2012;13(4):332-7.

21. Muller MR, Guimaraes SS. Impacto dos transtornos do sono sobre o funcionamento diário e a qualidade de vida. Estud Psicol. 2007;24(4):519-28.

22. Santos EI, Gomes AM. Vulnerabilidade, empoderamento e conhecimento: memórias e representações de enfermeiros acerca do cuidado. Acta Paul Enferm. 2013;26(5):492-8.

23. Bertolazi AN, Fagondes SC, Hoff LS, Dartora EG, Miozzo IC, de Barba ME, et al. Validation of the Brazilian Portuguese version of the Pittsburgh Sleep Quality Index. Sleep Med. 2011;12(1):70-5.

24. Schestatsky P, Félix-Torres V, Chaves ML, Câmara-Ehlers B, Mucenic T, Caumo W, et al. Brazilian Portuguese validation of the Leeds Assessment of Neuropathic Symptoms and Signs for patients with chronic pain. Pain Med. 2011;12(10):1544-50.

25. Conselho Nacional de Saúde (CNS). Diretrizes e Normas Regulamentadoras de Pes-quisas Envolvendo Seres Humanos. Resolução 466/12. [Internet]. 2012. Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/cns/2013/res0466_12_12_2012.html

26. Ferreira LT, Ceolim MF. Sleep quality in HIV-positive outpatients. Rev Esc Enferm USP. 2012;46(4):892-9. Portuguese.

27. Silva JG, Morgan DA, Alchieri JC, Medeiros HF, Knackfuss MI. Nível de dor as-sociado a variáveis sociodemográficas e clínicas em pessoas que vivem com o vírus da imunodeficiência humana e a síndrome da imunodeficiência adquirida. Rev Dor. 2017;18(1):51-8.

28. Merskey H, Bogduk N. Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms. 2nd ed. IASP Press; 1994. [Internet]. 2017 [citado em 28 de Jul 2017] Disponível em: https://www.iasp-ain.org/PublicationsNe-ws/Content.aspx?ItemNumber=1673.

29. Oliveira RM, da Silva LM, Pereira ML, Moura MA. [Pain management in patients with AIDS: analysis of the management structure of a reference hospital]. Rev Esc Enferm USP. 2013;47(2):456-63. Portuguese.

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31. Smith MT, Haythornthwaite JA. How do sleep disturbance and chronic pain inter-re-late? Insights from the longitudinal and cognitive-behavioral clinical trials literature. Sleep Med Rev 2004;8(2):119-32.

32. da Costa SV, Ceolim MF. [Factors that affect inpatients’ quality of seep]. Rev Esc Enferm USP. 2013;47(1):46-52. Portuguese.

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34. Reimão RS. Estudo abrangente. 2ª ed. São Paulo: Atheneu; 1996.35. Vasilceac FA. Estudos confirmam relação entre dor crônica e falta de sono. [Internet].

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36. Edwards RR, Almeida DM, Klick B, Haythornthwaite JA, Smith MT. Dura-tion of sleep contributes to next-day pain report in the general population. Pain. 2008;137(1):202-7.

37. Silva JM, Costa AC, Machado WW, Xavier CL. Avaliação da qualidade de sono em idosos não institucionalizados. ConScientiae Saúde, 2012;11(1):29-36.

38. Norman SE, Chediak AD, Freeman C, Kiel M, Mendez A, Duncan R, et al. Sleep disturbances in men with asymptomatic human immunodeficiency (HIV) infection. Sleep. 1992;15(2):150-5.

39. Cruess DG, Antoni MH, Gonzalez J, Fletcher MA, Klimas N, Duran R, et al. Sleep disturbance mediates the association between psychological distress and immune sta-tus among HIV-positive men and women on combination antiretroviral therapy. J Psychosom Res. 2003;54(3):185-9.

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41. Galvão MT, Soares LL, Pedrosa SC, Fiuza ML, Lemos LA. Quality of life and adherence to antiretroviral medication in people with HIV. Acta Paul Enferm. 2015;28(1):48-53.

42. Redeker NS. Sleep in acute care settings: a integrative review. J Nurs Scholarsh. 2000;32(1):31-8

43. Coren S. Ladrões de sono: um alerta sobre o risco de contrariar nosso relógio biológi-co. São Paulo: Cultura; 1996.

44. Instituto do Sono. Distúrbios do sono. [Internet] 2017. [citado em 28 de Abr 2017] Disponível em: http://www.sono.org.br/sono/disturbiosdosono.php.

45. Nokes KM, Kendrew M. Sleep quality in people with HIV disease. J Assoc Nurses AIDS Care. 1996;7(3):43-50.

46. Bergamasco EC, Cruz DA. Alterações do sono: diagnósticos frequentes em pacien-tes internados. Rev. Gaúcha Enferm. 2006;27(3):356-63. Disponível em: http://seer.ufrgs.br/RevistaGauchadeEnfermagem/article/view/4624.

47. Horta, WA. Processo de enfermagem. São Paulo: EPU;1979.48. Nanda Internacional. Diagnósticos de enfermagem da NANDA: definições e classifi-

cações 2009-2011. Porto Alegre: Artmed; 2010.

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ABSTRACT

BACKGROUND AND OBJECTIVES: There are a variety of ways to apply the transcutaneous electrical nerve stimulation (TENS) without an established way that provides better results in the treat-ment of nonspecific low back pain. The objective of this study was to evaluate which application of TENS has a better effect on the immediate reduction of the intensity of spontaneous and provoked pain in college students with nonspecific low back pain. METHODS: Quantitative, randomized and cross-sectional study. Twenty young individuals were divided into four groups and received a different intervention per week, totaling four weeks. The groups were Conventional TENS with the frequency of 100Hz, a pulse duration of 200μs; TENS with frequency and intensity variation with frequency variation and automatic pulse duration, TENS Burst with frequency modulated at 2Hz, pulse duration of 250μs; and placebo in which the subjects underwent a pacing protocol with no tingling sensation or muscle contrac-tion. All sessions had a total application time of 20 minutes. They were evaluated for spontaneous pain through the applica-tion of the visual analog scale (VAS), and pain provoked by the algometer and cold pain through the application of solid ice di-rectly to the skin, and VAS for the intensity of cold pain, all per-formed before and after each application of the electrotherapy. RESULTS: Only the visual analog scale of spontaneous pain showed significant results (p<0.05) when compared intragroups, in the three applied currents. CONCLUSION: The three forms used in the present study were able to reduce spontaneous pain after the intervention by elec-trostimulation.

Comparative analysis between three forms of application of transcutaneous electrical nerve stimulation and its effect in college students with non-specific low back pain Análise comparativa de três formas de aplicação de estimulação elétrica nervosa transcutânea e seu efeito na redução da dor em universitários com lombalgia inespecífica

Carla Maria Verruch1, Andersom Ricardo Fréz2, Gladson Ricardo Flor Bertolini1

Carla Maria Verruch - https://orcid.org/0000-0002-5072-407X;Andersom Ricardo Fréz - https://orcid.org/0000-0001-6085-1382;Gladson Ricardo Flor Bertolini - https://orcid.org/0000-0003-0565-2019.

1. Universidade Estadual do Oeste do Paraná, Cascavel, PR, Brasil. 2. Universidade Estadual do Centro Oeste, Guarapuava, PR, Brasil.

Submitted on December 11, 2018.Accepted for publication on March 06, 2019.Conflict of interests: none – Sponsoring sources: none.

Correspondence to: Rua Universitária, 2069 – Jardim Universitário85819-110 Cascavel, PR, Brasil.E-mail: gladsonricardo@gmail.com

© Sociedade Brasileira para o Estudo da Dor

Keywords: Analgesia, Low back pain, Transcutaneous electrical nerve stimulation.

RESUMO

JUSTIFICATIVA E OBJETIVOS: Há uma variedade de for-mas de aplicação de estimulação elétrica nervosa transcutânea (TENS), sem que haja uma forma definida com melhores resul-tados no tratamento para a dor lombar inespecífica. O objetivo deste estudo foi avaliar qual aplicação de TENS tem melhor efei-to sobre a redução imediata da intensidade da dor espontânea e provocada, em universitários com lombalgia inespecífica. MÉTODOS: Estudo quantitativo, aleatorizado e cruzado. Vin-te indivíduos jovens foram distribuídos em quatro grupos e realizaram uma intervenção diferente por semana, totalizando quatro semanas. Grupos TENS convencional com frequência de 100Hz, duração de pulso de 200μs; TENS variação de fre-quência e intensidade com variação de frequência e duração de pulso automática, TENS Burst com frequência modulada em 2Hz, duração de pulso 250μs; e placebo em que os indivíduos foram submetidos a um protocolo de estimulação sem nenhuma sensação de formigamento ou contração muscular. Todas as ses-sões tiveram uma aplicação total de 20 minutos. Foram avaliados pela dor espontânea por meio da aplicação da escala analógica visual (EAV), e dor provocada pelo dolorímetro e dor ao frio por meio da aplicação de gelo sólido diretamente na pele, e EAV para intensidade de dor ao frio, todos realizados antes e após cada aplicação de eletroterapia.RESULTADOS: Apenas a escala analógica visual de dor espon-tânea apresentou resultados significativos (p<0,05) quando com-parado intragrupos, nas três correntes aplicadas. CONCLUSÃO: As três formas utilizadas no presente estudo fo-ram capazes de reduzir a dor espontânea após a intervenção por eletroestimulação.Descritores: Analgesia, Dor lombar, Estimulação elétrica nervo-sa transcutânea.

INTRODUCTION

Low back pain is defined as pain or discomfort, located in the dorsal area between the last ribs and the gluteal folds, and may or may not present referred pain in the lower limbs. It represents a substantial economic burden for people in general, requiring

DOI 10.5935/2595-0118.20190024

ORIGINAL ARTICLE

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national and international measures aimed at prevention and re-duction of treatment costs1,2.Diagnostic screening, depending on the degree of specificity, can be classified in two ways: specific and nonspecific low back pain (LBP). Nonspecific LBP is characterized as a pain that is not at-tributed to a previous disease/injury, such as infections, tumors, fractures, structural deformities, root syndrome, among others3.Although not having a primary cause, nonspecific LBP has many risk factors related to childhood and adolescence, such as excessive heavy backpacks, improper posture, and ergonomics of school desks4. Although the first cases are linked to puber-ty, the occurrence of low back pain in students and healthcare professionals is possibly related to the amount of academic and professional tasks, coupled with inadequate furniture and physical requirements5.The first choice to treat LBP is always conservative, as it is effective in reducing pain. The use of pharmacological therapy, application of local heat and electrostimulation, besides being less invasive, costs less than the surgical treat-ment6. Transcutaneous electrical nerve stimulation (TENS) is considered a good treatment option for LBP because it is a non-invasive, non-pharmacological technique and respon-sible for activating afferent inhibitory neurons using elec-trodes on the skin surface7.This therapy can be performed in different clinical settings. When applied with a high frequency, such as conventional TENS therapy, it has an Aβ fiber depolarization effect, capa-ble of activating interneurons that are responsible for inhibiting the conduction of pain by the Aδ and C fibers8. When applied at low frequencies, such as the TENS burst therapy character-ized by strong stimuli, it depolarizes the fast pain (Aδ) and slow pain (C) fibers, which through the activation of pain modulating mechanisms located in the region of puns and bulb can produce descending analgesia. Both applications are effective in reducing pain through the release of endogenous opioids9.10. Another form of TENS application is the one in which there is an automatic variable intensity frequency (VIF), as well as changes in the pulse length, presenting combined effects of the therapies with high and low frequencies, aiming mainly to hinder the accommoda-tion phenomenon11. To evaluate the effectiveness of different types of electrostimula-tion, different pain stimuli can be measured, such as cold, ana-lyzing intensity and pain threshold, as well as the pressure pain threshold. Such stimuli are responsible for pain reactions and can occur by depolarization of C and Aδ fibers8,12. There are many ways of applying TENS, without having a defi-nite way to obtain better treatment results for nonspecific LBP. Thus, the objective of the present study was to evaluate which kind of application of TENS has a better effect on the immediate reduction of the intensity of spontaneous and provoked pain, in college students with nonspecific LBP. METHODS

The present study is characterized as quantitative, randomized and crossed-sectional. Data collection was performed at the

Physical Rehabilitation Center (CRF) - UNIOESTE and all par-ticipants signed the Free and Informed Consent Form (FICT).Eight male and 12 female volunteers participated in the study, aged from 18 to 27 years old (mean of 20.78±2.65 years), weight 70.25±14.97kg, height 1.68±0.07m, and body mass index (BMI) of 24.53±4.58, who presented nonspecific LBP for at least three months, and were included only those who were not performing any type of treatment. The exclusion criteria were contraindications for the use of electrostimulation of any kind, the use of a pacemaker or a metal implant.Data collection lasted for four weeks, and all 20 subjects were submitted, crossed-sectional, to the four sessions, once a week, in groups previously selected by lot, and the individual had to go through the four intervention groups, not being allowed to repeat the type of current application. The groups were: conventional TENS (CTG), burst TENS (BTG), VIF TENS (VTG) and placebo (PG).It was used the visual analog scale (VAS) to quantify the intensity of spontaneous pain, which presents values from zero to 10, where zero refers to no discomfort and 10 refers to the maximum bear-able discomfort, being measured before the other evaluations13. A pain stimulus under pressure and cold14 was applied to evaluate the provoked pain threshold. First, the Kratos® algometer was used, capable of producing a pressure of up to 50Kgf. All procedures were explained to the volunteers, and the pressure was applied in the low back area, always bilaterally, 2cm lateral to the spinous process of the vertebrae referred to as being more sensitive to pal-pation. The moment the pressure pain threshold was reached, the algometer was removed, and the value of the highest pressure exerted was written down. To evaluate the pain for cold, ice was applied directly to the skin in the low back area, at the same place of the pressure evaluation, writing down the time in seconds that the volunteer took to feel the pain stimulus, that is, the threshold of pain for cold. Besides, the VAS was also used to quantify the intensity of pain for cold after contact with the ice. All evaluations were performed before the application of the therapy and repeated at the end of the session, including in the PG. After the pain evaluation, the electrostimulation therapy was applied using the Ibramed Neurodyn II device, drawn for the participant in each intervention day. In all groups, the individ-ual was positioned in the prone position, with the electrodes ar-ranged longitudinally on the low back area (L1-L5). The gel was applied to create the interface for current transmission, and the electrodes were fixed with adhesive tape. Finally, the device was switched on following the parameters of each protocol. In the three types of current application, whenever there was ac-commodation, the intensity was increased, according to the pa-tient’s report. The total duration of therapy was 20 minutes in all groups14,15.In the CTG, the subjects were submitted to the application of the current with a frequency of 100Hz, a pulse duration of 200μs (microseconds), with comfortable amplitude, depending on the participant’s threshold, without occurring motor stimula-tion. In the VTG, the current application used as parameter the frequency of 2 to 247Hz, a pulse duration of 50 to 500μs and high amplitude, yet comfortable. And in BTG, the current was

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applied with frequency modulated at 2Hz, a pulse duration of 250μs, with sufficient amplitude to generate a rhythmic muscle contraction sensation, associated with tingling, yet comfortable.At the PG, the volunteers did not receive electrical stimulation, but at the beginning of the intervention, the evaluator explained that they were being submitted to a protocol below the sensory threshold, in which they would not have any sensation of tin-gling or muscular contraction. The electrodes were placed, and the device switched on, however, there was no electric current transmission. All procedures followed the ethical criteria required for work in humans, with prior approval by the Research Ethics Committee of the State University of the Oeste do Paraná (UNIOESTE), under number: 2.588.536 of 2018.

Statistical analysis For this size of the sample used, with a difference to be detect-ed and a standard deviation of 2.5, and a significance level of

5%, the calculated test power was 80% for ANOVA evaluation using the software Bioestat 5.0. The results were analyzed by de-scriptive and inferential statistics, and there was normality for the daily VAS (Shapiro-Wilk). Thus, one-way ANOVA was used with an evaluation of the size of the Cohen effect. For the other variables, the Friedman test was used for non-parametric data. The accepted level of significance was 5% (p <0.05). RESULTS

Table 1 shows the assessment of the spontaneous pain intensity by VAS, before and after the treatment with a p<0.0001, and when compared between the groups there was no significant dif-ference. When compared with PG, the effect sizes were consid-ered small for the initial evaluation (conventional - 0.13, VIF 0.13, and burst 0.05), as well as for the final evaluation (conven-tional 0.32; VIF -0.22 and burst -0.32).In the evaluation of pain by pressure stimulus with the al-gometer, there was no significant difference between initial and final evaluations intra-group or between the different ways of the current application (Fr: 7.1 and p=0.4185), as shown in table 2.For the evaluation of the threshold of pain for cold pain, there were no significant results in the intra-group analysis in both tests (Fr: 10.4 and p=0.1666) and (Fr: 32.4 and p<0.0001), re-spectively. Yet, the VAS presented a significant p-value, which occurred when the different evaluations of the different treat-ment groups were compared, not happening between the eval-uations in the same group or at similar moments in the four groups. Table 3 shows the other data.

Table 3. Presentation of the data in the median, first and third quartile, and the sum of ranks for the groups when assessing the pain threshold of cold pain (seconds) and the visual analog scale for cold pain, before and after treatment

Groups Median1st and 3rd Q

Sum of Ranks Median1st and 3rd Q

Sum of Ranks

Pain threshold to cold (seconds)

CTG 28.217.8 - 64.5

79.5 48.518.2 - 160.8

103.5

VTG 24.214.3 - 70.5

75 3317.7 - 152

104.5

BTG 34.515.7 - 65.3

87 41.519.7-104.3

108.5

PG 3315.6 - 81.3

79 32.514.8 - 90.3

83

Continue...

Table 2. Presentation of the data in the median, first and third quartile, and the sum of ranks for the groups when the threshold of pressure pain algometer (gf) was evaluated before and after treatment

Groups Median1st and 3rd Q

Sum of Ranks Median1st and 3rd Q

Sum of Ranks

CTG 5497.54159.8-6720

80 6222.54282.6-7150

103

VTG 50554138.7-6436.2

78 47004331.2-6810

89

BTG 52904700-7047.5

85 55704952.5-7905

110

PG 5700.54370-7089.6

87 50504113.3-8277.5

88

CTG = conventional TENS group; VTG = VIF TENS group; BTG = burst TENS group; PG = placebo group.

Table 1. Data on mean and standard deviation for the groups when evaluated by the visual analog scale, before and after treatment and value of difference and p between evaluations

Groups Initial evaluation Final evaluation Effect size

CTG 5.15 ± 2.64 2.4 ± 1.95 * -1.21

VTG 5.15 ± 2.45 2.65 ± 1.69 * -1.20

BTG 4.95±2.66 2.4 ± 1.95* -1.08

PG 4.8 ± 2.76 3.15±2.66 0.60CTG = conventional TENS group; VTG = VIF TENS group; BTG = burst TENS group; PG = placebo group; * significant value of p (5%) when compared to the initial evaluation.

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DISCUSSION

Three types of application of TENS therapy (conventional, burst and VIF) were tested for the analysis of the reduction of sponta-neous and induced pain by pressure and thermal stimuli. Since all three were effective in reducing spontaneous pain, no signifi-cant results were found to indicate the best for the treatment of low back pain.Several studies have shown that the use of TENS to treat LBP is a viable option, with significant evidence of its effectiveness, both for acute and chronic pain and with few contraindications for the patient7,16,17.The reduction of spontaneous pain evaluated by the VAS had a significant result for the three ways of TENS application, which reproduces the results found in a study18 that used a model of low frequency (20Hz, 220μs) TENS and interferen-tial current in the low back area. It also reproduced another study19 which evaluated the effectiveness of TENS in high and low frequencies. However, one study has shown that for the reduction of post-cesarean pain intensity, the high frequency would be better20.In a systematic review of 29 studies on the efficacy of conven-tional TENS, 16 had positive results in pain reduction. When evaluated specifically for pressure pain, 8 studies have proved their efficacy, while 4 have not shown significant results. As for the pain caused by cold, there is moderate evidence regarding its effectiveness. There are three low-quality studies with positive results, and one low-quality study with negative results for this type of stimulus21.A study comparing the application of TENS in low and high fre-quencies, as well as the combined approach, emphasized that the use of TENS with variable frequency and intensity, such as VIF, reduces the occurrence of the development of current tolerance and can produce a greater analgesic effect. However, this fact was not reproduced in the present study, due to the single application of each TENS intervention22.The samples were composed of subjects of both genders, most women, which may be a limitation of this study. A previous study pointed out that there are differences in the pain thresh-old between men and women, mainly regarding pressure pain, which is the most sensitive to the differences of gender23. This corroborates the results of previous studies using TENS in the

conventional mode (100Hz, 250μs) and the high voltage po-larized current (100Hz, 50μs) and TENS therapy in different frequency configurations, both in the elbow area that did not obtain significant values in the evaluation of pressure pain after the treatment with analgesic currents15,24.However, a comparative study between TENS therapy (100Hz, 40μs) and its association with cryotherapy (20 min-utes) was effective in increasing the pressure pain threshold in the forearm area in healthy individuals. However, the method used to apply the pressure algometer differed from the other studies, since it asked the participant to report when they felt pain proportional to level 3 of the VAS, which may be the cause of the uneven results25.Regarding its efficacy in the reduction of cold-induced pain, there are differences in the results of a study26, which using TENS at the frequency of 10Hz applied in acupuncture points was able to reduce the intensity of cold pain in the hand area. Another study27, which used the acupuncture mode (10Hz and 250μs) to assess cold pain by the hand immersion method in cold water, did not obtain significant results. This data is in line with this study that used different parameters of TENS current application with the same purpose and did not find significance in the pain threshold supported in seconds, and pain intensity, quantified by the VAS.

CONCLUSION

The three ways of TENS application, conventional, VIF, and burst, were effective in the treatment of spontaneous pain since there was a significant numerical reduction in the VAS after the intervention. However, as none of the three ways of application has been excelled in the efficacy of pain reduction, further studies are needed to see if a similar result will be found when performed with a more extended protocol or with same-gender volunteers. REFERENCES

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Table 3. Presentation of the data in the median, first and third quartile, and the sum of ranks for the groups when assessing the pain threshold of cold pain (seconds) and the visual analog scale for cold pain, before and after treatment – continuation

Groups Median1st and 3rd Q

Sum of Ranks Median1st and 3rd Q

Sum of Ranks

Visual analog pain scale to cold

CTG

53 - 6

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57.5

VTG

54 - 6

113.5 43 – 4

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BTG

54 - 6.5

126 3.53 – 6

80

PG

53 - 6

99 33 - 4.5

75.5

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16. Santos I, Rodrigues AA, Martins AB, Faria WC. Avaliação da efetividade da TENS e da eletroacupuntura na lombalgia. ConScientiae Saúde. 2008;7(4):519-24.

17. Dohnert MB, Bauer JP, Pavão TS. Study of the effectiveness of interferential current as compared to transcutaneous electrical nerve stimulation in reducing chronic low back pain. Rev Dor. 2015;16(1):27-31.

18. Facci LM, Nowotny JP, Tormem F, Trevisani VF. Effects of transcutaneous elec-trical nerve stimulation (TENS) and interferential currents (IFC) in patients with nonspecific chronic low back pain: randomized clinical trial. Sao Paulo Med J. 2011;129(4):206-16.

19. Chen C, Johnson MI. A comparison of transcutaneous electrical nerve stimulation (TENS) at 3 and 80 pulses per second on cold-pressor pain in healthy human partici-pants. Clin Physiol Funct Imaging. 2010;30(4):260-8.

20. Lima LE, Lima AS, Rocha CM, Santos GF, Bezerra AJ, Hazime FA, et al. Estimulação elétrica nervosa transcutânea de alta e baixa frequência na intensidade da dor. Fisioter Pesq. 2014;21(3):243-8.

21. Claydon LS, Chesterton LS, Barlas P, Sim J. Dose-specific effects of transcutaneous electrical nerve stimulation (TENS) on experimental pain: a systematic review. Clin J Pain. 2011;27(7):635-47.

22. DeSantana JM, Walsh DM, Vance C, Rakel BA, Sluka KA. Effectiveness of trans-cutaneous electrical nerve stimulation for treatment of hyperalgesia and pain. Curr Rheumatol Rep. 2008;10(6):492-9.

23. Palmeira CC, Ashmawi HA, Posso Ide P. [Sex and pain perception and analgesia]. Rev Bras Anestesiol. 2011;61(6):814-28. English, Multiple languages.

24. Zegalo BP, Silva CF, Mariani L, Jurkevicz R, Karvat J, Carvalho AR, et al. Efeitos da estimulação elétrica nervosa transcutânea e da corrente de alta voltagem em indivíduos saudáveis. Revista Saúde e Pesquisa (Maringá). 2016;9(2):291-7.

25. Maciel LF, Ferreira JJ, Santos HH, Andrade PR. Efeitos da estimulação elétrica ner-vosa transcutânea e da crioterapia sobre o limiar de dor induzida por pressão. Fisioter Pesq. 2014;21(3):249-56.

26. Montenegro EJ, Alencar GG, Siqueira GR, Guerino MR, Maia JN, Oliveira DA. Effect of low frequency transcutaneous electrical nerve stimulation of TE5 (waiguan) and PC6 (neiguan) acupoints on cold-induced pain. J Phys Ther Sci. 2016;28(1):76-81.

27. Cheroto AC, Yamada EF. Efeito da TENS e da corrente interferencial na dor induzida pelo frio. Rev Bras Reabilitação e Atividade Física (Vitória). 2014;3(1):7-13.

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ABSTRACT

BACKGROUND AND OBJECTIVES: Children with cerebral palsy are affected by postoperative painful processes. These chil-dren’s pain may be underestimated due to difficult communica-tion especially when a specific tool is not used. The objective of this study was to evaluate the pain in children with cerebral palsy in postoperative orthopedic surgery and the pain perception of parents and health professionals. METHODS: It is a cross-sectional, observational study performed at Associação de Apoio à Criança Deficiente in São Paulo. Fifty-one children with cerebral palsy were recruited, aged between 6-15 years, 51 parents/caregivers and 51 health professionals. Pain assessment was measured by an observer during the routine procedures in which the child was manipulated. After the procedure, the observer asked health professionals and parents about the child’s pain. RESULTS: Eighty-two percent of patients had postoperative pain, and of these, 50% had moderate and intense pain. In unar-ticulated patients, parents and caregivers had discordant percep-tions from the observer in 65% of the cases (p=0.05) and health professionals had discordant responses in 75% (p<0.001). In communicative patients, parents had discordant responses from the observer in 58% of the cases (p=0.20) and health profession-als had discordant responses in 55% of the cases (p=0.44). CONCLUSION: Children with cerebral palsy present moder-ate and intense pain in the postoperative period of orthopedic

Pain in children with cerebral palsy in the postoperative: perception of parents and health professionals A dor em crianças com paralisia cerebral no pós-operatório de cirurgia ortopédica: percepção de pais e profissionais da saúde

Aline Cristina da Silva Fornelli1, Jessica Borges de Oliveira Lopes2, Daniela Fernandes Lima Meirelles3, José Baldocchi Pontin4, Márcia de Almeida Lima2

Aline Cristina da Silva Fornelli – https://orcid.org/0000-0002-9316-0366; Jessica Borges de Oliveira Lopes – https://orcid.org/0000-0002-4562-8606; Daniela Fernandes Lima Meirelles – https://orcid.org/0000-0003-0356-0516;José Baldocchi Pontin – https://orcid.org/0000-0002-3767-3159; Márcia de Almeida Lima – https://orcid.org/0000-0001-7915-0201.

1. Hospital Sancta Maggiore, Departamento de Fisioterapia Hospitalar, São Paulo, SP, Brasil.2. Associação de Apoio a Criança Deficiente, Departamento de Fisioterapia Hospitalar, São Paulo, SP, Brasil.3. Clínica de Ortopedia, Departamento de Fisioterapia, São Paulo, SP, Brasil.4. Associação de Apoio a Criança Deficiente, Centro de Terapias, Fisioterapia, São Paulo, SP, Brasil.

Submitted on July 12, 2018.Accepted for publication on March 13, 2019.Conflict of interests: none – Sponsoring sources: none.

Correspondence to: Rua Professor Ascendino Reis, 724Fisioterapia Hospitalar04027-000 São Paulo, SP, Brasil.E-mail: mallsp@hotmail.com

© Sociedade Brasileira para o Estudo da Dor

surgeries. In the hospital, it is more challenging to detect pain in unarticulated patients without the use of a specific scale, even by experienced parents or professionals.Keywords: Cerebral palsy, Pain measurement, Postoperative pain.

RESUMO

JUSTIFICATIVA E OBJETIVOS: A criança com paralisia ce-rebral pode ser afetada por processos dolorosos relacionados ao pós-operatório, com dor subestimada devido à dificuldade de co-municação, especialmente quando uma ferramenta específica não é utilizada. O objetivo deste estudo foi avaliar a dor em crianças com paralisia cerebral no pós-operatório de cirurgia ortopédica e a percepção de pais e profissionais de saúde sobre a dor. MÉTODOS: Estudo transversal, observacional realizado na As-sociação de Apoio à Criança Deficiente em São Paulo. Foram recrutadas 51 crianças com paralisia cerebral, com idade entre 6 e 15 anos, 51 cuidadores e 51 profissionais de saúde. A dor foi avaliada por um observador durante os procedimentos de rotina em que a criança foi manipulada. Após o procedimento, o obser-vador perguntou aos profissionais de saúde e cuidadores sobre a dor da criança. RESULTADOS: Oitenta e dois por cento dos pacientes apresen-taram dor pós-operatória e desses, 50% dor moderada e intensa. Nos pacientes não comunicativos, os pais apresentaram percep-ções discordantes do observador em 65% dos casos (p=0,05) e os profissionais de saúde apresentaram respostas discordantes em 75% (p<0,001). Nos pacientes comunicantes, os pais apresen-taram respostas discordantes do observador em 58% dos casos (p=0,20) e os profissionais de saúde em 55% dos casos (p=0,44). CONCLUSÃO: Crianças com paralisia cerebral apresentam dor moderada e intensa no pós-operatório de cirurgias ortopédicas. Na fase hospitalar, a dor é mais difícil de ser detectada em pacien-tes não comunicativos sem o uso de escala específica, mesmo por pais ou profissionais experientes. Descritores: Avaliação da dor, Dor pós-operatória, Paralisia cerebral.

INTRODUCTION

The International Association for the Study of Pain (IASP) de-fines pain as an unpleasant experience associated with actual or potential tissue injury involving the sensory, emotional and cog-nitive aspects. The recognition of the stimulus by the nociceptors is called nociception, and pain is a conscientious experience that

BrJP. São Paulo, 2019 apr-jun;2(2):137-41

DOI 10.5935/2595-0118.20190025

ORIGINAL ARTICLE

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requires a cortical processing and an aversive interpretation of the nociceptive information1,2. The inability to report and quan-tify pain does not exclude the possibility of its existence since it is an individual, subjective, multidimensional experience and related to a real or potential injury3. The evaluation of pain in children with cerebral palsy (CP) is a complex and subjective task. In many cases, these children have severe cognitive deficits, difficulty in verbalizing and idiosyn-crasies that mask the expression of pain; and because of their condition, they present changes in their facial expression and are not able to clearly signal the presence or intensity of pain4. Facing this complex scenario, pain can be underestimated and undertreated if a correct form of evaluation is not established for these patients5,6.The correct assessment of pain is paramount for the follow-up and success of the treatment, especially when it comes to un-articulated children and with neuromuscular disorders. Failure to use specific instruments can make it difficult to detect pain, leading to under-treatment. In this sense, inadequate analgesia in this profile of children may lead to increased tonus, presence of muscle spasm in the postoperative period and progress to wors-ening the pain6,7.Scales for pain assessment are tools that facilitate the interac-tion and communication between the healthcare team members and the patients. The Face, Legs, Activity, Cry, Consolability (FLACC) scale is an instrument that assesses pain based on ob-servation of the patient’s face, leg, activity, cry, and consolabili-ty patterns. It is an easy-to-apply instrument initially designed to assess pain in pre-verbal children and subsequently validat-ed to measure postoperative pain in children with difficulty to communicate due to mild to severe cognitive impairment – FLACC-R8-10. The modified scale has the same indicators of the FLACC scale and incorporates specific pain behaviors in chil-dren with multi deficiencies. An open descriptor was added to each indicator to include specific pain behaviors of each child, described by parents, as increased tone.Lastly, pain has been a priority regarding education, assessment, and documentation. Increasingly, the pain sensation has received more attention from the healthcare teams, scientific community and quality, and safety accreditation organizations. The Ameri-can Agency for Research and Quality in Public Health and the American Society of Pain describe it as the fifth vital sign11. In this sense, as important as detecting pain is to assess it properly and treat it with safety12. The objective of this study was to evaluate the presence of pain in children with CP in the postoperative period of orthopedic sur-geries and to compare the findings with the ability of the health-care team and the caregivers to detect pain, considering children who can communicate and children who cannot. METHODS

A prospective, observational study conducted in the hospital-ization units of the Hospital da Associação de Apoio à Criança Deficiente (AACD), in the city of São Paulo, from July to Au-gust 2014.

The sample was of convenience, chosen due to the limited col-lection time and availability of the researchers. Regarding the sample calculation, due to the few numbers of research on this matter, the calculation was based on a pilot sample, and the cal-culated n, unfortunately, was approximately 216 subjects for the group of patients (articulated and unarticulated).The sample consisted of 51 patients and 102 evaluators. The group of 51 patients was divided into 2 groups: Group 1 UA = unarticulated children with cerebral palsy (n=20); Group 2 A = articulated children with cerebral palsy (n=31); of both genders, aged between 6 and 16 years, diagnosis of CP, hospitalized and submitted to corrective orthopedic surgery in any segment of the lower limbs. Regarding the Group of Evaluators (evaluators of the subjective perception of the pain of the child with CP) (n=102), it was also subdivided into two groups: Group 1 P/C = composed by the respective parents/caregivers (responsible) of the patients (n=51); Group 2 HP=health professionals, com-posed by physiotherapists and nursing technicians (n=51).In the preoperative period, the observer completed a form with the patients’ clinical and personal data taken from their medical records. Then the following vital signs of the patient at rest were collected: heart rate (HR), respiratory rate (RR) and peripheral oxygen saturation (SpO2). The period between the 1st and 2nd postoperative day was chosen as the moment of pain evaluation during the hospital routines in which it was necessary to manip-ulate the patient and the operated segment in bed, in activities such as bathing, change of decubitus position, and physiothera-py. The manipulations were performed by different health pro-fessionals, physiotherapists or nursing technicians; and all the professionals participating in the study were randomly selected when they were providing care to the selected patient.To assess the impressions of the caregiver and the health profes-sional regarding the presence or absence of pain in the patient, both were verbally asked by the observer if the patient has had pain or not during the routine procedure. To serve as a compar-ison parameter, at the same time, the observer also evaluated the patient’s pain, and used specific instruments for pain assessment: In group 1 (UA), the FLACC-R scale was used, with a score be-tween zero and 1011,12. In the patients in group 2 (A) the verbal numerical rating scale (vNRS) was used, which also varies from zero to 10. Both scales evaluate the intensity of pain through the values obtained between zero and 10, being zero absence of pain; 1-3 mild pain; 4-6 moderate pain; 7-10 severe pain.The research was approved by the Research Ethics Committee of the Associação de Assistência à Criança Deficiente (AACD), with opinion number 835.133 and 32717214.6.0000.0085. Statistical analysisThe data was tabulated in the Microsoft Excel spreadsheet and then analyzed using the SPSS 17.0 software. For the descrip-tive analysis, the position and dispersion measures (mean and standard deviation) were calculated. The test for the equality of two proportions was used to calculate the agreement between the answers given by the caregivers and the health professionals, and the responses obtained by the observer regarding the presence or absence of pain in the patients. Regarding the hypothesis that the

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vital signs were altered in the presence of pain, the paired Stu-dent t-test was used. Two scales were used to evaluate the pain, FLACC and vNRS, and to check whether both scales matched, the Pearson correlation test was performed. In this study, the null hypothesis was rejected when the alpha error was less than 5% (p<0.05). RESULTS

Fifty-one patients were evaluated, 22 female (44.2%) and 29 male (56.8%) articulated and unarticulated. Fifty-one health professionals were interviewed, 24 nursing technicians (47.05%) and 27 physiotherapists (52.9%), as well as 51 par-ents/caregivers (Table 1).Taking the observer’s assessment as a reference of the presence of postoperative pain during the manipulation of the patient, 82% of the patients had pain, regardless of the group (p<0.001) (Table 2), with 50% of the patients with moderate to severe pain intensity.The answers given by the caregivers and the health professionals were compared with the ones obtained by the observer, who used the FLACC-R (unarticulated) and vNRS (articulated) scales for the presence or absence of pain in both groups of patients. The answers obtained by the observer (FLACC-R scale) were compared with the reports of caregivers and health profession-als regarding the presence or absence of pain in the unarticulat-ed patient’s group. In both groups of evaluators, a statistically significant difference in the answers was observed in relation to the observer’s evaluation. Parents and caregivers had discor-dant perceptions from the observer in 65% of cases (p=0.05), and health professionals had discordant responses in 75% (p<0.001) (Figure 1).The dark gray bar represents the percentage of disagreement, and the light gray indicates the percentage of agreement in the an-swers obtained from health professionals and parents/caregivers. The observer responses (vNRS scale) were compared with the reports of caregivers and health professionals regarding the pres-ence or absence of pain in the group of articulated patients, and a significant disagreement was observed in the responses of both groups of evaluators. The caregivers had discordant respons-es when compared to the observer’s in 58% (p=0.20), and the health professionals had discordant responses when compared to the observers in 54% (p=0.44) (Figure 2).The dark gray bar represents the percentage of disagreement, and the light gray indicates the percentage of agreement in the an-swers obtained from health professionals and parents/caregivers.

Face, Legs, Activity, Cry, Consolability scale versus verbal nu-merical rating scaleThe agreement between the FLACC and vNRS scales was an-alyzed in the group of articulated patients, to evaluate whether the responses and intensities were the same. There was a mod-erate correlation with statistically significant agreement between them, regarding the presence and intensity of the pain (Table 3).

Table 1. General characteristics of the groups

Groups Subgroups n Time of engagement Age Gender Hospitalizations (previous/year)

Mean±SD Mean±SD F M Mean±SD

Group 1 A 31 - 10.97±2.5 48.3 51.6 0.277±0.273

Group 2 UA 20 - 10.10±2.8 35 65 0.692±0.833

Evaluators HP 51 4.15±4 - - - -

P/C 51 - - - - -

General 153 - 10.62±2.6 43.1 56.8 0.435±0.593A = articulated; UA = unarticulated; n = number; SD = standard deviation; HP = health professional; P/C = parents/caregivers; F = Female; M = Male.

Figure 1. Perceptions of evaluators in unarticulated children* p<0.001; **p=0.05

Disagreement

Agreement

Health Professionals Parents/Caregivers

* **75%

25%

65%

35%

Disagreement

Agreement

Health Professionals Parents/Caregivers

* **58%

42%

55%

45%

Table 2. Distribution of pain in all patients

Pain n % p-valueNo 9 17.6 <0.001Yes 42 82.4

Figure 2. Perceptions of evaluators in articulated children *p=0.2; **p=0.44

Table 3. Correlation between the scales used in the group of articu-lated patients

FLACC versus vNRSCorr (r) 58.0%p-value 0.001

FLACC = Face, Legs, Activity, Cry, Consolability; vNRS = verbal numerical rating scale.

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In order to evaluate the relationship between changes in the vital signs and the presence of pain in the patients, the vital signs were compared in the preoperative and post-manipulation periods, dividing the patients into those who had pain, versus those who did not to the vital signs of HR, MAP and RR (Table 4).For patients who had pain during manipulation, the change in the vital signs was statistically significant in relation to their pre-operative baseline values, HR (p<0.001), MAP (p=0.009) and RR (p<0.003). However, there was an increase in the RR variable in relation to the baseline values also in patients who did not have pain (p<0.006).

DISCUSSION

Orthopedic surgeries are among the most frequent in patients with CP, and these patients often present intense postoperative muscle spasms, causing pain and stress to the child, parents, and physicians7,13. In this study, the prevalence of pain in the lower limbs between the 1st and 2nd postoperative days was 82.4%, and in 50% the pain was moderate to severe. This result is slightly more than double the percentage found by Goodman and Mc-Grath13 in a study that observed pain on the 1st postoperative day in 40% of children with a mean age of 8 years.The control of acute postoperative pain is the responsibility of the anesthesiologist, the surgeon, and the nursing team14. On the other hand, all those involved in the assistance process; pa-tients, parents, and health professionals are responsible for the detection and assessment of the pain to be treated15. Pain relief is a patient’s right and must be ensured regardless of its level of consciousness, and the use of valid and reliable instruments for the pain assessment is paramount for its proper handling12,16. The present study evaluated the perception of “pain” by parents and health professionals in articulated and unarticulated chil-dren with CP during potential pain procedures such as the ma-nipulation performed by physiotherapists and nursing techni-cians. The fact that children could communicate seems to have been a decisive factor for better perception and detection of pain or no pain by parents/caregivers and health professionals, without the use of a specific scale. On the other hand, in the group of unarticulated patients, it was observed in the present study that the perception of the state of “pain” or “no pain” by parents/caregivers and health professionals was more difficult, showing high values of disagreement when compared to the observer’s responses.

Although parents and caregivers may be able to assess the sensa-tion of pain in daily activities in patients with cognitive impair-ment and/or difficulty in communicating17, the fact of being in a stressful situation in a hospital environment seems to influence their ability to perceive pain in their children, either because they are out of their daily family and professional routines, or because of the possibility of catastrophizing pain18. Concerning the perception of pain by health professionals, the reactions of fear, such as crying and increased tone presented by the children during the various care procedures and interventions could have made it difficult for the health professional to tell pain from fear since some reactions are similar19. These results are similar to the ones found in a review study where the professionals also had difficulty in detecting pain without the use of specific scales for the assessment20. In both groups of this study, however, a high percentage of dis-agreement in the patient’s pain perception was observed, which corroborates the findings by Bacellar21, in which the family members identified pain only in 41.2% of the cases, the nursing team in 33.7%, and physicians in 29.6%. It was observed that the intensity of pain obtained with both the vNRS and FLACC scales had a strong correlation in the articu-lated patients, but it is important to emphasize that in this study the perception of pain intensity by parents/caregivers and health professionals was not addressed. However, literature provides consistent data regarding the importance of using instruments to assess pain intensity22.The scales for pain assessment are subjective, and their purpose is to facilitate the detection and measurement of the intensity, and when talking about pain scales for unarticulated patients, these are, most of all, scarce23. A “gold standard” would be welcome for the detection of pain and its measurement in children unable to self-report, but such a standard pattern does not yet exist. An alternative would be a mixed method, where the pain behavior evaluation would be complemented by a physiological evalua-tion, that is, by the recording of the vital signs24. It was observed in this study that the pain interferes precisely in the values of HR, MAP, and RR. However, the change in RR seems to have no single relation with the presence of pain since we have also observed a significant increase in RR in the group that did not have pain during manipulation. It is possible that fear is also a determinant for this change.Another aspect to be highlighted is that although this was not the objective of this study, the presence of previous hospitalizations

Table 4. Comparison of patients with and without pain for heart rate, respiratory rate and pre-operative and post-manipulation mean arterial pressure

Preoperative Post-manipulation

Mean Median SD Mean Median SD p-value

HR With pain 97.6 95 15.7 120.5 123.5 20.9 <0.001

Without pain 101.1 102 13.6 119.6 113 13.9 0.054

RR With pain 19.1 19 1.8 21.4 21.5 4.7 0.003

Without pain 17.9 18 3.2 21.0 21 1.8 0.006

MAP With pain 59.9 59.5 8.2 65.1 63.5 9.7 0.009

Without pain 56.4 54 8.9 63.8 64 8.3 0.089HR = heart rate; RR = respiratory rate; MAP = mean arterial pressure.

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as a characteristic of the patients was observed in 100% of the sample. This fact has raised an important issue to be considered in the management of pain in patients with CP. In a systematic review by Petovello25 he reported that children who go through several hospitalizations develop greater fear and anguish due to the memory of stored pain and that in such cases, the painful memory anticipates their reactions to painful procedures that in turn may cause the cycle increase in tone and pain.Finally, detecting and treating the patient’s pain correctly, regard-less of their capacity to self-report is paramount for any health service. The National Council of the Rights of the Child and Adolescent, in its Resolution 41 on the Rights of Hospitalized Children and Adolescents, article 7 provides that the patient has “the right not to feel pain when there are ways to avoid it “26. In this sense, the recognition of the painful episode and the appli-cation of instruments to assess the pain according to each patient allows health professionals to handle the pain appropriately27.The limitations of this study are related to the limited time for data collection and, consequently, the small sample size. Consid-ering the importance of the topic, it is necessary to conduct more studies with a larger sample and perhaps to include samples with other characteristics such as different surgical interventions or institutions with established pain protocols. CONCLUSION

Children with CP have pain during manipulations in the initial lower limbs postoperative period. Even with parents present in the daily routine of the unarticulated patient and professionals of a referral institution in the care of this population, the pain can still not be properly detected without the use of a specific tool. Therefore, in the hospital setting, pain can be detected effectively with the use of specific scales for each population.

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26. Resolução nº 41, de 13 de outubro de 1995. Dispõe sobre os direitos da criança e do adolescente hospitalizados. Diário Oficial da República Federativa da União, Brasília (DF), 17 out 1995: Seção 1:16319-20.

27. Santos JP, Maranhão DG. Cuidado de Enfermagem e manejo da dor em crianças hospitalizadas: pesquisa bibliográfica. Rev Soc Bras Enferm Ped. 2016;1(1):44-50.

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ABSTRACT

BACKGROUND AND OBJECTIVES: Venipuncture is con-sidered a painful procedure, often performed in the neonatal intensive care unit. The objective of this study is to describe the behavioral and physiological responses of newborns undergoing venipuncture, with and without the use of non-pharmacological measures for the relief of pain.METHODS: A total of 84 newborns participated in this re-search. It was observed if the nurse prepared the newborn for the puncture. Newborns that did not receive the non-pharmacolog-ical approach were allocated in group 1, and those who received were to group 2. The behavioral and physiological parameters were assessed two minutes before and two minutes after the pro-cedure in all newborns. The data analysis was descriptive.RESULTS: Before the procedure, 45.5% of the newborns in group 1 had a contracted face; however, after the procedure, this number increased to 69.7%. After the procedure in group 2, 29.4% grumbled, 3.9% had a vigorous cry, 66.7% did not cry. Arms and legs movement had similar responses in both groups. After the procedure, 72.7% of newborns in group 1 had a heart rate higher than 160bpm. After the procedure in group 1, 15.2% had an oxygen saturation between 96 and 100% and this value increase to 58.8% in group 2.

Non-pharmacological measures for pain relief in venipuncture in newborns: description of behavioral and physiological responses Medidas não farmacológicas para alívio da dor na punção venosa em recém-nascidos: descrição das respostas comportamentais e fisiológicas

Priscila Pereira de Souza Gomes1, Ana Paola de Araújo Lopes2, Maria Solange Nogueira dos Santos3, Silvania Moreira de Abreu Façanha4, Ana Valeska Siebra e Silva5, Edna Maria Camelo Chaves5

Priscila Pereira de Souza Gomes - https://orcid.org/0000-0001-8743-145X;Ana Paola de Araújo Lopes - https://orcid.org/0000-0001-5409-2543;Maria Solange Nogueira dos Santos - https://orcid.org/0000-0002-8509-1989;Silvânia Moreira de Abreu Façanha - https://orcid.org/0000-0002-7853-3160;Ana Valeska Siebra e Silva - https://orcid.org/0000-0003-3664-5073;Edna Maria Camelo Chaves - https://orcid.org/0000-0001-9658-0377.

1. Universidade Estadual do Ceará, Programa de Pós-Graduação Cuidados Clínicos em En-fermagem e Saúde, Fortaleza, CE, Brasil.2. Universidade Estadual do Ceará, Departamento de Enfermagem, Fortaleza, CE, Brasil.3. Hospital Geral de Fortaleza, Fortaleza, CE, Brasil.4. Universidade Estadual do Ceará, Mestrado Profissional em Saúde da Criança e do Ado-lescente, Fortaleza, CE, Brasil.5. Universidade Estadual do Ceará, Fortaleza, CE, Brasil.

Submitted on August 22, 2018.Accepted for publication on March 22, 2019.Conflict of interests: none – Sponsoring sources: none.

Correspondence to: Av. Dr. Silas Munguba, 1700 - Campus do Itaperi60741-000 Fortaleza, CE, Brasil.E-mail: priscilaenfermagem_@hotmail.com

© Sociedade Brasileira para o Estudo da Dor

CONCLUSION: The behavioral and physiological responses presented by the newborns are altered when babies undergo ve-nipuncture without the use of measures for the relief of pain, the most common being: contracted face; grumbling; arms and legs flexed/extended; tachycardia; and hyposaturation.Keywords: Neonatal intensive care units, Newborn, Pain, Peripheral catheterization.

RESUMO

JUSTIFICATIVA E OBJETIVOS: A punção venosa é con-siderada um procedimento doloroso, realizado com frequên-cia na unidade de terapia intensiva neonatal. O objetivo deste estudo foi descrever as respostas comportamentais e fisiológicas de recém-nascidos submetidos à punção venosa, com e sem a utilização de medidas não farmacológicas para alívio da dor. MÉTODOS: Participaram da pesquisa 84 recém-nascidos. Foi observado se o profissional de enfermagem realizava o preparo do recém-nascido para a punção. Os recém-nascidos que não re-ceberam medida não farmacológica foram alocados no grupo 1 e os que receberam foram para o grupo 2. Foram avaliados os parâmetros comportamentais e fisiológicos dois minutos antes e dois minutos após o procedimento em todos os recém-nascidos. A análise dos dados ocorreu de forma descritiva. RESULTADOS: Antes do procedimento, 45,5% dos recém--nascidos no grupo 1 apresentavam a face contraída, entretanto, após o procedimento, esse número aumentou para 69,7%. De-pois do procedimento no grupo 2, 29,4% resmungaram, 3,9% tiveram choro vigoroso e em 66,7% o choro ficou ausente. Os movimentos de braços e pernas apresentaram respostas seme-lhantes nos dois grupos. Após o procedimento, 72,7% do grupo 1 apresentaram frequência cardíaca maior que 160bpm. Após o procedimento no grupo 1, 15,2% apresentaram saturação de oxigênio entre 96 e 100%, já no grupo 2, esse valor aumentou para 58,8%. CONCLUSÃO: As respostas comportamentais e fisiológicas apresentadas pelos recém-nascidos sofrem maiores alterações quando os bebês são submetidos à punção venosa sem o uso de medidas para alívio da dor, sendo as mais presentes: face contraí-da; resmungos; braços e pernas fletidos/estendidos; taquicardia e hipossaturação. Descritores: Cateterismo periférico, Dor, Recém-nascido, Uni-dades de terapia intensiva neonatal.

DOI 10.5935/2595-0118.20190026

ORIGINAL ARTICLE

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INTRODUCTION

Pain is an unpleasant sensory and emotional experience associat-ed with a real or potential tissue injury1. Newborns (NB) admit-ted to a neonatal intensive care unit (NICU) are usually submit-ted to painful procedures, such as surgeries, venous punctures, and aspirations. However, other seemingly simple care, such as changing diapers, weighing and removing tape can also result in noxious stimuli2.Pain is becoming increasingly important in the health area be-cause it causes a high level of discomfort and instability that can influence the alteration of vital signs and, consequently, the he-modynamics of patients. It is essential to recognize pain as a vital data that deserves to be valued and included in the planning of the care of the individuals3.Healthcare professionals have the responsibility to provide a sys-tematic approach in pain management, including assessment, prevention and treatment of pain in NB2. In a study conducted with nurses of a NICU of a university hospital, professionals re-ported that the non-verbalization of the newborns was the great-est difficulty found to recognize and assess pain4.Thus, the implementation of guidelines for pain control in clinical practice is not an easy task since it involves several orga-nizational and individual factors. Caregiving practices should be based on evidence and not on tradition, routine, or individ-ual’s experiences5.Both pharmacological and non-pharmacological measures are necessary to control pain. The pharmacological strategies are in-dicated for severe pain, usually caused by invasive, prolonged, more complex procedures, and include the use of opioids and local anesthetics, among others6.Non-pharmacological interventions are most commonly used for acute pain, caused by minor procedures, such as venipuncture and blood collection that cause agitation and stress7. The De-partment of Health recommends the use of non-pharmacolog-ical measures, such as sweetened solutions (glucose or sucrose), breastfeeding, non-nutritive sucking, skin-to-skin contact, and to reduce tactile stimuli8.The use of non-pharmacological measures, before painful proce-dures, is becoming a strategy of care that must be performed in newborns in hospital units. This is because the pain suffered by the NB causes organic repercussions that may compromise its devel-opment, and the pharmacological therapy presents several adverse effects due to the immaturity of the baby’s organic systems9.Oral glucose administration has been the most widely used measure in NB interventions. However, new strategies are being pointed out, such as the use of scents to promote pain relief and winding9. A flowchart to help to handle the pain in NICUs, created by nurses, states that breastfeeding and oral breast milk supplemen-tation need to be prioritized because it favors the mother’s par-ticipation in the care of the newborn. In addition to these strat-egies, the flowchart also recommends the use of environmental measures such as reducing the noise, stimuli, abrupt changes in brightness and temperature10.However, for the implementation of non-pharmacological mea-sures to take place effectively, it is necessary to make health pro-

fessionals aware of the right of the newborns to have the pain avoided and treated. They also need to know how these measures must be applied11.To use the pain relief measures properly, it is necessary to evalu-ate, identify and initiate pain treatment, as these actions contrib-ute to a faster recovery and better quality of care5. Venipuncture is considered a painful procedure and is frequent-ly performed in the NICU. Therefore, it is necessary to evalu-ate the behavioral and physiological responses of the newborns who undergo such procedure, since a reliable description of the pain experience is fundamental to identify the best treatment for each NB8. The objective of this study was to describe the behavioral and physiological responses of newborns undergoing venipuncture, with and without the use of non-pharmacological measures for pain relief.

METHODS

This is a cross-sectional study conducted in a NICU of a tertiary referral hospital in the city of Fortaleza, CE, Brazil. The insti-tution is a teaching hospital, accredited by the Unified Health System, which assists the mothers and children at risk. The study evaluated the behavioral and physiological parameters of newborns subject to venipuncture. To estimate the study sam-ple, we considered n=640 (NB admitted in 2014), confidence level=90%, P=50% (pain prevalence during puncture), Q=50% (complementary percentage of P), sampling error=10%. The calculation of the sample size resulted in 61 NB. However, the data was collected in 84 NB, considering the possibility of losses during the study, which did not occur. The study included those NB hospitalized in the unit during data collection, regardless of gestational age. NB under pharmacological measures for pain re-lief and those with congenital malformation were excluded from the study. Data collection was from September 2015 to June 2016. The data collection instrument used was a form containing the NB identification data. The assessment of pain before and after the venipuncture used the Neonatal Infant Pain Scale (NIPS), the heart rate and oxygen saturation, and the description of the non-pharmacological measure if any.The NIPS is a scale used to assess pain signs in the newborn. It has six pain indicators, one physiological and five behavioral, including facial expression, crying, movement of arms and legs, sleep/alertness state and respiratory pattern. The scale scores vary between zero, one and two points, depending on the character-istic presented. The minimum score is zero, and the maximum score is seven. The pain is characterized by the sum of points greater than or equal to four8. It is noteworthy that in this unit, the multiprofessional team was trained to use non-pharmacological measures before painful pro-cedures. Some strategies recommended are the use of oral glu-cose at 25%, facilitated containment, lap, and touch.Initially, the researchers were trained to collect data, after the approval of the research project. The data was collected in the morning and afternoon shifts. The researcher recorded whether

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the nurse or nurse technician prepared or not the newborn for the painful procedure. A damp gauze with glucose at 25% was offered two minutes before the procedure. The facilitated con-tainment was performed two minutes before the puncture. No time was established for the newborn to stay on the mother’s lap. The puncture was performed two minutes after the NB was placed in the crib. After the collection, all participants were ob-served for two minutes. The parameters were recorded two min-utes before and two minutes after the puncture.To better understand the data, the newborns were divided into two groups. Group 1 (G1) was comprised the NB with no non-pharmacological measures for pain relief, while group 2 (G2) was formed by the NB who received some non-pharmaco-logical measure before the puncture.The research complied with the standards of the Resolution 466/12. The NB was included in the study after the signing of the Free and Informed Consent Term (FICT) by the person re-sponsible for the NB. The study is part of an umbrella project and was approved by the Ethics Committee of the Institution under number 011201/2011.

Statistical analysisThe data were organized in an Excel database and analyzed by the Statistical Package for Social Science (SPSS) software, ver-sion 20.0. The analysis was performed through the absolute and relative frequencies, mean frequency and standard deviation. The results were presented in tables and discussed according to rele-vant literature.

RESULTS

Table 1 shows the clinical variables of the newborns participating in the study.As observed in table 1, most of the NBs were male (67.9%), low weight (73.8%), c-section delivery (73.8%) and premature (79.8%). The mean weight was 2.067±789g. The mean gesta-tional age was 34.6±3 weeks. The leading causes of hospitaliza-tion were respiratory distress (41.7%), prematurity (27.4%), hypoglycemia (8.3%), among others. The non-pharmacological measures used by the nursing team for the NB subjected to veni-puncture were glucose at 25% (72.5%), facilitated containment (21.6%) and lap (5.9%).Table 2 describes the behavioral responses of the newborns be-fore and after the puncture.According to table 2, of the 84 NB subjected to venipuncture, 51 (60.7%) were prepared with a non-pharmacological measure for pain relief. Regarding the behavioral responses, it is observed that before the procedure, in group 1, 45.5% had a contracted face. However, after the procedure this number increased to 69.7%. On the oth-er hand, in group 2, only 27.5% had a contracted face before the procedure, evolving to 33.3% afterward. After the procedure in group 1, 81.8% of the NB grunted, and 6.1% had vigorous crying. In group 2, after the procedure, 29.4% grunted, 3.9% had vigorous crying, and crying was ab-sent in 66.7%.

Table 1. Description of variables of the newborns in the study, For-taleza, CE

Variables n % Mean±SD

Gender Male Female

5727

(67.9)(32.1)

Weight (gr) <2500 ≥2500

6222

(73.8)(26.2)

2.067±789

Delivery type C-section Normal

6222

(73.8)(26.2)

Gestational age (weeks) <37 Between 37 and 41 ≥42

67170

(79.8)(20.2)

0

34.6±3

Diagnosis Respiratory distress Premature Hypoglycemia

35237

(41.7)(27.4)(8.3)

Sepsis 5 (5.9)

Jaundice 4 (4.8)

Neonatal infection 3 (3.6)

Congenital syphilis 2 (2.4)

Others 5 (5.9)

Non-pharmacological measures Glucose at 25% Facilitated contention Lap

37113

(72.5)(21.6)(5.9)

Source: Elaborated by the authors.

Table 2. Description of the behavioral responses of the newborns subjected to venipuncture, with and without non-pharmacological measures, Fortaleza, CE

Behavioral parameters at venipuncture

G1(n=33) G2 (n=51)

Beforen %

Aftern %

Beforen %

Aftern %

Facial Expression

Relaxed 18 (54.5) 10 (30.3) 37 (72.5) 34 (66.7)

Contracted 15 (45.5) 23 (69.7) 14 (27.5) 17 (33.3)

Crying

Absent 19 (57.6) 4 (12.1) 39 (76.5) 34 (66.7)

Grumble 13 (39.4) 27 (81.8) 9 (17.6) 15 (29.4)

Vigorous 1 (3) 2 (6.1) 3 (5.9) 2 (3.9)

Breathing

Relaxed 17 (51.5) 13 (39.4) 42 (82.4) 40 (78.4)

Altered 16 (48.5) 20 (60.6) 9 (17.6) 11 (21.6)

Arms

Relaxed 12 (36.4) 9 (27.3) 35 (68.6) 33 (64.7)

Flexed / extended 21 (63.6) 24 (72.7) 16 (31.4) 18 (35.3)

Legs

Relaxed 12 (36.4) 10 (30.3) 34 (66.7) 32 (62.7)

Flexed / extended 21 (63.6) 23 (69.7) 17 (33.3) 19 (37.3)

Conscious state

Sleeping / quiet 18 (54.5) 13 (39.4) 45 (88.2) 41 (80.4)

Uncomfortable 15 (45.5) 20 (60.6) 6 (11.8) 10 (19.6)Source: Elaborated by the authors.

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Regarding the movement of the limbs, the arms and legs showed similar responses when the newborns were subjected to the ve-nipuncture. After the procedure in group 1, 72.7% of the NB had their arms flexed/extended. However, after the procedure in group 2, it was observed that the arms were flexed/extended in 35.3% of the NB. Regarding the legs, 69.7% of the newborns in group 1 remained with the lower limbs flexed/extended after the procedure, and in group 2, the same was observed in 37.3% of the newborns.The NB showed an uncomfortable state of consciousness in 60.6% of the cases, after the puncture in group 1. On the oth-er hand, discomfort was observed in only 19.6% of the NB in group 2.Breathing is a physiological manifestation; however, because it is part of NIPS, it was checked at that time. Thus, it is possible to state that 39.4% of the NB in group 1 had relaxed breathing after the procedure, and 78.4% had the same after the procedure in group 2. Table 3 shows the heart rate and oxygen saturation of NB sub-jected to venipuncture. Thus, one can notice that 72.7% of the NB in group 1 had a heart rate higher than 160bpm (tachycar-dia), after the procedure. On the other hand, 35.3% of the NB in group 2 had tachycardia.After the procedure in group 1, only 15.2% of the NB had ox-ygen saturation between 96 and 100%; in group 2, this value increased to 58.8%.

Table 3. Description of the physiological responses of the newbor-ns subjected to venipuncture, with and without non-pharmacological measures, Fortaleza, CE

Physiological parame-ters at venipuncture

G1 (n=33) G2 (n=51)

Beforen %

Aftern %

Beforen %

Aftern %

Heart rate (bpm)

100-119 - 1 (3) - 3 (5.9)

120-139 8 (24.2) 3 (9.1) 11 (21.6) 9 (17.6)

140-159 23 (69.7) 5 (15.2) 31 60.8 21 (41.2)

≥160 2 (6.1) 24 (72.7) 9 (17.6) 18 (35.3)

Oxygen saturation (%)

81-85 - - - -

86-90 1 (3) 18 (54.5) - 10 (19.6)

91-95 10 (30.3) 10 (30.3) 11 (21.6) 11 (21.6)

96-100 22 (66.7) 5 (15.2) 40 (78.4) 30 (58.8)Source: Elaborated by the authors.

DISCUSSION

Among the invasive procedures performed in NICUs, veni-puncture is one of those with the highest percentage of mod-erate and severe pain12. Therefore, it is essential that health professionals use measures that help to control or reduce pain in the NB subjected to venipuncture. The results of the study showed that more than half of the NB had venipuncture and were prepared for the procedure with non-pharmacological measures for pain relief. This finding is the opposite of what

was found in a study to assess the pain in NB during peripher-al and capillary puncture, in which nurses used non-pharma-cological measures in NB who had already presented pain13. The absence of pain relief measures in the other punctures performed may be because there is no systematization of the procedures performed at the institution since the use of phar-macological, behavioral and environmental analgesic strate-gies is still inconsistent in Brazil14. Thus, it is necessary to implement guidelines and protocols in health institutions for the appropriate management of pain in NB in NICUs, con-sidering that this population is constantly subjected to stress-ful and painful procedures14.The organization, preparation of the material, the agility of the nursing professional at the moment of the puncture and the concern with the number of puncture attempts on the NB are measures that contribute to optimize the procedure and, therefore, reduce the pain. However, it is important to avoid the negative effects of the procedure using strategies to control the pain, such as non-pharmacological measures12. In the present study, the non-pharmacological measure most-ly used for pain relief was glucose at 25%, followed by facil-itated containment and lap. In a study performed with 110 NB submitted to venous and capillary puncture, the result was similar because glucose at 25% became the most used measure, also being mentioned coziness, therapeutic touch, and massage13. Studies have been conducted to evaluate the efficacy of non-pharmacological measures for pain relief. It is import-ant to emphasize an investigation conducted in Turkey about the effect of breastfeeding and sucrose in newborns submit-ted to venipuncture. In such an approach, it was shown that the mean NIPS score in the control group was significantly higher than in the breastfeeding and sucrose groups15. An-other study conducted in João Pessoa-PB found that the use of non-pharmacological measures (contention and non-nutri-tive suction) were able to reduce pain in the observed NB16.The use of NIPS to assess pain in newborns is recommended because the specific scales for newborns usually provide better knowledge about the subject, minimizing the insecurity of the professional and helping the team in the identification, evaluation, and application of measures for the relief and treatment of pain17. Regarding the responses presented, according to the NIPS, the study showed that after the procedure, the NB who did not receive any preparation had a higher percentual of the contracted face when compared to those who received. This result is similar to a study in which 32 NB undergoing veni-puncture showed suggestive signs of pain, and 100% had a contracted face13. In another study conducted with 29 NB, among those who showed suggestive signs of pain, the con-tracted face was described in 77.8%18.As for crying, most of the NB who did not receive the mea-sures presented grunts and vigorous crying. This data is in line with the results of a study that showed grunts (44.4%) and vigorous crying (44.4%) as suggestive signs of pain af-ter puncture18. Another study reports that the mean crying

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time was higher in the control group than in the groups that received the non-pharmacological measures for pain relief15. However, although very present, the crying observed in the form of grunts, both in the NB who received the preparation measures and in those who did not, should not be considered an isolated factor to identify the presence of pain, since it can be triggered by other stimuli, like sleep and hunger19.The movement of the arms and legs was similar, with a higher percentage of NB with relaxed limbs after the pro-cedure when non-pharmacological measures were used, in comparison to the ones that did not have preparation. This finding corroborates the results of a study also conducted in Fortaleza, where the movements of the arms were practically the same as those observed in the movements of the legs13. A study recommends that to make the assessment of pain more reliable, it is important to evaluate the motor activity with other indicators20, which reinforces the use of scales for pain analysis.As for the state of consciousness, the NB who received the non-pharmacological measures were considerably calmer after the procedure than those who did not receive. A study devel-oped with 26 nursing professionals found a similar result in which the interviewed professionals reported that after the use of non-pharmacological measures, newborns were much calmer and in better conditions for the procedure, reducing the period of exposure to painful stimulus20. Regarding breathing, the NB who went through the prepara-tion measures had relaxed breathing, for the most part. A sur-vey showed that among the NB who felt pain, the breathing in 88.9% was different from the baseline18. The alteration of the respiratory rate was one of the characteristics mentioned by health professionals to identify pain, even when they hav-en’t heard about the validated scales for this purpose20. In the present study, it was observed a variation in the heart rate, especially for higher values, in the NB who did not re-ceive preparation with the non-pharmacological measures. This result differs from what was found in research about the use of sucrose and breastfeeding for pain relief in NB sub-jected to venipuncture, where there was no difference in the mean heart rate before, during and after the procedure, even with the use of non-pharmacological measures for the relief of pain15.Finally, it was observed a decrease in oxygen saturation after the procedure, both in the NB who received non-pharmaco-logical measures and those who did not. However, the NB who did not receive preparation had a higher percentage of decrease in oxygen saturation. This is in line with the results of another study, in which the mean level of oxygen satura-tion after the procedure was significantly higher in the NB who received the preparation than in those who did not15.

As a limitation of the results of the study is the fact that the cross-sectional design does not allow to establish the relationship between cause and effect.

CONCLUSION

The behavioral and physiological responses presented by the NB were significantly altered when they were submitted to ve-nipuncture without the use of measures for pain relief. The most frequent responses were contracted face, grunts, arms and legs flexed/extended, tachycardia and hyposaturation.

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20. Costa LC, Souza MG, Sena EM, Mascarenhas ML, Moreira RT, Lúcio IM. Utilização de medidas não farmacológicas pela equipe de enfermagem para alívio da dor neona-tal. Rev Enferm UFPE. 2016;10(7):2395-403.

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ABSTRACT BACKGROUND AND OBJECTIVES: In temporomandibu-lar disorder, the pain is a very present and striking symptom, with a tendency to chronicity, through mechanisms of maladap-tive neuroplasticity. In the face of this, transcranial direct cur-rent stimulation appears as a possible strategy for the treatment of chronic pain in the temporomandibular disorder. This study aimed to evaluate the efficacy of anodal transcranial direct cur-rent stimulation in the pain symptoms and anxiety levels in in-dividuals with chronic myofascial temporomandibular disorder. METHODS: The participants received three different types of intervention in a randomized order: anodic in the primary mo-tor cortex, in the dorsolateral prefrontal cortex and sham stim-ulation. RESULTS: There were significant improvements in clinical pain in all stimulation protocols, with a relief of approximately 40% (p=0.001). There was no significant difference in the effect of the transcranial direct current stimulation between the different types of stimulation (p=0.14). There was a positive impact on anxiety symptoms, leading to a significant decrease in state anxi-ety levels (p=0.035) and trait (p=0.009). CONCLUSION: The use of the transcranial direct current stimulation improved the health status of patients with chronic myofascial temporomandibular disorder, promoting pain relief, decreased level of anxiety, and quality of life.Keywords: Orofacial pain, Rehabilitation, Transcranial stimula-tion by continuous current.

Use of non-invasive neuromodulation in the treatment of pain in temporomandibular dysfunction: preliminary study Uso da neuromodulação não invasiva no tratamento da dor em disfunção temporomandibular: um estudo preliminar

Tatyanne dos Santos Falcão Silva1, Melyssa Kellyane Cavalcanti Galdino1, Suellen Mary Marinho dos Santos Andrade1, Luciana Barbosa Sousa de Lucena1, Renata Emanuela Lyra de Brito Aranha1, Evelyn Thais de Almeida Rodrigues1

Tatyanne dos Santos Falcão Silva - https://orcid.org/0000-0002-0744-3504;Melyssa Kellyane Cavalcanti Galdino - https://orcid.org/0000-0001-7180-3458;Suellen Mary Marinho dos Santos Andrade - https://orcid.org/0000-0002-6801-0462; Luciana Barbosa Sousa de Lucena - https://orcid.org/0000-0002-2097-0544; Renata Emanuela Lyra de Brito Aranha - https://orcid.org/0000-0003-0352-4689; Evelyn Thais de Almeida Rodrigues - https://orcid.org/0000-0003-2169-9052.

1. Universidade Federal da Paraíba, João Pessoa, PB, Brasil.

Submitted on September 30, 2018.Accepted for publication on March 11, 2019.Conflict of interests: none – Sponsoring sources: none.

Correspondence to: Cidade Universitária, s/n - Castelo Branco III58051-085 João Pessoa, PB, Brasil. E-mail: tatyannefalcao@yahoo.com.br

© Sociedade Brasileira para o Estudo da Dor

RESUMO

JUSTIFICATIVA E OBJETIVOS: Na disfunção temporo-mandibular, a dor aparece de forma frequente e marcante, com tendência à cronicidade, através de mecanismos de neuroplasti-cidade mal adaptativo. Diante disso, a estimulação transcrania-na por corrente contínua surge como uma possível estratégia de tratamento da dor crônica em disfunção temporomandibular. O presente estudo objetivou avaliar a eficácia da estimulação trans-craniana por corrente contínua anódica nos sintomas dolorosos e, por conseguinte, nos níveis de ansiedade em indivíduos com disfunção temporomandibular muscular crônica. MÉTODOS: Os participantes receberam três tipos diferentes de intervenção cuja ordem foi randomizada: anódica no córtex motor primário, na região cortical dorsolateral pré-frontal e esti-mulação simulada. RESULTADOS: Houve melhorias significativas para a dor clí-nica em todos os protocolos de estimulação, com um alívio de aproximadamente 40% (p=0,001). Não houve diferença signifi-cativa no efeito da estimulação transcraniana por corrente con-tínua entre os diferentes tipos de estimulação (p=0,14). Ocorreu impacto positivo sobre os sintomas de ansiedade, com diminui-ção significativa nos níveis de ansiedade estado (p=0,035) e traço (p=0,009). CONCLUSÃO: O uso da estimulação transcraniana por cor-rente contínua melhorou a condição de saúde dos portadores de disfunção temporomandibular muscular crônica, promovendo um alívio do quadro álgico, diminuição do nível de ansiedade, além de gerar qualidade de vida. Descritores: Dor orofacial, Estimulação transcraniana por cor-rente contínua, Reabilitação.

INTRODUCTION

Temporomandibular dysfunction (TMD) is a disease of high prevalence that affects the masticatory muscles and/or the tem-poromandibular joint. Among the symptoms, pain appears fre-quently and markedly, with a tendency to chronicity1.2. Chronic pain represents a significant public health problem that impacts the performance of daily activities, physical and psychosocial functioning, as well as the patients’ quality of life (QoL), gen-erating a high cost for society and the health system1,3-5. Studies indicate that chronic pain results from a constant stimulus in the central nervous system (CNS), which in turn leads to central

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DOI 10.5935/2595-0118.20190027

ORIGINAL ARTICLE

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sensitization where there are changes in the excitability of the neuronal membrane due to physiological and structural changes. This mechanism is characterized by maladaptive neuroplasticity but can be reversed with treatment6-8.Chronic TMD pain is a complex and multidimensional phe-nomenon that is often associated with an altered emotional state9-16, requiring a multidisciplinary treatment that involves different therapies. Some aim to treat the muscles, others act on dental occlusion or joint structures, and there are those whose main focus is the psychoemotional factor1,17-19.It is believed that this neuronal modification, coupled with the emotional imbalance present in many patients with this disorder, leads to an unsatisfactory response to traditional therapies such as patient education in relation to self-care, pharmacotherapy, acupuncture, stabilizing occlusal splint, biofeedback, ultrasound, transcutaneous electrical nerve stimulation (TENS), cogni-tive-behavioral therapy, among others1,6,9,12,17,18.Given this context, it is evident the need for a therapy that acts directly on the CNS. This can be accomplished with drugs. However, many patients are refractory or have ad-verse effects, as the dependence and/or tolerance1,17,18. Given that, it is important to have new treatments involving the neuromodulation and neuroplasticity mechanisms, as the transcranial direct-current stimulation (tDCS), that can be a therapeutical alternative and also to complement the differ-ent types of treatment already in use20-23. Moreover, the tDCS corroborates the need to give to preference the reversible and non-invasive procedures1,17,18.tDCS emerges as a possible TMD treatment modality, to modify the pattern of the cortical activity and restore the normal acti-vation of pain processing centers, and consequently, promoting pain relief22,23. It is a simple, low-cost, non-invasive, painless, safe and well-tolerated technique20,23-27.Some studies show that the use of tDCS protocols is prom-ising, with good results in reducing pain symptoms in pa-tients with chronic pain20,23,24,26,28-31. The analgesic effect has been reported with anodic stimulation, mainly in the pri-mary motor cortex (M1)26-28,30,32-37. However, there is anoth-er protocol option of anodic stimulation that corresponds to the dorsolateral region of the prefrontal cortex (DLPF), which demonstrates the involvement in the processing of the emotional component of pain13,24,35,38-40. However, these results are still scarce and inconclusive, which indicates the need for further investigation, especially when it comes to TMD21,31,32,39,41,42. In this context, it is pertinent to investigate alternative meth-ods in the treatment of chronic muscular TMD in order to increase the range of possibilities and, therefore, to promote pain relief, functional recovery and, consequently, better QoL for a greater number of patients1,3,10,22. Considering the lack of studies comparing the effect tDCS in patients with chron-ic muscular TMD, the objective of the present study was to evaluate and compare the efficacy of anodic tDCS applied in different cortical regions (M1 and DLPF) to treat the painful symptoms and, therefore, the levels of anxiety in patients with TMD with chronic pain.

METHODS

A preliminary double-blind, cross-sectional, controlled study was conducted with three intervention arms, which sequence was determined at random. Initially, the sample consisted of patients with chronic muscu-lar TMD who sought treatment at the Orofacial Pain Control Service of the University Hospital Lauro Wanderly (HULW) of the Federal University of Paraíba (UFPB). Due to the difficulty in finding participants for the study, we used printed and elec-tronic ads, direct contact or health professional referrals from for the recruitment of volunteers. After the volunteers contact, screening appointments were scheduled for the evaluation of the selection criteria.Participants were evaluated by a trained researcher (P1), using the Diagnostic Criteria for Research in Temporomandibular Dysfunction (RDC/TMD) to confirm the TMD diagnosis. Those who met the eligibility criteria were invited to participate in the study. Those who agreed signed the Free and Informed Consent Term (FICT), in two copies, after a thorough reading and explanation of all the research procedures.To be included in the study, the individual should: (1) have previously signed the FICT; (2) be in the age range of 18-60 years, regardless of gender; (3) have a diagnosis of muscu-lar TMD corresponding to group I of RDC/TMD Axis I); (4) have a pain score equivalent to 4 or higher on the visual analog scale (VAS), present regularly for 6 months or more; (5) the presence of moderate depressive symptoms assessed by Axis II of the SCL-90 scale (RDC/TMD); (6) not being pregnant; (7) have no metal or electronic devices implanted in the head; (8) have no history of alcohol or drug abuse in the past 6 months; (9) not taking carbamazepine in the last 6 months (use of modulating CNS activity drugs); (10) have no history of epilepsy, stroke, moderate to severe traumatic brain injury, or migraine; (11) did not perform neurosurgery; (12) not having psychiatric disorder, such as schizophrenia or bipolar disorder; (13) have no other source of pain similar to muscular TMD, such as fibromyalgia. The present study had the following exclusion criteria: (1) two absences during the treatment sessions; (2) miss any inclusion criteria during the study, as becoming pregnant in the case of women.To characterize the sample, a sociodemographic questionnaire was used to collect information on age, gender, religion, marital status, schooling, family income, history of illness, use of drugs, treatments performed or in progress. In order to evaluate the levels of anxiety, pain and overall per-ception of change, the following instruments were used: The State-Trait Anxiety Inventory (STAI), VAS, and the Perception of Change Global Scale (PCGS).• The STAI objectively assesses both aspects of anxiety: trait and condition. It is an instrument with 40 descriptive statements about the person’s feelings, distributed in two parts (trait and state of anxiety), where each part is formed by 20 statements and the answers are given in a Likert-type scale of four points (1 - ab-solutely not to 4 - very much). The score of each questionnaire

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ranges from 20 to 80, with an anxiety level rating of low (20 to 33), average (33 to 49) and high (49 to 80)43.• PCGS is an understandable instrument capable of measuring the perception of change in health status and satisfaction with the treatment of patients with chronic musculoskeletal pain. It is a one-dimensional measure in which individuals classify their improvement associated with intervention on a 7-item scale ranging from 1 (no change) to 7 (much better)44.• The VAS allows the subjective experience of pain to be convert-ed into numerical data. Subjects were asked to mark their score on the horizontal rating scale from zero to 10 representing the pain intensity, in which zero means the absence of pain, (1-3) mild pain, (4-7) moderate pain, and (8-10) intense pain. It is a widely used instrument with valid and reproducible results for pain measurement45.Participants were allocated in a single group and received three different types of intervention, and the order was ran-domized for each participant. The treatment protocols were: 1. Anodic tDCS on the left M1 cortex (C3) and cathod-ic in the right supraorbital region (Fp2), 2. anode on the left DLPF (F3) and cathode on the right supraorbital re-gion (Fp2), and 3. simulated tDCS (placebo) with the same electrode arrangement as the first protocol (C3 and Fp2), but the current was stopped after 30 seconds, following the protocol of previous studies21,22,39,42.The neurostimulator used was the TCT (Research Version) de-veloped by Trans Cranial Research Limited (Hong Kong, Chi-na), with a kit containing the neurostimulator pads, sponges, rubber, electrodes, and connecting cables. The positioning of the electrodes followed the 10/20 international electroencephalo-gram system. They were wrapped by 5x7cm of sponge moistened with saline solution at 0.9%. The procedure took place in three steps, each step with five ses-sions. Each session lasted 20 minutes and was held daily (from Monday to Friday). A 2mA current with a current density equivalent to 0.05 A/m2 was applied. The stimulation proto-col used (regarding intensity, frequency of sessions, electrode/position size, and duration of treatment) was based on previous studies21-23,39,42. The painful symptoms and level of anxiety were quantified pri-or to initiation of treatment. Then, the order of the three types of intervention that each participant received was randomized, and the interventions started. At the end of the five sessions of each type of intervention, reevaluations were made regard-ing the levels of pain and anxiety, as well as the application of scales regarding the global perception of change and level of confidence. Based on previous studies, there was a four-week wash-out period between the different types of stimulation to avoid undesirable residual effects (carry-over)21.46-48. Thus, par-ticipants were re-evaluated for pain and anxiety levels before and after each step of the five stimulation sessions, with a four-week wash-out interval between the different treatment proto-cols. During the study, no participant received any other type of treatment for the disease in question, avoiding any effect besides the neuromodulation (except for the sporadic use of analgesic in the wash-out period).

The randomization was done by online computer software (www.random.org). The team involved in the study was prop-erly trained and blinded. For this purpose, each researcher was responsible for one step, without access to the other information. Regarding the role of each researcher (P), we had diagnosis (P1), randomization and hidden allocation (P2), treatment (P3), data collection (P1) and data analysis (P1). In order to blind the allocation, we used opaque and sealed en-velopes, sequentially numbered. The participants were identified by codes and were not aware of the type of intervention they received in the study. The clinical trial was registered at clinicaltrials.gov (registration number NCT03285685) after the approval of the HULW Eth-ics Committee in Research of the University (CAAE Opinion number 64862817.0.0000.5183).

Statistical analysisThe numerical data were presented in mean and standard de-viation, and their distribution was evaluated by the Kolmog-orov-Smirnov normality test. The alpha value was set at 5% (p<0.05). The analysis was performed with the SPSS statistical package version 21.0.The data were analyzed by repeated-measures ANOVA, followed by the Bonferroni’s post-hoc test. The primary dependent vari-able was pain intensity, and the factors were the different stimu-lation sites (M1, DLPF, and placebo) and time (at baseline, after five stimulation sessions and four weeks later). The secondary dependent variable, the trait-state of anxiety level, was analyzed similarly, with the scores presented in terms of mean and stan-dard deviation. The adverse effects were investigated after each stimulation ses-sion, and the data analysis was also performed by repeated mea-sures ANOVA. The results of the Global Perception of Change and Confidence Level scales were presented by mean and stan-dard deviation, which were analyzed by one-way ANOVA. The presence of correlations between the studied variables was inves-tigated using the Pearson correlation coefficient.

RESULTS

The present study went from March 2017 to December 2017. A total of 151 patients were screened, 13 met the eligibility criteria, but only nine accepted to participate in the study. After signing the FICT, the sequence of the different types of stimulation was randomized. During the study, four individuals were excluded from the research.With regard to the loss of follow-up, one participant received only the first tDCS step and was excluded since he no longer had pain. Others three participants gave up the last step due to lack of time. Therefore, only five participants concluded the study (Figure 1).Table 1 shows the main variables that characterized the sample, such as gender, age, duration of pain, VAS and STAI T and E data. The sample comprised only women, possibly because the studies show that female has two to three times more the risk of developing TMD48,50,51.

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Figure 1. CONSORT flowchart with the sequence of the study developmentDLPF = dorsolateral region of the prefrontal cortex.

Interval:4 weeks

Interval:4 weeks

Inclusion

Screening=151

Randomized (n=09)

Allocation

Follow-up

Loss of follow-up (reasons) (n=4)5 concluded

Analysis

Analyzed by ANOVA (n=5)

Step 1• M1, DLPF or Placebo (n=09)• All attended

Step 2• M1, DLPF or Placebo (n=08) • 01 did not attend (absence of pain)

Step 3• M1, DLPF or Placebo (n=05) • 03 did not attend (withdrawal)

Eligibility1. Muscular temporomandibular disfunction; 2. Free and Informed Consent Form; 3.18-60 years; 4. Visual analog scale ≥4; 5. Present pain ≥6 months; 6. Moderate SCL-90; 7. Not pregnant; 8. Absen-ce of metallic devices in the head; 9. Absence of alcohol or drug abuse in the last 6 months; 10. No use of modulating drugs of the central nervous system activity; 11. No history of epilepsy, stroke, traumatic brain injury; 12. Absence of psychiatric disorder; 13. No other source of pain.

Not included (n=142)• Miss some inclusion criteria (n=138)• Refused to participate (n=4)

All participants had used some type of analgesic and/or muscle relaxant drug before the study. Sporadically, the use of analge-sics (paracetamol or dipyrone) was reported in the wash-out period not to influence the results of the study. None were tak-ing central-acting drugs during study participation or had any comorbidities.According to the VAS scores pre and post-treatment, both the ac-tive stimulation and placebo generated significant improvement (p=0.001 and CI:0.93-3.47) with a decrease equivalent to 37% in the intensity of pain. In the tDCS in M1, it was observed an average difference pre and post-treatment of 2.8 (40%) (p=0.012

Table 1. Characterization of the sample with clinical and demographic data

Characterization of the sample (n=5) Mean (SD) Minimum Maximum

Age (years) 31 (10) 22 48

Duration of pain (months) 16 (12) 08 36

VAS 6.8 (0.8) 36 50

STAI-E 44.8 (6) 33 55

STAI-T 47.2 (9.7) 04 15SD = standard deviation; n = number of participants; BDI = Beck’s depression inventory; VAS = visual analog scale; STAI= State-Trait Anxiety Inventory.

Table 2. tDCS effect on pain intensity pre, post-intervention and after 4 weeks

tDCS type

VAS pre, mean (SD)

VAS post, mean (SD)

p-value VAS post-4w,

mean (SD)

p-value

M1 7 (1) 4.2 (2.6) 0.14 4.4 (1.6) 0.28

DLPF 4.4 (2.6) 3.4 (1.8) 2.6 (1.6)

Placebo 4.8 (1.7) 2 (1) 5.8 (2.7)

Total 5.4 (2) 3.2 (2) 0.001* 4.2 (2.3) 0.15p = value represents the significance by the repeated measures ANOVA test; tDCS = transcranial direct-current stimulation; DLPF = dorsolateral region of the prefrontal cortex; VAS = visual analog scale; *p<0.05.

and CI:0.6-5) in the pain score. It was smaller in the DLPF re-gion, only one score of improvement (p=0.69 and CI:-1.2-3.2). However, there was no significant difference in the tDCS effect between the types of intervention (p=0.14) (Table 2).Table 2 shows a substantial improvement in pain, especially in M1 and placebo stimulation (p=0.012 and CI:0.6-5). However, after four weeks of placebo stimulation, there was a large decrease in analgesia, including worsening in three of the five participants (p=0.003 e CI: -6,29– -1.3).

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Figure 2 shows that after four weeks the pain relief remained in the active stimulation protocols (M1 and DLPF), with an improvement in pain in the DLPF region, equivalent to 41%. However, according to the repeated measures ANOVA test, there was no difference between the different stimulation pro-tocols (p=0.28).

10,00

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Figure 2. Visual analog scale scores per stimulation protocol accor-ding to time (pre, post-intervention, and after 4 weeks)tDCS = transcranial direct-current stimulation; DLPF = dorsolateral region of the prefrontal cortex.

tDCS had a positive impact on the anxiety symptoms traced by STAI (Table 3). There was a significant decrease in levels of anxiety state (p=0.035) and trait (p=0.009) after the stim-ulation sessions. However, there was no difference between the types of intervention in both the anxiety state (p=0.43) and trait (p=0.69). Moreover, Pearson’s correlation coefficient did not detect a linear relationship between the pain and anx-iety variables (state: r=0.46 and p=0.081; trait: r=0.47 and p=0.86) (Table 3).

Table 3. Mean effect of tDCS on the level of state and trait anxiety after the intervention

Variables Mean (SD) CI95% p-value

STAI-E 4.8 (7.3) 0.39 – 9.2 0.035

STAI-T 4.1 (5.2) 1.2 – 7 0.009

p = value represents the significance by the repeated measures ANOVA test; CI = confidence interval; tDCS= transcranial direct-current stimulation; STAI = State-Trait Anxiety Inventory.

Participants showed a high level of confidence in the treatment received, on a scale ranging from 1 to 5. It is noteworthy that when participants received the placebo stimulation, they reported a slightly higher confidence (Mean [SD]: 4.4 [0.8] and CI: 3.5-5.5) compared to M1 regions (Mean [SD] : 4 [0.7] and CI: 3-4.8) and DLPF (Mean [SD]: 4.2 [0.8] and CI: 3-5.2), with no significant difference (p=0.74). There was a negative correlation between the confidence level and intensity of pain after the treatment (r=-0.61

and p=0.015), as well as a positive correlation between confidence and global perception of change (r=0.612 and p=0.015).Through the PCGS, the participants demonstrated a moder-ate and significant change in their health state, performance of daily activities, emotions and QoL due to the improve-ment in the pain situation, with an average score of approx-imately 5 (SD=1.3 and CI: 4.1-5.7), in a scale from zero to 7. This change has a slightly higher value in the tDCS in the cortical M1 area (Mean [SD]: 5.4 [1.1] and CI: 4-6.8), but there was no difference between the different stimulation protocols (p=0.67). Concerning the adverse effects during tDCS sessions, all three types of stimulation were well tolerated. When present, they had low intensity with no difference between the different stim-ulation protocols (p>0.05). After each stimulation session, the participants answered a questionnaire that listed some adverse effects, rating them on a 1 to 4 scale in absent, mild, moderate, or severe. No skin lesions were observed under or near the areas where the electrodes were positioned. No participant reported severe discomfort or worsening of the clinical picture during the intervention. Thus, it was confirmed that tDCS is safe and well tolerated, with tingling, itching and burning among the most prevalent adverse symptoms39,52,53.Since it was a blind study, when questioned after treatment, all subjects who participated in the study believed that they had received the active current.

DISCUSSION

The present study observed as primary endpoint a significant improvement in all stimulation protocols. Especially with the M1 and placebo stimulation, soon after the stimulation, when compared to the DLPF region. After four weeks, the analgesic effect persisted mainly in the active stimulation protocols. How-ever, there was no significant difference related to the perception of pain between the different stimulation protocols. It is worth mentioning that according to the standard recommendations of the Initiative on Methods, Measurement, and Clinical Trial Pain Evaluation (IMMPACT), the decrease in pain intensity by 50% is considered to be of substantial importance, and a 30% reduction is considered a moderately satisfactory clinical im-provement. Similarly, three controlled and parallel trials investigated the use of tDCS in subjects with TMD, but the stimulation was only in the M1 cortex. Oliveira et al.34 did not find a significant differ-ence between the groups, but they observed a great improvement in the pain intensity after the treatment, mainly in the group of active stimulation added to physiotherapy. Sakrajai et al.30 and Donnell et al.28 observed a significant difference in the pain pic-ture in the group that received active tDCS, noting that the latter used a high definition tDCS device on M1, which allows a more focal emission of the current.The most frequent protocol is the anodal stimulation on M1 for 20 minutes on five consecutive days, in which the pain relief lasts from two to six weeks26,28,30,36,37. The analgesic effect of the neurostimulation measured by VAS after four weeks of inter-

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vention showed a large decrease in analgesia due to the placebo stimulation, unlike the active tDCS in M1 and DLPF, in which the effect size tended to remain, with an improvement of 37 and 41%, respectively. As for the regions chosen in non-invasive neuromodulation for the treatment of pain, it is known that the M1, somatosensory (S1) and dorsolateral prefrontal cortices integrate what is called the “pain ma-trix”, which can be directly reached by the tDCS, and thereby influ-ence the dysfunctional pathway of how the pain is being processed, indirectly reaching the subcortical components31,32,54,55. Studies have shown that the M1 stimulation, especially on the left side, produces significant clinical improvements in patients with chronic pain, which has made this cortical region the main target of several neuromodulatory techniques, including tDCS, dedicated to the improvement of chronic pain in clinical tri-als26-28,30,32,33. The intricate neurophysiological mechanisms that explain the clinical efficacy of the M1 stimulation for pain relief are not fully understood. However, it is believed that its anal-gesic mechanisms involve the activation of top-down controls related to the excitation of the horizontal intracortical fibers and facilitating the descending control of pain inhibition. Neuroim-aging studies revealed the presence of chemical pain mediation through opioidergic, glutamatergic, GABAergic and serotoner-gic neurotransmissions21,32,33. Pain due to muscular TMD is believed to be strongly related to emotional distress9-16,56. And the DLPF cortex is the fulcrum of several brain networks involved in the cognitive, affective and sensory processing, which stimulation probably mediates the analgesic effects through the modulation of affective-emotional networks related to pain13,38,39. The left DLPF cortical region plays a role in the active control of pain perception through the bilateral modulation of the corti-cosubcortical and cortico-cortical pathways57. In addition, some studies have compared the effect of tDCS on M1 and DLPF cortices in individuals with chronic pain, in whom the stimula-tion in the DLPF region generated pain relief as good as the M1 group, and sometimes greater24,35,58.Considering previous studies and the relationship between the left DLPF area with the emotional aspects of pain, the present study hypothesized that the anodic neuromodulation on the left side would promote a more intense analgesic effect in the stim-ulation protocol in the DLPF region of the cortex compared to the stimulation in the M1 cortex, since that area is shown to be responsible for the processing of the emotional component of pain, often underlining the refractoriness of treatment1,40. Although the participants reported improvement in pain when they received the anodic current in the DLPF cortex, shortly af-ter the treatment, the analgesic effect was higher with the tDCS in M1. However, the size of the analgesic effect on both stimula-tion sites was similar after four weeks.A study involving patients with fibromyalgia compared the pro-tocol of 10 sessions, once a day, with the intensity of 2mA and duration of 20 minutes. tDCS was applied to the left side of the M1 or DLPF cortex, and it was observed that both regions induced significant improvements in pain and QoL. However, the M1 group was more effective in maintaining the observed

decrease in pain scores for up to 60 days35. This same group of scholars has previously used a five-session protocol in which only the stimulation in the M1 cortex generated a significant improvement in the pain picture37. Following this reasoning, it is possible that an increase in the number of tDCS sessions, from five to ten, will provide a more pronounced analgesic effect after the stimulation in the DLPF region. The psychosocial factor appears to be associated with TMD9-16, with patients with high levels of anxiety and/or depression being more prone to this dysfunction. And the longer the pain lasts, the higher the risks of behavioral, psychosocial, and cognitive problems, which worsens the prognosis14.As a secondary endpoint, the levels of anxiety state-trait after the stimulation sessions were evaluated according to the STAI-E and T. Some studies support the association between pain and anxi-ety, especially when the pain is muscular14,56. In this study, there was a significant decrease in the anxiety state-trait levels after the therapy. However, there was no difference between the different types of intervention nor a positive correlation between pain and anxiety, possibly due to the small size of the sample. Donnell et al.28 did not find any significant difference in the anxiety state after treatment. However, Oliveira et al.34 found improvements in the depressive symptoms.The participants reported a moderate and significant change in their health status, but there was no difference between the types of intervention (p=0.67). This data corroborates previous stud-ies that showed a relationship of negative influence between the pain and the performance of the daily activities, physical and psychosocial functioning, as well as the patients’ QoL3-5.The placebo effect corresponds to benefits attributable to brain-mind responses to the context in which a treatment is admin-istered. This effect, coupled with the fact that patients report a high level of confidence in the treatment received, justifies the high improvement of the participants who received the tDCS placebo. Similar improvement in the control group occurred in the studies by Donnell et al.28, Oliveira et al.34, and Sakrajai et al.30. In the latter, about one-third, half the patients experienced some kind of pain relief. This phenomenon is well observed in studies involving neuromodulation in the treatment of pain59,60.Some studies have also observed a reduction of anxiety in volun-teers allocated to placebo group61, an effect also observed in the present study.On the other hand, in the placebo stimulation, the pain picture worsened markedly after four weeks when compared to active tDCS. This may be justified by the optimized effect at the mo-lecular and clinical levels of the actual tDCS over placebo60,62, be-sides the fact that the clinical effects of the tDCS are cumulative and develop slowly, possibly due to neuroplastic changes21,23,28. Based on the findings of brain imaging analysis, placebo-based analgesia is considered to be a real phenomenon, i.e., biolog-ically measurable. They are mediated by a variety of processes including learning, expectations, and social cognition, and can influence several health-related clinical and physiological out-comes. The evidence of neuroscience believes that multiple brain systems and neurochemical mediators are involved, including opioids and dopamine61-63.

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Limitations of the study and future outlooksA limitation of the present study is due to the small size of the sample since it is a preliminary study. Perhaps the sample was in-sufficient to detect statistically significant effects in the variables of the studied protocols. Also, there was no follow-up of brain activity before and after treatment so that no results can be given about possible neurophysiological mechanisms related to tDCS.The persistence of the tDCS analgesic effect, especially in the active stimulations after four weeks, shows that the wash-out pe-riod adopted between the study steps possibly was not enough to avoid the residual effects of the stimulation performed in the pre-vious step, although the washout period has been defined based on previous studies21,46-48. Another important point regarding the difficulty of the par-ticipant’s compliance with the study is that his/her presence is required during 15 sessions. Also, between every five sessions, there was a four-week interval, causing the study to last ap-proximately four months for each participant. Moreover, the lack of comparison between the efficacy of tDCS and other conventional techniques, such as the occlusal splint, is anoth-er limitation, suggesting the need for further studies about these aspects. The results of this study should not be extrapolated to the clini-cal application of tDCS in the treatment of chronic TMD pain. It is suggested the development of new studies with significant sample size, aiming to quantify the effect size and differenc-es between the types of intervention, to facilitate the decision making regarding the best choice of treatment. Given that this is a study with preliminary data, the results need to be inter-preted with caution.

CONCLUSION

The present study suggests that the use of tDCS improved the health condition of patients with chronic muscular TMD, pro-moting relief of pain, decreased the level of anxiety, and a posi-tive contribution to QoL. The M1 cortex was the stimulated area that showed the best result, taking into account the effect of the treatment shortly after the five sessions of neurostimulation. It is worth mentioning that the tDCS has proved to be a safe and well-tolerated instrument.

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ABSTRACT

BACKGROUND AND OBJECTIVES: The hospital environ-ment is considered to be unhealthy, and, moreover, the work performed by nursing professionals presents several risk factors for the development of pain. In this sense, the present study aims to analyze the musculoskeletal disorders in the nursing team and to correlate with the level of physical activity, anthropometric characteristics and the professional profile at the University Hos-pital in Petrolina, Pernambuco. METHODS: This was a cross-sectional study with 143 nurs-ing professionals, of which 122 were female (37±7 years) and 21 were male (33±6 years). The individuals answered the Interna-tional Physical Activity Questionnaire and the Nordic Musculo-skeletal Questionnaire. RESULTS: Pain was reported in 77 volunteers, which corresponds to 53.8% of the sample. In 35 (24.4%) volunteers there was the presence of musculoskeletal disorders in more than one body seg-ment. Regarding pain distribution by body segment, the higher prevalence’s were observed in the lumbar region and the knees, both with 17.4%. In addition, there were associations between being male and pain in the elbows (PR=5.5, 95% CI: 1.1, 25.5, p=0.028) and ankles (PR=5.1, 95% CI: 1.3; 19.2, p=0.016), and pain and physical inactivity for the elbow segments (PR=3.4, 95% CI: 1.1, 10.3, p=0.027) and knees (PR=2.4, 95% CI: 1.1, 5.0, p=0.021). CONCLUSION: It can be noticed that the prevalence of pain in the team of professionals analyzed was high and that the risk

Self-reported musculoskeletal disorders by the nursing team in a university hospitalDistúrbios musculoesqueléticos autorreferidos na equipe de enfermagem em um hospital universitário

Edilson Gonçalves Maciel Júnior1, Francis Trombini-Souza2, Paula Adreatta Maduro3, Fabrício Olinda Souza Mesquita3, Tarcísio Fulgêncio Alves da Silva2

Edilson Gonçalves Maciel Júnior - https://orcid.org/0000-0001-6290-373X;Francis Trombini-Souza - https://orcid.org/0000-0001-8862-4691;Paula Adreatta Maduro - https://orcid.org/0000-0003-2174-2460;Fabrício Olinda Souza Mesquita - https://orcid.org/0000-0001-7514-2757;Tarcísio Fulgêncio Alves da Silva - https://orcid.org/0000-0001-5982-9954.

1. Universidade de Pernambuco, Faculdade de Fisioterapia, Petrolina, PE, Brasil. 2. Universidade de Pernambuco, Petrolina, PE, Brasil. 3. Universidade Federal do Vale do São Francisco, Hospital Universitário, Empresa Brasileira de Serviços Hospitalares, Petrolina, PE, Brasil.

Submitted on October 22, 2018.Accepted for publication on March 21, 2019.Conflict of interests: none – Sponsoring sources: none.

Correspondence to: Rodovia BR 203, Km 02, s/n - Vila Eduardo56328-903 Petrolina, PE, Brasil. E-mail: tarcisio.silva@upe.br

© Sociedade Brasileira para o Estudo da Dor

factors, such as physical inactivity and being male were associat-ed with a greater onset of musculoskeletal disorders.Keywords: Cumulative trauma disorders, Occupational health, Pain.

RESUMO

JUSTIFICATIVA E OBJETIVOS: O ambiente hospitalar é considerado como insalubre, além disso, a atividade laboral de-sempenhada pelos profissionais de enfermagem apresenta diver-sos fatores de risco para o desenvolvimento de dor. Nesse sen-tido, o presente estudo teve por objetivo analisar os distúrbios musculoesqueléticos na equipe de enfermagem e correlacionar com o nível de atividade física, características antropométricas e o perfil profissional no Hospital Universitário em Petrolina, Pernambuco. MÉTODOS: Trata-se de um estudo transversal, com 143 profis-sionais de enfermagem, sendo 122 do sexo feminino (37±7 anos) e 21 do sexo masculino (33±6 anos). Os indivíduos responderam aos questionários Internacional de Atividade Física e ao Nórdico de Sintomas Osteomusculares. RESULTADOS: Foi constatada a presença de dor em 77 volun-tários, o que equivale a 53,8% da amostra. Em 35 (24,4%) vo-luntários houve a presença de distúrbios musculoesqueléticos em mais de um segmento corporal. Quanto à distribuição de dor por segmento corporal, foram observadas maiores prevalências na re-gião lombar e nos joelhos, ambas com 17,4%. Além disso, foram verificadas associações entre o sexo masculino e dor nos cotove-los (RP=5,5, IC 95%:1,1;25,5, p=0,028) e tornozelos (RP=5,1, IC 95%:1,3;19,2, p=0,016), e dor e inatividade física para os segmentos em cotovelos (RP=3,4, IC 95%:1,1;10,3, p=0,027) e joelhos (RP= 2,4, IC95%: 1,1; 5,0, p=0,021). CONCLUSÃO: Observou-se que a prevalência de dor na equipe de profissionais analisada foi elevada, e que fatores de risco como a inatividade física e o sexo masculino, foram associados com maior surgimento dos distúrbios musculoesqueléticos.Descritores: Dor, Saúde do Trabalhador, Transtornos traumáti-cos cumulativos.

INTRODUCTION

Work-related musculoskeletal disorders (WRMD) are disar-rangements that affect the muscle structures, tendons, synovi-al membranes, nerves, fascia, and ligaments, in a combined or isolated form, with or without the degeneration of work-related

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DOI 10.5935/2595-0118.20190028

ORIGINAL ARTICLE

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tissues. Currently, the literature adopts the term musculoskeletal disorders (MSD) in place of the WRMD expression1. MSD is becoming a relevant problem for public health, es-pecially in industrialized countries, affecting workers in dif-ferent sectors because they determine a variety of signs and symptoms, such as pain, discomfort, the feeling of weight, fatigue, paresthesia, movement limitation, among others, that may be concurrent or not. Generally, they start insidiously and evolve rapidly if there are no changes in the working con-ditions1,2.In this sense, it is possible to say that the workspace presents several risk factors for the onset of MSD, mainly due to the association between inadequate work environment and the poor physical conditions of the workers. The hospital envi-ronment can generate emotional stress and physical injuries due to its unhealthy nature with continuous exposure to one or more factors that can lead to diseases or illness resulting from the very nature of the work and its organization1,3. Among health professionals, the nursing staff has a high in-cidence and prevalence of MSD4,5, due to the demanding hospital environment. Generally, the activities performed by these workers are directly related to the patient and may re-quire inappropriate postures; work overload; weightlifting; repetitive movements and tension in addition to factors such as poor work organization; inadequate equipment and exces-sive demand for productivity6.The objective of this study was to analyze MSD in the nursing team and to correlate with the level of physical activity (PA), anthropometric characteristics and the professional profile at the University Hospital (UH) of Petrolina, Pernambuco. METHODS

This is a cross-sectional study. The analyzed population com-prises professional nurses, and nursing technicians’ employees of the Federal University Vale do São Francisco (UNIVASF), in the city of Petrolina, Pernambuco. All were invited to par-ticipate, and the research was carried out with a convenience sample of 143 nursing professionals. The inclusion criteria were a minimum age of 18 years; the presence of employment relationship with at least one month in the UH. The exclusion criteria were all subjects who did not meet the requirements described or who did not agree to participate in the research.Demographic and anthropometric data were collected, such as gender, age, mass, and height. In addition, two evaluation tools were applied, the Nordic Musculoskeletal Questionnaire (NMQ), and the International Physical Activity Question-naire (IPAQ). The NMQ was used in its general form that comprises all the anatomical area for the evaluation of the major symp-toms of MSD. This instrument was validated in Brazil in 20027 and con-sists of multiple or binary choices regarding the occurrence of symptoms in several anatomical regions in which they are more common, according to figure 1. The pain referred to in the last seven days was considered for analysis in this study.

Another important factor in evaluating workers is the Physi-cal Activity Index by IPAQ since the more physically inactive the individual, higher the chances to develop certain limita-tions and comorbidities, including pain9,10. This instrument is the result of studies conducted by normative health agencies, such as the World Health Organization (WHO) and the de-sire to unify a questionnaire that could be useful in all world’s populations to facilitate research11,12. The IPAQ short version was used for the interviews. The reference used to evaluate PA was the previous week. Thus, a set of questions was asked related to the frequency and du-ration of moderate, vigorous PA, and walking. The adopted evaluation system categorized the participants as very active; a) active; insufficiently active; b) insufficiently active, and sedentary. For the data analysis, the volunteers who answered the IPAQ were classified into two categories: active - representing the participants who obtained results as “very active” or “active”; and insufficiently active - the population that obtained results as “insufficiently active a” and “insufficiently active b” at the PA level. The individuals classified as sedentary were excluded from the study because they represented a tiny sample in re-lation to the others.The research was approved by the Ethics and Research Com-mittee of UNIVASF (Opinion 1386029). All participants were aware of the research objectives and signed the Free and Informed Consent Term (FICT).

Statistical analysisThe data was processed in the Microsoft Excel software and ana-lyzed using the Statistical Package for the Social Sciences (SPSS)

Figure 1. Anatomic regions investigated by the Nordic Musculoskele-tal Questionnaire8

Head

Neck

Shoulders

Chest

Elbows

Forearms

Lower back

Wrist/Handshands

Thigh

Knees

Legs

Ankles/Feet

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program, version 22.0. The descriptive results were explored by the mean, standard deviation; absolute and relative frequencies. The Student’s t-test was used for the comparison between the two groups. The prevalence ratios were used in the adjusted analysis, as a measure of association, estimated by the Poisson regression, with adjustment for a robust variance. Those that had a p<0.05 were associated with the outcome studied. RESULTS

The study population consisted of 374 nursing professionals. Of these, 143 professionals participated in the present study, being 26 nurses (18.2%) and 117 nursing technicians (81.8%). Of the total number of volunteers, 122 (85.3%) were female, and 21 (14.7%) were male. Table 1 shows the characteristics of the pro-fessionals evaluated.Regarding the level of PA referred to in the IPAQ, according to the categorization adopted in the present study, 74 individuals (51.8%) were classified as “active” and 69 (48.2%) as “insuffi-ciently active”.The pain was reported in 77 volunteers, equivalent to 53.8% of the sample. Of these, 15 are nurses (57.6%), and 62 are nursing technicians (52.9%). Overall, 35 (24.4%) volunteers reported pain in more than one body segment. Table 2 shows the prevalence of pain by body segments. The MSD complaints were distributed as follows: lumbar region and knees (17.4%) each; neck and shoulders (13.2%) each; chest region (11.1%); wrist and hand (9.7%); ankle and foot (8.3%); thigh (7.6%) and elbow (2%).Table 3 shows the association between the pain outcome and the independent variables studied, with the adjusted values of the prevalence ratios obtained with the Poisson regression. The vari-

ables that remained in the final model were gender; function; PA level; mass; body mass index (BMI) and age. However, only the regressions that obtained statistically significant results (p≤0.05) are presented. DISCUSSION

Low back pain was the most prevalent in this study, corrobo-rating some findings in the literature13-15. Other body segments significantly affected were shoulders and cervical. This can be explained by the very nature of the work of the nursing team, responsible for most of the direct patient care. It is known that activities related directly to patients are often accompanied by static postures; anterior torso tilt and asymmetric lifting of loads; elements recognized in the literature as risk factors for the devel-opment of MSD in these regions13. Also, in a recent study with nurses in Pakistan, the identified factors that most contributed to the development of MSD were working in the same position for prolonged periods (93.1%); working in tight spaces (78.6%) and handling loads apart from the body (64.1%)16.In the present study, it was not possible to observe significant dif-ferences in pain regarding the professional profile. Nursing tech-nicians had more physical and biomechanical risk factors that lead to MSD since they have more direct contact with patient demands, such as transfers, personal hygiene, among others16. On the other hand, nurses would be more exposed to psycho-social risk factors and cognitive demand, since they are the ones who perform most of the administrative functions of the sector17.Males had higher prevalence ratios for elbow pain (PR=5.5, CI95%:1.1, 25.5) and ankle (PR=5.1, CI95%:1.3, 19.2) in

Table 1. Anthropometric characteristics of the nursing professionals and nursing technicians of the study

Variables Gender Function

Female Male p-value Nurse Nursing technician p-value

Age (years) 37±7 33±6 0.028 34±7 37±7 0.031

Mass (kg) 65.5±12.5 80±15.6 ≤0.001 66.5±14.9 67.9±13.8 0.631

Height (m) 1.59±0.06 1.71±0.07 ≤0.001 1.62±0.07 1.6±0.08 0.311

Body mass index 25.8±4.7 27.1±4.3 0.253 25±4.1 26.2±4.8 0.211p: Student’s t-test.

Table 2. Prevalence of pain per body segment in the nursing profes-sionals of the study

Prevalence of pain

Body segment Absolute frequency Relative frequency (%)

Lower back 25 17.4

Knees 25 17.4

Neck 19 13.2

Shoulders 19 13.2

Chest 16 11.1

Wrist and hand 14 9.7

Ankle and foot 12 8.3

Thigh 11 7.6

Elbow 3 2.0

Table 3. Poisson regression analysis with estimates of prevalence ratios and 95% confidence interval of the association between the presence of pain in each segment and the independent variables

Body segment

Independent variable Adjusted analysis - PR CI 95% p-value

Elbow GenderFemale Male

5.5 1.0 (1.1-25.5) 0.028

PA level Active Insufficiently active

3.4 1.0 (1.1-10.3) 0.027

Knee PA level Active Insufficiently active

2.4 1.0 (1.1-5.0) 0.021

Ankle GenderFemale Male

5.1 1.0 (1.3-19.2) 0.016

PR = prevalence ratio PA = physical activity; CI = confidence interval.

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relation to the females. In a survey with Australian nursing stu-dents, males had a higher prevalence of MSD than females. In this population, men were more involved in the manual han-dling of patients18, possibly exposing them to greater overloads in the elbow region. This may explain the higher occurrence of pain in this gender, and it is linked to anthropometric and cultural factors.As for ankle pain, it is possible to say that both individual factors such as the type of footstep and the BMI, as well as work-re-lated factors such as working hours and aspect of each sector, are relevant for complications19. Many of these factors were not analyzed in the present study. However, BMI did not show a significant difference between the genders.Other relevant results in the present study were higher preva-lence rates of elbow pain (PR:3.4 CI95%:1.1-10.3) and knee (PR:2.4 CI95%:1.1-5.0) in individuals who are insufficiently active in relation to the active ones.A recent study20 found an association between decreased muscle strength and self-reported pain. Others have shown the benefi-cial effects of physical exercises to prevent or even reduce pain21-

25. In a clinical trial with industrial technicians in Denmark, upper limb muscles endurance was positively associated with the prevention and improvement of forearm pain. Physiological adaptations due to the forces exerted during the exercises, such as the increase in the synthesis of type I collagen in the eccentric phase of the movement may be associated with better work per-formance and lower association with MSD23.Regarding the knee segment, a three-week aerobic exercise pro-gram showed a considerable increase in the percentage of CD4+

CD28+ cell activation compared to the pre-intervention peri-od24, thereby reducing the pain and inflammatory conditions triggered during work and daily activities25. However, other fac-tors such as a history of injuries in other joints of the lower limbs and a varus alignment are of great importance in predicting the risk of MSD in this site26.Regarding the limitations of the present study, one can high-light the self-report nature of the research instruments (NMQ and IPAQ, mainly), which makes it difficult to rule out the possibility of overestimation or underestimation bias. Anoth-er factor was the cross-sectional character of the study, where only associations should be made, not inferring any causality. In addition, there were no pain associations with aspects such as double work journey; working hours; daily activities; the practice of sports; among others, since they were not collect-ed due to the characteristics of the research instruments and proposed objectives.

CONCLUSION

It can be noticed that in the sample of the evaluated profession-als, the prevalence of musculoskeletal symptoms was high, sug-gesting a relationship between these symptoms and the activities performed by the nursing professionals. Moreover, some risk

factors such as physical inactivity and being male were associated with increased pain.

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2. Magnago TS, de Lima AC, Prochnow A, Ceron MD, Tavares JP, Urbanetto Jde S. Inten-sity of musculoskeletal pain and (in) ability to work in nursing. Rev Lat Am Enfermagem. 2012;20(6):1125-33. English, Portuguese, Spanish.

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8. Hugue TD, Pereira Júnior AA. Prevalência de dor osteomuscular entre os funcionários administrativos da Unifebe. Rev Unifebe. 2011;1(9):1-9.

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15. Freimann T, Coggon D, Merisalu E, Animägi L, Pääsuke M. Risk factors for musculos-keletal pain amongst nurses in Estonia: a cross-sectional study. BMC Musculoskelet Di-sord. 2013;14:334.

16. Rathore FA, Attique R, Asmaa Y. Prevalence and perceptions of musculoskeletal disorders among hospital nurses in Pakistan: a cross-sectional survey. Cureus. 2017;9(1):e1001.

17. Moreira RF, Sato TO, Foltran FA, Silva LC, Coury HJ. Prevalence of musculoskeletal symptoms in hospital nurse technicians and licensed practical nurses: associations with demographic factors. Braz J Phys Ther. 2014;18(4):323-33.

18. Smith DR, Leggat PA. Musculoskeletal disorders among rural Australian nursing students. Aust J Rural Health. 2004;12(6):241-5.

19. Reed LF, Battistutta D, Young J, Newman B. Prevalence and risk factors for foot and ankle musculoskeletal disorders experienced by nurses. BMC Musculoskelet Disord. 2014;15:196.

20. Correa LQ, Rombaldi AJ, Silva MC. Physical activity level and self-reported musculoskele-tal pain perception among older males. Rev Dor. 2016;17(3):183-7.

21. Sundstrup E, Jakobsen MD, Brandt M, Jay K, Aagaard P, Andersen LL. Strength training improves fatigue resistance and self-rated health in workers with chronic pain: a randomi-zed controlled trial. Biomed Res Int. 2016;2016:4137918.

22. Sundstrup E, Jakobsen MD, Andersen CH, Jay K, Persson R, Aagaard P, et al. Effect of two contrasting interventions on upper limb chronic pain and disability: a randomized controlled trial. Pain Physician. 2014;17(2):145-54. Erratum in: Pain Physician. 2014;17(3):E275.

23. Andersen LL, Jakobsen MD, Pedersen MT, Mortensen OS, Sjøgaard G, Zebis MK. Effect of specific resistance training on forearm pain and work disability in industrial technicians: cluster randomised controlled Trial. BMJ Open. 2012;2(1):e000412.

24. Freitas DA, Guedes MB, Fonseca SF, Amorim MR, Gomes WF, Melo GE, et al. Efeito de um programa de treinamento aeróbio na dor, desempenho físico e funcional e na resposta inflamatória em idosos com osteoartrite de joelho-resultados preliminares. Rev Ter Man. 2012;10(47):52-9.

25. Dobson JL, McMillan J, Li L. Benefits of exercise intervention in reducing neuropathic pain. Front Cell Neurosci. 2014;8(1):102.

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ABSTRACT

BACKGROUND AND OBJECTIVES: Newborns at high risk in the intensive care unit are exposed to painful, repetitive and prolonged procedures that may be related to changes in brain development and behavioral abnormalities. The objective of this study was to relate pain and free cortisol of premature newborns undergoing therapeutic procedures in intensive care units. METHODS: A quantitative, descriptive, cross-sectional study conducted with 32 premature newborns submitted to venipunc-ture, who were evaluated for pain and stress related to assisted ventilation; sedatives, prenatal corticoid, type of venipuncture, site, and the number of attempts. RESULTS: Preterm newborns undergoing invasive ventilation had a predominance of moderate pain in 12 (37.5%) and cor-tisol increase in 14 (43.8%) of them. Venipuncture triggered moderate and intense pain, 10 (31.3%), and in 17 (53.1) the cortisol levels increased. More than half was due to peripherally inserted central catheter placement, so that 10 (43.8) had mod-erate pain. The results of the research suggest that the exposure of newborns to invasive procedures is stressful, especially when repeated several times. CONCLUSION: Repeated venous puncture associated with therapeutic procedures intensified pain and altered cortisol, causing stress in premature newborns. Keywords: Intensive care unit, Nursing, Pain measurement, Physiological stress, Premature newborn.

Analysis of pain and free cortisol of newborns in intensive therapy with therapeutic procedures Análise da dor e do cortisol livre em recém-nascidos em terapia intensiva com procedimentos terapêuticos

Cibele Thomé da Cruz Rebelato1, Eniva Miladi Fernandes Stumm2

Cibele Thomé da Cruz Rebelato - https://orcid.org/0000-0002-1875-8309;Eniva Miladi Fernandes Stumm - https://orcid.org/0000-0001-6169-0453.

1. Associação Hospital de Caridade de Ijuí, Unidade de Terapia Intensiva Neonatal, Ijuí, RS, Brasil.2. Universidade Regional do Noroeste do Estado do Rio Grande do Sul, Departamento de Enfermagem, Ciências da Vida, Programa de Pós-Graduação Scricto Sensu, Ijuí, RS, Brasil.

Submitted on November 05, 2018.Accepted for publication on April 29, 2019.Conflict of interests: none – Sponsoring sources: none.

Correspondence to: Rua do Comércio, 3000 – Bairro Universitário98700-000 Ijuí, RS, Brasil.E-mail: cibelethome@bol.com.br

© Sociedade Brasileira para o Estudo da Dor

RESUMO

JUSTIFICATIVA E OBJETIVOS: Os recém-nascidos de alto risco em unidade de terapia intensiva, são expostos a procedi-mentos dolorosos, repetitivos e prolongados que podem estar relacionados a alterações no desenvolvimento do cérebro e ano-malias comportamentais. O objetivo deste estudo foi relacionar a dor e o cortisol livre de recém-nascidos prematuros, com proce-dimentos terapêuticos instituídos em terapia intensiva. MÉTODOS: Pesquisa quantitativa, descritiva, transversal, rea-lizada com 32 recém-nascidos prematuros submetidos à punção venosa, que foram avaliados quanto à dor e estresse relacionado à ventilação assistida; sedativos, corticoide no pré-natal, tipo de punção venosa, local e número de tentativas. RESULTADOS: Recém-nascidos prematuros submetidos à ven-tilação invasiva apresentaram predomínio de dor moderada em 12 (37,5%) e aumento de cortisol em 14 (43,8%) deles. A pun-ção venosa desencadeou dor moderada e intensa, 10 (31,3%) e em 17 (53,1) ocorreu aumento do nível de cortisol. Mais da metade ocorreu para passagem de cateter central de inserção periférica, de modo que 10 (43,8) tiveram dor moderada. Os resultados da investigação, sugerem que a exposição dos recém--nascidos a procedimentos invasivos é estressante, especialmente quando repetido várias vezes. CONCLUSÃO: A punção venosa repetida associada a procedi-mentos terapêuticos intensificou a dor e alterou o cortisol, o que implica em estresse ao recém-nascido prematuro.Descritores: Enfermagem, Estresse fisiológico, Mensuração da dor, Recém-nascido prematuro, Unidades de terapia intensiva.

INTRODUCTION

The high-risk newborn (NB) in the neonatal intensive care unit (NICU) is exposed to painful procedures, repeated, prolonged events, related to a deficiency of brain development and behav-ioral abnormalities1. Neonatal pain may trigger stress. In addition, the stress caused by the NICU environment may result in higher plasma corti-sol levels than surgery. Increased concentrations of stress-related hormones in sick and preterm NB is associated with an increased risk of mortality2. Therefore, it is incumbent on nurses to use pharmacological and non-pharmacological measures in order to prevent and reduce pain and neonatal stress.In a research study in California with 237 neonatal nurses, 81% of them reported the use of pain assessment instruments, 83%

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DOI 10.5935/2595-0118.20190029

ORIGINAL ARTICLE

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felt confident with pharmacological measures, and 79% with nonpharmacological3. The authors pointed out that pain man-agement was correlated with adequate training and pain assess-ment instruments from care protocols. Cortisol is a glucocorticoid that exerts physiological effects on the metabolism of carbohydrates, proteins, and fatty acids and plays an important role in the physiological response to stress4,5.Cortisol also has negative feedback effects on the hypothalamus to reduce the formation of corticotrophin-releasing hormone, and on the anterior pituitary, decreasing the formation of the adrenocorticotrophic hormone. On the other hand, stress has a physiological effect on the secre-tion of adrenocorticotrophic hormone, triggering, in minutes, an increase of up to 20 times in the secretion of cortisol6. In this sense, a research quantified the severity of common stress-ors for premature infants7. Seventeen physicians and 130 nurses working in NICU participated in the research, and classified the severity of the perceived stress of 44 acute events (peripheral ve-nous access, peripheral arterial access, central venous access, ven-tilation, nutrition, medical procedures, surgery, radiology and others) and 24 life conditions, characterized as chronic (receiving intranasal oxygen due to repeated bronchopulmonary dysplasia and infection), in preterm infants with gestational age of 28, 28 to 32 and after 32 weeks. Physicians and nurses have realized that almost all events are stressful for NB to some degree and become equally stressful over the ages. Thus, this article aimed to correlate pain and cortisol free of preterm NB with therapeutic procedures instituted in NICUs, in order to assess the occurrence of stress in these NB.

METHODS

A quantitative, descriptive, cross-sectional study conducted at a NICU of a philanthropic hospital institution, size IV, in the northwest of the State of Rio Grande do Sul. This unit provides eight neonatal beds of the Unified Health System (SUS), with a multiprofessional team, composed of pediatricians, nurses, nurs-ing technicians, physiotherapists, and speech therapists.The calculation of the sample was for convenience. 32 preterm NB hospitalized at the NICU between March and October 2016 participated in the study and met the included inclusion criteria: being premature, not having undergone another painful procedure one hour before venipuncture and signing the Free Informed Consent Term (FICT). Data collection was performed through a research protocol com-posed of a form with identification data, sociodemographic, and clinical data of the NB obtained directly from their medical re-cords. The particular form contemplates the variables: assisted ventilation; sedatives, prenatal corticoid, type of venipuncture, site, and the number of attempts. Pain assessment was performed with the Neonatal Infant Pain Scale (NIPS), and cortisol, with diuresis samples from the NB.The diuresis samples of the NB participating in the research were obtained by collector device, or directly from the bladder cathe-ter after being submitted to venipuncture for peripheral access, or a peripherally inserted central catheter (PICC) insertion. The

first diuresis sample was obtained after exposure of the NB to this procedure. The urine samples were kept without a preservative in a refrigerator at 2 to 8ºC and then sent to the Laboratory of Clinical Analysis and for analysis by electrochemiluminescence. 11 NB, in whom the diuresis samples collected were insufficient for cortisol analysis, were excluded from the research.All the ethical precepts governing human research (Resolution 466/12 of the Ministry of Health)8 were respected. The study was approved by the Ethics and Research Committee, in Decem-ber 2015, CAAE nº 50914015.8.0000.5350, opinion number 1.354.128.

Statistical analysisData analysis was performed with descriptive statistics, involv-ing position measurements (lower limit, upper limit, quartile 1, median, quartile 3 and mean) and of dispersion (standard devi-ation and range), and Student’s t-test, with the use of SPSS 17.0 software.

RESULTS

Table 1 shows that invasive ventilation, which routinely preterm NB undergo, triggers a predominance of moderate pain in 37.5%. In the NBs with continuous positive airway pressure (CPAP), moderate or severe pain occurred in 9.4% of the sam-ple and severe pain occurred in 15.6% of the cases in the NB in the hood. Regarding the puncture site, in the upper limbs, 68.8% of the NB received the largest number of punctures and presented mod-erate and severe pain at the same frequency, which was 31.3%. Regarding the purpose of the puncture, more than half occurred for the passage of PICC, so that 10 NB (43.8%) had moderate pain. Still concerning venipuncture, in terms of the number of attempts, infants submitted to a single venipuncture presented moderate pain in 12.5% and severe pain in 9.4% of the sample. Regarding invasive ventilation, table 2 shows an increase of cor-tisol in 43.8% of the NB. 12.5% of the newborns in CPAP and 9.4% of those in the hood had alterations in cortisol levels. The highest number of punctures was in UL in 68.8% of NB, and 53.1% presented increased cortisol level. Regarding the pur-pose of the puncture, more than half occurred for the passage of PICC, so that in 43.8% there was an increase in free cortisol levels. Also, regarding venipuncture in terms of number of at-tempts, 25% of NB submitted to a single venipuncture showed alterations in the cortisol level.Table 3 presents the descriptive measures of cortisol according to some variables, where it is observed in each of them that the lower limbs (LL) and the lower limbs (UL) have a large range. Also, a broader standard deviation is observed in relation to the mean. It is observed that there is a significant difference only between the means of cortisol levels with variable “type of puncture.” Figure 1 shows the position measurements (LL, UL, quartile 1, median, and quartile 3), where four cases of outliers are identified, in which the values of cortisol levels were very high. These preterm newborns (PTNB) are considered to be the most stressed.

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Table 1. Pain analysis, according to variables of newborns in the neonatal intensive care unit. March-October 2016

Variables Puncture pain assessment Totaln (%)Categories No pain

n (%)Mild pain

n (%)Moderate pain

n (%)Severe pain

n (%)

Ventilation Invasive ventilation 1(3.1) 1(3.1) 12(37.5) 4(12.5) 18(56.3)

Nasal CPAP - - 3(9.4) 3(9.4) 6(18.8)

Hood - - 1(3.1) 5(15.6) 6(18.8)

Ambient air - - 1(3.1) 1(3.1) 2(6.3)

Puncture site Cephalic region - - 1(3.1) - 1(3.1)

UL 1(3.1) 1(3.1) 10(31.3) 10(31.3) 22(68.8)

LL - - 4(12.5) 1(3.1) 5(15.6)

Cephalic region, UL and LL - - - 2(6.3) 2(6.3)

UL and LL - - 2(6.3) - 2(6.3)

Type of puncture Passage of PICC 1(3.1) - 10(31.3) 7(21.9) 18(56.3)

Peripheral venous access - 1(3.1) 7(21.9) 6(18.8) 14(43.8)

Number of attempts One 1(3.1) 1(3.1) 4(12.5) 3(9.4) 9(28.1)

Two - - 4(12.5) 3(9.4) 7(21.9)

Three - - 3(9.4) 2(6.3) 5(15.6)

Four - - 3(9.4) 2(6.3) 5(15.6)

Six - - 3(9.4) 1(3.1) 4(12.5)

Eight - - - 1(3.1) 1(3.1)

Nine - - - 1(3.1) 1(3.1)

Total 1(3,1) 1(3.1) 17(53.1) 13(40.6) 32(100)CPAP = continuous positive airway pressure; UL = upper limbs, LL = lower limbs; PICC = peripherally inserted central catheter.

Table 2. Cortisol analysis, according to the variables of newborns in the neonatal intensive care unit. March-October/2016

Variables Cortisol Total

Categories 2 to 27n (%)

Greater than 27n (%)

Ventilation Invasive ventilation 4(12.5) 14(43.8) 18(56.3)

Nasal CPAP 2(6.3) 4(12.5) 6(18.8)

hood 3(9.4) 3(9.4) 6(18.8)

Ambient air - 2(6.3) 2(6.3)

Puncture site Cephalic region - 1(3.1) 1(3.1)

UL 5(15.6) 17(53.1) 22(68.8)

LL 2(6.3) 3(9.4) 5(15.6)

Cephalic region, UL and LL - 2(6.3) 2(6.3)

UL and LL 2(6.3) - 2(6.3)

Type of puncture Passage of PICC 4(12.5) 14(43.8) 18(56.3)

Peripheral venous access 5(15.6) 9(28.1) 14(43.8)

Number of attempts One 1(3.1) 8(25.0) 9(28.1)

Two 4(12.5) 3(9.4) 7(21.9)

Three 2(6.3) 3(9.4) 5(15.6)

Four 1(3.1) 4(12.5) 5(15.6)

Six 1(3.1) 3(9.4) 4(12.5)

Eight - 1(3.1) 1(3,1)

Nine - 1(3.1) 1(3,1)

Total 9(28.1) 23 32(100)CPAP = continuous positive airway pressure; UL = upper limbs, LL = lower limbs; PICC = peripherally inserted central catheter.

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Table 3. Descriptive statistics and Student t test of cortisol according to the variables of the newborns. March-October/2016

Variables Categories Cortisol

n LL UL Range Median Mean Standard deviation p-value

Gender Female 15 3.04 557.1 554.06 52.60 124.93 157.24 0.380

Male 17 16.94 598.0 581.06 45.20 78.77 135.92

Sedation Yes 16 3.04 598.0 594.96 52.50 121.43 182.17 0.424

No 16 6.51 373.0 366.49 37.80 79.39 98.91

Ventilation Invasive 18 3.04 598.0 594.96 49.25 110.89 173.85 0.632

Non-invasive 14 6.51 373.0 366.49 45.60 86.92 103.91

Corticoid Yes 14 3.04 598.0 594.96 32.60 110.86 198.86 0.727

No 18 6.51 373.0 366.49 52.90 92.28 91.36

Type of puncture

Passage of PICC 18 3.04 598.0 594.96 52.90 142.11 182.33 0.044*

Peripheral venous access 14 3.76 169.5 165.74 41.65 46.79 41.14

Number of attempts

One 9 25.30 169.5 144.20 41.20 54.07 44.16 0.267

More than one 23 3.04 598.0 594.96 53.20 118.54 167.36* There was a significant difference for p<0.05; LL = lower limbs; UL = upper limbs; PICC = peripherally inserted central catheter.

Figure 1. Cortisol position measurements according to gender, sedation, ventilation, corticosteroid, type of puncture, and number of attempts. March-October/2016

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However, to better understand the relationships, we opted to exclude these four extreme values of cortisol, which are: 598; 557.1; 373 and 224.1. The results are shown in table 4, showing that there is a significant difference in the value of cortisol in the corticosteroid variable.

DISCUSSION

The long-term effects of untreated neonatal pain include adverse neurological outcomes, increased pain response, increased soma-tization, and other neuropsychological changes9. In this sense, pharmacological therapies should be used in conjunction with non-pharmacological interventions.

One research analyzed the association of pain assessment scores obtained through re-assessment, according to the Joint Commis-sion (JC), with painful events and analgesic use in 196 prema-ture infants on mechanical ventilation. In general, 2% of the pain scores suggested the presence of pain, 0.1% of the pain scores were associated with analgesia. Ventilated NB who were exposed to multiple procedures on a single day did not demon-strate high pain scores, despite frequent preventive or continuous analgesics10. The authors concluded that pain assessment scores obtained through reassessments were poorly correlated with procedures or conditions associated with pain. Low pain scores through reas-sessment may not correlate with low pain exposure. Although

Figure 1. Cortisol position measurements according to gender, sedation, ventilation, corticoid, type of puncture, and number of attempts. Mar-ch-October/2016PICC = peripherally inserted central catheter.

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Table 4. Descriptive statistics and Student’s t-test of cortisol according to the variables of the newborns

Variables Categories Cortisol

n LL UL Range Median Mean Standard deviation P value

Gender Female 12 3.04 169.5 166.46 43.25 59.97 58.28 0.406

Male 16 16.94 119.0 102.06 43.20 46.32 24.67

Sedation Yes 14 3.04 154.4 151.36 49.25 56.23 40.59 0.616

No 14 6.51 169.5 162.99 32.60 48.08 44.63

Ventilation Invasive 16 3.04 154.4 151.36 45.95 52.56 39.14 0.956

Non-invasive 12 6.51 169.5 162.99 37.80 51.65 47.47

Corticoid Yes 12 3.04 71.10 68.06 27.90 33.07 21.39 0.022*

No 16 6.51 169.5 162.99 51.45 66.50 48.368

Type of punc-ture

Passage of PICC 14 3.04 154.4 151.36 43.95 57.55 43.82 0.509

Peripheral venous access 14 3.76 169.5 165.74 41.65 46.79 41.14

Number of attempts

One 9 25.30 169.5 144.20 41.20 54.07 44.16 0.873

More than one 19 3.04 154.4 151.36 46.70 51.28 42.25Retrospective cases of cortisol outlier (598; 557.1; 373; 224.1); * there was significant difference for p<0.05; PICC = peripherally inserted central catheter; LL = lower limit; UL = upper limit.

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JC supervision occurs, the results of this study suggest that doc-umentation of pain reassessment may not directly facilitate the effective management of pain in NICUs10. Additional research is needed to explore scales, to reassess pain in the NICU to identify best practices, and to facilitate the management of the accumu-lated pain experience in premature infants. A Swiss study with 120 ventilated NB and assessed for the presence of pain in procedures during 14 days showed that the NB were submitted to 38,626 procedures, an average of 22.9 procedures per patient, and 75.6% were painful11. The most frequent was the manipulation of CPAP nasal cannulas. The pain assessment occurred four to seven times a day, 99.2% of the patients received non-pharmacological and pharmacologi-cal measures of pain, and 70.8% received glucose as preventive analgesia for pain.Regarding the use of corticosteroids in prenatal care, the same is indicated for pregnant women in labor, from 23 to 34 weeks of gestational age. One study assessed 463 pregnant women and their 514 NB12. With regard to NB, they presented better Apgar scores at 1 and 5 minutes, less need for intervention in the deliv-ery room and lower SNAPPE II (Score for Neonatal Acute Phys-iology with Perinatal Extension-II) for mortality and morbidity prediction in NICUs, were born in better clinical conditions, greater weight and gestational age. They also used less exogenous surfactant, and the NB remained shorter on mechanical ventila-tion and oxygen therapy. However, it was associated with an increase in neonatal sepsis be-cause the NB whose mothers received antenatal corticosteroids had a higher incidence of positive blood cultures and greater use of antibiotics and necrotizing enterocolitis. Investigations about antenatal treatment and the risk of infection are conflicting. Venipuncture is a painful procedure often performed in a NICU. Some authors have analyzed the efficacy of snoring PTNB for ve-nipuncture. It was a study composed of 42 NB, 21 in the control group, and 21 in the treatment. When submitted to venipunc-ture, the pain was assessed with the Premature Infant Pain Profile Scale. In the treatment group, the NB were snored before the puncture, and the pain was significantly lower (p<0.05)13.A study of 38 PTNB of very low weight at Hermann Children’s Hospital in Texas submitted to radial venous puncture for blood collection and/or calcaneal puncture were assessed for cardiac variability in response to pain stimuli14. They found a change in heart rate variability during procedures, coupled with evidence that a low-frequency response improved with advancing correct-ed gestational age.Regarding cortisol, a hormone that assesses stress, a review of the integrative literature that analyzed 16 articles showed that the examination of retinopathy and the heel puncture provoked an increase in salivary cortisol level15. However, measures with music, prone position, and the use of the same crib between the twins reduced the level of salivary cortisol. The difficulties re-ported refer to the low rate of saliva sampling, and because they did not use control groups.The assessment of salivary cortisol concentration is a precise method to indicate neonatal stress16. The use of glucocorticoids in prenatal care, such as betamethasone, interferes with the re-

sponse to stress due to suppression of the adrenal gland. NB with a weight between 1,500 and 2,500g showed a more intense reac-tion to stress, with mean salivary cortisol of 6,650.0±2,660.0ng/dL. The authors state that the intense reaction of the NB to stress is detrimental to several physiological, functional, and structural systems in the short and long period.PTNB, especially those of 24-32 weeks, undergo repeated painful procedures during a period of rapid brain development and stress system programming. They have nociceptive circuits to perceive pain; however, their sensory systems are immature so that an im-balance of excitatory versus inhibitory processes can lead to in-creased nociceptive signaling in the central nervous system17. Also, specific cells in the central nervous system of PTNB are particular-ly vulnerable to excitotoxicity, oxidative stress, and inflammation. Thus, increased exposure to stress related to neonatal pain has been associated with altered brain microstructure, levels of stress hormone, and changes in cognitive, motor, and behavioral devel-opment17. Therefore, it is vital that pain-related stress in PTNB is accurately identified, adequately managed, and that pain man-agement strategies are assessed and performed for short- and long-term protective effects.One study longitudinally examined gestational age and devel-opmental differences in the self-regulating abilities of preterm infants in response to a painful stressor, as well as the associ-ations between behavioral and cardiovascular responses18. Heel puncture blood samples from children 28 to 31 and from 32 to 34 weeks of gestational age at birth were assessed. Both groups presented behavioral and cardiovascular indications of stress in response to the blood draw. However, the NB at gestational ages more extreme (28-31 weeks) were more physiologically reactive. In this sense, the greater vulnerability to the stress of premature infants of 28-31 weeks compared to those of 32-34 weeks of gestation and the implications of this subsequent development are discussed.Early life stress may alter the function of the hypothalamic axis (HPA) and the adrenal gland19. Differences in cortisol levels were found in PTNB exposed to procedural stress during neo-natal intensive care compared with full-term NB, but only a few studies investigated whether the HPA axis alteration per-sists with child growth. In addition, there is a lack of knowledge about what can contrib-ute to these alterations in cortisol. In this context, a prospective cohort study examined salivary cortisol profiles in response to the stress of cognitive assessment as well as the diurnal rhythm of cortisol in children (n=129) born at different levels of prema-turity (24-32 weeks gestation), term (38-41 weeks of gestation), and at 7 years of age19. The authors demonstrated that cortisol profiles were similar in preterm and term NB, although preterms presented higher corti-sol at bedtime compared to full-term infants. Importantly, in the preterm group, greater stress related to procedural neonatal pain was associated with higher levels of cortisol on the day of study (p=0.044) and lower daytime cortisol at home (p=0.023), with effects observed mainly in boys. Also, attention deficit, negativ-ity, and neuropsychological problems were associated with the cortisol response in the cognitive assessment in preterm NB19.

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Thus, pain and stress may contribute to the alteration of HPA axis function to school age in preterm infants, and gender may be an important factor. Early postnatal exposure to invasive pro-cedures is stressful, especially when repeated several times a day during a period of immaturity.

CONCLUSION

The repeated venipuncture procedure intensified pain and al-tered cortisol. Upper limbs were more sensitive to pain reactions than lower limbs.

REFERENCES

1. Jeong IS, Park SM, Lee JM, Choi YJ, Lee J. Perceptions on pain management among Korean nurses in neonatal intensive care units. Asian Nur Res. 2014;8(4):261-6.

2. Taddio A, Katz J. Pain, opioid tolerance and sensitisation to nociception in the neo-nate. Best Pract Res Clin Anaesthesiol. 2004;18(2):291-302.

3. Prevention and management of procedural pain in the neonate: An Update. Pediatrics. 2016;137(2):e20154271.

4. Hingre RV, Gross SJ, Hingre KS, Mayes DM, Richman RA. Adrenal steroidogenesis in very low birthweight preterm infants. J Clin Endocrinol Metab. 1994;78(2):266-70.

5. Gordon BA, Fletcher MA. Neonatology and pathophysiology management of the newborn. 15th ed. Philadelphia: Lippincott Wiliams and Wilkins; 1999.

6. Jett PL, Samuels MH, McDaniel PA, Benda GI, Lafranchi SH, Reynolds JW, et al. Variability of plasma cortisol levels in extremely low birth weight infants. J Clin En-docrinol Metab. 1997;82(9):2921-5.

7. Newnham CA, Inder TE, Milgrom J. Measuring preterm cumulative stressors within the NICU: The Neonatal Infant Stressor Scale. Early Hum Dev. 2009;85(9):549-55.

8. Brasil. Resolução CNS Nº 466 - Ministério da Saúde. [citado em 2017 jan. 06]. Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/cns/2013/res0466_12_12_2012.html.

9. Anand JJ, Hall RW. Pharmacological therapy for analgesia and sedation in the newborn. Arch Dis Child Fetal Neonatal Ed. 2006;91(6):F448-53.

10. Rohan AJ. The utility of pain scores obtained during ‘regular reassessment process’ in premature infants in the NICU. J Perinatol. 2014;34(7):532-7.

11. Cignacco E, Hamers J, van Lingen RA, Stoffeld L, Büchi S, Müller R, et al. Neonatal procedural pain exposure and pain management in ventilated preterm infants during the first 14 days of life. Swiss Med Wkly. 2009;139(15):226-32.

12. Duarte JL. [Antenatal corticosteroid use and clinical evolution of preterm newborn infants]. J Pediatr. 2004;80(6):529-30; autor reply 530. Portuguese.

13. Lopez O, Subramanian P, Rahmat N, Theam LC, Chinna K, Rosli R. The effect of facilitated tucking on procedural pain control among premature babies. J Clin Nurs. 2015;24(1-2):183-91.

14. Padhye NS, Williams AL, Khattak AZ, Lasky RE. Heart rate variability in response to pain stimulus in VLBW infants followed longitudinally during NICU stay. Dev Psychobiol. 2009;51(8):638-49.

15. Mörelius E, He HG, Shorey S. Salivary cortisol reactivity in preterm infants in neonatal intensive care: an integrative review. Int J Environ Res Public Health. 2016;13(3): pii: E337.

16. Cabral DM, Antonini SR, Custódio RJ, Martinelli CE Jr, da Silva CA. Measurement of salivary cortisol as a marker of stress in newborns in a neonatal intensive care unit. Horm Res Paediatr. 2013;79(6):373-8.

17. Vinall J, Grunau RE. Impact of repeated procedural pain-related stress in infants born very preterm. Pediatr Res. 2014;75(5):584-7.

18. Lucas-Thompson R, Townsend EL, Gunnar MR, Georgieff MK, Guiang SF, Ciffuen-tes RF, et al. Developmental changes in the responses of preterm infants to a painful stressor. Infant Behav Dev. 2008;31(4):614-23.

19. Brummelte S, Chau CM, Cepeda IL, Degenhardt A, Weinberg J, Synnes AR, et al. Cortisol levels in former preterm children at school age are predicted by neonatal procedural pain-related stress. Psychoneuroendocrinology. 2015;51:151-63.

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ABSTRACT BACKGROUND AND OBJECTIVES: Chronic pain is one of the main challenges for health systems. Pain education and self-motivated strategies have great potential in the treatment of people with chronic pain, especially by modifying beliefs and behavior. The development of board games for educational pur-poses can contribute to the learning of pain concepts and be-havioral strategies. The objective of this study was to develop a board game (ConheceDor) to be used as an intervention tool for pain education. CONTENTS: The systematic review for the development of the game ConheceDor, considered the following search strate-gy: “chronic pain”, “musculoskeletal pain”, “health education”, “patient education”, “neuroscience education”, “pain education”, “therapeutic neuroscience education”. The primary outcomes considered were pain intensity and disability. Fifteen studies were included, with a total of 1,486 participants. Six studies reported reduction on pain of at least 10%, and two studies reported an improvement of at least 30% on disability. For the development of the game, we elaborated the layout of the board, the rules and other components (dice, cards, and pins). The cards of the game included the contents commonly used in the randomized controlled trials: negative thoughts, pain neurophysiology, stress management, and relaxation, coping and exercises. CONCLUSION: The development of the present board game was based on the critical appraisal of the content of education-

ConheceDOR: the development of a board game for modern pain education for patients with musculoskeletal pain ConheceDOR: desenvolvimento de um jogo de tabuleiro para educação moderna em dor para pessoas com dor musculoesquelética

Juliana Carvalho de Paiva Valentim1, Ney Armando Meziat-Filho2, Leandro Calazans Nogueira2, Felipe J. Jandre Reis3

Juliana Carvalho de Paiva Valentim - https://orcid.org/0000-0001-9522-8523;Ney Armando Meziat-Filho - https://orcid.org/0000-0003-2794-7299;Leandro Calazans Nogueira - https://orcid.org/0000-0002-0177-9816;Felipe J. Jandre Reis - https://orcid.org/0000-0002-9471-1174.

1. Instituto Federal de Educação, Ciência e Tecnologia do Rio de Janeiro, Rio de Janeiro, RJ, Brasil.2. Centro Universitário Augusto Motta, Programa de Pós-Graduação em Ciências da Re-abilitação, Rio de Janeiro, RJ, Brasil. 3. Universidade Federal do Rio de Janeiro, Instituto Federal de Educação, Ciência e Tecno-logia do Rio de Janeiro, Rio de Janeiro, RJ, Brasil.

Submitted on July 09, 2018.Accepted for publication on December 10, 2018.Conflict of interests: none – Sponsoring sources: none.

Correspondence to: Instituto Federal do Rio de Janeiro, Campus RealengoRua Carlos Wenceslau, 343 – Realengo21715-000 Rio de Janeiro, RJ, Brasil. E-mail: felipe.reis@ifrj.edu.br

© Sociedade Brasileira para o Estudo da Dor

al strategies present in the literature. The board game can be a potent resource to be applied in clinical practice in people with musculoskeletal pain. Keywords: Chronic pain, Experimental games, Health educa-tion, Neuroscience-based education.

RESUMO

JUSTIFICATIVA E OBJETIVOS: A dor crônica é um dos principais desafios para os sistemas de saúde. As estratégias com-portamentais e a educação em dor apresentam grande potencial no tratamento de pessoas com dor crônica, especialmente pela modificação de crenças e do comportamento. Os jogos de ta-buleiro podem ser uma estratégia educativa que contribui para a aprendizagem dos conceitos sobre dor e estratégias compor-tamentais. O objetivo deste estudo foi desenvolver um jogo de tabuleiro (ConheceDor) como ferramenta de intervenção para educação em dor. CONTEÚDO: A revisão sistemática para o desenvolvimento do jogo ConheceDor, considerou a estratégia de busca com os descri-tores “chronic pain”, “musculoskeletal pain”, “health education”, “patient education”, “neuroscience education”, “pain education”, “therapeutic neuroscience education”. Os desfechos primários considerados foram a intensidade da dor e a incapacidade. Foram incluídos 15 estudos com um total de 1.486 participantes. Seis estudos apresentaram redução da dor de pelo menos 10% e dois estudos atingiram uma melhora de pelo menos 30% na incapaci-dade. Para o desenvolvimento do jogo foram elaborados o layout do tabuleiro, as regras e os demais componentes (dados, cartas, pinos). As cartas do ConheceDor incluíram os temas mais utili-zados nos estudos identificados que foram: pensamentos negati-vos, neurofisiologia da dor, manuseio do estresse e relaxamento, enfrentamento e exercícios físicos. CONCLUSÃO: A criação de um jogo de tabuleiro considerou uma análise crítica da literatura dos conteúdos das estratégias educativas presentes nos ensaios clínicos. O desenvolvimento dessa intervenção pode ser um recurso para ser aplicado na práti-ca clínica em pessoas com dor musculoesquelética. Descritores: Dor crônica, Educação com base em neurociência, Educação em saúde, Jogos experimentais.

INTRODUCTION

The health conditions that are characterized by the presence of pain can lead to disability and high costs to the individual and

DOI 10.5935/2595-0118.20190030

REVIEW ARTICLE

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society. Chronic musculoskeletal pain, especially cervical and low back pain are among the main health conditions associated with disability1. Nowadays, cognitive-emotional and behavior-al factors, in addition to the physical factors, are considered as contributing to the disability observed in people with chronic pain2-4.Pain may be associated with the presence of emotional changes such as catastrophic thoughts, anxiety, fear, kinesiophobia, mal-adaptive behaviors, and depression5-8. The literature highlights pain education (PE) and behavioral interventions to intervene in this components9,10. Recently, a systematic review evaluated the efficacy of pain neuroscience education in patients with chronic musculoskeletal pain and identified that the intervention con-tributed to the reduction of pain, disability, and catastrophiza-tion11. Behavioral and cognitive interventions help in the decon-struction of negative thinking patterns, beliefs, emotional states, and maladaptive behaviors, with the main objectives of reduc-ing symptom-related distress, improving functionality, assisting in changing adaptive patterns, and teaching techniques for the self-management of pain12.Educational games can contribute to the learning process since they favor the interaction of the participants and the assimilation of concepts in a playful way13,14. Considering that the develop-ment of individuals is related to the learning process acquired through the socio-cultural interaction13, the use of games as a teaching-learning proposal allows the content to be presented and the concepts constructed during the course of the game14. Educational games can be relevant tools used in the PE process to teach and learn the contents as well as for the modification of behaviors through the construction of knowledge. The objective of this study was to develop a board game (Know-ing Pain, in Portuguese ConheceDor) to serve as a tool to pro-mote the knowledge about the pain concepts and the motiva-tional strategies for people with chronic musculoskeletal pain.

CONTENTS

A systematic review of the literature of intervention studies using PE or behavioral strategies was carried out to develop the board game. The protocol defined for this study followed the recom-mendations of the Preferred Reporting Items for Systematic Re-views and Meta-Analyzes (PRISMA). The question of the review was: “what are the contents of education and pain relief inter-ventions used in randomized clinical trials that have promoted benefits for pain and disability outcomes in people with chronic musculoskeletal pain”? These contents, identified exclusively in clinical trials, were used to elaborate the domains of the board game ConheceDor.

Inclusion and exclusion criteria The studies considered were randomized controlled trials that investigated the effects of PE based on neuroscience or behav-ioral, self-management or motivational strategies on pain and disability. The studies should include participants over 18 years of age and with musculoskeletal pain lasting longer than 12 weeks. Interventions could be done in person or at distance

(online, telehealth, among others), individually or in a group. In case there has been an intervention with contact with the health professional and the other group having received the in-tervention at a distance, the in-person intervention was used. The studies should be available for access, and there was no restriction on the language of publication provided that the translation was available. We excluded studies that used as main intervention education based on only biomedical con-cepts, as well as those that provided an orientation of posture or only orientations based on purely biomechanical concepts. The exclusion of this type of study was because these concepts contribute to the increase of catastrophization, anxiety, and fear related to pain11. The control groups could be from usual treatment, waiting list or other educational strategies. Also, PE or behavioral strategies could be associated with other inter-ventions such as exercises, for example. The primary outcomes considered for the study were pain intensity and disability. The secondary outcomes included changes in catastrophizing, ki-nesiophobia, anxiety, depression, improvement perception, patient satisfaction, and return to work. In addition to these criteria, a minimum score of six on the PEDro scale was adopt-ed for methodological quality.

Search strategy for the identification of the studiesA search was performed on the Pubmed, PEDro, Scopus, and Web of Science databases in February 2018. The search strategy utilized the following descriptors: “chronic pain” OR “musculo-skeletal pain” AND “health education” OR “patient education” OR “neuroscience education” OR “pain education” OR “ther-apeutic neuroscience education” (Annex 1). The search terms were adapted for use with other bibliographic databases in com-bination with specific database filters for controlled trials, when available.

Selection of studies and data extractionAfter the search, the results were imported to the EndNote Web. Considering the eligibility criteria, two researchers inde-pendently selected the potentially eligible articles based on the title, abstract and full text. There was no blinding for the journal or authors. The data extraction was performed, and the diver-gences were resolved by consensus. In the absence of consensus, a third evaluator could be convened. The data extracted included the author (year), clinical condition, population, intervention group, the control group, follow-up, outcomes and content of interventions.

Data analysisIn order to identify the contents used in the educational inter-ventions of the clinical trials included in the present study, the data analysis was performed descriptively. The intragroup differ-ence between baseline and post-intervention measures was con-sidered to attest the modification of the interventions on pain and disability outcomes. The follow-up time was grouped in short (up to 3 months), medium (3 to 6 months) and long (over 6 months), and the largest follow-ups were considered for group-ing. The change in outcomes was presented as a percentage. The

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reduction of at least 10% in pain intensity and an improvement of at least 30% in disability was considered a significant change. After identifying the studies that reached these values of change, the contents of the interventions were grouped by similarity and presented by their absolute frequencies. The overall quality of the evidence was evaluated using the PE-Dro scale which has 11 items and a total score of 10 according to the following criteria: eligibility criteria; random allocation; secret allocation; comparability at the baseline; participants; blind therapist surveyors; suitable follow-up; intention-to-treat analysis; comparison between groups; accuracy and variability. The highest score on the PEDro scale indicated better method-ological quality.

Board game developmentAfter the identification of the studies, the development of the ConheceDor board game began. For this stage, two researchers identified the contents of the interventions used in the studies included in the systematic review and then developed the main elements to visually compose the board that included the layout, the number, and content of the houses and cards, the rules and other components (dice and pins). For the development of the charts of the board domains, the content addressed in at least 50% of the studies was selected.

Description of the studiesThe initial search identified a total of 2,907 studies. Of these, 1,945 duplicate studies were excluded. The screening of titles and abstracts identified 44 potential articles and, after a detailed

analysis of the full text of the studies, the final sample for anal-ysis was composed of 15 studies (Figure 1). The main reasons for the exclusion of the articles were: not being a clinical trial, not describing how the educational proposal was performed and presenting a score lower than six on the PEDro scale. The stud-ies that did not meet the inclusion criteria were excluded, that is, access not available (n=3); educational content not described (n=2) or education combined with other intervention (n=1); no evaluation of the outcomes considered for the inclusion (n=1); addressing patients with acute pain or cancer-related pain (n=2); using posture-orientation based content (n=2) and with a PEDro score <6 (n=18).

Characteristics of the articles includedFifteen studies were included, totaling 1,486 people with chron-ic musculoskeletal pain. Five studies with people with chron-ic low back pain15-19, four studies with musculoskeletal pain of different origins20-23, two studies with participants with chron-ic neck pain24,25, one study with patients with chronic fatigue syndrome26, one study with fibromyalgia27, one study with par-ticipants with spinal pain or upper back pain28, one study with patients with chronic knee pain29.Among the interventions, seven studies (46.7%) used neurosci-ence-based PE15,17,18,22,25,26,29, five studies (33.4%) used PE and behavioral strategies20,21,23,24,27, one study (6.7%) used only be-havioral strategies19, one study (6.7%) used general health guide-lines28 and one study (6.7%) associated neuroscience-based PE with hypnosis16. Table 1 presents the characteristics of the studies included in the systematic review.

Figure 1. The selection process of the studies for inclusion in the systematic review

Iden

tifica

tion

Scr

eeni

ngE

ligib

ility

Incl

uded

Records identified by search in the database(n=2907)

Records after the exclusion of duplicates(n=1945)

References selected(n=94)

Full text articles evaluated for eligibility

(n=44)

Articles excluded by title and abstract (n=1851)

Studies included(n=33)

Full text articles excluded (n=11)• Unavailable access (n=03)• Lack of educational content (n=02)• Different outcomes (n=01)• Other type of pain (n=02)• Posture Guidance (n=02)• Combined education (n=1)

Studies included in the qualitative synthesis (n=15)

Full text articles(n=18)

• PEDro < 6 (n=18)

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Table 1. Summary of the studies included (n=15)

Authors Clinical condition Population Intervention group Control group Follow-up Outcomes

Andersen et al.28

Pain in the spine or upper back

n=141 F=78; Age=45.2±0.5 years

Personalized physical activity group = 1.5h of general health gui-delines + aerobic and strength exercises for 50min (n=47). Group of sel-f-management=1.5h of general health guideli-nes + weekly workshop of 2.5h for 6 weeks in groups of 12 to 18 peo-ple (n=47).

Reference treatment group = 1.5h of ge-neral health guideli-nes (n=47).

3 months Intensity of pain with VAS (zero to 100mm);Ability to work (VAS zero to 100mm); TSK.

Bennell etal.29

Chronic knee pain

n=148 F=83; Age=61.1±7.5 years

Three internet interven-tions: educational ma-terial on the exercises + educational material on coping + 7 consul-tations via Skype with a physiotherapist for exercise prescription (n=74).

Two interventions via the internet: edu-cational material on the exercises + edu-cational material on coping (n=74).

3 and 9 mon-ths

Mean pain during gait in the previous week (zero to 10);WOMAC and PSC.

Brage etal.24

Chronic neck pain

n=20 F=20; Age=41.4±12.2 years

4 sessions of 1.5h on education + 8 sessions of 30min with speci-fic exercises (shoulder girdle and shoulder, balance and aerobic training) (n=10).

4 sessions of 1.5h, covering topics on mechanisms, ac-ceptance, coping strategies and defi-nition of pain goals based on the con-cepts of pain mana-gement and cogniti-ve-behavioral thera-py (n=10).

4 and 12 months

Pain (NRS from zero to 10); Neck-related disabi-lity (NDI); Perceived Global Ef-fect (GPE).

Carmody etal.23

Chronic muscu-loskeletal pain (low back and neck pain, with and without radi-culopathy, arth-ritis)

n=101F=3; Age=67.5±9.5 years

Cognitive behavioral therapy by telephone (12 weeks) (n=50)

Telephone edu-cation (12 weeks) (n=51)

2, 5, 8 and 12 months

Health-related qual-ity of life (SF-12v2);BDI; PBCL; CSQR; Intensity of pain (pain journal for two weeks);PSC.

Chiauzzi etal.15

Chronic low back pain

n=199F=134; Age=46.1±11.9 years

Online education for low back pain (painACTION-Back Pain) (pa inACTION-Back Pain) n=104)

Low back pain guide that should be read in 4 weeks (n=105)

1, 3 and 6 months

BPI, ODQ, DASS, PGIC, CPCI, PSC, PSEQ FABQ.

Gallagher, McAuley and Moseley22

Chronic muscu-loskeletal pain

n=79F=48; Age=43.5±11 years

Booklet on pain educa-tion through metaphors (n=40).

Information booklet on pain (n=39).

3 months PBQ, PSC, NRS 0-10, PSFS.

Lefort etal. 20

Chronic muscu-loskeletal pain

n=110F=82Age=39.5 years

Psychoeducation pro-gram (2 hours per week for 6 weeks) (n=57)

Waiting list (n=53) 6 weeks SF-36, PRI, SF-M-PQ, SF-BDI; SOPA--D, VAS=100mm.

Meeus etal.26

Chronic fatigue syndrome

n=48F=40Age=40.3±10.4 years

Neuroscience-based pain education (n=24)

Information on self--management see-king the balance between activity and rest to avoid exacer-bations and esta-blish realistic goals to increase activity (n=24).

Post-t reat-ment

NPT, PCS, TSK, PCI.

Continue...

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Table 1. Summary of the studies included (n=15)

Authors Clinical condition Population Intervention group Control group Follow-up Outcomes

Moseley, Nicholas and Hodges18

Chronic low back pain

n=58F=33Age=43.58 years

Neuroscience-based pain education (n=31)

Education on the anatomy of the spi-ne (n=27)

Post-t reat-ment

RMDQ, SOPA-R, PSC.

Nicholas et al.19

Chronic pain n=141F=96Age=73.9±6.5 years

Self-management of pain (8 sessions of 2h for 4 weeks) + encou-ragement to practi-ce exercises at home (n=49)Self-management of pain (8 sessions of 2h for 4 weeks) (n=53)

Waiting list (n=39) 1, 6 and 12 months

NRS, mRMDQ;DASS-21, TSK, PSEQ, PRSS.

Ris et al.25 Chronic neck pain

n=200F=149Age=45.1 years

Pain education with a focus on the unders-tanding/acceptance of pain and goals set-ting (4 sessions (1.5h each, once a month) + 8 sessions of exer-cises (neck muscles, balance, oculomotor training, shoulder girdle (n = 101)

Pain Education with a focus in the understanding/ac-ceptance of pain and goals setting (4 sessions (1.5h each, once a month) (n=99)

4 months SF-36, NDI, BDI-II, TSK.

Rizzo et al. 16

Chronic low back pain

n=100F=80Age=50±13.5 years

Neuroscience-based pain education (4 sessions; 2 times/week) + hypnosis (2h of self-hypnosis in 2 weeks + book with hypnosis suggestions) (n=50)

Neuroscience-ba-sed pain education (4 sessions; 2 times/week) (n=49)

3 months NRS, RMDQ, PSC, GPE, PSFS.

Ryan et al.17

Chronic low back pain

n=38F=25Age=45.3±10.7 years

Neuroscience-based pain education + 6 sessions of exercises for 8 weeks (10min warm-up, 20-30min aerobic phase, and 10-15min slowdown) (n=20).

Neuroscience-ba-sed pain education(2.5 h reformulation of beliefs and attitu-des regarding pain) (n=18)

3 months NRS, TSK-13, PSEQ.

Thorn etal.21

Chronic muscu-loskeletal pain

n=73F=65Age=52.8±13.1 years

Cognitive-Behavioral Therapy + homework(1.5h, once/week, 10 weeks) (n=49)

Education on pain neurophysiology (1.5h, once/week, 10 weeks) (n=34)

6 months BPI, RMDS, PSC, CES-D, QOLS.

Van Oosterwijck et al.27

Fibromyalgia n=30F=26Age=45.8±10.5 years

N e u r o s c i e n c e - b a -sed pain education (2 sessions; 30 minutes) (n=15)

Self-management (self-management techniques and han-dling of daily acti-vities in relation to their symptoms).(2 sessions, 30 mi-nutes) (n=15)

3 months FIQ), SF-36, PCI, PCS, TSK, PVAQ.

VAS = visual analog scale; PSC = Pain Catastrophizing Scale; WOMAC = Arthritis Self-Efficacy Scale; TSK = Tampa Scale of Kinesiophobia; NDI = Neck Disability Index; GPE = Global Perceived Effect; SF-12v2 = Short Form 12v2 Health Survey; BDI - Beck Depression Inventory; PBCL = Pain Behavior Checklist; CSQR = Coping Strategies Questionnaire Revised; BPI = Brief Pain Inventory; ODQ = Oswestry Disability Questionnaire; DASS = Depression Anxiety Stress Scale; PGIC = Patient Global Impression of Change; CPCI = Chronic Pain Coping Inventory; PSEQ = Pain Self-Efficacy Questionnaire); FABQ = Fear-Avoidance Beliefs Ques-tionnaire; PBQ = Pain Biology Questionnaire; NRS = Numerical Rating Scale; PSFS = Patient-Specific Functional Scale; SF-36 = Medical Outcomes Study Short Form-36; PRI = Pain Rating Index; SF-MPQ = Short Form-McGill Pain Questionnaire; SF-BDI = Short Version - Beck Depression Inventory; SOPA-D = Survey of Pain Attitudes); NPT = Neurophysiology of Pain Test; PCI = Pain Coping Inventory; RMDQ = Roland Morris Disability Questionnaire; SOPA-R = Survey of Pain Attitudes-Revised; mRMDQ = Roland Morris Disability Questionnaire-Modified; DASS-21 = Depression Anxiety Stress Scales; PRSS = Pain Response Self-Sta-tements Scale; BDI-II = Beck Depression Inventory-II; RMDS = Roland-Morris Disability Scale; CES-D = Center for Epidemiological Studies Depression Scale; QOLS = Quality of Life Scale -QOLS; FIQ = Fibromyalgia Impact Questionnaire; SF-36 = Medical Outcomes Short Form 36 Health Status Survey; PVAQ = Pain Vigilance and Awareness Questionnaire.

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Methodological quality of the studies includedThe risk of bias of the articles included in the present systematic review was independently assessed by two reviewers who used the PEDro scale to analyze the methodological quality (Table 2). Change in pain and disabilityRegarding the primary outcomes (pain intensity and disabil-ity), six studies reported pain reduction of at least 10% and two studies achieved at least 30% improvement in disability compared to baseline. The percentages of modification for

pain and disability, considering the follow-up time are pre-sented in table 3.

The content of interventions and domains found in the studiesConsidering the contents covered in the studies of the systematic review it was possible to observe that the most frequent contents included negative thoughts and behavior (n=5)15,19,21,23,29, stress management and relaxation techniques (n=5)15,19,21,23,29, pain neurophysiology (n=4)16,17,19,23, exercises and return to activity (n=4)15,16,19,29 and coping strategies (n=3)15,23,29. Figure 2 shows

Table 3. Percentage of change from baseline on pain and disability outcomes considering the follow-up periods of the studies included

Authors Change from baseline (%)

Short (≤3 months) Medium (3-6 months) Long (>6 months)

Pain Disability Pain Disability Pain Disability

Andersen et al.28 - 6.3 - - - - -

Bennell et al.29 -17.4 15.0 - - -24.1 20.9

Brage et. al24 - - - - 2.0 12.2

Carmody et. al.23 -11.6 - -13.9 - -16.2 -

Chiauzzi et al.15 -7.8 6.7 -9.5 5.1 -14.8 2.5

Lefort et al.20 -16.1 8.7 - - - -

Moseley, Nicholas, Hodges18 - 6.6 - - - -

Nicholas et al.19 -12.3 23.8 -12.5 20.4 -9.5 16.2

Ris et al.25 - 2.2 - - - -

Rizzo et al.16 -29.1 43.2 - - - -

Ryan et al.17 -51.3 60.1 - - - -

Thorn et al.21 - - -20.6 -16.6 - -The figures in bold meet the inclusion criteria of at least 10% pain reduction and 30% improvement in function.

Table 2. Methodological quality of the studies included considering the PEDro scale criteria

Studies Criteria Total

1 2 3 4 5 6 7 8 9 10 11

Andersen et al.28 X V X V X X V V V V V 7

Bennell et al.29 V V V V X X X V V V V 7

Brage et. al24 V V V V X X V X V V V 7

Carmody et. al.23 V V X V X X V X V V V 6

Chiauzzi et al.15 V V X V X X X V V V V 6

Gallagher, McAuley and Moseley22 X V V V X X X V X V V 6

Lefort et al.20 V V V V X X V V V V V 8

Meeus et al.26 V V V V X X V V X V V 7

Moseley, Nicholas and Hodges18 V V X V X X V V X V V 7

Nicholas et al.19 V V X V X X V X V V V 6

Ris et al.25 X V V V X X X X V V V 6

Rizzo et al.16 V V V V X X V V V V V 8

Ryan et al.17 X V V V X X V V X V V 7

Thorn et al.21 V V V V X X X X V V V 6

Van Oosterwijck et al.27 V V X V V X V V V V V 81 = Eligibility Criteria; 2 = Random allocation; 3 = Secret allocation; 4 = Comparability at baseline; 5 = Blinding of participants; 6 = Blinding of therapists; 7 = Blinding of evaluators; 8 = Suitable follow-up; 9 = Analysis by intention-to-treat; 10 = Comparison between groups; 11 = Measurement of accuracy and variability. X = absence; V = presence.

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the frequency of the intervention themes. For the development of the cards of the board domains, the content addressed in at least 50% of the studies were selected.

Development of the ConheceDor gameFor the development of the game ConheceDor game, we con-sidered some examples of board games on the market that have a diversity of models, colors, shapes, and objectives. The game consists of a board, 110 cards, one die and the number of mark-ers (pawns) according to the number of participants. The board layout was rectangular measuring 250mm by 500mm, with 50 houses, consisting of a path signaled by the words “Start” and “End,” shortcuts, symbols and drawings (Figure 3).The visual identity of the game ConheceDor is mainly composed of the colors green, yellow and red to attract the eyes to the board. The character present in the identity represents a young man with pain positioned on the spot that the game begins. Along the way, there are several aspects related to pain such as sleep, negative thoughts, drug use, and exercises until the end of the course where the character is illustrating his recovery. The presence of these graphic elements suggests that the theme of the game exemplifies a person with pain until the recovery.The number of game houses available on the market that were evaluated during the ConheceDor game development goes from 40 to 60. Therefore, the 50 houses for the ConheceDor game were divided into colors (blue, orange, green, red and black), houses “choose your way” and “X” houses. The colors of the houses that represent the game domains were defined by consensus among the developers: negative thoughts (kinesiophobia and catastro-phization) (orange), pain neurophysiology (green), stress man-

agement (black) relaxation/coping (blue) and physical exercises/activities (red). The game cards were divided into domain cards according to the colors of the board houses and “X” cards. For the house “choose your way,” the player can choose any of the cards of the five domains to respond. The game cards assess the pain knowledge based on “true or false” answers where the player will judge whether a particular statement is beneficial or harmful to a person with pain. The statements used in the game cards were developed based on the scales and questionnaires used to assess patients with pain such as the Tampa Scale of kinesiopho-bia (TSK), Pain Catastrophizing Scale, Self-efficacy Scale, the Neurophysiological Pain Questionnaire and Attitudes to Pain. When the scales used questions, they have been converted into statements. In house X the player is punished that can be to stay one round without playing or to return some houses ac-cording to the result obtained when throwing the dice. All cards are rectangular with a dimension of 90mm x 60mm, printed on millboard, totaling 110 cards being 20 cards per domain and 10 X cards (Figure 3). In the beginning, players (maximum of 4) are invited to set the order of the match by throwing the dice. The participant who obtains the highest number will be the first to start the match, followed by the participant with the second highest result, and so on. When moving his marker, the player must follow the com-mand according to the house of the board that can be one of the domain cards, “choose your way” and house “X.” The other play-er will read the card and indicate the correct answer after the first player has answered. If the player’s answer is correct, he will have the right to throw the dice once more. If the answer is wrong, he will switch to the other player. It is only allowed to throw the

Figure 2. Absolute frequency of the themes in the interventions considering the studies included in the systematic review

Dealing with recurrence/maintenance

Improving communication

Alternative treatments

Goals setting

Diet

Negative thoughts/behaviors

Coping

Exercises and return to activities

Stress management/relaxation

Sleep hygiene

Pain neurophysiology

Number of studies

0 1 2 3 4 5 6

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dice twice, even if the player’s answer is correct. In the “choose your way” house, the player can choose the card he wants to an-swer, and if the answer is correct, he will have the right to follow the “shortcut,” shortening his path. The winner will be the one who arrives first at the “FIM” (End) house.

DISCUSSION

The systematic review of the clinical trials conducted in the present study identified the contents used in PE interventions based on neuroscience and behavioral strategies that contrib-uted to the improvement of pain and disability in people with musculoskeletal pain. In the analysis of the 15 studies that met the inclusion criteria, it was observed that the main con-tents included the handling of negative thoughts and behav-ior, pain neurophysiology, stress management and relaxation techniques, coping strategies, exercises and return to activities. A study carried out in Salvador developed a PE booklet ad-dressing the following topics: pain definition, pain classifica-tion (acute and chronic), living with pain, myths about pain, strategies for dealing with pain30.

The reduction of pain and disability was assessed in the short term (up to three months) by most studies, three studies evalu-ated in the medium term (three to six months) and five studies in the long term (longer than six months). The reduction in pain intensity ranged from 6.7 to 51.3% and the improvement in dis-ability from 2.2 to 60%. It is possible that this difference among the studies was due to the characteristics of the population (for example, the health condition addressed), the content of the in-tervention and the form of administration. The present study did not seek to investigate the effectiveness of the neuroscience-based PE since other studies have already presented these results11,31,32. In the meta-analysis conducted by Geneen et al.32, which included different types of educational interventions, the authors did not identify the effect of educa-tion on pain intensity relative to the comparison group imme-diately after and within three months of follow-up. However, for disability, when using neuroscience-based PE, there was evi-dence of significant improvement immediately after. This effect was not observed in the other types of education investigated in the studies. Other findings in the review by Geneen et al.32

included significant improvement in catastrophizing and pain

Figure 3. Components of the ConheceDor game (board, cards, dice, and pins)

KINESIOPHOBIA

A person with

pain should be

afraid of doing

exercises.

FALSE

ANXIETY

TRUE

A person that

feels sad all

the time can

increase his/

her pain.

Conhece

DorCHOOSE

YOUR WAY

NEGATIVE THOUGHTS

CHOOSE YOUR WAY

CHOOSE YOUR WAY

START

END

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awareness only in the studies that used neuroscience-based PE. The systematic review by Louw et al.11 showed that neurosci-ence-based PE improved the knowledge about pain, disabili-ty, catastrophizing, pain-related fear, attitudes and behaviors related to pain, return to activities, and decreased the use of Health Services. However, the heterogeneity of the studies was not considered, and the meta-analysis was not performed. Re-cently, in a systematic review with meta-analysis, it was identi-fied the evidence of moderate quality that the addition of PE to physiotherapy promoted short-term improvement in pain and also moderate evidence for the improvement of disability when PE was conducted isolated or combined with physiotherapy. For the kinesiophobia and catastrophizing outcomes, the au-thors found no statistical or clinical difference31.The objective of the elaboration of the board game was to de-velop an educational tool with an interactive interface, facili-tating the understanding of theoretical contents about pain and behavioral strategies. Games are considered an active and useful tool in the teaching-learning process of patients. This is only possible because the playfulness allows the acquisition of the concepts attractively and pleasantly. Another characteristic of games is the horizontal relationship between the educator and the learner since games stimulate the interaction among partic-ipants, as well as motivating and supporting learning33. How-ever, it should be noted that it is still necessary to validate the game with the target audience. During the validation process, it is essential to introduce the game to the target audience so they can evaluate the layout of the game that includes the shape of the board, the colors of the houses, the cards (both their format and the clarity of the information) and the playability that relates to how enjoyable the game is, the time it takes to play and the clarity of the rules. In this way, it is possible that the game needs some modifications after being submitted to this validation process. Although the development and use of board games in the health area are not very frequent, the few that exist have shown positive results about the learning and education of patients33. There are some examples of games in the literature, such as a board game aimed at promoting active and healthy aging. This game acted like a playful pedagogical resource in nursing care, contributing to the construction of knowledge in the elderly health area34. Fernandes et al.35 described the development of a board game called “Family Nursing Game” aimed at nurses. The participants emphasized the preference for the game, due to the source of interaction and reflection it allows among the participants and for having motivated family care. Pires and Guilhem36, developed a board game titled “(IN) DICA-SUS” and realized that the learning sought by the paths of the game for health professionals contemplates the plural aspects of hu-man formation, such as group interaction, active participation, the capacity for self-reflection, the motivation for the study and the willingness to achievement. It is possible that the intervention strategies using board games have the potential to improve the knowledge about the theo-retical content and to facilitate the acquisition or modification of behaviors. During the game, the relationship established be-

tween the game and the knowledge is comprehensive due to the numerous cognitive and social phenomena that the game allows the player to experience such as problem-solving, language learn-ing, role-playing, among others37.Although some PE interventions have already been developed for Brazil30,38, it is believed that this is the first board game based on a systematic review and critical analysis of the studies on the subject. Also, the characterization of these interventions allowed the development of a board game with previously used content that has demonstrated its effects, especially for pain and disabil-ity in people with musculoskeletal pain, based on studies with good methodological quality (PEDro≥6). Thus, this study can contribute by filling a gap in the literature that is the develop-ment of educational strategies easy to apply to people with pain. However, this study is not free of limitations either. The biggest was not having conducted the content validation process by a panel of experts and a sample of the target audience. This is a step that should occur after the development of the game, and then the effectiveness of the intervention should be compared to other forms of educational strategies. Therefore, new studies are necessary to evaluate the acceptability, usability, and applicability of the board game by patients and health professionals. These subsequent studies can significantly contribute to fix any issues and to enhance to the board game. CONCLUSION

The systematic review followed by the evaluation of the content of the educational interventions allowed to identify the main themes used in clinical trials. This process contributed to the development of a board game for PE that may be a tool to be applied in the clinical practice to treat people with musculoskel-etal pain.

Annex 1. Search strategy

#1 MeSH descriptor: [Chronic Pain] explode all trees

#2 MeSH descriptor: [Pain] explode all trees

#3 Widespread Chronic Pain

#4 MeSH descriptor: [Patient Education as Topic] explode all trees

#5 Patient Education or Education of Patients

#6 Education or neuroscience or neurobiology or neurophysiology or pain education or pain science or modern pain education or the-rapeutic neuroscience education

#7 MeSH descriptor: [Behavior Therapy] explode all trees

#8 Randomised controlled trial or clinical trial as a topic or randomi-sed or placebo or randomly or trial

#9 #1 or #2 or #3

#10 #4 or #5 or #6 or #7

#11 #8 and #9 and #10

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29. Bennell KL, Nelligan R, Dobson F, Rini C, Keefe F, Kasza J, et al. Effectiveness of an internet-delivered exercise and pain-coping skills training intervention for persons with chronic knee pain: A randomized trial. Ann Intern Med. 2017;166(7):453-62.

30. Mendez SP, Sá KN, Araújo PC, Oliveira IA, Gosling AP, Baptista AF. Elaboration of a booklet for individuals with chronic pain. Rev Dor. 2017;18(3):199-211.

31. Wood L, Hendrick PA. A systematic review and meta‐analysis of pain neuroscience education for chronic low back pain: short‐and long‐term outcomes of pain and disa-bility. Eur J Pain. 2018; [Epub ahead of print]

32. Geneen LJ, Martin DJ, Adams N, Clarke C, Dunbar M, Jones D, et al. Effects of education to facilitate knowledge about chronic pain for adults: a systematic review with meta-analysis. Syst Rev. 2015;4:132.

33. Beinner MA, Morais EA, Reis IA, Reis EA, Oliveira SR. O uso de jogo de tabu-leiro na educação em saúde sobre dengue em escola pública. J Nurs UFPE online. 2015;9(4):7304-13.

34. Olympio PC, Alvim NA. Board games: gerotechnology in nursing care practice. Rev Bras Enferm. 2018;71(Suppl 2):818-26. English, Portuguese.

35. Fernandes CS, Martins MM, Gomes BP, Gomes JA, Gonçalves LH. Family nu-rsing game: desenvolvendo um jogo de tabuleiro sobre família. Esc Anna Nery. 2016;20(1):33-7.

36. Pires MR, Guilhem D. Jogo (IN) DICA-SUS: estratégia lúdica na aprendizagem sobre o Sistema Único de Saúde. Texto Context Enferm. 2013;22(2):379-88.

37. Aizencang N. Jugar, aprender y enseñar. Relac que potencian los aprendizajes. 2005; 38. Reis FJ, Bengaly AG, Valentim JC, Santos LC, Martins EF, O’Keeffe M, et al. An

E-Pain intervention to spread modern pain education in Brazil. Braz J Phys Ther. 2017;21(5):305-6. 

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ABSTRACT

BACKGROUND AND OBJECTIVES: Pregnancy causes phys-iological and anatomical changes in the woman’s body, affecting several systems such as the musculoskeletal. During pregnancy or in the postpartum period, these changes may cause low back pain or low pelvic pain, preventing the normal movement of these structures and causing suffering. The objective of this study was to discuss the diagnosis and treatment of pregnancy-related lumbosacral pain, focusing on terminology, epidemiology, risk factors, pathophysiology, prognosis, diagnosis, and treatment. CONTENTS: We searched the literature in Pubmed, Cochrane Library, Ovid and Google using the terms “low back pain”, “pel-vic girdle pain”, “lumbopelvic pain”, “posterior pelvic pain”, “pregnancy-related low back pain”, “pregnancy-related pelvic gir-dle pain” and “pregnancy-related lumbopelvic pain”, for articles in English, Portuguese and Spanish in the last 20 years or older, where relevant. CONCLUSION: Pregnancy is one of the main causes of lumbo-sacral pain, and one of the most frequent diseases during gesta-tion. The correct management of this pathology reduces negative impacts on the life of pregnant women.Keywords: Low back pain, Pelvic pain, Pregnancy.

RESUMO

JUSTIFICATIVA E OBJETIVOS: A gestação causa alterações fisiológicas e anatômicas no corpo da mulher, podendo afetar di-versos sistemas como o musculoesquelético. Durante a gestação ou no período pós-parto, essas alterações podem causar dor lombar ou dor pélvica baixa, impedindo a movimentação normal dessas estruturas e causando sofrimento. O objetivo deste estudo foi dis-cutir o diagnóstico e o tratamento da dor lombossacral relacionada à gestação, com foco na terminologia, epidemiologia, fatores de risco, fisiopatologia, prognóstico, diagnóstico e tratamento.

Pregnancy-related lumbosacral pain Dor lombossacral relacionada à gestação

Fábio Farias de Aragão1

Fábio Farias de Aragão - https://orcid.org/0000-0002-8528-254X.

1. Maternidade Natus Lumine, Departamento de Anestesiologia, São Luís, MA, Brasil.

Submitted on February 10, 2018.Accepted for publication on October 09, 2018.Conflict of interests: none – Sponsoring sources: none.

Correspondence to: Av. Grande Oriente, 23 – Renascença65075-180 São Luís, MA, Brasil.E-mail: fabio.aragao30@hotmail.com

© Sociedade Brasileira para o Estudo da Dor

CONTEÚDO: Foi realizada busca na literatura no Pubmed, Co-chrane Library, Ovid e Google, utilizando-se os termos “low back pain”, “pelvic girdle pain”, “lumbopelvic pain”, “posterior pelvic pain”, “pregnancy-related low back pain”, “pregnancy-related pelvic girdle pain” e “pregnancy-related lumbopelvic pain”, por artigos em inglês, português e espanhol nos últimos 20 anos, ou mais antigos, quando relevantes. CONCLUSÃO: A gestação é uma das principais causas de dor lombossacral e esta é uma das doenças mais frequentes durante a gestação. O correto manuseio desta doença reduz os impactos negativos na vida da gestante. Descritores: Dor pélvica, Gestação, Lombalgia.

INTRODUCTION

Pregnancy causes physiological and anatomical changes in the woman’s body and can affect several systems (such as cardiovas-cular, respiratory, endocrine, renal, among others), as well as the musculoskeletal system. These changes are necessary to meet the increased metabolic demand of the mother during pregnancy, the fetal needs and allow the pregnant woman and the fetus to prepare for the birth1. On the other hand, in many women, during pregnancy or in the postpartum period, changes in the musculoskeletal system will cause lower back or pelvic pain, pre-venting the normal movement of these structures and causing suffering. Pregnancy is one of the main causes of lumbosacral pain, being one of the most frequent diseases during pregnancy and it has gained importance in recent years due to the impact it has on the pregnant woman’s life and the costs involved2.Absenteeism is directly related to the intensity of pain and the de-gree of disability. Absenteeism doubles in pregnant women with pelvic pain (PP) or low back pain (LBP) when compared with other women3. Pregnant women with LBP and PP face difficul-ties in daily activities, such as getting up, sitting for prolonged periods, walking longer distances, dressing, carrying weights and even sexual difficulties. In more severe cases, crutches or wheel-chairs may be required4,5.The objective of this study was to discuss the diagnosis and treat-ment of pregnancy-related lumbosacral pain (PRLSP), focusing on terminology, epidemiology, risk factors, pathophysiology, prognosis, diagnosis, and treatment.

CONTENTS

Pubmed, Cochrane Library, Ovid and Google were searched, using the terms “low back pain”, “pelvic girdle pain”, “lum-bopelvic pain”, “posterior pelvic pain”, “pregnancy-related low back pain”, “pregnancy-related pelvic girdle pain” and “preg-

DOI 10.5935/2595-0118.20190031

REVIEW ARTICLE

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nancy-related lumbopelvic pain”, for articles in English, Portu-guese and Spanish in the last 20 years or more, when relevant. The most relevant articles on the topic were selected and in-cluded in the study.

PATHOPHYSIOLOGY

The PRLSP etiology is not well-defined. Weight gain during pregnancy, associated with changes in posture required to ac-commodate the increased abdominal and breast volume lead to a change in the load pattern on the joints and other mus-culoskeletal structures, leading to pain6. From the biomechan-ical point of view, the increase of the uterine volume leads to stretching and weakening of the abdominal muscles, generat-ing an increase of tension on the lumbar muscles. Also, the in-creased volume of the breast and the abdomen shifts the center of gravity forwards, causing changes in the posture with pelvic anteversion and increased lumbar lordosis, leading to increased load on the lumbar spine and sacroiliac ligaments. The in-creased axial load compresses the intervertebral discs, expelling the fluids from the disc and decreasing their height, which may contribute to LBP7. From the endocrine point of view, there is a ligament laxity related to the increased levels of progester-one, estrogen, and relaxin, making the hip and spine joints less stable8. From the vascular point of view, the compression of the large abdominal vessels by the gravid uterus causes venous stasis and hypoxemia, compromising the metabolic activity of the nerve structures, causing pain9. TERMINOLOGY

Many papers use different terminologies, making it uncertain that the terms refer to the same condition. Madeira et al.10 used the terms pelvic pain, posterior low back pain, and combined pain. Wu et al.11 introduced the term “pregnancy-related”, tak-ing into account that the symptoms may begin after birth and proposed the use of the terms “pregnancy-related pelvic girdle pain”, “pregnancy-related low back pain” and “pregnancy-relat-ed lumbopelvic pain”. This study adopted the terms proposed by Wu et al.11.

EPIDEMIOLOGY

The incidence of PRLSP varies greatly, affecting between 24 and 90% of pregnant women. There is a large variation in the incidence due to the lack of a universally accepted classification system12. In some studies, this prevalence may reach 95.23% of pregnant women13. According to Cochrane review, more than two-thirds of the pregnant women have LBP, and approximate-ly one-fifth have PP12. It usually starts around the 18th gesta-tional week, with a peak between the 24th and 36th weeks11. Be-tween the 12th and the18th gestational weeks, the prevalence of PRLSP is around 62%, and 33% of the pregnant women had PP, 11% had LBP, and 18% had both. At the end of gestation, around the 35thweek, the incidence of LBP may reach 71.3% and PP 64.7%14.

RISK FACTORS

Among the predictive factors of lumbosacral pain, we can men-tion strenuous work during pregnancy and history of PRLSP11. The incidence of LBP is higher in pregnant women with ad-vanced maternal age, history of LBP in previous pregnancies, elevated body mass index (BMI), joint hypermobility, pain wors-ening when lying down for prolonged periods and higher levels of anxiety14,15. The history of LBP in previous pregnancies is a strong predictor for recurrence in subsequent pregnancies, with a probability around 85%16. In relation to PP, strenuous work, his-tory of low back pain, or trauma on the pelvic bones, advanced pregnancy stages, higher BMI and higher depression scores are important predictors14,17.There is a relationship between pain intensity, catastrophizing levels of pain, depression, and anxiety. Anxiety during pregnan-cy is related to complications including abortion, pre-eclamp-sia, prematurity, and low birth weight. Depression and anxiety are important predictors of postpartum depression18. Pregnant women with PRLSP have a three times greater chance of present-ing symptoms of postpartum depression than pregnant women without pain19. CLINICAL PRESENTATIONS

PRLSP may manifest as PP, LBP, or with the association of the two. Both are more intense with the advance of pregnancy and, in some cases, pain may radiate to the gluteal region, thigh, leg, and foot11,12. It is essential to differentiate between LBP and PP since they have different etiologies and require specific treatment strategies20.Pregnancy-related pelvic pain (PRPP) is located between the posterior iliac crest and the gluteal fold, particularly close to the sacroiliac joints, and can radiate to the posterior aspect of the thigh. Pain in the pubic symphysis may occur in associa-tion or alone, with possible irradiation to the anterior aspect of the thigh21. The pain is intermittent and may be precipitated by prolonged postures, usually occurring during daily tasks such as walking, sitting or standing20. The first manifestation of pain occurs during pregnancy, with painful palpation of the gluteal musculature and the topography of the sacroiliac joints, and pos-itive PP provocation tests22.The posterior PP is defined as low without the component of the pubic symphysis. It is characterized by a stinging pain in the gluteal region, distal and lateral to the L5 to S1 area, and may or may not radiate to the posterior aspect of the thigh and knee. It is intermittent, usually associated with weight lifting, the range of movement of the spine and hips within the normal range, in addition to positive posterior PP provocation test23.The pregnancy-related low back pain (PRLBP) occurs between the upper region of the spinal process of the last thoracic verte-bra, inferiorly by the sacrum and laterally by the lateral borders of the erector muscle of the spine and can irradiate to the leg21. The pain is usually exacerbated by anterior flexion, causes move-ment restriction in the lumbar region, and is exacerbated by the palpation of the erector spinae muscles20. The first manifestation

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may occur before pregnancy. The lumbar range of motion de-creases, usually there is no relation to ambulation or to perform daily tasks such as sitting or standing, and the PP provocation tests are negative22. While PRPP is more intense and disabling during pregnancy, PRLBP appears to be more intense and more common after birth24. DIAGNOSIS

In pregnant women with PRLSP, a good patient’s history and physical examination are necessary to exclude other causes of pain, to differentiate between LBP and low PP, the level of dis-ability and propose an individualized treatment. The warning signs may be a history of traumas, weight loss, cancer, use of steroids and other states of immunosuppression, neurological symptoms, fever, among others. These red flags may indicate the presence of hidden causes such as inflammatory, infectious, trau-matic, neoplastic, degenerative or metabolic causes25.The diagnosis of PRLSP is based on the symptoms, as there are few available tests. However, it is important to differentiate be-tween PRLBP and PRPP, since the management and prognosis of the two conditions are different. The location of the pain, its characteristics, and intensity, triggering factors and provocation tests are useful20.In relation to PRPP, in addition to the clinical presentation de-scribed, the European Guidelines recommend performing a func-tional test (straight leg elevation), four tests for the sacroiliac (pos-terior provocation of PP, Patrick-Fabere, Gaenslen and palpation of the long dorsal sacroiliac ligament) and two tests for pubic sym-physis (palpation of the pubic symphysis and modified Trende-lenburg pelvic girdle test)21. The diagnosis of PRPP is considered positive with a positive functional test plus one of the tests for sac-roiliac, or one of the positive pubic symphysis tests26. PRPP can be categorized into five subgroups: 1) Pelvic girdle syndrome, when the pain is present in the three pelvic joints; 2) bilateral sacroiliac syndrome, when the pain is referred in both sacroiliac joints; 3) Unilateral sacroiliac syndrome, with pain present in one sacroiliac joint; 4) Simphysiolysis, when only the pubic symphysis presents pain; and 5) Miscellanea group, when there is pain in one or more pelvic joints, but with inconsistent conclusions. This classification is important because the number of joints involved seems to inter-fere in both pain intensity and function27.Several questionnaires have been applied in pregnant women with PRLSP in order to evaluate the functionality and direct the most appropriate treatment for each case. The resulting disability from the pain is generally measured using the Quebec Back Pain Disability Scale. Although this scale has been developed to assess the degree of disability in patients with not-pregnancy related low back pain, it has been adapted for this use16. Other evalu-ation methods are also used to evaluate the degree of disability and functionality of pregnant women (Roland-Morris, Oswestry, Disability Rating Index (DRI) and others), without being devel-oped for this purpose. For example, the DRI used by Olsson and Nilsson-Wikmar28, which evaluates, in one of its 12 items, the ability of the pregnant woman to run, may not reflect the reality of most pregnant women, especially in the third quarter.

The Pregnancy Mobility Index (PMI) was developed specifically for pregnant women with PRLSP, accessing their ability to per-form daily activities. It is possible to evaluate the mobility and quality of life of the pregnant woman29.The Pelvic Girdle Questionnaire (PGQ) is a specific instrument to measure the PP during pregnancy and postpartum30. The Bra-zilian version of the questionnaire was validated in 2014 and helps to evaluate and monitor the impact that PRPP can have on the functionality of pregnant women, considering all the social and cultural context in which they are inserted, as well as help-ing to find more appropriate ways to plan a specific treatment for this condition31. Thus, the development of specific question-naires for PRLSP and its subtypes may facilitate the diagnosis and help with the appropriate treatment.Although the diagnosis of PRLSP is basically clinical, the use of imaging exams may be necessary, especially when warning signs are present. Preferably, one should opt for those with non-ioniz-ing radiation, such as ultrasonography and magnetic resonance imaging (MRI). Despite the fear that MRI could induce tera-togenicity, acoustic lesion and heating effects in the fetus, no changes were observed when 1.5T devices were used. The safety of the 3T devices is not established yet32. In 2013, the American College of Radiology recommended MRI to be used in pregnant women, independently of the gestational age when the benefits are greater than the risk33.Regarding the exams that use ionizing radiation, doses lower than 50mGy, when administered in gestations above two weeks, they seem to be very low to be clinically detected. Doses be-tween 50 and 100mGy, when administered between 2 and 25 weeks, can be teratogenic but do not show a teratogenic effect in pregnancies above 25 weeks. Doses above 100mGy have the potential for fetus injury, especially in pregnant women who may undergo further exams, leading some authors to discuss the in-dication to abort34. PROGNOSIS

Inadequate follow-up and management of pregnant women with PRLBP and PRPP may lead to chronic pain. Persistent PRLSP, both recurrent and continuous, is directly related to the symp-toms during pregnancy. While most of the pregnant women show improvement in the first six months after delivery, some women will experience the symptoms for a prolonged time16. After delivery, there is a higher demand for activities that increase the intensity of LBP, such as lifting and carrying weight. It is dif-ficult to avoid these activities due to the necessary care required by the newborn35.A study that evaluated 464 pregnant women with PRLSP during pregnancy showed that 43.1% had pain six months after delivery, 36.2% had recurrent pain, while 6.9% had continuous pain36.Pregnant women with more pronounced symptoms (continuous pain) are more likely to be away from work and to use health services than women with less pronounced symptoms (recurrent pain). Pregnant women with more pronounced symptoms may fall in a specific subgroup of pregnant women with persistent PRPP where the prognosis is less favorable37.

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Pregnant women with PRPP can have serious consequences sev-eral years after pregnancy. One in 10 can have pain up to 11 years postpartum, especially those with a history of PRLSP in previous pregnancies, higher number of positive tests for pain provocation and pressure tests on the pubic symphysis, positive Trendelenburg or Faber38. The pregnant woman should be evalu-ated during pregnancy and in the postpartum period and treated appropriately to avoid suffering, costs increase and to reduce the chance of a transition to chronicity. Subgroups of pregnant women with PRLSP should be identi-fied and directed to specific treatments. Pregnant women clas-sified as having combined pain (LBP and PP), especially at the beginning of pregnancy, should receive special attention since they have a higher intensity of symptoms and a greater chance of chronification39. TREATMENT

The treatment of PRLSP is a difficult task because of the myth that it is a normal condition in pregnancy and the fear that the treatment will cause changes in the pregnant woman and the fetus. One of the treatment strategies is based on prevention. When seeking effective pain management, conservative mea-sures are more often used for obvious reasons, although these treatments typically do not show high success rates. Treatment options include physiotherapy, transcutaneous electrical nerve stimulation, pharmacological treatment, acupuncture, the use of pelvic belts, among others.

EXERCISES

Exercise-based treatment is the most common component in PRLSP management. Stabilization exercises are the most commonly used techniques, followed by pelvic floor exercises, strengthening exercises and repeated directional exercises40.In a Cochrane review of 2015 that evaluated the effects of any in-tervention to prevent or treat LBP, PP or the association of both in women at any stage of pregnancy, soil exercises in their various formats reduced the pain scores and the functional impairment in pregnant women with LBP, with an additional improvement when information on pain management is provided to the preg-nant woman. Hydrotherapy seems to reduce the incidence of ab-senteeism in pregnant women with LBP. Regarding PP, physical activity does not seem to improve the prognosis when compared to usual prenatal care. Moreover, acupuncture appears to be su-perior to stabilization exercises to reduce PP. Although LBP and PP are distinct diseases and cannot be directly compared, the exercises, when compared to usual prenatal care, do not seem to improve the prognosis of PP. These observations suggest that the stabilization of the anatomical source of the symptoms is para-mount for the proper management of the pain12. PHYSICAL MEASURES

The use of simple devices, such as a nest-shaped pillow, may be helpful to reduce pain and insomnia in later stages of pregnancy.

The pillow supports the abdomen when the pregnant woman adopts the lateral decubitus position, and it seems to lessen the symptoms41. Another device is the pelvic belt, which acts by pressing the joint surfaces promoting stability and reducing the mobility of the sacroiliac joint, with a reduction in pain. The use of non-rigid pelvic belts significantly reduces the pain scores and functional impairment compared to stabilization exercises. They should be used only for a short time12.

ACUPUNCTURE

The use of acupuncture for the treatment of PRLSP is increasing over the years, and several studies have shown its analgesic po-tential in pregnant women with PRLSP when compared to con-trol42,43. Acupuncture seems to relieve LBP and pelvic girdle pain during pregnancy. In addition, it increases the ability to perform some physical activities and helps decrease the need for drugs, which is a good advantage in that period20. Acupuncture seems to stimulate the endogenous opioids system12. When used as an adjuvant, acupuncture provides greater pain reduction than the standard treatment alone, improving daily activities in pregnant women with PRLSP44,45. Although it is considered a safe tech-nique, acupuncture should be performed by experienced people, since some points that supply the uterus and cervix should be avoided, as they may induce labor24. PHARMACOLOGICAL TREATMENT

Paracetamol is the first-line analgesic in the treatment of pain during the pregnancy. It is a non-opioid analgesic and, al-though the mechanism of action is not yet completely known, it can inhibit the synthesis of central prostaglandin and mod-ulate the serotonergic descending inhibitory pathways. At the recommended doses, the use of paracetamol during pregnan-cy is safe46. Nonsteroidal anti-inflammatory drugs (NSAIDs) are usually second-line analgesics. Due to the risk of early fetal loss, oligohydramnios, fetus renal injury, and premature closing of the arterial duct, NSAIDs during pregnancy must be used with caution47. Antidepressants, anticonvulsants, lo-cal anesthetics and clonidine can be a good alternative during pregnancy. Amitriptyline, due to the time of use and a large number of published studies, seems to be a good option for the treatment of neuropathic pain during pregnancy since it was not associated with an increased incidence of malforma-tions48. Venlafaxine also appears to be unrelated to increased malformations49. However, the use of high doses of antide-pressants during pregnancy, or their use near the term, can lead to neonatal withdrawal syndrome. Sodium valproate has a possible teratogenic effect, alteration of the neurolog-ical development50. Some countries have already banned its use in pregnant women and women of childbearing poten-tial with bipolar disorders51. There are only a few reports of pregnant women using gabapentin, and there is no evidence of an increase in the incidence of malformations52. It may be related to an increased risk of fetal loss, restricted intrauterine

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growth, and preterm birth53. It has a C classification by the Food and Drug Administration (FDA) and B3 by the Austra-lian Drug Evaluation Committee (ADEC).Regarding pregabalin, it does not appear to be associated with a significant increase in malformations when used in the first quar-ter, mainly as a monotherapy54. Cyclobenzaprine is considered safe during pregnancy and is one of the most commonly used analgesics for the treatment of PRLSP. Despite a report of early closure of the arterial duct, it is widely used in pregnant wom-en55. It has a B classification from the FDA. During lactation, about 50% of the drug passes to the breast milk. Most opioids are considered class B or C during pregnancy by the FDA, being considered D mainly in the third quarter due to the risk of neo-natal withdrawal syndrome. However, it is prudent to evaluate each drug individually. Codeine is not related to the increased incidence of malformations and fetal survival rate, and it is classi-fied as A by ADEC56. Tramadol seems to be related to an increase in the incidence of malformations (clubfoot and cardiovascular defects) when used near conception, not causing significant ef-fects when used in later stages of pregnancy57,58. It is considered Class C by the FDA and ADEC. There are no reports of malfor-mations related to morphine when used in the first quarter, but it should be used with caution. Newborns exposed to opioids with shorter half-lives, such as morphine, are more likely to have neonatal withdrawal syndrome59,60. It is Class B by the FDA and C by ADEC. Transdermal fentanyl seems to be a good option for the treatment of chronic pain during pregnancy and lactation. Although it may cause neonatal withdrawal syndrome when used at high doses or close to term, it does not appear to pass to the breast milk61. Most opioid treatments during pregnancy are of short duration, but women who use opioids chronically before pregnancy keep on their use, often until the term. While long-term treatment with opioids in pregnancy is not recommended, it may be necessary in the case of chronic pain or treatment of dependence. Methadone and buprenorphine may be used to pre-vent withdrawal syndrome62.

NON-SURGICAL TREATMENTS

The use of steroids in the epidural space during pregnancy is con-troversial, although one dose is of low risk for the fetus. Its use is indicated in pregnant women with new symptoms, consistent with compression of the lumbar nerves (for example, unilateral loss of deep reflex, motor and sensitive alterations in the distri-bution of one dermatome)63. There are case reports describing the peridural administration of steroids in pregnant women with sciatica and signs of radicular pain with the improvement of the feeling of pain, but some evolved for the surgical treatment due to recurrence or progression of the neurological symptoms. In patients with PRLSP, the peridural analgesia seems to have a good result, given either as a single dose or for a short time interval in the periods of increased pain. However, whatever is the case, it should be considered as a temporary method of pain relief until birth17. The administration of steroids and local anes-thetics on the pubic symphysis and sacroiliac joints has also been reported with good analgesic response64.

SURGICAL TREATMENT

The role of surgery for the treatment of PRLSP during pregnan-cy is limited. When indicated, it is required good coordination between the surgeon and the obstetrician. The prone position may be used in the first quarter, but in the second, the lateral decubitus for either side may be used. In the third quarter, the left lateral decubitus should be used due to the compression of the vena cava by the gravid uterus, but as of the 34th week, the pregnancy interruption should be discussed. As of the 23rd week, the fetal heart rate should be monitored64.There are reports in the literature of surgical interventions during pregnancy for the treatment of disc herniations causing neuro-logical deficits (sensory, motor, bladder and/or intestinal alter-ations), including discectomy, microdiscectomy, laminectomy, and endoscopic surgery. Surgery, when well indicated, has a good success rate and a return of the function, with no increase in morbidity or mortality63.

CONCLUSION

PRLSP is a common pathological condition that can occur in most pregnant women. Despite this, there are still questions about the diagnosis and proper management of this condition. On the other hand, the localization of the pain is common to other conditions, being important the search for warning signs as pain irradiating to the leg, neurological deficits (paresthesia and/or weakness), alterations in intestinal and bladder functions, fever, amongst others. Although the clinical diagnosis is more common and adequate, in some cases, it is necessary to perform imaging tests, preferably the techniques that do not use non-ionizing radia-tion (ultrasound and MRI). The treatment of PRLSP is a difficult task because it is considered a normal condition during pregnancy and there is the fear that the treatment may cause changes in the pregnant woman and the fetus. One of the treatment strategies is based on prevention. When seeking effective pain management, conservative measures are more often used for obvious reasons, although these treatments typically do not show high success rates. The most commonly used drugs are paracetamol and NSAIDs. For more intense pain, opioids can be used, but they should not be administered for prolonged periods or close to the term. The use of epidural or joint blockades is being reported with good re-sults. The surgical treatment is restricted to more severe cases but, when well indicated, it has a good success rate and the return of function, with no increase in morbidity or mortality. Thus, it is very important that health professionals know that there are safe strategies for the management of PRLSP that reduces the suffering and brings comfort to the pregnant woman.

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ABSTRACT

BACKGROUND AND OBJECTIVES: The primary protocol for the control of temporomandibular disorders prioritizes re-versible and less invasive measures. However, conservative treat-ment is sometimes ineffective. Therefore, the use of hyaluronic acid has been suggested as a therapeutic alternative to verify the effectiveness of the hyaluronic acid in patients who are not re-sponsive to the most conservative treatments, helping them in the control of pain. This article aims to perform a literature re-view on the efficacy of this substance in the treatment of internal changes of the temporomandibular joint. CONTENTS: The search strategy used the Pubmed portal and the Web of Science database for the last 10 years. We included articles in English that evaluated the efficacy of the hyaluronic acid in the intra-articular disorders of temporomandibular joint, and excluded articles from literature review, clinical case reports, theses, and dissertations. Fifteen studies, classified as randomized clinical trials, prospective and retrospective studies, case-control, pilot study, and systematic reviews were selected. The hyaluronic acid is of fundamental importance in the function and lubri-cation of joint tissues due to its high molecular weight. When degenerative and inflammatory changes are present, their con-centration and molecular weight are diminished, and the injec-tion of this acid raises these levels, which can generate pain relief. CONCLUSION: Intra-articular therapy with hyaluronic acid is effective in the reduction of symptomatologic levels and the functional restoration of the temporomandibular joint. Keywords: Hyaluronic acid, Intra-articular injections, Viscos-supplementation, Temporomandibular joint disorder.

Effects of the hyaluronic acid infiltration in the treatment of internal temporomandibular joint disordersEfeitos da infiltração de ácido hialurônico no tratamento das desordens internas da articulação temporomandibular

Liliane Emilia Alexandre de Oliveira1, Jandenilson Alves Brígido2, Aline Dantas Diógenes Saldanha2

Liliane Emilia Alexandre de Oliveira - https://orcid.org/0000-0001-7843-8780;Aline Dantas Diógenes Saldanha - https://orcid.org/0000-0001-8000-2361;Jandenilson Alves Brígido - https://orcid.org/0000-0002-9590-0372.

1. Faculdade Metropolitana da Grande Fortaleza, Fortaleza, CE, Brasil. 2. Faculdade Metropolitana da Grande Fortaleza, Faculdade de Odontologia, Fortaleza, CE, Brasil.

Submitted on August 07, 2018.Accepted for publication on December 14, 2018.Conflict of interests: none – Sponsoring sources: none.

Correspondence to: Rua Guilherme Rocha, 1299, apto 1505 – Centro60030-141 Fortaleza, CE, Brasil. E-mail: lilianemiliaa@gmail.com

© Sociedade Brasileira para o Estudo da Dor

RESUMO

JUSTIFICATIVA E OBJETIVOS: O protocolo primário de controle das disfunções temporomandibulares prioriza as medi-das reversíveis e menos invasivas. Entretanto, o tratamento con-servador mostra-se, algumas vezes, ineficaz, e como alternativa terapêutica, tem sido sugerido o uso de ácido hialurônico para com isso, verificar a sua efetividade em pacientes não respon-sivos aos tratamentos mais conservadores e poder ajudá-los no controle da dor. O objetivo deste estudo foi rever na literatura a eficácia dessa substância no tratamento das alterações internas da articulação temporomandibular. CONTEÚDO: A estratégia de busca utilizou o portal eletrônico Pubmed e a base de dados Web of Science, nos últimos 10 anos. Foram incluídos artigos em inglês que avaliaram a eficácia do ácido hialurônico nas desordens intra-articulares da articulação temporomandibular, e excluídos artigos de revisão de literatura, relatos de casos clínicos, teses e dissertações. Foram selecionados 15 estudos, classificados como ensaios clínicos randomizados, estudos prospectivos e retrospectivos, caso-controle, estudo pilo-to e revisões sistemáticas. O ácido hialurônico tem importância fundamental na função e lubrificação dos tecidos articulares, de-vido ao seu alto peso molecular. Quando alterações degenerativas e inflamatórias estão presentes, sua concentração e peso molecu-lar estão diminuídos, e a injeção desse ácido eleva esses níveis, o que pode gerar alívio da dor. CONCLUSÃO: A terapia intra-articular com ácido hialurônico é efetiva na diminuição dos níveis sintomatológicos e no restabe-lecimento funcional da articulação temporomandibular.Descritores: Ácido hialurônico, Injeções intra-articulares, Viscos-suplementação, Transtornos da articulação temporomandibular.

INTRODUCTION

The temporomandibular joint (TMJ) consists of a ginglymoar-throidal joint that allows hinging movements on one axle and sliding movements on another axle1. The synovial fluid nourishes and lubricates the joint tissues, and its quality and quantity are directly related to the joint normal function and health1,2.Temporomandibular dysfunction (TMD) is a collective term that encompasses clinical disorders in the TMJ, chewing muscles and associated structures. Among the signs and symptoms, the individuals may have pain, limitation of the mandibular move-ments and clicling1,3. The possible etiological factors are trau-ma in the facial structures; occlusal factors; increased emotional

DOI 10.5935/2595-0118.20190032

REVIEW ARTICLE

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stress; source of deep pain; muscle hyperactivity; parafunctional activities and orthopedic instability1,4. TMDs of articular origin include dislocation of the disc with and without reduction, ar-thralgia, osteoarthritis, and TMJ osteoarthrosis3.The disc displacement of the TMJ is described as an abnormal relationship of the mandibular condyle with the joint disc, fos-sa and articular eminence, which can occur with and without disc reduction5. TMJ arthralgia is a localized pain (of moderate to severe intensity) located in the TMJ and adjacent tissues4. In osteoarthrosis, there is a chronic and non-inflammatory degen-eration that affects the cartilaginous tissue of the synovial joints and is associated with the remodeling processes of the subchon-dral bone and the involvement of the synovial tissue2,3. TMJ os-teoarthritis occurs when there is a compromise of the dynamic balance between the collapse and repair of the joint tissues5,6.One of the minimally invasive therapies for the control of the TMJ internal disorders is known as viscosupplementation (infiltration of hyaluronic acid in the TMJ). The hyaluronic acid (HA) is an acidic mucopolysaccharide that is present in the primary substance of animal tissues, being the major component of the synovial fluid and has vital importance in the lubrication of the articular tis-sues2,3,7. In the degenerative and inflammatory disorders, its con-centration and weight are reduced, and the HA injection elevates these levels, which may be related to pain relief since it contains anti-inflammatory effects, such as inhibition of phagocytosis, che-motaxis, prostaglandin synthesis, metalloproteinases activity, and removal of oxygen radicals from the synovial tissue5,8.The primary protocol to control TMD prioritizes simple, revers-ible and less invasive approaches. However, the conservative treat-ment is sometimes ineffective, and as a therapeutic alternative, the use of HA has been suggested. Thus, checking the effectiveness of the HA in patients who are not responsive to more conservative treatments can help to control their pain. Therefore, the objective of the present study was to review the literature on the efficacy of this substance in the treatment of internal changes of the TMJ. CONTENTS

A literature review was conducted using the Pubmed electronic portal and the Web of Science database, using the MeSH keywords: “Temporomandibular Joint Disorder”, “Hyaluronic Acid”, “Vis-cosupplementation” and “Injections”, “Intra-articular”. The arti-cles were selected according to the pre-established eligibility crite-ria. The inclusion criteria were studies related to the effects of the HA on intra-articular changes of the TMJ; studies that reported

the applicability of the HA; articles in English published in the last ten years. The exclusion criteria were literature reviews; clinical case reports; theses and dissertations; articles not available in full.After searching the database and the electronic portal, the du-plicates were removed, and the titles and abstracts were read to identify potentially eligible articles that met the inclusion cri-teria. The articles that met the exclusion criteria were removed from the study. It is worth mentioning that the full text of each selected article was carefully evaluated. The initial selection generated a total of 415 articles, of which 107 duplicates were removed. After being adapted to the inclusion criteria, 288 ar-ticles remained, and 15 articles were selected in full after an ex-ploratory reading and critical analysis of titles and abstracts. The detailed selection method of the articles, according to the search mechanisms, is summarized in table 1.The articles selected were randomized clinical trials, prospective and retrospective studies, case-control, pilot study, and system-atic reviews that evaluated, primarily, the efficacy of the HA in-filtration for the treatment of internal temporomandibular joint disorders. Of the 15 articles selected, 4 are systematic reviews, 2 of these were published in 2017, 2 in 2016 and 2010, respec-tively. The publication period ranged from 2009 to 2017. Study samples varied from 25 to 141 patients. The age of the groups of patients ranged from 17 to 65 years. In most the analyzed cases, the follow-up of the results was of short and medium term, be-tween three and six months. Table 2 shows the selection of the studies included with their main characteristics.

Table 2. Description of the studies included in the review

Authors Typeof study

Objective n Diagnosis Main findings Conclusion

Long etal.5

R a n d o m i z e d clinical trial

To compare HA infiltration in the lower and upper joint space

120 DDSR Pain improvement in both groups

The intra-articular infiltration of HA in the upper and lower joint space was effective

Korkmaz etal.9

Prospective cli-nical study

Compare the HA therapy and the treatment with the occlusal splint

_ DDCR Better results with the HA therapy

The injection of HA and the occlusal splint therapy were effective in relieving the signs and symptoms of DDCR

Continue...

Table 1. Article selection flowchart

Articles selection

Search strategy

Pubmed Hyaluronic acid and temporomandibular joint disor-der: 104Temporomandibular joint disorder and viscosupple-mentation: 4Injections, intra-articular and temporomandibular joint disorder: 216

Web of Science

Hyaluronic acid and temporomandibular joint disor-der: 54Temporomandibular joint disorder and viscosupple-mentation: 8Injections, intra-articular and temporomandibular joint disorder: 29

Articles removed

Duplicates: 107

15 selected articles

Inclusion and exclusion criteria: 33 articles excludedReading of titles and abstracts: 260 articles excluded

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Table 2. Description of the studies included in the review – continuation

Authors Typeof study

Objective n Diagnosis Main findings Conclusion

Guarda-Nardini etal.10

Re t rospect i ve clinical trial

To compare the efficacy of the HA infiltration therapy in different age groups

76 Osteoarthritis of the TMJ

The HA was effec-tive in most of the evaluated symptoms

The treatment protocol was more effective in people over 45 years of age

Li et al.11 Randomized cli-nical trial

To compare the effects of HA infiltration in the lower and upper joint space

141 Osteoarthritis of the TMJ and DDSR

Improvement of TMJ function in both groups

The HA infiltration is an effective method for the treatment of DDSR asso-ciated with osteoarthritis

Bonotto etal.12

Re t rospect i ve clinical study

Discuss the viscosupple-mentation in the treatment of internal alterations of the TMJ

55 DDSR and os-teoarthritis of the TMJ

There was an increa-se in mouth ope-ning in patients with DDSR and osteoar-thritis

The viscosupplementa-tion with HA is conside-red a good alternative to improve the function of the TMJ in the short term

Goiato etal.13

Systematic re-view

Compare the HA injections and other drugs used in the arthrocentesis of the TMJ

_ Internal TMJ disorders

Intra-articular injec-tions of HA are bene-ficial to improve the functional symptoms of TMD

Positive results were ob-served with the HA the-rapy, but other therapies may be used

Iturriaga etal.14

Systematic re-view

Analyze the evidence of the efficacy of the HA

_ Osteoarthritis of the TMJ

The application of HA had positive re-sults

Further research is nee-ded.

Guarda-Nardini, Manfredini andFerronato15

Pilot study Provide data about the effect of a cycle of five arthrocentesis plus HA in-filtration

31 DDCR and ar-thralgia

Improvement regar-ding all variables of the study

Five infiltrations of HA after arthrocentesis was effective to ameliorate the DDR symptoms

Aktas,Yalcin andSencer16

Ret rospect i ve clinical study

Analyze the prognosis of arthrocentesis with and without HA

25 DDSR It is sufficient to use only arthrocentesis in patients without degenerative altera-tions

Having a standardized study group for future studies is necessary

Guarda-Nardini etal.17

C a s e - c o n t r o l study

Determine the effective-ness of viscosupplemen-tation with the HA

25 Osteoarthritis of the TMJ

Improvement in all outcome parameters

Effective therapy for pain improvement and the TMJ function

Guarda-Nardini etal.18

Re t rospect i ve clinical study

Evaluate theeffect of viscosupplemen-tation with HA

49 Osteoarthritis Significant reduction of pain over time

Further studies are re-quired

Guarda-Nardini etal.19

Re t rospect i ve clinical study

Evaluate the efficacy of the HA in elderly patients

50 Osteoarthritis of the TMJ

Significant improve-ment of signs and symptoms

There was no significant difference between the groups

Guarda-Nardini etal.20

Randomized cli-nical trial

Compare the efficacy of a single session protocol with a five-session proto-col of HA infiltration in the TMJ

30 Osteoarthritis of the TMJ

There was greater reduction of pain in the group treated with the 5-session protocol of HA infil-tration

The five-session protocol showed better results in 6 months

Manfredini, Piccotti andGuarda-Nardini21

Systematic re-view

Evaluate the clinical stu-dies on HA infiltration in the TMJ

_ TMJ disorders All studies reported a decrease in pain levels

The results are similar to those obtained with corticosteroid injection and the use of occlusal splints

Manfredini et al.22

Prospective ran-domized clinical trial

Evaluate the efficacy of platelet-rich plasma with growth factors injection versus HA

100 Internal TMJ disorder and osteoarthritis

The group treated with platelet-rich plasma with growth factors injection had better results

The injection of pla-telet-rich plasma with growth factors after ar-throscopy has shown to be more effective than the HA injection in pa-tients with internal TMJ disorders

n = number of patients; TMJ = temporomandibular joint; HA = hyaluronic acid; DDSR = anterior disc displacement without reduction; DDCR = anterior disc displa-cement with reduction.

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DISCUSSION

In its first reports, the HA was used to treat racehorses diag-nosed with traumatic arthritis. It was later used in humans to treat osteoarthritis involving larger joints such as knees, hips, and shoulder21. In 1979, it was first used in intracapsular changes of the TMJ16,19,22, and since then some studies have tried to evaluate the efficacy of the technique as well as to establish a protocol for its use20. Its metabolic activity contributes to cell renewal and facilitates the nutrition of the avascular areas of the disc and the articular cartilage due to its combination with the glycosamino-glycans originated by proteoglycans5,19.Viscosupplementation consists of intra-articular infiltration of HA in the TMJ17 to eliminate or reduce the symptomatic levels and restoring the masticatory function by qualitative and quan-titative enhancement of the synovial fluid16,17, mainly because of the metabolic and mechanical properties of the HA5. Viscos-upplementation alone or in combination with other modalities such as arthrocentesis is being considered a treatment option for inflammatory or biomechanical changes of the TMJ18,20. It is believed that the decrease of painful symptoms with vis-cosupplementation may occur by the blockade of endogenous receptors and pain substances in the synovial tissues16,18. The in-filtration of HA can improve or normalize the functionality of the TMJ by disrupting the adhesions or adherences between the mandibular fossa and the articular disc16,17. Moreover, it may de-crease the secondary wear allowing better perfusion of nutrients and metabolites of the synovial fluid to the vascular tissues17. Although the HA is kept in the joint only for a few days, the results last for months18,21. The low molecular weight of the HA molecules showed the best in vivo results and are more likely to induce the synthesis of the endogenous HA19,20. However, prod-ucts that have a high molecular weight are less able to pass into the intracellular environment17,20,21 and ends up precluding their action on the synoviocytes and chondrocytes, which is necessary for the reduction of the synovial inflammation and the resto-ration of the properties of the synovial fluid19.A systematic review conducted by Iturriaga et al.14 evaluated the regulation of inflammatory mediators when applying HA in patients with TMJ osteoarthritis (OA). The results showed that the application of HA had a positive effect on the regulation of the inflammatory mediators. The mediators studied were plas-minogen, activating system, and nitric oxide levels. The evidence available suggested that the application of HA regulates several inflammatory mediators in osteoarthritic processes in the TMJ. However, the authors stated that further evidence is needed in this regard, through the study of specific TMJ diseases, comple-menting the evaluation of clinical parameters with quality exper-imental studies with larger sample sizes.In this context, the efficacy of the HA treatment was also evalu-ated by Guarda-Nardini, Ferronato and Manfredini2, but in pa-tients with different age groups diagnosed with OA. From this study, it was suggested that the protocol of treatment applied until then was more effective in older patients. In the study con-ducted by Long et al.5, 120 patients diagnosed with disc dis-placement without reduction (DDSR) received an HA infiltra-

tion. One group of patients received injections in the upper joint space, and the other group was treated with injections in the lower joint space. The clinical symptoms were evaluated at the follow-up visits of 3 and 6 months. The parameters evaluat-ed were maximum mouth opening (MMO), pain intensity on a visual analog scale (VAS) and the Helkimo’s clinical dysfunction index. The MMO, VAS, and Helkimo index of the two groups improved significantly, with no difference between the groups.In agreement with the study by Long et al.5, Bonotto et al.12 discussed the viscosupplementation technique in the treatment of internal TMJ alterations in 55 patients with disc displacement with reduction (DDCR) and DDSR. The results showed a sig-nificant increase in mouth opening in all groups. These results remained constant over four months of follow-up, and the au-thors stated that the viscosupplementation with HA could be a good alternative, in the short-term, to the functional restoration of the TMJ in patients with internal TMJ alteration that did not respond to conservative treatments.With the study by Li et al.,11 it was possible to compare the ef-fect of the HA injections in the upper and lower joint space in patients diagnosed with DDSR in association with OA by cone beam computed tomography. It showed that the HA injections in the upper and lower joint space are effective methods to treat DDSR in association with OA, corroborating previous studies using the HA in the treatment of degenerative alterations and DDSR and DDCR of the TMJ5,12. Korkmaz et al.9 compared the effectiveness of single and double infiltrations of HA and the therapy with an occlusal splint to treat DDCR. The patients were divided into four groups: control (group 1), single HA injection (group 2), double HA injection (group 3) and therapy with an occlusal splint (group 4). The re-sults showed functional improvement and a decrease in the pain symptoms in all groups, but the patients who underwent the HA therapy had better results. Thus, they concluded that the HA is more effective in improving the clinical signs and symptoms of DDCR than the occlusal splint therapy.Accordingly, Guarda-Nardini, Manfredini and Ferronato15 eval-uated the short-term effect of a weekly cycle of five arthrocentesis associated with HA injections to control the signs and symptoms of 31 patients with DDCR. At the end of the treatment, there was a significant improvement over baseline in all variables ana-lyzed and maintained for three months of follow-up. Thus, they concluded that a cycle of five weekly injections of HA performed immediately after arthrocentesis, is effective in improving the signs and symptoms of DDCR. Goiato et al.13 conducted a systematic review to investigate whether intra-articular injections of HA are more effective than other drugs used in TMJ arthrocentesis and showed that in-tra-articular injections of HA are beneficial in the control of pain and the functional symptoms of TMD. However, corticosteroids and nonsteroidal anti-inflammatory drugs can be used with sat-isfactory results. Manfredini et al.22 evaluated the efficacy of platelet-rich plasma in growth factor (PRGF) versus HA injection after arthroscopic surgery in patients with OA. Group A (n=50) received a PRGF injection, and Group B (n=50) an HA injection. The mean age

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was 35.5 years (ranging from 18 to 77 years), and 88% of the patients were women. The pain intensity (VAS) and maximum mouth opening before and after the procedure were analyzed statistically. The best results were observed in the PRGF treated group, with a significant reduction in pain at 18 months com-pared to patients treated with HA. Regarding mouth opening, there was an increase in both groups, with no significant differ-ence, besides an improvement in the functional capacity of the group treated with PRGF.Some early studies supported the efficacy of HA injections to treat internal TMJ disorders. However, recent evidence suggests that it may also be effective in inflammatory and degenerative disorders21, especially if it is associated with arthrocentesis9. These considerations allowed widening the indications for HA injections to a broader range of TMDs3,8. CONCLUSION

Most of the studies analyzed showed that the intra-articular infil-tration of HA is an effective treatment, both in short and medi-um terms, for the internal alterations of the TMJ provided that a correct diagnosis is made, and the patient has not responded successfully to the more conservative therapies. HA infiltration can eliminate or diminish the levels of the symptoms and restore the function through the qualitative and quantitative improve-ment of the synovial fluid. REFERENCES

1. Okeson JP, de Leeuw R. Differential diagnosis of temporomandibular disorders and other orofacial pain disorders. Dent Clin North Am. 2011;55(1):105-20.

2. Guarda-Nardini L, Ferronato G, Manfredini D. Two-needle vs. single-needle techni-que for TMJ arthrocentesis plus hyaluronic acid injections: a comparative trial over a six-month follow up. Int J Oral Maxillofac Surg. 2012;41(4):506-13.

3. Guarda-Nardini L, Ferronato G, Favero L, Manfredini D. Predictive factors of hya-luronic acid injections short-term effectiveness for TMJ degenerative joint disease. J Oral Rehabil. 2011;38(5):315-20.

4. Escoda-Francolí J, Vázquez-Delgado E, Gay-Escoda C. Scientific evidence on the use-fulness of intraarticular hyaluronic acid injection in the management of temporoman-dibular dysfunction. Med Oral Patol Oral Cir Bucal. 2010;15(4):e644-8.

5. Long X, Chen G, Cheng AH, Cheng Y, Deng M, Cai H, et al. A randomized con-trolled trial of superior and inferior temporomandibular joint space injection with hyaluronic acid in treatment of anterior disc displacement without reduction. J Oral

Maxillofac Surg. 2009;67(2):357-61.6. Tang XL, Zhu GQ, Hu L, Zheng M, Zhang JY, Shi ZD, et al. Effects of intra-articular

administration of sodium hyaluronate on plasminogen activator system in temporo-mandibular joints with osteoarthritis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010;109(4):541-7.

7. Manfredini D, Bonnini S, Arboretti R, Guarda-Nardini L. Temporomandibular joint osteoarthritis: an open label trial of 76 patients treated with arthrocentesis plus hyal-uronic acid injections. Int J Oral Maxillofac Surg. 2009;38(8):827-34.

8. Pavelka K, Uebelhart D. Efficacy evaluation of highly purified intra-articular hyal-uronic acid (Sinovial(®)) vs hylan GF-20 (Synvisc(®)) in the treatment of symptomatic knee osteoarthritis. A double-blind, controlled, randomized, parallel-group non-infe-riority study. Osteoarthritis Cartilage. 2011;19(11):1294-300.

9. Korkmaz YT, Altintas NY, Korkmaz FM, Candirli C, Coskun U, et al. Is hyaluronic acid injection effective for the treatment of temporomandibular joint disc displace-ment with reduction? J Oral Maxillofac Surg. 2016;74(9):1728-40.

10. Guarda-Nardini L, Cadorin C, Frizziero A, Ferronato G, Manfredini D. Comparison of 2 hyaluronic acid drugs for the treatment of temporomandibular joint osteoarthri-tis. J Oral Maxillofac Surg. 2012;70(11):2522-30.

11. Li C, Long X, Deng M, Li J, Cai H, Meng Q. Osteoarthritic changes after superior and inferior joint space injection of hyaluronic acid for the treatment of temporoman-dibular joint osteoarthritis with anterior disc displacement without reduction: a cone-beam computed tomographic evaluation. J Oral Maxillofac Surg. 2015;73(2):232-44.

12. Bonotto D, Machado E, Cunali RS, Cunali PA. Viscosupplementation as a treatment of internal derangements of the temporomandibular joint: retrospective study. Rev Dor. 2014;15(1):2-5.

13. Goiato MC, da Silva EV, de Medeiros RA, Túrcio KH, Dos Santos DM. Are intra-ar-ticular injections of hyaluronic acid effective for the treatment of temporomandibular disorders? A systematic review. Int J Oral Maxillofac. Surg. 2016;45(12):1531-7.

14. Iturriaga V, Bornhardt T, Manterola P, Brebi P. Effect of hyaluronic acid on the regu-lation of inflammatory mediators in osteoarthritis of the temporomandibular joint: a systematic review. Int J Oral Maxillofac Surg. 2017;46(5):590-5.

15. Guarda-Nardini L, Manfredini D, Ferronato G. Short-term effects of arthrocentesis plus viscosupplementation in the management of signs and symptoms of painful TMJ disc displacement with reduction. A pilot study. Oral Maxillofac Surg. 2010;14(1):29-34.

16. Aktas S, Yalcin SS, Sencer S. Prognostic indicators of the outcome of arthrocentesis with and without sodium hyaluronate injection for the treatment of disc displacement without reduction: a magnetic resonance imaging study. Int J Oral Maxillofac Surg. 2010;39(11):1080-5.

17. Guarda-Nardini L, Rossi A, Ramonda R, Punzi L, Ferronato G, Manfredini D. Effec-tiveness of treatment with viscosupplementation in temporomandibular joints with or without effusion. Int J Oral Maxillofac Surg. 2014;43(10):1218-23.

18. Guarda-Nardini L, Cadorin C, Frizziero A, Masiero S, Manfredini D. Interrelation-ship between temporomandibular joint osteoarthritis (OA) and cervical spine pain: effects of intra-articular injection with hyaluronic acid. Cranio, 2017;35(5):276-82.

19. Guarda-Nardini L, Manfredini D, Stifano M, Staffieri A. Marioni G. Intra-articular injection of hyaluronic acid for temporomandibular joint osteoarthritis in elderly pa-tients. Stomatologija. 2009;11(2):60-5.

20. Guarda-Nardini L, Rossi A, Arboretti R, Bonnini S, Stellini E, Manfredini D. Sin-gle- or multiple-session viscosupplementation protocols for temporomandibular joint degenerative disorders: a randomized clinical trial. J Oral Rehabil. 2015;42(7):521-8.

21. Manfredini D, Piccotti F, Guarda-Nardini L. Hyaluronic acid in the treatment of TMJ disorders: a systematic review of the literature. Cranio. 2010;28(3):166-76.

22. Manfredini D, Favero L, Gregorini G, Cocilovo F, Guarda-Nardini L. Natural course of temporomandibular disorders with low pain-related impairment: a 2-to-3-year fol-low up study. J Oral Rehabil. 2013;40(6):436-42.

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ABSTRACT

BACKGROUND AND OBJECTIVES: The Integrative and Complementary Practices were implemented in the Unified Health System as adjunctive modalities in the treatment of pain. This arti-cle focuses on crenotherapy and hydrotherapy, whose agents are the natural mineral waters and common for the rehabilitation of func-tional alterations. The scarcity of these practices for the treatment of pain in the literature justifies this review. This study aimed to check the scientific productions about the efficacy of balneology/balneo-therapy/crenotherapy and hydrotherapy in the treatment of pain.CONTENTS: It is an integrative review, carried out in May 2018, searching in the electronically available scientific articles, in full, in the LILACS, Pubmed, BVS and CINAHL database in peri-odicals published in the last 10 years focusing on crenotherapy and hydrotherapy for pain relief, in the Portuguese, English and Spanish language. The descriptors used were: “Pain”, “Balneolo-gy”, “Crenotherapy”, “Hydrotherapy” “Efficacy”; “Effectiveness” in the three languages, combined with the Boolean expressions AND/Y/E and OR/O/U/OU, finding 2306 articles, of which 111 were identified, and only 27 met the inclusion criteria, analyzed and incorporated the evidence that emerged in pain relief. CONCLUSION: This study showed that most of the evidence emerged from the studies analyzed regarding the efficacy of hy-drotherapy and balneology in pain pictures focused on levels 1 to 3. Of the 27 studies, 18 showed the efficacy of hydrotherapy and eight of balneology in the pain symptomatology and one in relation to the lack of knowledge of the use of these complemen-tary therapies in pain relief. Keywords: Balneology, Balneotherapy, Crenotherapy, Efficacy, Hydrotherapy, Pain.

Hydrotherapy and crenotherapy in the treatment of pain: integrative review Hidroterapia e crenoterapia no tratamento da dor: revisão integrativa

Juliane de Macedo Antunes1, Donizete Vago Daher1, Vania Maria de Araújo Giaretta2, Maria Fernanda Muniz Ferrari1, Maria Belén Salazar Posso2

Juliane de Macedo Antunes - https://orcid.org/0000-0002-9763-8291;Donizete Vago Daher - https://orcid.org/0000-0001-6249-0808;Vania Maria de Araújo Giaretta - https://orcid.org/0000-0003-4231-5054;Maria Fernanda Muniz Ferrari - https://orcid.org/0000-0001-6606-8938;Maria Belén Salazar Posso - https://orcid.org/0000-0003-3221-6124.

1. Universidade Federal Fluminense, Niterói, RJ, Brasil. 2. Universidade de Taubaté, São Paulo, SP, Brasil.

Submitted on July 04, 2018.Accepted for publication on May 02, 2019.Conflict of interests: none – Sponsoring sources: none.

Correspondence to: Rua Iperoig, 749-111 – Perdizes 05016-000 São Paulo, SP, Brasil.E-mail: mbelen@terra.com.br

© Sociedade Brasileira para o Estudo da Dor

RESUMO

JUSTIFICATIVA E OBJETIVOS: As Práticas Integrativas e Complementares foram institucionalizadas no Sistema Único de Saúde como modalidades coadjuvantes no tratamento da dor. Este artigo focalizou a utilização de crenoterapia e hidroterapia, cujos agentes são as águas minerais naturais, comum para a rea-bilitação de alterações funcionais. A escassez da literatura dessas práticas no tratamento da dor, justifica esta revisão. O objetivo deste estudo foi verificar a produção cientifica sobre a eficácia da balneologia/balneoterapia/crenoterapia e da hidroterapia no tratamento da dor. CONTEÚDO: Revisão integrativa, realizada em maio de 2018, cuja busca de artigos científicos disponíveis eletronicamente e na íntegra, na base de dados, LILACS, Pubmed, BVS e CI-NAHL em periódicos publicados nos últimos 10 anos enfocaram a crenoterapia e hidroterapia para o alívio da dor nos idiomas Português, Inglês e Espanhol. Os descritores utilizados foram: Dor, Balneologia, Crenoterapia, Hidroterapia, Eficácia; nos três idiomas, combinados com as expressões booleanas AND/Y/E e OR/O/U/OU encontrando 2306 artigos, identificados 111 e destes, apenas 27 atenderam aos critérios de inclusão, analisados e incorporadas as evidências emergidas no alívio da dor. CONCLUSÃO: Este estudo mostrou que a maioria das evidên-cias emergidas dos trabalhos analisados quanto à eficácia da hi-droterapia e crenoterapia em processos álgicos concentraram-se nos níveis 1 a 3. Dos 27 estudos, 18 mostraram a eficácia da hidroterapia e oito da balneoterapia e crenoterapia nos sintomas dolorosos, e um em relação ao desconhecimento do uso dessas práticas integrativas no alívio da dor.Descritores: Balneologia, Balneoterapia. Crenoterapia, Dor, Efi-cácia, Hidroterapia.

INTRODUCTION

In 2002, the World Health Organization (WHO)1 established the Pain Management Protocol for the relief of pain and in the document “WHO Traditional Medicine Strategy 2002-2005” recognizing the importance, efficacy, and quality of Comple-mentary Medicine, encouraging the integration of their knowl-edge to those of the Western Medicine in health systems. The text of this Strategy continues with the encouragement of the use of Integrative and Complementary Practices (PICS) for the development of access policies, for rational, responsible, safe practice and at the same time, recommending the development of studies that validate them1.

BrJP. São Paulo, 2019 apr-jun;2(2):187-98

DOI 10.5935/2595-0118.20190033

REVIEW ARTICLE

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The PICS were institutionalized in the Unified Health System (SUS) by the National Policy on Integrative and Complementary Practices (PNPIC), approved by Ordinance GM/MS No. 971/5/3/20062. The purpose of the Ministry of Health (MS)2 is to offer the Bra-zilian population access to PICS by standardizing them to meet the demands of the public health network, being transversal in its actions in the Unified Health System (SUS), and present at all levels of health care, making available to the population modalities to follow: aromatherapy, art therapy, ayurveda, bio-dance, bioenergetics, family constellation, chromotherapy, cir-cular dance, geotherapy, hypnotherapy, homeopathy, imposition of hands, anthroposophic medicine/anthroposophy, applied to health, Traditional Chinese Medicine – acupuncture, auricu-lotherapy, meditation, music therapy, naturopathy, osteopathy, ozone therapy, phytotherapy, chiropractic, reflexotherapy, reiki, shantala, integrative community therapy, floral therapy, social thermalism/cryotherapy and yoga2. Except for acupuncture, that is minimally invasive; the others are characterized by non-inva-sive interventions and an important rebalancing of the physical, mental, and emotional energies.These PICS help the pharmacological treatment and alleviate the suffering caused by pain, considered one of the great public health problems, improving the quality of life (QoL)3,4. Pain is a symptom frequently present in the patient and requires physical, psychosocial, and psychoemotional evaluation determining the agent of his/her suffering by the multiprofessional team3-5.This article will specifically focus on the use of hydrotherapy (HT) (common water) and crenotherapy (CT) (thermal water) for pain relief, which have water as an essential element. The different modes of therapeutical application of water receive the names of social ther-malism, balneotherapy (BT), thalassotherapy, CT, and HT2. The BT/CT designation refers to the therapeutic use of natural mineral waters whose chemical composition can be classified as sulphurated, radioactive, bicarbonate, ferruginous, among others, for the prevention, treatment, and rehabilitation of various diseas-es. It is a millenary practice introduced in Brazil by the Portuguese empire for the treatment of several organic signs and symptoms of patients, as a complementary therapy to other treatments2,5.HT consists of the external and therapeutic use of common wa-ter with different application and temperature forms. It is an im-portant resource for the rehabilitation of functional alterations, having as a principle the physical, chemical, physiological, and kinesiological effects obtained by immersion of the body in swimming pool6,7, usually heated. Exercises in the heated wa-ter improve joint movement, relaxation, reduction of muscle tension, muscular spasms, an increase of muscle strength and endurance6, besides benefiting the venous return, improving pe-ripheral circulation and favoring the decrease of pain6,7. HT and CT do not present associated risks, being a convenient method, but they must be used with discretion, responsibility, and performed by trained professionals2,6,7. HT and CT, al-though they are millenarian therapeutic methods, like PICS used for the treatment of pain, seem to have been little contemplated in scientific studies in the national and international literature. This study aimed to evaluate the efficacy of CT and HT in the treatment of pain through an integrative review of the literature.

CONTENTS

It is an integrative review that allows the search, the critical eval-uation, the synthesis, analysis, and incorporation of the evidence of the national and international scientific productions emerged from the subject investigated8,9, with a retrospective temporal cut, respecting the copyright of the literature used, according to Law No. 9610/1998 of the Ministry of Education and Culture (MEC)10.After, the following steps were followed: 1. establishment of the guiding question; 2. objective; 3. criteria for inclusion and exclu-sion of articles; 4. information extracted from selected articles; 5. analysis and presentation of the studies8,9. The guiding question was: “How does national and international scientific production evaluate the efficacy of HT and BT/CT in pain therapy”? The databases used were: Latin American and Caribbean Health Sciences Literature (LILACS), Virtual Health Library (VHL); Cumulative Index to Nursing and Allied Health Literature (CI-NAHL) and National Library of Medicine (Pubmed) using con-trolled descriptors from the Health Sciences Descriptors (DeCS) and the Medical Subject Headings (MeSH), “dor (pain,) (dolor); eficácia (efficacy/effectiveness), (eficácia); BT/CT (balneology) (crenotherapy) and (hydrotherapy) (HT). Also used an uncon-trolled descriptor: hidrotherapy (crenotherapy) two or more DeCS/MeSH among those mentioned were combined and the Boolean expressions E/AND/Y/ and OU/OR/O/U (Table 1)

Table 1. Combination of descriptors with Boolean expressions used in the search strategy (EB)

EB Combination of the descriptors with the Boolean expres-sions E/AND/Y/ and OU/OR/O/U

1a Balneoterapia e dor (balneology, balneologia and/y pain/dolor)

2a Crenoterapia e dor (crenotherapy/and/y pain/dolor)

3a Hidroterapia e dor (hydrotherapy/and/y pain/dolor)

4a Balneoterapia e dor ou crenoterapia e dor; (balneology bal-neologia and/y pain or crenotherapy and/y pain, dolor)

5a Balneoterapia e dor e eficácia ou crenoterapia e dor e efi-cácia (balneology and pain, dolor and efficacy or effecti-veness or crenotherapy and/y efficacy or effectiveness, or eficácia, efetividade and/y pain, dolor.

6a Hidroterapia e dor (hydrotherapy, and pain, hidroterapia dolor)

7a Hidroterapia e dor e eficácia ou terapia aquática, dor e eficácia ou (hydrotherapy and pain, dolor and efficacy or effectiveness, eficácia, efetividade).

The review period was from May 2008 to May 2018, seeking to cover more recent studies of CT and HT and its efficacy in pain relief. The inclusion criteria were: scientific papers in English, Spanish and Portuguese available electronically and excluded editorials, letters, theses, dissertations, monographs, manuals, abstracts of congresses; articles duplicated in more than one da-tabase, counting only one; or that did not address the research question, the objective and descriptors. After the critical and careful reading of the abstracts and, a pos-teriori, of the complete articles, the information was organized and recorded in a specially structured form, composed to iden-tify title, author, year of publication, objectives, methods and

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results of articles analyzed, including or excluding them for the analysis, presentation of the main results and classification of the emerging evidence. The precepts of the PRISMA checklist, 200911 were considered to analyze meta-analyzes and systematic reviews that guide the eligibility, inclusion of articles, and the level of scientific evidence (LE), favoring the preparation of figure 1. The search was carried out independently by 2 reviewers who after the refinement of the searches, classified the quality, sci-entific validity, and reliability of the articles by the Level of Evidence (LE)12,13, that is, level 1: the evidence from system-atic review or meta-analysis of relevant randomized controlled trials or from clinical guidelines based on systematic reviews of randomized controlled trials; level 2, evidence derived from at least one well-delineated randomized controlled trial; lev-el 3, evidence obtained from well-delineated non-randomized controlled trials; level 4, evidence from well-delineated cohort and case-control studies; level 5, evidence originating from a systematic review of descriptive and qualitative studies; level 6, evidence derived from a single descriptive or qualitative study; level 7, evidence from the opinion of authorities and/or report of expert committees”12,13.The analysis of table 2 shows that of the 1,160 articles screened in the databases, 1,049 were excluded because they did not meet the inclusion criteria, with 111 articles remaining eligible. Af-ter the evaluation of the full text, 84 were excluded, of which only 27 were included. One article (3.7%) was found in VHL (IBEC), and five articles (18.5%) were found in LILACS, none in CINAHL database and 21 (77.8%) in Pubmed from a total of 27 analyzed.

Iden

tifica

tion

Scr

eeni

ngE

ligib

ility

Incl

uded

Articles identified by search-ing databases

(n=2306)

Screneed (n=1160) excluded (n=1049) = n=111

Articles analyzed (n=111)

Complete articles analyzed (n=27)

Articles excluded (n = 84)

Total=(111-84=n=27)

Figure 1. Flowchart with eligibility representation and inclusion of articles

Table 2. Summarized registry of titles, author, periodical, year, database, objectives, method, and results

Articles Authors and database

Type of studies and n

Synthesis Conclusion Level of evidence

A1 Ceylan e Bollşlk14

Pubmed

Crossover de-sign, experimen-tal, randomized controlled trial. n=35

35 socio-demographically homogeneous premature infants with 33-37 weeks’ gestation with a birth weight <1,500 g in the NICU were selected from a pub-lic hospital in Denizli, Turkey. Two bath methods: 20 babies of the Experimental Group wrapped with tissue (EG) and 15 wrapped with a sponge of the Control Group (CG) were applied at intervals of 3 days. Vital signs and oxygen saturation levels were measured before and at min-utes 1, 5, 15, 30 after bathing. The mean water temperature was 37.76±0.16°C for CG and 37.58±0.8°C for EG. Video-re-corded baths evaluated pain and stress behaviors by independent observers. p<0.05 was used for all statistical analy-sis; excluded babies with signs of infec-tion, neurological problems, skin integri-ty, congenital defects, deterioration, use of analgesic drugs, sedatives or muscle relaxants. The bath application sequence was computer-randomized (Predictive Analytics Software, SPSS Inc., Chicago, IL, USA).

The baby’s bath wrapped with fabric has a positive effect on the baby’s vital signs, oxygen satura-tion levels, cry time, and level of stress and pain compared to the condition of the common bath. The pain scores of the babies during and after the tissue baths were smaller (p = 0.001) than the standard baths. Baby bath wrapped in fabric is a harmless and safe nursing practice

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Articles Authors and database

Type of studies and n

Synthesis Conclusion Level of evidence

A2 Avila et al.15

PubmedExper imenta l before and af-ter, non-ran-domized.n=20

20 women with fibromyalgia syndrome with pain and restriction of three-dimen-sional scapular movement underwent 3 evaluation sessions, one before, one after 8 weeks and at the end of 16 weeks of a hydrotherapy treatment program with 2 sessions of 45min/weekly/16 weeks. Data were analyzed by ANOVA for pain and quality of life variables. The effect on the scapular movement evaluated by Cohen’s coefficient d. The pain intensity by VAS=8 at the time before compared with evalua-tions 2 and 3 at the time after, evolved to zero intensity.

The proposed HT program was effective in improving quality of life, pain intensity (p<0.05), re-flecting the improvement of the scapular movement from -1.93 to 1.61 and the impact of fibromy-algia in women with this disease.

3

A3 Batten et al.16

PubmedExperimental, non- random-ized, before and after.n=43

The normal postpartum HT protocol without drug use was aimed at relieving the pain of 45 women who were immersed in hot water for 30 minutes and 1 hour postpartum. The pain scores were evaluated before the bath, 15 and 30 minutes later. There was a signifi-cant reduction in scores.

This treatment significantly re-duced VAS pain = 8 between the onset of the bath and 2 (p <0.001) at 15 and 30 minutes and (p=0.97) between the two times. It offered a non-pharmacological alternative, in which there are tra-ditionally limited options.

3

A4 Cipriano and Oliveira17

LILACS

Experimental, p ro s p e c t i v e , non- random-ized controlled trial.n=20

The authors verified the influence of elas-tic bandaging in the treatment of posterior pelvic pain and functionality in the activities of the daily life of pregnant women. It is a controlled and prospective clinical trial with 20 pregnant women, 10 in each group, aged between 18 and 39 years old: experimen-tal group (EG) (elastic bandage and HT) and control group (CG) (HT). The pain was evalu-ated by the numerical visual scale (NVS) and the functionality through the Rolland-Morris disability questionnaire.

They concluded that there was no statistical difference between the two groups (p<0.05) with these two evaluation instruments for the treatment of posterior pel-vic pain and the improvement of functionality in daily activities in pregnant women. An elastic bandage can be used to treat low back pain during pregnancy safely.

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A5Matsumoto et al.18

Pubmed

Meta-analysisn=102

Meta-analysis performed in the databas-es: Medline, Embase, Cochrane Library and in the database of the Japan Medical Abstracts Society using two approaches, MeSH terms (Medical Subject Headings) and free words published from 2004 to 12/31/2016 in the English or Japanese languages of randomized controlled tri-als of 102 publications involving 734 patients(359 EG and 375 CG), analyzing the effect of balneotherapy/crenother-apy (BT/CT) for the treatment of pain, stiffness and improvement of physical function compared to patients with os-teoarthritis of the knee lasting ≥2 weeks. The Osteoarthritis Index (WOMAC) and VAS for pain were used. They analyzed the improvement in the WOMAC score in the final follow-up ranging from 2 to 12 months postintervention.

This meta-analysis indicated that BT/CT was clinically effec-tive in relieving pain, stiffness, and improvement of function, as evaluated by the WOMAC score, compared to controls with high heterogeneity (88 to 93%).

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A6 Vanderlaan19

PubmedRetrospective cohort study, n= 164

The use of HT for pain management in la-bor in 268 participants. Of these, 80 were excluded by medical decision, and 24 evolved to pharmacological treatment. The mean duration of immersion use was 156.3min±122.7 at T ±37ºC.

The induction of labor was as-sociated with a decline in the supply of HT during labor pro-vided comfort, besides being a non-pharmacological strategy, low cost, safe and effective, pro-motes normal delivery.

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Articles Authors and database

Type of studies and n

Synthesis Conclusion Level of evidence

A7 Koyuncu et al.20

Pubmed

Exper imenta l r a n d o m i z e d controlled trial.n=60

The authors investigated the efficacy of BTCT in relieving chronic neck pain of 60 patients, randomized into two groups: experimental (EG) (n=30) and control (CG) (n=30). All patients in both groups were treated with a physiothera-py program (FT) of 15 standard sessions consisting of hot pack, ultrasound and TENS. The EG patients were also treat-ed by the BT/CT program of 15 sessions lasting 20 minutes/day. VAS, modified neck disability index (mNDI) and Not-tingham health profile score (NHT) were used for all patients, being evaluated at three different times as pretreatment, posttreatment and the third week after treatment. The 2 groups were homoge-neous both socioeconomically and clin-ically. Intergroup analysis revealed the superiority of EG in all parameter.

The authors conclude that com-bined therapy of BT/CT and FT provided clear clinical improve-ment and remains long-term. All EG parameters were superior to FT alone in reducing pain and improving the quality of life of pa-tients with chronic neck pain.

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A8 Branco et al.21

PubMedExperimental, blinded, ran-domized con-trolled trial.n=140

140 adult patients of both genders were evaluated for the efficacy of hot sulfurous (AS) and non-sulfurous waters (ANS) in the treatment of knee osteoarthritis (OAK). Randomized in three groups: AS group (n=47), ANS (n=50) and control group pharmacological treatment (n=43). The AS group received 30 individual thermal baths (three baths/20min/week for 10 weeks) at 37-39 ° C. The pain was measured by the VAS, physical function Index WOMAC; Lequesne Algo functional Index, LAFI; Stanford Health Evaluation Questionnaire (SHAQ) and analgesic drug use. The pa-tients were evaluated before treatment (T1), at the endpoint of treatment (T2) and two months after intervention (T3). The significance level (p<0.05) for intra and in-tergroup comparisons.

Pain intensity decreased signifi-cantly during movement, at rest and at night, as well as analgesic use, with even better WOMAC, LAFI and HAQ scores from base-line to T2 and T3 (p<0.001). Both AS and TM methods were effec-tive in the treatment of OAK. AS baths produced a good impact of clinical rehabilitation in reduc-ing pain and improving physical function in OAK patients.

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A9 Kümpel et al.22

LILACSBefore and after experimental, non- random-ized controlled trial.n=26

A prospective study, in which 26 patients with knee osteoarthritis (OAK) received hy-drokinesitherapy treatment, 2 times/week with a duration of 50 minutes each session in 4 phases: warm-up, stretching, strength-ening and relaxation. They were evaluated before and after treatment, using goniomet-ric evaluation, pain=VAS, and Six-Minute Walk Test.

There was an improvement in the ability to perform ADL and physical capacity, as well as a decrease in pain with a mean pre-treatment of 8.9±1.2 and 5.1±1.7 (p<0.0001) and signifi-cant improvement in capacity to increase range of movement.

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A10 Fonseca et al.23

PubmedBefore and af-ter, non-ran-domized con-trolled trialn=4

Four athletes with age = 24.0±3.6 years old, mass=78.4±2.4kg, body fat =13.1%±3.6%) were randomly selected for post-training re-covery using HT (6.0°C±0.5°C) for 19 min; the control group received a passive recov-ery. All completed the study. Serum levels of lactate dehydrogenase, creatine phosphoki-nase, LDH, aspartate aminotransferase, and alanine aminotransferase were measured; muscle pain and recovery perceived by VAS and muscular power of the upper and lower limbs in the pre-workout, post-recovery, 24 and 48 hours. Significance level p <0.005).

HT decreased muscle pain (3.1±1.0 versus 1.5±1.1 (p=0.004) and improved post-workout recovery, increased muscle strength compared to passive recovery (p=0.0058), LDH levels were lower than those in the con-trol group (p=0.03). Higher per-ceived muscle power in HT than in control for both upper limbs p=0.001, HT has been widely ap-plied as a recovery method; how-ever, there are few publications demonstrating the evidence of its efficacy.

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Articles Authors and database

Type of studies and n

Synthesis Conclusion Level of evidence

A11 Forestier, Erol Forestier and Francon 24

Pubmed

S y s t e m a t i c review of ran-domized exper-imental studiesn=36

Systematic review of 421 randomized controlled trials in the Medline databas-es via Pubmed, PEDRO, and Cochrane Central Register of controlled clinical trials. Of these, only 36 were included up to September 2015. Inclusion: ar-ticles from experimental randomized controlled trials on knee osteoarthri-tis (OAK) with separate data from hot mineral water baths, mud therapy, hot showers, and supervised massage and water exercises (EG), compared with any other intervention or no treatment (CG); follow-up> 3 months, pain measurement and/or function and/or overall evaluation of the patient and quality of life at 3, 6 and 9 months.

A review of 36 randomized controlled trials covering 2833 patients with high heterogeneity (88 to 93%) showed that HT and CT treatment performed in SPA centers in Europe and the Mid-dle East seem to improve pain and the function of patients with OAK. When CT is associated with exercise program demon-strates superiority to home ex-ercise only for pain and function at 3, 6 and 9 months with no dif-ference in the quality of life and drug consumption. 

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A12 Chen et al.25

Pubmed

Meta-analysisn=15

Seven databases were searched: PubMed, the Cochrane Library, Springer; China National Knowledge Infrastructure, Chongqing VIP, Chinese Biomedical, and Wanfang by October 2014. Randomized controlled trials evaluating 2 weeks of Chinese Herbal Bath Therapy (CHBT) for OAK were selected. The effects of CHBT on clinical symptoms and pain level (VAS). The meta-analysis of 15 studies with 1618 individuals who met the eligibility criteria was performed. The bath prescription in-cluded, on average, 13 Chinese herbs with instructions for using steam and washing around the knee for 20 to 40 minutes, once or twice a day. The mean duration of treatment was 3 weeks.

Chinese herbal bath therapy may be effective in reducing OAK pain (mean difference -0.59 points, p<0.00001), when compared to standard Western treatment. No serious adverse events have been reported.

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A13 Ezheltha Suji and Sharmila Jansi Rani26 Pubmed

Before and after experimental, non- random-ized controlled trial.n=60

To evaluate the efficacy of foot bath ver-sus exercises in reducing pain among pa-tients with OAK. Sixty patients with OAK and ankle were selected by intentional sampling at Issac Bone & Joint Special-ty Hospital, Marthandam in Kanyakumari district. Demographic, clinical, and VAS variables of group I and group II were col-lected before and after the administration of the foot bath versus exercises on the first, third, and fifth days of treatment. The analysis was done using descriptive and inferential statistics.

There was a significant associ-ation between age, disease du-ration, family history of osteoar-thritis, physical mobility, and any condition associated with osteo-arthritis and the level of pre-test pain among patients. The results showed that foot bath (0.52) had a better effect on reducing joint pain in knees and ankles than in exercises (1,20) (p <0.001). (1.20) (p<0.001).

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A14 Ibarra Cornejo et al.27

BVS (IBECS)

Systematic re-view of exper-imental, ran-domized con-trolled trials n=6

Systematic review of randomized con-trolled trials (RCTs) on the efficacy of HT in the pain therapy of OAK patients in the databases of: PEDro and Medline of 01/01/2004 and 07/31/2014 in the Span-ish and English languages, with selection of independent studies by two reviewers and a classification of studies with a score ≥ 5 on the PEDro scale. We found 119 el-igible articles, selected based on title and abstract, of which only 6 primary doc-uments were examined. All used VAS to measure pain.

The authors inferred that the pri-mary studies included showed strong evidence that HT was effective in reducing pain in all (mean p<0.003) and improved quality of life and physical func-tion in patients with osteoarthritis of the knee at 6 to 12 weeks of follow-up

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Type of studies and n

Synthesis Conclusion Level of evidence

A15 Karagülle and Karagülle28

Pubmed

S y s t e m a t i c review of ran-domized con-trolled trialsn=8

The objective was to evaluate the recent evidence on the efficacy of BT and SPA therapy for patients with low back pain. The databases for RCT published in Pubmed and Cochrane Central Register between 07/2005 and 12/2013. The Jadad scale was used to classify the methodological quality of eligibility, and of the total of 114, left 8, being three with scores> 3, indicating good quality. All trials tested the efficacy of BT/CT versus common water in SPA for low back pain. Of the 8 RCTs: 2 in BT and 6 in SPA therapy.

Evidence from all RCTs indicates that the efficacy of BT/CT in low back pain is encouraging and reflects the consistency of pre-vious evidence. All reported that BT/CT was superior in long-term therapy with tap water in pain reliever. Although when SPA therapy is combined with CT, geotherapy and/or exercises, and/or education is effective in the treatment of low back pain, it is superior or equally effective to short- and long-term control treatments.

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A16 Liu et al.29

PubmedExperimental, non- random-ized controlled trial. n=108

108 healthy primiparous women with single gestations in labor in China were studied. Of these, 80 progressed to normal delivery, 38 (EG) (mean of 28.66 ± 3.08 years old) were immersed in water maintained at 35-38°C and 70 (CG) (mean of 27.89 ± 2.99 years old) underwent conventional labor. Pain scores were evaluated (VAS) when cervical dilata-tion was 3 cm before entering the bathtub, and 30 and 60 min after.

The authors concluded that im-mersion of water during labor reduces pain with lower scores than in the control group at 30 min and 60 min after cervical dilatation of 3 cm respectively in both, p <0.001). The symp-toms of stress urinary inconti-nence (SUI) at 42 days postpar-tum were also higher in the CG (25.5% to 6.1% (EG) p = 0.035 and the rate of cesarean sec-tion was lower (p=0.026). There was no significant difference (p>0.05) in the duration of labor and postpartum bleeding and Apgar Index.

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A17 Baena-Beato et al.30

Pubmed

Experimental, r a n d o m i z e d controlled trialn=49

To understand the physical and psycholog-ical factors and reduction of disability after the aquatic/HT exercise of 49 patients of both genders sedentary with chronic low back pain. The patients were randomized: in EG-E1 (n=24, two months, five times/week) CG (n=25) according to the aquatic space program.

The authors concluded that the two-month intensive program of high-frequency (five times/week) HT significantly decreased lev-els of chronic low back pain and increased the mobilization of sedentary people; there were no changes in the standardized mental component (p<0.114); in-creased quality of life (p<0.001) and improved body composition and physical fitness of p<0.01 of EG. The CG did not present a significant change in any pa-rameter.

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A18 Baena-Beato et al31

Pubmed

Before and af-ter, experimen-tal, non-ran-domized con-trolled trialn=60

Sixty patients were included 30 of each gender; between 50 and 60 years old; body mass index, between 21 and 27 kg/m² with chronic low back pain. The 8-week aquatic/HT therapy program was conducted in a 25×6m indoor pool, 140cm deep and 30/31°C of T of water, and patients exercised 2 to 5 days/week. Each session lasted from 55 to 60 min-utes, (10 minutes of warm-up, 20 to 25 minutes of aerobic exercises, 15 to 20 minutes of resistance exercises, and 10 minutes of recharge).

Significant correlations were found between change in disabil-ity and VAS (resting, flexion and extension), curl-up and ranged from -0.353 to 0.582, all other parameters p <0.01. Significant predictors of change in disability after treatment were improve-ment of resting pain, flexion and extension and abdominal muscle resistance with HT.

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Articles Authors and database

Type of studies and n

Synthesis Conclusion Level of evidence

A19 Bender et al.32

Pubmed Meta-analysisn=18

Meta-analysis of randomized controlled trials with Hungarian hot springs, pub-lished between 1989 and 2012 in the Pubmed, Web of Science, Scopus, PEDro and Web of Knowledge databases. A total of 122 studies were identified, and 18 clin-ical trials were included. Of these, 5 eval-uated the effect of HT and CT on chronic low back pain, 4 on OAK and 2 on hand osteoarthritis and 1 evaluated BT/CT on chronic pelvic inflammatory diseases, the others 6) verified its effect on several labo-ratory parameters.

CT significantly reduces pain caused by different musculo-skeletal diseases, regardless of the qualitative and quantitative composition of mineral water, evidencing the beneficial effect of CT in pain with weight support and at rest in patients with joint and degenerative spinal diseas-es, as well as, in chronic pelvic inflammatory disease and antiox-idant states.

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A20 Larmer et al.33

PubmedS y s t e m a t i c review of ran-domized con-trolled trials. n=24

A systematic review was conducted at databases: EBSCO Health Databases (including Medline, CINAHL and SPORT Discus and Ovid), AMED Aliado and Complementary Medicine, Scopus, Co-chrane Library and PEDro including only randomized controlled trials in English that investigated the effect of HT on adult pain in any form of arthritis who had not undergone joint replacement surgery and that all had at least one patient-report-ed outcome (PRO) or VAS, published up to 08/2012 for a total of 375 intervention studies, systematic reviews and critical reviews.149 studies were excluded, 122 documents of these were identified, only 24 were included.

Exercise in water has been shown to be effective in reduc-ing pain by improving the func-tion and performance of ADL in people with arthritis. Few studies have demonstrated that HT is superior to other forms of exer-cise. More research is needed to develop a valid and reliable and reproducible method. Inadequate outcome measures may have af-fected HT research, possibly ex-plaining the lack of high-quality evidence for this intervention.

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A21 Lee et al.34

PubmedExperimental, r a n d o m i z e d controlled trialn=80

In order to verify the efficacy of hot HT in labor pain and delivery experiences during the first stage of labor, 80 wom-en were randomized: 41 in the CG and 39 in the EG in the teaching materni-ty hospital of Taipei City. The EG was showered at a controlled temperature of 37 ° C for 20 minutes. After a full 5-minute bath, in the sitting or standing position, the women spent 15 minutes directing the shower water to any re-gion of the body they desired. The CG received standard care. The pain and the delivery experience were evaluated using the VAS and the Labour Agentry Scale (LAS), respectively.

HT with hot water is economi-cal, convenient, easy to imple-ment, and the authors further stated that this PIC reduced pain (p<0.001). This non-pharmaco-logical intervention has helped women in labor to participate ful-ly in this process, with the contin-ued support of health profession-als, to feel comforted and to have a more positive overall delivery experience.

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A22 Cechetti, Fabro and Martini35

LILACS

Systematic re-view of clinical trialsn=8

They analyzed the efficacy of HT in pa-tients with hip and knee osteoarthrosis (OAQJ) by reviewing clinical studies, with data collection in the Scielo, Med-line, LILACS and Pubmed systems, list-ing articles in full, from 2003 to 2011. 8 articles were found, of these, 3 address HT in treatment for OAQJ, and 5 only for OAK. From the collected articles, the tests that served as parameters for analysis were the WOMAC, Lequesne Index, VAS-pain, physical function, and muscle strength. 

The authors showed that the studies analyzed show that HT in osteoarthrosis is effective when used to alleviate discomfort and pain, reflecting on the improve-ment of the quality of life of pa-tients with this disease. The lack of studies related to HT makes it difficult the approach of the pro-fessional.

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Articles Authors and database

Type of studies and n

Synthesis Conclusion Level of evidence

A23 Marques et al.36

LILACS

D e s c r i p t i v e qualitative and q u a n t i t a t i v e cross-sectional study,n=35

In order to investigate the knowledge and acceptance of PICS by physicians and SUS users. Three physicians and 35 SUS users were investigated for future implantation of PICS in the Basic Health Units (BHU).

This study demonstrated that. 100% did not know the PICS in general, and after a clear expla-nation of the researcher, 31.42% knew and would accept the use of phytotherapy, 51.42% acupuncture, 37.1% homeopa-thy, and none knew and would use CT. The 3 BHU physicians showed indifference, not ac-ceptance, and acceptance, re-spectively. the implementation of outreach programs for patients and especially for physicians pre-scribing PICS.

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A24 Stark and Miller37

Pubmed

Before and af-ter, experimen-tal, non-ran-domized con-trolled trial n=24

They explored the effects of bathing during labor using a single post-test pre-test group design at a small community hospital in Michigan. 24 women were observed for pain and comfort level. They used vital signs, VAS for pain, and the Gagge thermal com-fort scale. The contractions were palpated in the shower by the physician.

There were significant differenc-es in cervical dilatation (p=0.001), tension and pain (p=0.003) and fetal heart rate (p=0.001) after HT, although effective in relieving pain, reducing anxiety, induc-ing relaxation, HT is rarely used during labor.

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A25 Ferreira et al.38

PubmedBefore and af-ter, experimen-tal, non-ran-domized con-trolled trialn=8

To evaluate the effect of HT on pain and qual-ity of life of patients with rheumatoid arthritis (RA), nine patients were selected, aged 56.4 ± 5.2 years old, but only 8 were included, excluding those that were contraindicated, after physical therapy evaluation, also per-formed before and after treatment, including the application of the Short-Form-36 Ques-tionnaire (SF-36) and evaluation of morning stiffness, pain and sleep quality by VAS. The treatment consisted of 10 HT sessions of 45min each, 2 times/week. The data were treated statistically, with p<0.05.

They concluded that HT is a very used resource in the rehabilita-tion of these patients with RA due to the physical properties and physiological effects of water and the proposal made possible an improvement in health-related quality of life (p<0.05), reduction of pain symptoms (p=0.004), morning stiffness (p=0.003), and improvement in sleep quality (p=0.006). After the treatment, it was possible to verify the re-duction of morning stiffness and pain besides the improvement in sleep quality.

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A26 Silva et al.39

PubmedExperimental, blinded, ran-domized clinical trialn=57

They aimed to evaluate the efficacy of HT in 64 individuals of both genders with OAK compared to individuals with OAK in floor exercises. Randomized homogeneously from the Rheumatology Outpatient Clinic of the Hospital São Paulo (UNIFESP/EPM), performing exercises for 18 weeks. Patients with clinical and radiographic diagnosis of OAK were included with the American Col-lege of Rheumatology criteria in Western Ontario and WOMAC with 3 subscales: pain, stiffness and physical function and pain ranging from 30 to 90mm in VAS the previous week. They were evaluated during walking, by VAS at rest and immediately af-ter a walking test (50FWT) 50 feet (15.24m), walking time measured in quick and com-fortable steps during and the Lequesne In-dex. Measurements recorded by a blinded investigator at the beginning and at the 9 and 18 weeks after the intervention com-menced. 57 patients concluded the study.

HT was superior to ground ex-ercise in pain relief (p <0.001) before and after walking during the last follow-up. The authors concluded that both types of exercises (HT and terrestrial) re-duced knee pain and increased their function in participants with OAK. Water-based exercises are a suitable and effective alterna-tive for pain reduction and im-provements in WOMAC and Le-quesne scores. Pain before and after 50FWT decreased signifi-cantly in both groups, but there was no significant difference in pain in the previous week be-tween groups.

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The critical analysis of the results (Table 2) showed that LEs ranged from 1 to 5, with 8 (29.6%) three meta-analyzes18,25,32, five systematic reviews of RCTs (SRRCT)24,27,28,33,35 and 6 (22.2%) randomized clinical trials (RCT)14,20,21,30,34,39 were found in LE 1 and 2 respectively; non-randomized controlled tri-als (NRCT)15-17,22,23,26,29,31,37-38,40 11 (40.7%) (LE 3); a Cohort19 (3,7%) in LE 4; in LE 5 only one (3.7%) qualitative and quan-titative descriptive study was identified36 and none in the LE 6 and 7. Therefore, the studies focused on the hierarchical levels of evidence 1 to 312,13 considered high and moderate and when related to the quality of strong and sufficient evidence levels13, respectively, demonstrating that the PICS studied appear to be effective in pain control. However, they should be further ex-plored and studied scientifically to validate them academically.Regarding the type of study, adding the meta-analysis18,25,32

(11.1%) and SRRCT24,27,28,33,35 (18.5%) and RCT14,20,21,30,34,39

(22.2%) had a total of (51.8%) higher than the number of non-randomized clinical trials (NRCT)15-17,22-23,26,29,31,37-38,40 (40.7%), ratifying the quality of evidence raised regarding the ef-ficacy of BT/CT and HT in relieving pain of various symptoms. This study showed that the focus of 18 (66.66%) articles focused on the efficacy of HT in the pain of several etiologies and eight (29.6%) in CT in pain. Among these 18 articles, 11 (61.1%) are NRCT 15-17,22-23,26,29,31,37-38,40; six (33.3%) of RCT14,20,21,30,34,39

and one of SRRCT24,27,28,33,35 (5.6%) predominating those of os-teoarticular origin, being (62.5%) of LE 1 and three (37.5%) of LE 2 of musculoskeletal origin, confirming the scientific rigor of the studies and the PICS are recommended for the treatment of these types of pain problem. An SRRCT28 has shown that evidence from RCTs on the efficacy of BT/CT in chronic low back pain is encouraging and reflects the consistency of previ-ous evidence. Moreover, the authors28 suggest that well-designed, conducted and reported RCTs are needed to test short- and long-term effects to control pain and to demonstrate broader beneficial effects.

Articles Authors and database

Type of studies and n

Synthesis Conclusion Level of evidence

A 27 Silva et al.40

BVS (LILACS)Experimental, non- random-ized controlled trial.n=10

The authors compared the efficacy of HT and TENS in improving the symptoms of 10 patients with fibromyalgia (48.8±9.8 years old) divided into 2 groups: one treated with HT (EG) and one with TENS (CG). All sub-jects were evaluated before and after treat-ment for flexibility (by third finger-soil index), pain (by VAS) health-related quality of life (using the SF-36 and Nottingham Health Profile (NHP) questionnaires and depression (by the Beck’s inventory). The data were treated statistically, with a significance level set at p <0.05.

Both treatments were effec-tive in improving physical fitness, but TENS (p≤0.007) provided better pain scores and in a greater number of analyzed variables than HT (p≤0.076), suggesting to be more effective in the treat-ment of fibromyalgia. How-ever, patients treated with HT could present better results if the treatment time was longer, since the therapeutic pool may have greater effect on conditioning and long-term functional capacity.

3

VAS = visual analog scale; NICU = neonatal intensive care unit; ADL = activities of daily living; TENS = transcutaneous electrical nerve stimulation; HT = hydrotherapy; HB=BT/CT = balneotherapy/cryotherapy; WOMAC = Western Ontario and McMaster Universities Osteoarthritis.

The PICS in question were included in PNPIC1 in 2006 in Brazil, whose scientific studies in the country are still incipient. However, “therapies are present in 9,350 establishments in 3,173 municipalities, of which 88% are offered in basic care. In 2017, 1.4 million individual visits were recorded in PIC. In addition to the collective activities, the estimate is that about 5 million peo-ple per year participate in these practices in the SUS. Scientific evidence has shown the benefits of integrated treatment between conventional medicine and PICS”13.The three meta-analyzes18,25,32 analyzed (LE1) evidenced the ef-ficacy and beneficial results of CT(2) and HT(1) for pain con-trol in knee osteoarthritis (OAK) and hand (OAH), chronic low back pain, chronic pelvic pain, degenerative joint and spinal diseases, antioxidant occurrences, metabolic and inflammatory parameters, increasing blood flow and muscle relaxation. Also, HT with Chinese herbs25 may be effective in reducing OAK pain when compared to standard western treatment. Similarly, the five (27.7%) SRRCT24,27,28,33,35 solidly demonstrated the efficacy of CT(2) and HT(5), when combined or even isolated, in labor pain, in the low back pain, arthritis and OAK, and in the hip and ankle.Regarding the RCTs14,20,21,30,34,39 of LE2, the six (22.2%) an-alyzed the efficacy of CT(2) and HT(4) concerning pain in labor, as in of the newborn (NB), musculoskeletal and osteo-articular. All showed a significantly better effect not only on the intensity of pain and stress but also on other parameters evaluated in comparison to the baseline condition of each one, demonstrating that these PICS are economical, harmless, effec-tive and safe.Analyzing the 11 NRCT15-17,22,23,26,29,31,37,38,40 all investigated HT in several painful situations, as in pain in fibromyalgic women15,40; in puerperae16; in the pelvic pain of pregnant women17; in osteoarticular and musculoskeletal pain22,23,26,38,40, pain during labor29,37, all of which are effective in improving painful symptoms.

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This review also included a qualitative and quantitative cross-sectional study36 that investigated the knowledge and ac-ceptance of PICs by SUS physicians and users to show the lack of knowledge of users and professionals, and also considering that such article could stimulate further research since 100% of the respondents ignored the existence of most PICS. This study finds resonance in another, eight years later, that verified the knowledge, and the use of PICS for pain control by the population of the larger cities of Vale do Paraíba Paulista41 with similar results, since of 100 respondents, only 17.5% knew and 82.5% did not know them. The population still does not know the PICs that the SUS offers, using in greater number the old-er therapy, acupuncture, which was already part of the SUS, which shows the importance of studying, explaining, dissemi-nating and presenting the PICS and its advantages the commu-nity. Therefore, systematic, randomized and controlled studies are needed that result in high, strong and sufficient evidence13 of PICS in the treatment of pain, which render people partially or totally disabled, transiently or permanently, triggering stress, suffering, and loss of quality of life (QoL)4, The limiting factors for the actual realization of the use of PICS are the scarce scientific evidence of a strong and sufficient lev-el13 and the lack of knowledge about their use by health pro-fessionals. However, even limited, it seems correct to say that this study showed the efficacy of CT and HT in the treatment of pain in organic changes such as the knee, hand and ankle osteoarthritis; the musculoskeletal; those of obstetric origin. It also warns of the need for further research on how PICS may contribute to pain relief and reiterates that it is now mandatory to measure, control and record it by EAS health professionals as the Fifth Vital Sign. Given the above, including PICs in the treatment of pain, is an important issue to ensure comprehen-sive health care.

CONCLUSION

Most of the evidence emerged from the studies analyzed focused on levels 1 to 3 regarding the effective use of PICS, CT, and HT. Of the 18 articles on the efficacy of HT, eight on CT in the pain charts of knee, hand and ankle and musculoskeletal osteoarthri-tis and one in obstetric pain.In most studies, evidence for the efficacy of PICS, CT, and HT was focused on levels 1 to 3. The efficacy of HT was demon-strated in 18 articles: five in labor pains, two in fibromyalgia, ten musculoskeletal and pain caused by osteoarthritis of the knee, hand, hip and ankle, and in an article concerning the pain of newborns. The efficacy of CT was evidenced in eight articles of musculoskeletal pain due to knee, hand, hip and ankle osteoar-thritis; and a qualitative article that shows the lack of knowledge of users and professionals about the use of PICS in SUS. It also showed that there are few scientific subsidies to scientifically sub-stantiate the use of HT and CT in the treatment of pain, needing to increase the knowledge of these PICs with actions of perma-nent education, and at the same time, stimulate the increase of the scientific production by the health professionals for the effec-tive use of these PICS.

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23. Fonseca LB, Brito CJ, Silva RJ, Silva-Grigoletto ME, da Silva WM Junior, Franchini E. Use of cold-water immersion to reduce muscle damage and delayed-onset muscle soreness and preserve muscle power in Jiu-Jitsu athletes. J Tthl Train. 2016;51(7):540-9.

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31. Baena-Beato PÁ, Delgado-Fernández M, Artero EG, Robles-Fuentes A, Gatto-Cardia MC, Arroyo-Morales M. Disability predictors in chronic low back pain after aquatic exercise. Am J Phys Med Rehabil. 2014;93(7):615-23.

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33. Larmer PJ, Bell J, O’Brien D, Dangen J, Kersten P. Hydrotherapy outcome measures for people with arthritis: a systematic review. N Zealand J Physiother. 2014;42(2):54-67.

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da osteoartrose de quadril e joelho. Fisioter Bras. 2012;13(5):384-9.36. Marques LA, Vale F, Vieira VR, Nogueira VA, Mialhe FL, Silva LC. Atenção far-

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40. Silva TF, Suda EY, Marçulo CA, Paes FH, Pinheiro GT. Comparação dos efeitos da estimulação elétrica nervosa transcutânea e da hidroterapia na dor, flexibilidade e qual-idade de vida de pacientes com fibromialgia. Fisioter Pesqui. 2008;15(2):118-24.

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ABSTRACT

BACKGROUND AND OBJECTIVES: The cauda equina syn-drome is a neurological condition prevalent in dogs which neu-rological signs are caused by the compression of the nerve roots located in the lumbosacral spinal canal and is frequently associ-ated with pain, claudication, paresis or paralysis of the hindlimbs and changes in the functioning of the sphincters. The objective of this study was to check the effects of the epidural injection with the combination of dexamethasone, bupivacaine and mor-phine on the relief of pain and neurological signs in a dog with traumatic cauda equina syndrome. CASE REPORT: Case study of a 2-year old Red Heeler dog, weighing 16kg with a diagnosis of post-trauma cauda equina syndrome. The evaluation consisted of neurological and pain assessment (visual analog scale), quality of life (“5H2M”) and infrared thermography. After the initial evaluation and authori-zation of the tutor, the dog was submitted to general anesthesia and a lumbosacral epidural block, guided by electrostimulation, with the association of dexamethasone, bupivacaine and mor-phine. After the procedure, the dog showed immediate remission of claudication, paresis and satisfactory analgesia on days 0, 15, 30 and 60 after the intervention. CONCLUSION: The epidural block was effective in improving pain, quality of life and neurological signs and may be an excel-lent alternative in dogs with pain syndromes associated with the spinal canal. Keywords: Epidural anesthesia, Cauda equina syndrome, Pain, Polyradiculopathy, Veterinary.

Interventional analgesic block in a dog with cauda equina syndrome. Case reportBloqueio analgésico intervencionista em cão com síndrome da cauda equina. Relato de caso

Rodrigo Mencalha1, Camila de Souza Generoso1, Daniel Sacchi de Souza1

Rodrigo Mencalha - https://orcid.org/0000-0002-5941-2902;Camila de Souza Generoso - https://orcid.org/0000-0003-4885-7487;Daniel Sacchi de Souza - https://orcid.org/0000-0002-5401-8447.

1. Faculdade de Medicina Veterinária, Centro de Ensino Superior de Valença, Valença, RJ, Brasil.

Submitted on November 20, 2018.Accepted for publication on February 18, 2019.Conflict of interests: none – Sponsoring sources: none.

Correspondence to: Rua Sargento Vitor Hugo, 161 – Fátima27600-000 Valença, RJ, Brasil. E-mail: rodrigo.mencalha@faa.edu.br

© Sociedade Brasileira para o Estudo da Dor

RESUMO

JUSTIFICATIVA E OBJETIVOS: A síndrome da cauda equi-na é uma afecção neurológica prevalente em cães cujos sinais neurológicos são causados pela compressão de raízes nervosas localizadas no canal espinhal lombossacral sendo frequentemen-te associada à dor, claudicação, paresia ou paralisia de membros pélvicos e alterações do funcionamento dos esfíncteres. O objeti-vo deste estudo foi verificar os efeitos da injeção peridural com a associação de dexametasona, bupivacaína e morfina no alívio da dor e dos sinais neurológicos em um cão com síndrome da cauda equina de origem traumática. RELATO DO CASO: Estudo do caso de um animal da espécie canis familiaris, raça red heeler, fêmea, 2 anos de idade e 16kg de peso corporal com diagnóstico de síndrome da cauda equina pós--trauma. A avaliação consistiu no exame neurológico completo, avaliação de dor (escala analógica visual), de qualidade de vida (“5H2M”) e por termografia infravermelha. Após a avaliação inicial e autorização do tutor, a cadela foi submetida à anestesia geral e a um bloqueio intervencionista peridural lombossacral, guiado por eletroestimulação, com a associação de dexameta-sona, bupivacaína e morfina. Após o procedimento, a cadela apresentou imediata remissão da claudicação, da paresia e uma satisfatória analgesia nos dias 0, 15, 30 e 60 após a intervenção. CONCLUSÃO: O bloqueio peridural intervencionista foi eficaz na melhora da dor, da qualidade de vida e dos sinais neurológi-cos, podendo ser uma excelente alternativa em cães com síndro-mes dolorosas associadas ao canal espinhal.Descritores: Anestesia peridural, Cauda equina, Dor, Polirradi-culopatia, Veterinária.

INTRODUCTION

Cauda equina syndrome (CES) is a neurological condition prev-alent in dogs whose signs appear due to the compression of the nerve roots called cauda equina. Anatomically, these roots, locat-ed between the 7th lumbar vertebrae and the 5th coccygeal verte-brae, may be the target of multifactorial compressions1.The clinical signs most observed in these animals are associated with pain in the lumbosacral region, limb claudication of the pelvic limbs, with or without muscle weakness2, and may present paresis or paralysis. Also, the presence of changes in propriocep-tion and urinary and/or fecal incontinence is not uncommon3. The syndrome usually happens with changes in the animal’s daily activities such as running, jumping, climbing stairs, and exercise usually exacerbates these signs3.

BrJP. São Paulo, 2019 apr-jun;2(2):199-203

DOI 10.5935/2595-0118.20190034

CASE REPORT

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Conventional diagnosis usually associates the animal’s history with clinical and neurological findings. However, imaging scans such as radiography and computerized tomography are essen-tial for determining the exact location of the injury. In addition, infrared thermography may contribute to the determination of peripheral and central neuropathic syndromes in humans4-7, so that, it is possible that it has good predictive value in the diagno-sis of CES in dogs. Among the clinical findings, the presence of proprioceptive deficits, muscular atrophy, paraparesis, and uri-nary and fecal incontinence are notorious8.In veterinary medicine, the conservative treatment with the use of anti-inflammatories is one of greater adhesion among the pro-fessionals. However, depending on the severity of the injuries, decompression surgery may be critical to the positive outcome. The prognosis depends on the etiology, time elapsed of the dis-ease, the degree of neurological impairment and the type of treat-ment used9.The objective of this study was to verify the effects of epidural injection with the association of dexamethasone, bupivacaine, and morphine on pain relief, on quality of life improvement and neurological signs in a dog with traumatic CES.

CASE REPORT

This is a case report study, which the Free and Informed Con-sent Form (FICT) of the Valença Higher Education Center of the Dom André Arcoverde Educational Foundation has been ex-plained and signed by the person responsible for the animal, who was aware of all the stages of the study. Interventionist analgesic blockade was performed in the operating room on the day sched-uled with the guardian of the animal after signing the FICT.On evaluation day, the evaluator A performed basic neurological examinations such as superficial and deep pain tests, panniculus reflex, patellar tendon reflexes, and proprioception. Evaluator A observed severe limb claudication in the left pelvic limb, bilat-eral patellar hyperreflexia and conscious proprioception deficit in the left pelvic limb. There was no change in urinary and anal sphincter function. The evaluator B evaluated pain and quality of life (QoL) using the visual analog scales (VAS) and QoL “5H2M”, respectively, and a complete infrared thermography examination. The VAS is a numerical scale from zero (absence of pain) to 10 (worst pain imaginable), in which the tutor was asked to indicate, quanti-tatively, the pain presented at the time of evaluation. The QoL scale is an instrument developed to assist tutors and veterinar-ians in bioethical decisions related to life and death. This scale is known as “5H2M” which evaluates the clinical status of the animal through the parameters H-hurt, H-hunger, H-hydration, H-hygiene, H-happiness), M-mobility and M-more good than bad days. The 5H2M is a numerical scale from zero to 70 with the score of 35 being the minimum acceptable to attest adequate QoL10. Infrared thermography was performed with a FLIR T420 camera in an air-controlled environment at 21º C, 60% relative humidity, with no light and respecting the acclimation period of 20 minutes as recommended by the American Infrared Ther-mography Guidelines for Animals11.

The pain score defined by the tutor’s evaluation was VAS=8, and the QoL score was “5H2M”=20. In the thermographic exam-ination, there were significant changes in the thermal patterns in the dermatomeres (secondary hypo radiation to the sympathetic neurovegetative hyperreactivity) of the left pelvic limb (affected) in different segments, namely: EI1 and EI2 = knee medial facet; EI3 and EI4 dorsal aspect of the tibiotarsal joint; EI5 and EI6 dorsal aspect of the metatarsus (Figure 1).After initial evaluations and data collection, the animal was referred to the operating room for an interventionist analgesic blockade. The technique chosen in this study was based on the data observed in humans12 and also on the difficulty of the tutor in adhering to the conservative treatment with oral anti-inflam-matory because it is a herding dog whose dwelling in a rural area would interfere with the administration of the drug. Thus, electro stimulation-guided epidural administration com-bining dexamethasone (4mg)13, bupivacaine 0.125% (0.22mL.kg-1), and morphine (0.1mg.kg-1)14 was the selected approach.Based on the above, the technique proposed in the study fol-lowed the order below: Intravenous catheterization with a 22G device and anesthetic in-duction with 4mg.kg-1 of propofol. The animal was kept in 100% oxygen under an orofacial mask; electrocardiographic monitoring in DII, pulse oximeter, plethysmography, and noninvasive blood pressure; rigorous trichotomy and antisepsis of the lumbosacral region. A 50mm gage neurostimulation needle was introduced in the lumbosacral region (L7-S1) with the neuro localizer calibrat-ed at 0.7mA, 0.1ms and 1Hz15; localization of the epidural space after motor responses of abduction of the pelvic limbs and tail lateralization; infiltration of the dexamethasone, bupivacaine and morphine solution with slow injection for about 60 seconds. After the analgesic blockade, the animal was taken to the post-anes-thetic recovery room and discharged after 60 minutes of observation. Besides, the need for a veterinary reassessment was clarified to the tu-tor on 15, 30 and 60 days after the intervention, since in case of no remission of symptoms, further epidural infiltration may be necessary.

Figure 1. Thermography of the dog’s pelvic limbs in the position of two supports EI1 (mean 31.9° C); EI2 (mean 29.5° C); EI3 (mean 30.7° C); EI4 (mean 28.0° C); EI5 (mean 29.8° C); EI6 (mean 27.3° C). Temperature variation (EI-1 - EI2) = 2.4° C; (EI3-EI4) = 2.7° C; (EI5-EI6) = 2.5° C).

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The clinical signs, pain scores, and QoL were reassessed 15, 30 and 60 days after the procedure and the skin temperature and thermographic image were repeated 60 days later. The data col-lected in the pre- and post-intervention phases were registered in the Windows Microsoft Excel, Software version 2016.Table 1 presents the pain data, measured by VAS and QoL eval-uated by the “5H2M” pre- and post-analgesic intervention. Through VAS, it was observed that the dog had a decrease in pain intensity after 15 days of the intervention (VAS=2), reach-ing a zero score as of day 30. In the QoL assessment, the score reached 70 points in the day 60 evaluation. Table 2 presents data referring to the cutaneous thermometry of the EI1 and EI2 regions (medial face of the knee); EI3 and EI4 (dorsal aspect of the tibiotarsal joint) and EI5 and EI6 dorsal aspect of the metatarsal before and after the intervention. Figure 2 shows the thermal image of the affected and contralateral limbs performed 60 days after the intervention. Infrared thermography monitoring showed a significant improvement in the sympathet-ic vasomotor hyperreactivity of the left pelvic limb (affected) in segments 2, 4 and 6 with a temperature difference of 1.0° C, 0.1° C and 0.4° C, in relation to the contralateral limb, respectively. In general, the animal presented clinical improvement in all do-mains evaluated, including neurological signs (proprioception, patellar reflex, claudication, and cutaneous panniculus reflex) and pain and QoL scores.

Table 1. Neurological signs, pain score, and quality of life pre- and post-intervention

Domains Pre-intervention (Day 0) Post-intervention (Day 15) Post-intervention (Day 30) Post-intervention (Day 60)

Claudication Present in LPL Discrete in LPL Absent Absent

Pain (VAS) 8 2 0 0

Reflex of the Panniculus Normal Normal Normal Normal

Proprioception Decreased in LPL Normal Normal Normal

Quality of Life (“5H2M”) 20 50 70 70

Patellar Reflex Increased in RPL/LPL Increased in RPL/LPL Normal NormalVAS = visual analog scale; LPL = left pelvic limb; RPL = right pelvic limb.

Table 2. Cutaneous thermometry of the EI1 and EI2 regions (medial face of the knee); EI3 and EI4 (dorsal aspect of the tibiotarsal joint)

Regions Pre-intervention (Day 0) Post-intervention (Day 60)

EI1 31.9o C 32.0o C

EI2 29.5o C 31.0o C

EI1-EI2 2.4o C 1.0o C

EI3 30.7o C 31.2o C

EI4 28.8o C 31.1o C

EI3-EI4 2.7o C 0.1o C

EI5 29.8o C 29.8o C

EI6 27.3o C 29.4o C

EI5-EI6 2.5o C 0.4o C

Figure 2. Thermographic image of the pelvic limbs of the dog in po-sition on two supportsEI1 (mean 32.0° C); EI2 (mean 31.0°C); EI3 (mean 31.2° C); EI4 (mean 31.1°C); EI5 (mean 29.8° C); EI6 (mean 29.4° C). Temperature variation (EI-1 - EI2) = 1.0° C; (EI3-EI4) = 0.1° C; (EI5-EI6) = 0.4° C).

DISCUSSION

CES in dogs is a neurological condition whose clinical signs are related to the nerve root lesion of the 7th lumbar vertebra, sacral or coccy-geal vertebrae, caused by dorsoventral stenosis of the vertebral canal1. Congenital stenosis, disc protrusions, and spondylosis are among the most frequent disorders of the syndrome. However, traumatic situa-tions such as vertebral fractures and dislocations and diskospondylitis (spondylodiscitis) are also associated with this syndrome9.

In the present report, it was observed dorsoventral stenosis of the vertebral canal in the lumbosacral region without the involve-ment of sacral or coccygeal vertebrae. Clinical signs are inherent to the affected segment of the medulla and/or involved nerve, so, depending on the affected region it is common to observe the presence of lumbosacral pain, claudication, muscular atrophy in the area inherent to the sciatic nerve, paresis, tail weakness, uri-nary and/or fecal incontinence disorders and paresthesia2.Lumbosacral pain is the most prevalent clinical characteristic in these animals. Therefore, the presence of an antalgic posture with hyperkyphosis of the spine is notorious. In the present report, the tutor’s search for pain and palliative care was due to the ani-mal’s reluctance to perform common activities such as running, playing or jumping. Also, it was reported by the tutor the refusal of food in the days before the appointment. In addition to the notorious presence of lumbosacral pain, the animal in this report presented severe claudication in the left pelvic limb. This clinical sign is the second most frequent in this syndrome, which is asso-ciated with pain referred by the incarceration of the nerve roots of L6, L7, and S1. These roots contribute to the formation of the sciatic nerve, and its compromising may lead to motor deficits16.

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The motor activity contributes to the increase in the circulatory demand of the spinal cord and cauda equina. However, due to spinal canal stenosis, hypoperfusion results in ischemia of the nerve roots and subsequent root pain and/or referred pain in the limbs, tail, and perineum9. The images obtained by infrared thermography corroborate this statement since an intense area of hyporadiation was observed in the left pelvic limb, secondary to sympathetic neurovegetative hyperreactivity, probably due to the incarceration of the nerve roots of L7 and S1. Paresis or paralysis of the pelvic limbs only occurs when the nerve roots of L4 to S2 are affected or even in the traumatic inju-ries of the nerves that make up the limb. However, if the sciatic nerve is affected, the animal can support the weight of the resting limb on the back of the paw16. In the present report, intermittent paresis of the left pelvic limb was observed, which was totally eliminated after the interventionist blockade. The urination and defecation reflexes were not altered in this studied animal. Usually, they will be absent when lesions occur in the nerve roots or segments of the spinal cord from S1 to S3 whose sites contribute to the formation of the pudendal nerve. The injuries inherent to the cranial segments in this region do not compromise the functioning of these sphincters17. When lesions are associated only with the sacral and coccygeal nerve roots, the presence of atonic tail is also prevalent, which was also not observed in the dog of this study. Paresthesia occurs as a result of irritation of sensitive fibers of the cauda equina which are derived from dermatomeres innervated by the sciatic and pudendal nerves, due to the compression of the vertebral canal. These abnormal sensations can occur with burning, stinging, tingling or shock, which induces the animal to lick and/or bite the affected areas causing dermatological abrasions and self-mu-tilation8. After the appointment, the tutor reported an excess of bite in the lumbosacral region. However, due to the presence of ectopar-asites, it was not possible to attest the reliability of this information.The treatment of animals affected by CES is directed to the cause and severity of the injury, being classified as conservative or sur-gical. Usually, conservative treatment in veterinary medicine is based on the systemic use of anti-inflammatory/analgesic and confinement. However, due to the long period of treatment, the known adverse effects inherent in non-steroidal anti-inflamma-tory drugs and corticosteroids are frequent in these animals18. Thus, due to recent advances in the area of pain interventionist medicine, this study preconized the use of anti-inflammatory and analgesic drugs directly at the site of the injury to optimize anti-inflammatory and analgesic therapy and minimizing long-term use of these drugs and their subsequent adverse effects.Interventionist pain medicine is a broad area of medicine that of-fers many possibilities for diagnosis and treatment of many types of pain, through minimally invasive procedures, usually with the use of needles. Imaging tests such as ultrasound and radiographs are critical to the accuracy of drug infusion into the desired tar-get and to minimize the risks of iatrogenic failures and injuries. In the present report, epidural analgesic blockade (lumbosacral translaminar) with the combination of dexamethasone, bupivacaine, and morphine was chosen. Bupivacaine is a local anesthetic that pro-motes long-term motor and sensory blockade. However, the use of

low-concentration bupivacaine (0.125%) was preconized to avoid motor blockage of the pelvic limbs. The association of morphine with the analgesic combination aimed at the installation of long-term an-algesia because, due to its low degree of ionization, it is estimated that its analgesia is of nearly 16 hours when administered via epidural19,20.The use of epidural dexamethasone is not a common practice in veterinary medicine. However, it has been highly explored in interventionist blockades in humans. Corticosteroids exert their anti-inflammatory action, interrupting the arachidonic acid pathway of the damaged cell membrane. Its epidural use is associated with the reduction of the edema, fibrin deposition, capillary dilatation, leukocyte migration, capillary fibroblast pro-liferation, and collagen deposition8. In addition, some studies suggest that corticosteroids may reduce the hyperexcitability of the nerve cell by directly affecting the cell membrane conduc-tion9. Thus, since CES often presents with edema of the nerve roots and an intense inflammatory process, the choice of inter-ventionist analgesic treatment has substantial support since the mechanism of action of these drugs leads to the reduction of the edema of the nerve roots and even the adjacent tissues. Among the corticosteroids described for use in epidural injection in humans stand out the methylprednisolone acetate, triamcino-lone salts, and dexamethasone9. In humans, methylprednisolone is the most widely used drug with doses ranging from 40 to 120mg per injection. Dexamethasone has been frequently used in anal-gesic blockades with the main advantage being its high potency and duration. In veterinary medicine, only one study reports the use of epidural dexamethasone13. This work evaluated the analge-sic influence of different doses of dexamethasone (2, 4 and 8 mg) associated with lidocaine in dogs submitted to ovary salpingohis-terectomy. It was observed in this study that there was a growing potentiation of postoperative analgesia with the use of epidural dexamethasone in a dose-dependent manner. The first veterinary clinical study with epidural corticosteroids evaluated 38 dogs with Hansen lumbosacral disc protrusion type II after epidural infil-tration of methylprednisolone acetate. In that study, the epidural infiltration, performed by fluoroscopy, was carried at standard in-tervals for the first three treatments and, subsequently, on demand, which improvement was perceived by the tutor in 79% of the an-imals and 53% were considered totally cured18.An important factor in the administration of corticosteroids via epidural is the choice of the diluent. Usually, the association should be performed with an isotonic physiological solution or local anesthetic. Some authors have been recommending dilu-tion in local anesthetic because it gives the patient better comfort after epidural injection8. The volume of the epidural solution is also the subject of intense discussion in veterinary medicine. Traditionally, it is recommend-ed the use of an average volume of about 0.25mL.kg -1 21. How-ever, larger volumes are used when more cranial dermatomeres are desired22. In humans, the discussion of this subject is also wide and controversial. Some authors believe that small volumes of the solution are insufficient to reach the ventral aspect of the epidural space. However, other authors believe that the effect of the corticosteroid is independent of the volume injected but is due to the closest possible administration to the affected site12.

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In case only one corticosteroid epidural injection is enough to relieve pain, and neurological signs of the patient usually are not indicated to repeat the procedure1. In the present report, the re-mission of clinical signs associated with pain and neurological components were solved with a single injection of the proposed combination. In humans, some patients respond well to the sec-ond or third epidural corticosteroid injection12. However, there are no reports of repeated injections into companion animals.Because this is an exclusively interventionist analgesic procedure, the failure of the technique becomes more severe than the anes-thetic epidural blockade performed by surgery because, in case of perioperative technique failure, another analgesic modality is promptly put in place. Therefore, it is essential that the proce-dure is performed with equipment that minimizes the risk of erratic injection, such as the peripheral nerve stimulator and/or ultrasound. In the present report, the epidural injection was per-formed with the aid of the peripheral nerve stimulator regulated at 0.7mA, 0.1ms, and 1Hz15. In humans, the use of fluoroscope has gained prominence in the last decade and has been used in almost all interventionist blockades. The wide clinical epidural use of corticosteroids in humans is generally related to the relief of pain syndromes resulting from inflammation of the neural structures of the epidural and peri-neural spaces12, which may be used for low back pain, sciatic pain, sacral pain, radicular pain, radiculopathy, lumbosciatalgy, nerve root compression, protrusion, prolapse or disc hernia and lumbar canal stenosis. Thus, it is valid the discussion about the epidural use of corticosteroids in these syndromes mentioned in dogs and cats since the result is likely to be similar to those ob-tained in humans. The complications inherent to interventionist epidural blockade are associated with the technique itself and the side effects of the selected drugs. The complications of the technique are perfora-tion of the dura-mater, accidental subarachnoid or intravascular injection. The minor complications, when the interventionist blockade is associated with the local anesthetic, are arterial hy-potension, motor block, and prolonged sensory block. Major complications include meningitis, systemic infection, epidural hematoma, abscess, CES, neurotoxicity, and the development of hyperadrenocorticism when corticosteroids are used12.

CONCLUSION

Interventionist epidural blockade was effective in pain relief, QoL, and neurological signs, and may be an excellent alternative in dogs with pain syndromes associated with the spinal canal.

REFERENCES

1. Orendácová J, Marsala M, Sulla I, Kafka J, Jalc P, Cizková D, et al. Incipient cauda equina syndrome as a model of somatovisceral pain in dogs: spinal cord structures involved as revealed by the expression of c-fos and NADPH diaphorase activity. Neu-roscience. 2000;95(2):543-57.

2. Tan JM, Wu J, Shi JG, Shi GD, Liu YL, Liu XH, et al. Brain-derived neurotrophic factor is up-regulated in severe acute cauda equina syndrome dog model. Int J Clin Exp Med. 2013;6(6):431-7.

3. Saey V, Martlé V, Van Ham L, Chiers K. Neuritis of the cauda equina in a dog. J Small Anim Pract. 2010;51(10):549-52.

4. Neves EB, Vilaça-Alves J, Rosa C, Reis VM. Thermography in neurologic practice. Open Neurol J. 2015;9:24-7.

5. Niehof SP, Huygen FJ, van der Weerd RW, Westra M, Zijlstra FJ. Thermography imaging during static and controlled thermoregulation in complex regional pain syn-drome type 1: diagnostic value and involvement of the central sympathetic system. Biomed Eng Online. 2006;5:30.

6. Niehof SP, Beerthuizen A, Huygen FJ, Zijlstra FJ. Using skin surface temperatu-re to differentiate between complex regional pain syndrome type 1 patients after a fracture and control patients with various complaints after a fracture. Anesth Analg. 2008;106(1):270-7.

7. Gulevich SJ, Conwell TD, Lane J, Lockwood B, Schwettmann RS, Rosenberg N, et al. Stress infrared telethermography is useful in the diagnosis of complex regional pain syndrome, type I (formerly reflex sympathetic dystrophy). Clin J Pain. 1997;13(1):50-9.

8. De Decker S, Watts V, Neilson DM. Dynamic lumbosacral magnetic resonance ima-ging in a dog with tethered cord syndrome with a tight filum terminale. Front Vet Sci. 2017;4:134.

9. Spector LR, Madigan L, Rhyne A, Darden B 2nd, Kim D. Cauda equina syndrome. J Am Acad Orthop Surg. 2008;16(8):471-9.

10. Villalobos AE. Quality-of-life assessment techniques for veterinarians. Vet Clin North Am Small Anim Pract. 2011;41(3):519-29.

11. Turner TA, Waldsmith J, Marcella K, Henneman K, Purohit RC, Morino D, et al. Veterinary guidelines for infrared thermography. The American Academy of Thermo-logy. https://aathermology.org/organization-2/guidelines/veterinary-guidelines-for--infrared-thermography/.

12. Cocicov AF, Cocicov HL, da Silva MB, Skare TL. [Epidural steroids for low back pain syndromes]. Rev Bras Anestesiol. 2004;54(1):129-41. English, Portuguese.

13. Hermeto LC, Rossi R, Bicudo NA, Assis KT, Escobar LL, Camargo PS. The effect of epidurally administered dexamethasone with lignocaine for post-operative anal-gesia in dogs undergoing ovariohysterectomy. A dose-response study. Acta Cir Bras. 2017;32(4):307-18.

14. Steagall PVM, Simon BT, Teixeira Neto FJ, Luna SPL. An update on drugs used for lumbosacral epidural anesthesia and analgesia in dogs. Front Vet Sci. 2017;4:68.

15. Otero PE, Verdier N, Ceballos MR, Tarragona L, Flores M, Portela DA. The use of electrical stimulation to guide epidural and intrathecal needle advancement at the L5-L6 intervertebral space in dogs. Vet Anaesth Analg. 2014;41(5):543-7.

16. Marsala J, Sulla I, Jalc P, Orendacova J. Multiple protracted cauda equina constrictions cause deep derangement in the lumbosacral spinal cord circuitry in the dog. Neurosci Lett. 1995;193(2):97-100.

17. Kaiser R, Nasto LA, Venkatesan M, Waldauf P, Perez B, Stokes OM, et al. Time factor and disc herniation size: are they really predictive for outcome of urinary dysfunction in patients with cauda equina syndrome? Neurosurgery. 2018;83(6):1193-200.

18. Janssens L, Beosier Y, Daems R. Lumbosacral degenerative stenosis in the dog. The results of epidural infiltration with methylprednisolone acetate: a retrospective study. Vet Comp Orthop Traumatol. 2009;22(6):486-91.

19. Rosen MA, Hughes SC, Shnider SM, Abboud TK, Norton M, Dailey PA, et al. Epi-dural morphine for the relief of postoperative pain after cesarean delivery. Anesth Analg. 1983;62(7):666-72.

20. Fuller JG, McMorland GH, Douglas MJ, Palmer L. Epidural morphine for analgesia after caesarean section: a report of 4880 patients. Can J Anaesth. 1990;37(6):636-40.

21. Dias RSG, Soares JHN, Castro DDSE, Gress MAKA, Machado ML, Otero PE, et al. Cardiovascular and respiratory effects of lumbosacral epidural bupivacaine in iso-flurane-anesthetized dogs: the effects of two volumes of 0.25% solution. PLoS One. 2018;13(4):e0195867.

22. Valverde A. Epidural analgesia and anesthesia in dogs and cats. Vet Clin North Am Small Anim Pract. 2008;38(6):1205-30.

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ABSTRACT

BACKGROUND AND OBJECTIVES: The chikungunya virus is a human pathogen responsible for a disease characterized by fe-ver, headache, myalgia, skin rash and acute and persistent arthral-gia. The purpose of this case report was to describe the orofacial manifestations of a patient infected with the chikungunya virus. CASE REPORT: A female patient was referred to the Univer-sidade Federal de Juiz de Fora, MG dental clinic due to severe facial pain. Two weeks earlier, she had been diagnosed with chi-kungunya virus infection by ELISA. After the febrile period and skin rash, the patient presented severe pain in the shoulders, knees, and face, which make it difficult to move and perform daily activities. She was diagnosed with temporomandibular dis-orders (arthralgia and myofascial pain in the masseter muscle on the right side). The patient was counseled about diet free of pain, hot packs and massages in the painful region. She was already self-medicated with corticosteroids. In addition, she was in-structed to seek a specialist for her body pain. The manifestations caused by infection were healed after 10 days of the beginning of the use of corticosteroids and counseling. CONCLUSION: To date, no reports have been published in the literature about the orofacial manifestation of chikungunya virus, which could serve as a basis to aid in diagnosis temporo-mandibular joint disorders secondary to chikungunya virus or resulting from possible psychological alteration due to constant generalized pain) and treatment. The detailed anamnesis pro-vided information about a probable temporomandibular joint disorder secondary to Chikungunya virus infection, and it was remarkable as improvement of the systemic factors resulted in the remission of orofacial symptomatology.Keywords: Chikungunya virus, Facial pain, Temporomandibu-lar joint disorders.

Orofacial manifestations of chikungunya infection. Case report Manifestações orofaciais após infecção por vírus da chikungunya. Relato de caso

Ana Paula Varela Brown Martins1, Juliana Stugisnki-Barbosa2, Paulo Cesar Rodrigues Conti2

Ana Paula Varela Brown Martins - https://orcid.org/0000-0003-4236-9335;Juliana Stuginski-Barbosa - https://orcid.org/0000-0002-7805-5672;Paulo Cesar Rodrigues Conti - https://orcid.org/0000-0003-0413-4658.

1. Universidade de Campinas, Faculdade de Odontologia de Piracicaba, Piracicaba, SP, Brasil.2. Universidade de São Paulo, Faculdade de Odontologia de Bauru, Bauru, SP, Brasil.

Submitted on September 17, 2018.Accepted for publication on March 23, 2019. Conflict of interests: none – Sponsoring sources: none

Correspondence to:Departamento de OdontologiaAv. Dr. Raimundo Monteiro Rezende, 330, sala 301 – Centro35010-173 Governador Valadares, MG, Brasil. E-mail: anapaula.martins@ufjf.edu.br

© Sociedade Brasileira para o Estudo da Dor

RESUMO

JUSTIFICATIVA E OBJETIVOS: O vírus chikungunya é um patógeno humano responsável por uma doença caracterizada por febre, dor de cabeça, mialgia, erupção cutânea e artralgia agu-da e persistente. O objetivo deste relato de caso foi descrever as manifestações orofaciais de uma paciente infectada pelo vírus chikungunya.RELATO DO CASO: Paciente do sexo feminino foi encaminha-da para a clínica odontológica da Universidade Federal de Juiz de Fora, MG, devido à dor orofacial grave. Duas semanas antes, ela havia sido diagnosticada com infecção por vírus chikungunya. Após período febril e erupção cutânea, a paciente apresentou dor intensa nos ombros, joelhos e face, que dificultava a movimen-tação e realização das atividades diárias. Foi diagnosticada com desordens temporomandibulares (artralgia e dor miofascial com referência do músculo masseter no lado direito). A paciente foi orientada sobre dieta livre de dor, compressas quentes e massagens na região dolorosa. Ela já se automedicava com corticosteróides. Foi instruída a procurar especialista para suas dores no corpo. As manifestações provocadas pela infecção foram curadas após 10 dias do início do uso de corticosteroides e aconselhamento. CONCLUSÃO: Até o momento, nenhum relato foi publicado na literatura sobre a manifestação orofacial do vírus chikungun-ya, que poderia servir de base para auxiliar no diagnóstico de disfunção temporomandibular secundária ao vírus chikungunya ou resultante de possível alteração psicológica por dor generali-zada constante) e tratamento. A anamnese detalhada forneceu informações sobre uma provável disfunção temporomandibular secundária à infecção pelo vírus chikungunya e foi notável, pois a melhora dos fatores sistêmicos resultou na remissão do sintoma orofacial.Descritores: Dor facial, Vírus chikungunya, Transtornos da arti-culação temporomandibular.

INTRODUCTION

Orofacial pain can occur as a sequela of various causes, for ex-ample of infectious disease. Chikungunya virus (CHIKV) is a mosquito-transmitted virus in the Alphavirus genus in the fam-ily Togaviridae1, which is readily transmitted to humans by in-fected mosquito vectors, Aedes aegypti and Aedes albopictus2,3. It is a debilitating viral illness of global concern due to its esca-lating outbreaks in different parts of the world2. In the human organism, the virus causes an acute infection characterized by high fever, debilitating polyarthralgia causing intense pain and swelling, myalgia, rigor, myositis, headache, chills, fatigue, pho-tophobia, and skin rash3,4. In addition, severe neurological and

DOI 10.5935/2595-0118.20190035

CASE REPORT

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hemorrhagic diseases and deaths were associated with an out-break of CHIKV3.However, the infection is self-limiting and usually resolves with-in 3-4 days except for the joint symptoms that may persist for a longer period2; many patients experience recurring disabling pain for months to years5,6. The long-term chronic arthralgia and myalgia can have an enormous impact on the individual’s qual-ity of life7, and on society in terms of morbidity and economic productivity7,8.Despite the pathological significance of CHIKV infection, the physiological and molecular mechanisms occurring during viral infection are still not well-defined2. Thus, the objective of this study was to report a clinical case of orofacial manifestations after CHIKV infection. CASE REPORT

A 38 years old female came to the Dentist Department of the Juiz de For a Federal University, Governador Valadares campus, with a complaint of severe pain on the right side of her face. About 2 months before the first dentistry visit, the patient was diagnosed with a Chikungunya virus infection, through clini-cal diagnosis: high fever, skin rashes, and joint pain, especially knees, shoulders, and hands. The medical history showed a diag-nosis of osteoarthrosis in the knees several years ago.For the first phase of the systemic treatment, analgesic was pre-scribed by the physician to control pain and fever, in addition to rest. The treatment was not successful in reducing pain. She sought other physicians, and non-steroidal anti-inflammatory (NSAIDs) and muscle relaxants were prescribed. The patient reported pain improvement only during the drug effects. After remission of the acute phase, pain in the knees, especially the right, and in the shoulders remained, resulting in difficulty in locomotion and execution of activities at work.Additionally, 10 days at the end of the acute phase, the patient reported severe pain in rest in the right ear region, upper posteri-or teeth on the right side, which got worse during function, with severe intensity (8/10), a burning and in stitches quality, lasting 30 minutes if she did not take medications. The orofacial pain was daily (about 3 episodes a day), and no parafunctional habits were reported.During palpation of the right temporomandibular joint (TMJ) and masseter muscle, it was possible to reproduce the pain re-ported by the patient in the right region: in front of the ear and upper posterior teeth. The diagnosis was arthralgia and myofas-cial pain with reference (to the superior posterior teeth). As well as clinical findings of muscle pain in the left masseter, bilateral sternocleidomastoids (SCM) and bilateral trapezius.The patient received advice and home care that included verbal and written instructions about the TMD etiology and prognosis, pain-free diet, relaxing exercises of the jaw muscles, maintain a good posture, use of reminders to avoid possible parafunctional habits, avoid stimulant substances and cervical stretching, appli-cation of a heating pad on painful masticatory muscles (for 15 minutes) followed by stretching and self-massage twice a day. The patient was instructed to look for a rheumatologist or or-

thopedist physician because the pains of the knees and shoulders were more intense (10/10) than those of the face.After 30 days, the patient attended for reevaluation. She reported that she had already started using corticosteroids (prednisone) by herself (35mg/day). She had a global improvement and didn’t complain of pain in knees, shoulders or face. She had already returned to daily activities. She also reported sleep bruxism. During palpation, there was bilateral sensitivity in the masseter, temporal and SCM, of moderate to severe intensity – no pain in TMJ. A maxillary full-coverage occlusal appliance was made of hard acrylic and was fabricated in a dental laboratory. Counsel-ing was reinforcement.Twenty days later, the patient returned, and she had begun the process of reducing corticosteroid intake. She didn’t report pain, but during palpation, it was still perceived moderate pain in the same muscles. The splint was delivered and adjusted immediate-ly, with instruction to wear only at night while sleeping.After 30 days of splint use, the patient returned reporting that she is in the final phase for the complete withdrawal of the cor-ticosteroid and with the absence of symptomatology. During palpation, the patient reported little sensitivity in the masseter and temporal muscles, with slight intensity (not familiar to the patient). Counseling has been strengthened. DISCUSSION

The purpose of this study was to report an unusual case of Chi-kungunya infection where, after the acute phase of this pathol-ogy, the patient was diagnosed with TMD. To date, no reports have been published in the literature on the orofacial manifesta-tion of Chikungunya infection.The Chikungunya fever is one of the epidemics around the world2. Acute chikungunya symptoms in humans appear 3-12 days after a bite by an infected mosquito8. CHIKV replicates in the skin, and disseminates to the liver, muscle, joints, lym-phoid tissue and brain, presumably through the blood3,4. The symptoms of CHIKV infection in humans joint are debilitating arthralgia that affects the peripheral joints, causing intense pain and swelling1. Besides, it includes high fever, headache, myalgia, conjunctivitis, periorbital pain, erythematous rash, and petechial spots3,4. Research in animals evidenced arthritis, tenosynovitis, and myositis in CHIKV infected neonatal and adult mice9.CHIKV is also primarily arthritogenic, and muscle tissue has been proposed to be their target3,4. Most infected individuals complain of severe joint pain which is often incapacitating5,6. The arthralgia usually occurs in more than one joint, usually symmetrical and almost any joint can be affected, particularly in peripheral joints are affected more frequently10. Synovitis or periarticular swelling has been reported in 32-95% of patients, with large joint effusions occurring in 15% of individuals infect-ed with Chikungunya10. The inflammatory response in the joint is very similar to that in rheumatoid arthritis, with leucocyte in-filtration, cytokine production, and complement activation11,12. However, there is no data about TMJ pain in literature.A study was done on muscle biopsies of CHIKV infected pa-tients with myositis syndrome has identified muscle satellite cells

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and not muscle fibers as the primary target viral infection13. The outbreak of CHIKV in the Réunion has documented 97.7% of myositis incidence upon CHIKV infection14. In this case report, during palpation, the clinical findings were the presence of active trigger points in the masticatory muscles that reported pain in the upper posterior teeth, reproducing one of the patient’s main complaints. There was no clinical evidence supporting a myositis diagnosis of masticatory muscles: the presence of edema, erythe-ma and/or increased temperature over the muscle15. The explana-tions for this may be the end of the acute phase of the pathology or the effect of the drugs for the systemic symptomatology since there are no reasons for the masticatory muscles not to be affect-ed by CHIKV infection.The acute phase of CHIKV infection typically lasts from a few days to a couple of weeks16. The convalescent phase of CHIKV infection is associated with the resolution of fever and viremia an induction of adaptive immunity6,17. However, arthralgia and/or myalgia may persist for weeks, months or even years6,17 as in this case. About 43-75% of CHIKV-infected patients experience per-sistent symptoms, including fatigue and joint pain, stiffness, and swelling, for about years5. Risk factors for developing chronic joint pain after acute CHIKV infection include increased age, hypertension and disease severity during the acute stage17, be-sides immunosuppressed organisms18. Diabetes, cardiovascular disease, neurological disorders, and chronic pulmonary diseases are risk factors for developing severe CHIKV disease19.The ability of CHIKV to replicate and persist in the joints and muscle tissues is not clear13. The pain led our patient to have diffi-cult locomotion. Most working adults become disabled with loss of mobility, hand impairment, and depressive reaction, which can last for weeks to months2. This loss of mobility was one of the main complaints associated with the difficult to raise her arms reported by the patient. Besides, the patient also reported difficulty in performing the mandibular movements, which may be justified by arthralgia and myofascial pain. Pre-existing arthri-tis (including rheumatoid arthritis and osteoarthritis) has been associated with prolonged rheumatic symptoms after infection with Ross River virus, chikungunya virus, or the related alphavi-rus Pogosta virus17. Several of the shared cytokines such as tumor necrosis factor, interleukin-1, interleukin-6, and interleukin-17 are established therapeutic targets during rheumatoid arthritis, showing their importance in pathogenesis2,20. The expression of this pro-inflammatory cytokines correlates with the severity of CHIKV-induced disease in patients21. Based on these similari-ties, Burt, Chen, Mahalingam20 suggested that arthritogenic vi-rus infection could exacerbate pre-existing joint pathology. This pain exacerbation in the patient’s knee could be explained by the presence of a previous osteoarthrosis diagnose some years ago. There is no information in the literature about CHIKV virus infection in TMJ and/or masticatory muscles. However, as CHIKV has a high ability to spread and replicate in various tis-sues of the human body, an infected patient may have orofacial manifestations as there is no plausible explanation that the virus does not affect the masticatory muscles and TMJ, characteriz-ing temporomandibular disorder (TMD). In this case, we could

point that TMD was secondary to CHIKV infection, as there is a temporal pattern with infection some days before the orofa-cial complaints. Systematic pathophysiologic conditions, such as this infectious condition caused by CHIKV, may influence local TMDs and should generally be managed in cooperation with the patient´s primary care physician or other medical specialists (15). Pre-existing conditions of pain, as happened with this pa-tient with severe pain widely spread after the CHIKV infection, may be considered as an independent risk factor for the early onset of TMD22.Another aspect to be analyzed regarding the TMD is the fact that their onset may be associated to possible psychological alteration present in the patient due to the long period with strong symp-toms of continuous pain in several structures of her body22,23. Thus, orofacial alterations would be consequences of psychoso-cial factors and not due to the direct action of CHIKV in the structures of the masticatory system. CHIKV could be consid-ered as the initiating factor that might cause the onset of TMD because it has a multifactorial etiology; this infection may have interacted with other preexisting factors15.A critical issue associated with CHIKV infection refers to the management of patient complaints, since, there are no dou-ble-blind, placebo-controlled studies to suggest the best thera-peutic approach to these cases24. Since nowadays, there are not enough studies to determine the evolution of muscle involvement associated with CHIKV, although it appears that viral myositis, in general, tends to remission24. Good responses to high doses of steroids have been reported in many cases of arthropathy25. Steroids could regulate gene function and inactivate the relat-ed proteins involving pro-inflammatory cytokines, which could attenuate inflammatory myopathy26. The patient stated that the pain only relieved after she had started taking the corticoid. Due to the high prevalence and the cyclical appearance of the outbreak of CHIKV infection, it is necessary to control the proliferation of the infected mosquito and more studies related to the treatment. The association of corticosteroids, counseling and home therapy has proven to be effective for symptomat-ic remission. A detailed anamnesis and physical examination could provide information about the secondary origin of the TMD. The case emphasizes the importance of a comprehen-sive evaluation of a patient with preexisting pain when new symptoms arise, worsening the systemic condition. In this case, the improvement of the systemic disease (CHIKV infection) associated with counseling and splint resulted in the remission of the orofacial symptomatology. REFERENCES

1. Haese NN, Broeckel RM, Hawman DW, Heise MT, Morrison TE, Streblow DN. Ani-mal models of Chikungunya virus infection and disease. J Infect Dis. 2016;214(Suppl 5):S482-7.

2. Dhanwani R, Khan M, Lomash V, Rao PV, Ly H, Parida M. Characterization of chikungunya virus induced host response in a mouse model of viral myositis. PLoS One. 2014;9(3):e92813.

3. Schwartz O, Albert ML. Biology and pathogenesis of chikungunya virus. Nat Rev Microbiol. 2010;8(7):491-500.

4. Dupuis-Maguiraga L, Noret M, Brun S, Le Grand R, Gras G, Roques P. Chikungunya disease infection-associated markers from the acute to the chronic phase o arbovirus--induced arthralgia. PLoS Negl Trop Dis. 2012;6(3):e1446.

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5. Gérardin P, Fianu A, Malvy D, Mussard C, Boussaïd K, Rollot O, et al. Perceived morbidity and community burden after a chikungunya outbreak: the TELECHIK survey, a population-based cohort study. BMC Med. 2011;9:5.

6. Schilte C, Staikowsky F, Couderc T, Madec Y, Carpentier F, Kassab S, et al. Chikun-gunya virus-associated long-term arthralgia: a 36-month prospective longitudinal stu-dy. PLoS Negl Trop Dis. 2013;7(3):e2137.

7. Marimoutou C, Ferraro J, Javelle E, Deparis X, Simon F. Chikungunya infection: self-reported rheumatic morbidity and impaired quality of life persist 6 years later. Clin Microbiol Infect. 2015;21(7):688-93.

8. Burt FJ, Chen W, Miner JJ, Lenschow DJ, Merits A, Schnettler E, et al. Chikungunya virus: an update on the biology and pathogenesis of this emerging pathogen. Lancet Infect Dis. 2017;17(4):e107-e117.

9. Rulli NE, Rolph MS, Srikiatkhachorn A, Anantapreecha S, Guglielmotti A, Mahalin-gam S. Protection from arthritis and myositis in a mouse model of acute chikungunya virus disease by bindarit, an inhibitor of monocyte chemotactic protein-1 synthesis. J Infect Dis. 2011;204(7):1026-30.

10. Borgherini G, Poubeau P, Staikowsky F, Lory M, Le Moullec N, Becquart JP, et al. Outbreak of chikungunya on reunion island: Early clinical and laboratory features in 157 adult patients. Clin Infect Dis. 2007;44(11):1401-7.

11. Burt FJ, Rolph MS, Rulli NE, Mahalingam S, Heise MT. Chikungunya: a re-emer-ging virus. Lancet. 2012;379(9816):662-71.

12. Nakaya HI, Gardner J, Poo YS, Major L, Pulendran B, Suhrbier A. Gene profiling of Chikungunya virus arthritis in a mouse model reveals significant overlap with rheu-matoid arthritis. Arthritis Rheum. 2012;64(11):3553-63.

13. Ozden S, Huerre M, Riviere JP, Coffey LL, Afonso PV, Mouly V, et al. Human muscle satellite cells as targets of chikungunya virus infection. PLoS One. 2007;2(6):e527.

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17. Sissoko D, Malvy D, Ezzedine K, Renault P, Moscetti F, Ledrans M, et al. Pos-t-epidemic chikungunya disease on Reunion Island: course of rheumatic mani-festations and associated factors over a 15-month period. PLoS Negl Trop Dis. 2009;3(3):e389.

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19. Economopoulou A, Dominguez M, Helynck B, Sissoko D, Wichmann O, Quenel P, et al. Atypical Chikungunya virus infections: clinical manifestations, mortality and risk factors for severe disease during the 2005-2006 outbreak on Réunion. Epidemiol Infect. 2009;137(4):534-41.

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Dear Editor,

We’ve read with great interest the paper “Immediate analgesic effect of the 2KHz interferential current in chronic low back pain: randomized clinical trial”1. Neuromodulation is based on the concept that the electrical stimulation-induced paresthesia can be an-algesic. Its historical basis emanates from the gate control theory of pain proposed by Melzack and Wall in 19652. Neuromodulation gave us access to pain modulation systems and helped to mature the understanding of the pathophysiology of pain3. However, the current understanding of pain is still rudimental and the evidence that neuromodulation works, is modest. A current review conduct-ed by Cochrane concluded that “we are still unable to conclude with confidence that in people with chronic pain, the transcutaneous electrotherapy is detrimental or beneficial to control pain, disability, health-related quality of life, drug use for pain relief or overall perception of change”4. However, the results presented by this study have convinced us that the interferential current has its role in the management of chronic low back pain; not because of its long-term analgesic effect but because of its immediate analgesic effect that proved to be satisfactory in the preparation of the patient to receive kinesiotherapy, which has more robust levels of evidence in the control of chronic low back pain5. That is, electrotherapy is not a panacea, much less the basis of the non-surgical management of low back pain, but it can play its role as a bridge to access more robust therapies, relieving immediate pain, thus allowing the beginning of other therapies. We encourage the authors to continue the work investigating the behavior of pain in other frequencies and perhaps to elaborate a protocol for the adjuvant use of the interferential current in the treatment of chronic low back pain. Keywords: Analgesia, Low back pain, Electrical stimulation therapy.

Conflict of interests: none - Sources of support: none.

Ricardo Vieira Teles FilhoUniversidade Federal de Goiás, Faculdade de Medicina,

Departamento de Ortopedia e Traumatologia, Goiânia, GO, Brasil.https://orcid.org/0000-0003-4822-1526.

E-mail: ricardovteles@gmail.com

REFERENCES

1. Almeida N, Paladini LH, Pivovarski M, Gaideski F, Korelo RI, Macedo AC. Immediate analgesic effect of 2KHz interferential current in chronic low back pain: randomized clinical trial. BrJP. 2019;2(1):27-33.

2. Melzack R, Wall PD. Pain Mechanisms: a new theory. Science, 1965;150(3699):971-9.3. Kumar K, Rizvi S. Historical and present state of neuromodulation in chronic pain. Curr Pain Headache Rep. 2014;18(1):387. 4. Gibson W, Wand BM, Meads C, Catley MJ, O’Connell NE. Transcutaneous electrical nerve stimulation (TENS) for chronic pain ‐ an overview of Cochrane Reviews. Cochrane Data-

base Syst Rev. 2019;(2):CD011890.5. Adamczyk WM, Buglewicz E, Szikszay TM, Luedtke K, Bąbel P. Reward for pain: hyperalgesia and allodynia induced by operant conditioning: systematic review and meta-analysis. J

Pain. 2019;25. (Epub ahead of print].

Analgesic effect of the interferential current in chronic low back pain managementEfeito analgésico da corrente interferencial no manuseio da dor lombar crônica

© Sociedade Brasileira para o Estudo da Dor

DOI 10.5935/2595-0118.20190036

LETTER TO THE EDITOR

INSTRUCTIONS TO AUTHORS

The Brazilian Journal of Pain (BrJP), printed version: ISSN 2595-0118, electronic version: ISSN 2595-3192, is the multidis-ciplinary medical journal of the Brazilian Society for the Study of Pain (SBED). This is a journal focusing on the study of pain in clini-cal and research contents, gathering scientists, physicians, dentists, veterinaries, epidemiologists, psychologists, physiotherapists and other health professionals aiming at publishing their basic or applied research in this area of knowledge. Articles are of full responsibility of the authors and its periodicity is quarterly. All submitted papers are reviewed and the journal follows the Uniform Requirements of Manuscripts submitted to Biomedical.

Journals (URM) – The International Committee of Medical Journal Editors – ICMJE.Submitted articles are sent to 2-4 reviewers, who are asked to return their evaluation within 20 days. After receiving the opinion, authors have 15 days to answer to reviewers’ suggestions. Articles with no answer within six months shall be resubmitted. As many reviews as necessary shall be carried out and the final approval decision will depend on the editor. Authors are asked to present guarantees that no material violates existing copyrights or the rights of third parties.BrJP follows the Editorial Policy Statements of the Council of Sci-ence Editors – CSE. Additional information about ethic and misbe-havior aspects may be found in the website (http://www.dor.org.br) or by the online submission system.

GENERAL INFORMATIONArticles shall be submitted online: www.gnpapers.com.br/brjp/, including the Copyright Assignment document duly signed by the author(s). A submission letter shall be forwarded together with man-uscript files with information about originality, conflicts of interest or sponsoring, as well as with the statement that the article is not currently being evaluated by another journal nor has been previously published. The letter shall also state that BrJP shall have the exclusive right of publication of the article, if accepted, and that ethic aspects are respected in case of studies involving animals or humans.Articles may be submitted in Portuguese or English; however, the printed publication shall be in the original language of submission and the electronic publication shall be in Portuguese and English.Authors are responsible for stating conflicts of interests in the man-uscript itself, as well as to acknowledge financial support, when applicable.

Final Correction and Approval for Publication: When accepted, articles shall be sent to the editorial processing, which shall take place within 5 days, and then submitted to authors in the PDF for-mat for their final approval, before being forwarded for publication and printing. Authors shall have 3 days to approve the final PDF.

WAYS TO SUBMITT PAPERSSubmitted manuscripts shall be followed by a Submission Letter with the following data: originality, conflicts of interests, financing, that the article is not being evaluated by another journal and has notbeen previously published. This letter shall also have the information that BrJP shall have the exclusive right of publication of the article, if accepted, and that ethic aspects are respected in case of studies involving animals or humans.The manuscript shall have the following items:

COVER PAGE:Title: The title shall be short, clear and concise to help its classification.When necessary, a subtitle may be used. The title shall be sent in Portuguese and English.

Author(s): Complete name(s) of author(s) and affiliations (in the order: University, College, Hospital, Department; mini-resumes shall not be accepted).Author for correspondence: Name, conventional address, Zip Code, city, state, country and electronic address.Sponsoring sources: (if applicable).1. Structured abstract, with no more than 250 words. For Research articles and Clinical Trials, please include: BAKGROUND AND OBJECTIVES, METHODS, RESULTS and CONCLUSION. Forcase reports, please include: BACKGROUND AND OBJECTIVES, CASE REPORT and CONCLUSION. For review articles, please include: BACKGROUND AND OBJECTIVES, CONTENTS and CONCLUSION. Please include up to six keywords. We recommend the use of Bireme’s Health Sciences Descriptors – DeCS, available at http://decs.bvs.br/.2. Abstract: The English version of the abstract shall be forwarded together with the article. Please include up to six keywords.3. Body of text: Organize the text according to the types of be-low described articles. In original articles with humans or animal’s ethic aspects shall be informed in addition to the number and the year of the Institution’s Ethics Committee process. Acknowledg-ments to other collaborators may be mentioned at the end, before the references.

TYPES OF ARTICLESThe submission of experimental or clinical research articles, with hu-mans or animals, implies that authors have obtained approval from the relevant Ethics Committee and that they comply with the Dec-laration of Helsinki. This type of statement shall be included in the chapter “METHODS”.For all articles including information about patients or clinical pic-tures, the written and signed consent from each patient or relative shall be obtained to be forwarded to the journal with the submissionprocess. Generic drug names shall be used. When trade names are used in the research, these names shall be included in brackets in the chapter “METHODS”.

ORIGINAL ARTICLES1. Introduction – this section shall briefly describe the scope and previous evidence-based knowledge for the design of the research, based on subject-related references. At the end, the research objec-tive shall be clearly stated. Please include up to six authors.Methods – shall include study design, sample selection processes, ethic aspects, exclusion and inclusion criteria, clear description of interventions and methods used, in addition to data analysis as well as sample power and applied statistical tests.Results – shall be objectively described, further explained with fig-ures and tables when needed. Analyses carried out and their results shall be included.Discussion – this section shall discuss research results at the light of previous knowledge published by scientific duly mentioned sources.This section may be divided in sub-chapters. Please include study limitations and close with the conclusion of the paper. Whenever possible, include clinical implications and information about impor-tance and relevance of the study.Acknowledgments – acknowledgments to collaborators, among others, may be mentioned in this section, before references.References – shall be formatted according to Vancouver standards (http://www.jcmje.org).Figures and Tables – shall be sent separately from the text of the article in a format allowing for edition (figures in Excel and tables in Word).

© Sociedade Brasileira para o Estudo da Dor

CASE REPORTS1. Case reports with relevance and originality are invited to be submit-ted to BrJP. A limit of 1800 words shall be respected. Findings shall be clearly presented and discussed at the light of scientific literature, mentioning references. Please include up to three authors. The body of the text shall contain: INTRODUCTION, CASE REPORT, DIS-CUSSION, Acknowledgments and References. Figures and tables il-lustrating the text may be included.

2. REVIEW ARTICLESLiterature reviews on relevant pain subjects, with literature critical re-view and systematically carried out are welcome. They shall contain no more than 3000 words and be structured as follows: INTRODUC-TION, CONTENTS, CONCLUSION, REFERENCES.

3. LettersLetters or comments to any published article shall be sent to the journal, with no more than 400 words and up to five references.

REFERENCESBrJP adopts the “Vancouver Standards” (http://www.jcmje.org) as style to format references. These shall be presented in the text in numerical sequential order in superscript. Unpublished papers shall not be men-tioned and preferably avoid mentioning abstracts presented in scientific events. References older than 5 years shall be mentioned if fundamental for the article. Articles already accepted for publication may be men-tioned with information that they are in publication process. Up to six authors may be mentioned and, if there are more, include et al. after the names. Journal title shall be abbreviated.

EXAMPLES OF REFERENCESJournal articles:- 1 author - Wall PD. The prevention of postoperative pain. Pain. 1988;33(1):289-90.- 2 authors - Dahl JB, Kehlet H. The value of pre-emptive analgesia in the treatment of postoperative pain. Br J Anaesth. 1993;70(1):434-9.- More than 6 authors - Barreto RF, Gomes CZ, Silva RM, Signorelli AA, Oliveira LF, Cavellani CL, et al. Pain and epidemiologic evaluation of patients seen by the first aid unit of a teaching hospital. Rev Dor. 2012;13(3):213-9.

Article with published erratum:Sousa AM, Cutait MM, Ashmawi HA. Avaliação da adição do tramadol sobre o tempo de regressão do bloqueio motor induzido pela lidocaína. Estudo experimental em ratos avaliação da adição do tramadol sobre o tempo de regressão do bloqueio motor induzido pela lidocaína. Estudo experimental em ratos. Rev Dor. 2013;14(2):130-3. Erratum in: Rev Dor. 2013;14(3):234.

Supplement article:Walker LK. Use of extracorporeal membrane oxygenation for preopera-tive stabilization of congenital diaphragmatic hernia. Crit Care Med. 1993;2(2Suppl1):S379-80.

Book: (when strictly necessary)Doyle AC, editor. Biological mysteries solved, 2nd ed. London: Science Press; 1991. 477-80p.

Book chapter:Lachmann B, van Daal GJ. Adult respiratory distress syndrome: animal models. In: Robertson B, van Golde LMG, editors. Pulmonary surfac-tant. Amsterdam, 2nd ed. Batenburg: Elsevier; 1992. 635-63p.Theses and dissertations: Shall not be accepted.

ILLUSTRATIONS AND TABLESAll illustrations (including figures, tables and pictures), shall be compul-sorily mentioned in the text in the preferred place for their inclusion. Please number them in Arabic numbers. All shall have title and cap-tions. Please use pictures and figures in black and white and restrict their number to a maximum of three. The same result shall not be expressed by more than one illustration. Graphic signs, figures of acronyms used in tables or figures shall have their correlation mentioned as footnote.Figures and tables shall be sent separately from the text and in format allowing for edition, according to the following recommendations.

Digital FormatSubmission Letter, Manuscript and Figures shall be forwarded in DOC format (Windows Word standard); figures in bars or lines shall be for-warded in Excel (extension XLS). Pictures shall be digitalized with mini-mum resolution of 300 DPI, in JPEG format. File name shall express illustration type and number (Figure 1, Table 2, for example). Copies or reproductions of other publications shall be allowed only after attach-ment of express authorization of the Editing Company or of the Author of the original article.

Ethics:When reporting experiments with human beings, please indicate wheth-er procedures were in compliance with ethical standards of the Commit-tee in charge of the human experiment (institutional or regional), and with the Declaration of Helsinki from 1975, amended in 1983. The number of the Research Ethics Committee approval shall be mentioned.

Registry of Clinical Trial:BrJP respects World Health Organization and International Committee of Medical Journal Editors – ICMJE policies for the registry of clinical trials, acknowledging the importance of such initiatives for internation-al disclosure of information about clinical research with open access. So, as from 2012, preference shall be given to the publication of articles or studies previously registered before a Platform of Clinical Trials Regis-try meeting the requirements of the World Health Organization and of the International Committee of Medical Journal Editors. The list of Platforms of Clinical Trials Registry may be found at http://www.who.int/ictrp/en, from the International Clinical Trials Registry Platform (ICTRP). Among them there is the Brazilian Registry of Clinical Trials (ReBEC), which is a virtual platform with free access for the registry of experimental and non-experimental studies carried out with human beings, in process or closed, by Brazilian and foreign researchers, which may be accessed at http://www.ensaiosclinicos.gov.br. The registry num-ber of the study shall be published at the end of the abstract.

Use of Abbreviations:Title, summary and abstract shall not contain abbreviations. When long expressions are present in the text, they do not have to be repeated after INTRODUCTION. After their first mention in the text, which shall be followed by the initials in brackets, it is recommended that their initials in capital letters replace them.