Vol. 01 No 01 Jan/Fev/Mar. 2018

ISSN - 2595-0118

BrJPBRAZILIAN JOURNAL OF PAIN Vol. 01 No 01 Jan/Fev/Mar. 2018

capa brjp 2018.indd 1 13/03/2018 17:24:31 Com a duloxetina você oferece ao seu paciente melhor qualidade de vida. (3)

» Melhora da dor.(4,5) » Redução dos sintomas depressivos. (4,5) » Eﬁcácia e rápido início de ação.(6)

Apresentações: » 30 e 60mg com 30 e 60 cápsulas.

VELIJAMD - cloridrato de duloxetina 30 mg com 10, 30 ou 60 cápsulas de liberação retardada; e 60 mg com 30 ou 60 cápsulas de liberação retardada. Uso oral e adulto (acima de 18 anos de idade). Indicações: transtorno depressivo maior (TDM); dor neuropática diabética; fibromialgia (FM) em pacientes com ou sem transtorno depressivo maior (TDM); estados de dor crônica associados à dor lombar crônica; estados de dor crônica associados à dor devido à osteoartrite de joelho (doença articular degenerativa), em pacientes com idade superior a 40 anos; e transtorno de ansiedade generalizada (TAG). Contraindicações: pacientes com hipersensibilidade aos componentes da fórmula. Não deve ser administrado concomitantemente com IMAO ou dentro de, no mínimo, 14 dias da interrupção do tratamento com um IMAO; também se deve aguardar, no mínimo, 5 dias após a interrupção do tratamento com VelijaMD, antes de se iniciar o tratamento com um IMAO. Este medicamento não é recomendado para pacientes com doença renal em fase terminal (necessitando de diálise), com disfunção renal grave (clearance de creatinina < 30 mL/min); ou ainda em pacientes com insuficiência hepática. Precauções e Advertências: a possibilidade de tentativa de suicídio é inerente ao TDM e pode persistir até que ocorra remissão significativa dos sintomas depressivos. Os pacientes com alto risco devem ser acompanhados estritamente no início do tratamento, e os médicos devem incentivar os pacientes a relatar quaisquer tipos de pensamentos ou sentimentos aflitivos. Deve ser usada com cautela em pacientes com história de mania ou de convulsão. Deve ser evitado seu uso em pacientes com glaucoma de ângulo estreito descompensado. Em pacientes com hipertensão conhecida e/ou outra doença cardíaca, é recomendada a monitoração da pressão arterial. A duloxetina deve ser usada com cautela em pacientes com uso substancial de álcool (elevações graves das enzimas hepáticas. Embora estudos clínicos controlados com duloxetina não tenham demonstrado qualquer prejuízo do desempenho psicomotor, da memória ou da função cognitiva, seu uso pode estar associado à sonolência e à tontura. A segurança e eficácia em pacientes pediátricos não foram estabelecidas. Não foram observadas diferenças na segurança e eficácia entre indivíduos idosos (≥ 65 anos) e indivíduos mais jovens. .É recomendado cuidado no uso de duloxetina em pacientes com doenças ou condições que produzam alteração no metabolismo ou nas respostas hemodinâmicas. A duloxetina não foi sistematicamente avaliada em pacientes com história recente de infarto do miocárdio ou doença cardíaca instável. Uso em gestantes durante o 3º trimestre de gravidez: recém-nascidos expostos a ISRSs ou IRSNs durante o 3º trimestre desenvolveram complicações, exigindo hospitalização prolongada, suporte respiratório e alimentação via sonda. Os médicos devem considerar cuidadosamente a relação entre riscos e benefícios do tratamento com duloxetina em mulheres no 3º trimestre de gravidez. Atenção: Este medicamento contém açúcar (sacarose), portanto deve ser usado com cautela em portadores de diabetes. Cada cápsula contém 0,02g (VelijaMD 30 mg) ou 0,04g (VelijaMD 60 mg) de sacarose. Gravidez e lactação: categoria de risco na gravidez: C. Não há estudos bem controlados e adequados conduzidos em mulheres grávidas. Não houve evidência de teratogenicidade em estudos com animais. A duloxetina e/ou seus metabólitos são excretados no leite de ratas lactantes, mas não foi avaliada no leite humano, portanto, não é recomendada a amamentação. Este medicamento não deve ser utilizado por mulheres grávidas sem orientação médica ou do cirurgião-dentista. Interações com medicamentos, alimentos e álcool: houve relatos de reações graves (hipertermia, rigidez, mioclonia, instabilidade autonômica com possíveis flutuações rápidas dos sinais vitais e alterações do estado mental, incluindo agitação extrema, progredindo para delirium e coma), às vezes fatais, em pacientes recebendo um inibidor da recaptação de serotonina em combinação com um IMAO. Antidepressivos tricíclicos (ATC): pode ocorrer inibição do metabolismo dos ATC, sendo necessária redução da dose e monitoramento das concentrações plasmáticas do ATC. Inibidores do CYP1A2 (como por ex.: fluvoxamina, quinolonas): pode ocorrer aumento da concentração da duloxetina. Fármacos metabolizados pela CYP2D6 (como por ex.: desipramina, tolterodina): pode aumentar as ASC destes fármacos. Inibidores da CYP2D6 (como por ex.: paroxetina): pode aumentar a concentração da duloxetina. O uso concomitante de duloxetina com álcool não é recomendado. Antiácidos e medicamentos que aumentam o pH gastrointestinal podem promover uma liberação precoce de VelijaMD. Entretanto, a coadministração da duloxetina com antiácidos que contêm alumínio ou magnésio (51 mEq) ou com famoditina não resultou em efeito significativo das antagonistas H2: taxas ou da quantidade absorvida da duloxetina (40 mg). Não há informações sobre a coadministração de duloxetina com inibidores da bomba de prótons. Erva-de-são-João (Hypericum perforatum): pode ser mais comum a ocorrência de eventos indesejáveis. Fármacos que atuam no SNC: pode ocorrer sinergia dos efeitos. Fármacos com altas taxas de ligação às proteínas plasmáticas: pode aumentar as concentrações livres destes fármacos. Lorazepam: aumento da sedação, em comparação ao uso isolado de lorazepam. Reações Adversas e alterações de exames laboratoriais: Muito comuns (≥ 10%): constipação, boca seca, náusea, dor de cabeça, tontura, sonolência. Comuns (≥ 1% e < 10%): palpitação, diarreia, vômito, dispepsia, diminuição do apetite, perda de peso, fadiga, rigidez muscular/contração muscular, tontura, letargia, tremor, sudorese, fogachos, visão turva, anorgasmia, insônia, diminuição da libido, ansiedade, distúrbio da ejaculação, disfunção erétil, bocejo, hiperidrose, suores noturnos; visão borrada, disgeusia, ansiedade, hesitação urinária. Raras (≥ 0,01% e < 0,1%): taquicardia, palpitação, vertigem, midríase, distúrbio visual, eructação, gastroenterite, estomatite, calafrios, sensação de anormalidade, sensação de calor e/ou frio, mal estar, sede, aumento da pressão arterial, aumento de peso, distúrbios do sono, agitação, bruxismo, hesitação urinária, rubor facial, extremidades frias, anorgasmia, desorientação, noctúria. Muito raras (< 0,01%): desidratação, desorientação, reação de fotossensibilidade. Alterações laboratoriais: pequenos aumentos médios nos valores de ALT, AST, CPK e fosfatase alcalina. Posologia: dose diária inicial: 60 mg em tomada única, com ou sem alimento. Dose máxima diária: 120 mg, dividida em duas tomadas diárias. Doses acima de 120 mg não foram sistematicamente avaliadas. Para os pacientes cuja tolerabilidade é preocupante, pode ser considerada uma dosagem inicial mais baixa. Para pacientes com insuficiência renal deve ser considerada uma dosagem inicial mais baixa e aumento gradativo conforme a necessidade, realizando monitoração constante. Tratamento Prolongado/Manutenção/Continuação: é consenso que os episódios agudos do TDM necessitam de uma terapia farmacológica de manutenção, geralmente por vários meses ou mais longa. Não há evidências disponíveis suficientes para determinação da duração do tratamento com duloxetina. Os pacientes devem ser periodicamente reavaliados quanto à necessidade de manutenção do tratamento e qual a dosagem apropriada. Dor neuropática associada à neuropatia diabética periférica: a eficácia da duloxetina deve ser avaliada individualmente, já que a progressão da neuropatia diabética periférica é bastante variável e o controle da dor, empírico. Reg.MS 1.0033.0167/Farm. Resp.: Cintia Delphino de Andrade CRF-SP nº 25.125. LIBBS FARMACÊUTICA LTDA/ CNPJ 61.230.314/0001-75/Rua Alberto Correia Francfort, 88/Embu-SP/Indústria Brasileira /VELIJA-MB12-17/Serviço de Atendimento LIBBS: 08000-135044. VENDA SOB PRESCRIÇÃO MÉDICA. SÓ PODE SER VENDIDO COM RETENÇÃO DA RECEITA. VELIJAMD É UM MEDICAMENTO. DURANTE SEU USO, NÃO DIRIJA VEÍCULOS OU OPERE MÁQUINAS, POIS SUA AGILIDADE E ATENÇÃO PODEM ESTAR PREJUDICADAS. A persistirem os sintomas, o médico deve ser consultado. Documentação Científica e informações adicionais estão à disposição da classe médica, mediante solicitação. Referências bibliográficas: 1. SKLJAREVSKI, V. et al. Efficacy of duloxetine in patients with chronic pain conditions. Curr. Drug Ther., v. 6, n. 4, p. 296-303, 2011. / 2. WIERMANN, E.G. et al. Consenso brasileiro sobre manejo da dor relacionada ao câncer. RBOC, v.10, n.38, p.132-143, 2014. / 3. OGAWA, K. et al. Correlation between pain response and improvements in patient-reported outcomes and health-related quality of life in duloxetine-treated patients with diabetic peripheral neuropathic pain. Neuropsychiatr. Dis. Treat. v. 11, p. 2101-7, 2015. / 4. ROBINSON, M.J. et al. Relationship between major depressive disorder and associated painful physical symptoms: analysis of data from two pooled placebo-controlled,randomized studies of duloxetine. Int. Clin. Psychopharmacol., v.28, n.6, p.330-8, 2013. / 5. PERGOLIZZI, J.V. et al. A review of duloxetine 60 mg once-daily dosing for the management of diabetic peripheral neuropathic pain, fibromyalgia, and chronic musculoskeletal pain due to chronic osteoarthritis pain and low back pain. Pain Pract, v. 13, n. 3, p. 239-52, 2013. / 6. BRANNAN, S.K. et al. Onset of action for duloxetine 60 mg once daily: double-blind, placebo-controlled studies. J. Psychiatr. Res., v. 39, n. 2, p. 161-72, 2005. / 7. GUIA DA FARMÁCIA. São Paulo: Contento, v. 25, n.302, jan. 2018. (Suplemento Lista de Preços). CONTRAINDICAÇÃO: PACIENTES COM HIPERSENSIBILIDADE AOS COMPONENTES DA FÓRMULA. INTERAÇÃO MEDICAMENTOSA: FÁRMACOS QUE ATUAM NO SNC: PODE OCORRER SINERGIA DOS EFEITOS. VELIJAMD É UM MEDICAMENTO. DURANTE SEU USO, NÃO DIRIJA VEÍCULOS OU OPERE MÁQUINAS, POIS SUA AGILIDADE E ATENÇÃO PODEM ESTAR PREJUDICADAS. CONTENTS

Volumen 1 – nº 1 EDITORIAL January to March, 2018 Revista Dor is changing its name!______1 Trimestral Publication Eduardo Grossmann

The challenge of measuring pain ______2 SOCIEDADE BRASILEIRA PARA O Renato Leonardo de Freitas, José Aparecido da Silva ESTUDO DA DOR DIRECTORY Biennium 2018-2019 ORIGINAL ARTICLES Characteristics and perception of social support by patients with fibromyalgia in President Facebook ______4 Eduardo Grossmann Felipe Azevedo Moretti, Sandra Santos Silva, Claudia Galindo Novoa Vice-President Paulo Renato Barreiros da Fonseca Association between musculoskeletal symptoms and perceived stress in public servants of a Federal University in the South of Brazil ______9 Scientific Director Letícia Maria da Silva Almeida, Samuel de Carvalho Dumith José Oswaldo de Oliveira Junior Administrative Director Detection of pain with neuropathic characteristics in patients with diabetes mellitus Dirce Maria Navas Perissinotti assisted in primary care units______15 Treasurer Francisca Lidiane Ximenes da Silva Aguiar, Luciana Fernandes Pastana Ramos, Cléa Nazaré Juliana Barcellos de Souza Carneiro Bichara Secretary Janaina Vall The effect of the Pilates method on the treatment of chronic low back pain: a clinical, randomized, controlled study ______21 Pedro Henrique Brito da Silva, Dayane Ferreira da Silva, Jéssyka Katrinny da Silva Oliveira, Av. Conselheiro Rodrigues Alves, 937 Franassis Barbosa de Oliveira Cj. 2 – Vila Mariana 04014-012 São Paulo, SP Pain and musculoskeletal discomfort in military police officers of the Ostensive Phone: (55) 11 5904-2881/3959 Motorcycle Patrol Group ______29 www.dor.org.br Katianna Karolinna Fernandes Maia Braga, Francis Trombini-Souza, Michele Vantini Checchio E-mail: [email protected] Skrapec, Diego Barbosa de Queiroz, Andréa Marques Sotero, Tarcísio Fulgêncio Alves da Silva

Pain self-efficacy questionnaire and its use in samples with different pain duration time__ 33 Quotations of Brazilian Journal of Pain Fernanda Salloume Sampaio Bonafé, João Marôco, Juliana Alvares Duarte Bonini Campos shall be abbreviated to Br J Pain.

Scapular dyskinesis was not associated with pain and function in male adolescent athletes __40 Br J Pain is not responsible Valéria Mayaly Alves de Oliveira, Hitalo Andrade da Silva, Ana Carolina Rodarti Pitangui, whatosever by opinions. Muana Hiandra Pereira dos Passos, Rodrigo Cappato de Araújo

Advertisements published in this edition do no Parafunctional habits and its association with the level of physical activity in generate conflict of intestests. adolescents______46 Gabriela Navarro, Aline Fernanda Baradel, Larissa Canzanese Baldini, Natália Navarro, Ana Lúcia Franco-Micheloni, Karina Eiras Dela Coleta Pizzol

Indexada na SciELO Indexada na LILACS Indexada na Latindex Comparison of combined therapy with ultrasound-associated interferential current in healthy subjects ______51 Publication edited and produced by Bárbara Caroline Royer, Carla de Fátima Albuquerque, Cecília Felix da Silva, Gabriela Walker MWS Design – Phone: (055) 11 3399-3038 Zancanaro, Gustavo Kiyosen Nakayama, Gladson Ricardo Flor Bertolini

Journalist In Charge REVIEW ARTICLES Marcelo Sassine - Mtb 22.869 Post-traumatic stress disorder and temporomandibular dysfunction: a review and clinical implications______55 Art Editor Dyna Mara Araújo Oliveira Ferreira, Camila Cristine de Oliveira Vaz, Juliana Stuginski- Anete Salviano Barbosa, Paulo César Rodrigues Conti SCIENTIFIC EDITOR Inflammatory mediators related to arthrogenic temporomandibular dysfunctions_ ____60 Durval Campos Kraychete Federal University of Bahia, Salvador, BA – Brazil. Rodrigo Lorenzi Poluha, Eduardo Grossmann

CO-EDITORS Ângela Maria Sousa University of São Paulo, São Paulo, SP – Brazil. Osteoarthritis of the hands and muscle strengthening exercises: an integrative update and Dirce Maria Navas Perissinotti review of the literature______66 University of São Paulo, São Paulo, SP – Brazil. Eduardo Grossmann Isabelle Ferreira da Silva Souza, Rosa Sá de Oliveira Neta, Renata Trajano Jorge Caldas, Federal University of Rio Grande do Sul, Porto Alegre, RS – Brazil. Irimar de Paula Posso Michely Nery, Marcelo Cardoso de Souza University of São Paulo, São Paulo, SP – Brazil. Janaina Vall Federal University of Ceara, Fortaleza, CE – Brazil. Tapentadol: what every doctor needs to know about this new drug ______72 José Aparecido da Silva University of São Paulo, Ribeirão Preto, SP - Brazil. Bernardo De Marchi Mosele, Daniel Benzecry de Almeida, Válery Baggio Hess José Oswaldo Oliveira Júnior University of São Paulo, São Paulo, SP – Brazil. Juliana Barcellos de Souza CASES REPORTS Federal University of Santa Catarina, Florianópolis, SC – Brazil. Lia Rachel Chaves do Amaral Pelloso Personality, coping and atypical facial pain. Case reports ______77 Federal University of Mato Grosso, Cuiabá, MT, Brazil. Maria Belén Salazar Posso Ludmila Christofoletti, Maria de Fátima Vidotto de Oliveira, Silvia Regina Dowgan Tesseroli Christian University Foundation, Pindamonhangaba, SP – Brazil. de Siqueira Sandra Caires Serrano Pontifícia Universidade Católica de Campinas, São Paulo, SP – Brazil. Telma Regina Mariotto Zakka University of São Paulo, São Paulo, SP – Brazil. Orofacial myofunctional disorder, a possible complicating factor in the management of

EDITORIAL COUNCIL painful temporomandibular disorder. Case report______80 Abrahão Fontes Baptista temporomandibular dolorosa. Relato de caso Federal University of Pernambuco, Recife, PE – Brazil. Alexandre Annes Henriques Melissa de Oliveira Melchior, Laís Valencise Magri, Marcelo Oliveira Mazzetto 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 Pain treatment and recovery of functionality in a former athlete diagnosed with School of Medicine of Botucatu, Botucatu, SP – Brazil. myofascial pain syndrome in the course of syringomyelia. Case report______87 Hazem Adel Ashmawi University of São Paulo, São Paulo, SP – Brazil. Renato Carvalho Vilella Ismar Lima Cavalcanti University Iguacu, Rio de Janeiro, RJ – Brazil. Jamir Sardá Junior INSTRUCTIONS TO AUTHORS______90 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 BOARD Allen 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 Medicine Guwol – Dong Mamdong-gu, Incheon – Korea. Mark Jensen Washington University, Washington – USA. Ricardo Plancarte Sánchez National Institute of Cancerology, Mexico – Mexico Submitted to articles online: EDITORIAL COORDINATION Evanilde Bronholi de Andrade http://www.sgponline.com.br/dor/sgp/. 12

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DOSES ADAPTÁVEIS AO TIPO DE ARTICULAÇÃO E-mail: [email protected] Br J Pain. São Paulo, 2018 jan-mar;1(1):1 EDITORIAL

Revista Dor is changing its name! A Revista Dor está mudando de nome!

DOI 10.5935/2595-0118.20180001

In the past two years, due to the excellent work of the Chief Editor Prof. Dr. Durval Campos Kraychete and his supporting team, Revista Dor has published a myriad of high-level scientific articles that lead to an important rise in its score, placing it at the same level of many of the scientific journals focused on the research and treatment of pain.

However, unfortunately, our beloved Portuguese language is not widely known. Although all articles of Revista Dor are also presented in English and can be easily accessed in full on the World Wide Web, few readers from other countries access the excellent papers published.

Therefore, from now on, Revista Dor will be named Brazilian Journal of Pain – Br J Pain, with the objective to facilitate the indexation in other databases, since most of the Brazilian Scientific Journals indexed in Medline and other international indexes have changed their names into English. Moreover, most Scientific Journals of non-English speaking countries listed in these indexes have their names in English.

Hence, for the Chief Editor of our Scientific Journal to be successful in his objective of climbing to new levels is that Revista Dor: Pesquisa, Clínica e Terapêutica is now renamed Brazilian Journal of Pain, without losing the already existing LILACS, Scielo and Latindex indexations.

With this bold step, the official Scientific Journal of the Brazilian Society for the Study of Pain will attract the scientific work of many national and international authors and definitely be inserted into the world scientific scenario!

Prof. Dr. Eduardo Grossmann Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil. E-mail: [email protected]

1 Br J Pain. São Paulo, 2018 jan-mar;1(1):2-3 EDITORIAL

The challenge of measuring pain Os desafios de mensurar a dor

DOI 10.5935/2595-0118.20180002

Pain is an experience described in terms of sensorial, motivational, and cognitive characteristics and, many times, with emotional se- quelae. That is why the use of many pain measurements, such as the multidimensional scales and questionnaires, result, partially, from the recognition and evaluation of its different components and dimensions. However, in the past, a myriad of studies on the subject and its analgesia have considered pain as a unitary dimension, varying only in intensity. But, as the results of experimental studies can depend on different dimensions of the symptom at the moment of the evaluation, pain can be felt in a peculiar way by each patient. Using a simple measurement of the pain sensation can introduce significant variability in the mechanisms and in the effective pain treatment1. What do patients understand when describing the magnitude of the pain they are feeling? Do they refer to the sensorial intensity, to the presence of specific sensorial qualities, or to their suffering, anxiety, anguish? Would the pain records be usually associated with one of these dimensions, or do their meaning vary among individuals? If the study of the pain sensation needs to have a scientific basis, it is essential to measure it. For example, in case there is the need to know the efficacy of different analgesic drugs, we need numbers, comparable objective data, so, over time, we can say if the pain has somehow decreased. Besides the importance of knowing if a drug has reduced the intensity of pain, it is also important to know if the drug has especially reduced the quality of the discomfort as the burning pain, or if the feelings of discomfort and displeasure, associated with pain, have disappeared in some way. However, the parameters that describe the quality of pain are not always universal, but subjective, idiosyncratic, because they depend on the cultural repertoires and individual patterns. Now, usually, the assessment of clinical pain is based on the oral reports or on the descriptors commonly used by the patients to describe the pain they are experiencing at that moment. One of the problems is related to the extent that these commonly used oral descriptors share the same meaning in the main dimensions of pain because one pain descriptor can have more than one meaning. This led, for example, to the development of the McGill pain assessment questionnaire as an instrument to assess the sensorial, emotional, and evaluative qualities of pain, together with several other aspects, such as intensity, pattern, and location. This questionnaire has been translated and standardized for different cultures, races, and gender, due to the huge variability in the meaning of the different pain descriptors used by the patients to describe both acute and chronic clinical pain. However, the idiosyncratic variability of the meanings attributed to pain cannot and should not be regarded as an impeditive to the development of methods that allow to investigate it objectively. Currently, it is known that both the relief and cure, the feeling of being relieved/cured are completely different concepts that need to be observed, so the treatment of the patient with pain reaches its full objectives2. In fact, apparently, we all agree that pain is a subjective, personal and multidimensional experience that involves psychological, behavioral, emotional, cognitive and sensorial dimensions. Since it is a multifaceted phenomenon, pain is also affected by past experience and culture. Thus, measure the intensity of pain is of utmost importance for the researchers and physicians because its measurement is essential to evaluate the methods of control. Pain assessment/measurement is a fundamental prerequisite for effective treatment and management. Since pain is a genuinely subjective experience, only those that feel it can determine its severity and the adequate relief. In other words, only the patient’s perspective is the correct. Therefore, its self-assessments are most precise and trustworthy. As a consequence, it is reasonable to ask if such phenomenon can be assessed or measured. Since pain is a subjective experience, it is only possible to assess or measure it by means of the several responses or reactions manifested by those that experience it3. However, which aspect of pain must be primarily considered, assessed or measured? Its intensity or its varied hedonic components? To this end, it is essential to define or to clarify the meaning of the assessment and measurement terms in the context of pain.

Renato Leonardo de Freitas Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Coordenador do Centro Multiusuário de Neuroeletrofisiologia e do Laboratório de Dor & Emoções, Ribeirão Preto, SP, Brasil. E-mail: [email protected]

José Aparecido da Silva Universidade de São Paulo, Faculdade de Filosofia Ciências e Letras, Ribeirão Preto, SP, Brasil E-mail: [email protected]

2 Os desafios de mensurar a dor Br J Pain. São Paulo, 2018 jan-mar;1(1):2-3

REFERENCES 2. Da Silva JA, Ribeiro-Filho NP, Matsuhima EH. Mensurando o quinto sinal vital: a dor. Ribeirão Preto: FUNPEC-Editora; 2010. 144p. 1. Da Silva JA, Ribeiro-Filho NP. Avaliação e mensuração da dor: pesquisa, teoria e prá- 3. Da Silva JA, Ribeiro-Filho NP. Avaliação e mensuração de dor clínica. Ribeirão Preto: tica. Ribeirão Preto: FUNPEC Editora; 2006. Livreto educativo, FUNPEC Editora; 2014.

3 Br J Pain. São Paulo, 2018 jan-mar;1(1):4-8 ORIGINAL ARTICLE

Characteristics and perception of social support by patients with fibromyalgia in Facebook Características e percepção de apoio social por pacientes com fibromialgia no Facebook

Felipe Azevedo Moretti1, Sandra Santos Silva2, Claudia Galindo Novoa1

DOI 10.5935/2595-0118.20180003

ABSTRACT RESUMO

BACKGROUND AND OBJECTIVES: Analyze the interactive JUSTIFICATIVA E OBJETIVOS: Analisar o comportamento behavior, characteristics, perception of social support, and inter- interativo, as características, a percepção de apoio social e os in- ests of patients with fibromyalgia on online discussion groups. teresses de pacientes com fibromialgia em grupos de discussão METHODS: A participatory netnography has been conducted online. for 6 months on Facebook in order to keep track of a fibromy- MÉTODOS: Foi feita uma netnografia participativa que acom- algia community with more than 8,000 members. An electronic panhou por 6 meses uma comunidade de Fibromialgia com mais survey composed by a validated social support scale was sent to de 8.000 membros no Facebook. Um inquérito eletrônico sobre the members of the group. Another online survey was applied by suporte social com escala validada foi enviado aos membros do the group coordinator in order to build the users’ profile. grupo. Outro questionário online para traçar o perfil dos usuári- RESULTS: The online environment has often been indicated os foi aplicado pela coordenadora do grupo. as the only place to get something off one’s chest. Regular tes- RESULTADOS: O ambiente online foi apontado frequente- timonials on social discrimination due to Fibromyalgia were mente como único local de desabafo. Registraram-se depoimen- recorded, coming from the family itself, from friends and even tos regulares sobre discriminação social decorrentes da Fibromi- from health professionals. Patients’ rights and new treatments are algia - advindos da própria família, de amigos e, até mesmo, de among the topics of greatest interest. The target group seemed to profissionais de saúde. Direitos dos pacientes e novos tratamentos have a social echo, but it has difficulties to generate engagement aparecem dentre os temas de maior interesse. O grupo acompan- among its members. Low social support was reported by most of the 444 respondents. However, many also criticized the group hado mostrou ter repercussão social, mas apresenta dificuldades positively. There were 3,217 people who responded the survey para gerar envolvimento entre os membros. Baixo apoio social applied by the coordinator: 97.5% female respondents, 86.2% foi alegado pela maioria dos 444 respondentes. No entanto, mui- were between 31 and 60 years old, 60.1% were diagnosed by a tos também criticaram positivamente o grupo. O questionário rheumatologist, 16.5% by an orthopedist, and 6.8% by a general aplicado pela coordenadora teve 3.217 respondentes, a saber: practitioner. The five most unpleasant symptoms informed were: 97,5% do sexo feminino; 86,2% com idade entre 31 e 60 anos; pain, anxiety, memory problem, irritability, and tingling. 60,1% cujo diagnóstico foi dado por um reumatologista, 16,5% CONCLUSION: New forms of online education and social por ortopedista e 6,8% por clínico geral. Os cinco principais support for fibromyalgia on online groups are relevant resources sintomas mais desagradáveis citados pelos pacientes foram: dor, to be considered in patient care programs. ansiedade, problema de memória, irritabilidade e formigamento. Keywords: Fibromyalgia, Social networks, Social support. CONCLUSÃO: Novas formas de educação online e de apoio social em grupos virtuais para fibromialgia são recursos relevantes a serem considerados em programas de atenção a pacientes. Descritores: Apoio social, Fibromialgia, Redes sociais.

INTRODUCTION

1 1. Universidade Federal de São Paulo, Programa de Pós-Graduação em Gestão e Informática A systematic review by Cochrane showed that the mere iden- em Saúde, São Paulo, SP, Brasil. tification of similar cases or symptoms among individuals with 2. Associação Brasileira dos Fibromiálgicos, Itanhaém, SP, Brasil. similar problems on online networks can be an excellent instru- Submitted in October 03, 2017. ment to handle chronic conditions, among them the fibromyal- Accepted for publication in January 04, 2018. Conflict of interests: none – Sponsoring sources: Programa Telessaúde Brasil Redes. gia (FM), offering improvement for the health of the users, promoting bigger autonomy and proactivity, as well as benefits that Correspondence to: Rua Botucatu, 740 - 3ºA - Sala 307 – Vila Clementino improve social interaction, reduce hopelessness, provide more 04023-062 São Paulo, SP, Brasil. knowledge about the disease, expand behavior strategies and E-mail: [email protected] better clinical outcomes of diseases such as rheumatoid arthri- © Sociedade Brasileira para o Estudo da Dor tis (RA), cancer and FM1,2. However, the authors suggest more 4 Characteristics and perception of social support by Br J Pain. São Paulo, 2018 jan-mar;1(1):4-8 patients with fibromyalgia in Facebook studies as a way to consolidate the best practices and to compare considered to provide high capillarity, decentralization and a the results from different strategies. greater likelihood of social impact). Moreover, one of the mottos Making use of educational initiatives in the treatment of FM has of the group was the creation of strong bonds among members - proved to be a valuable resource to control pain, fatigue, and de- one of the study objectives of the research. pression with benefits that usually remain in the long run, show- It is worth mentioning that netnography has proven to be a use- ing superiority to the conventional treatment alone and with ful method in research aiming at new findings related to digital evidence of cost-effectiveness in economic analysis3,4. communication10, even in the health area11. These benefits have already proved to be viable, useful and After the selection of the community, we requested a formal au- promising in the online universe of FM support and education thorization from the coordination to follow the group, who sup- groups5. However, there is still a shortage of studies to evalu- ported the study and notified users of the research. ate the results of different models and identify the difficulties, The phase of participative netnography began with electronic an- the potential and possible promising actions to be offered by the notations of posts with many shares or likes, field records on top- existing groups or groups that will be created, even as a guiding ics of greatest interest and listing of interactive behaviors stored mechanism to improve the service provided. in a temporary record by the software OneNote. In addition, over According to van Uden-Kraan et al.6, a researcher from the Uni- six months, the main researcher interacted with the members of versity of Twente (The Netherlands) who studies the subject of the virtual community, conducting interviews and distributing virtual support groups to chronic problems, it is possible to find an electronic survey on social support. The survey consisted of important weaknesses in terms of quality and validity of the in- a social support validity scale, the Social Support Satisfaction formation that sometimes travel online. In addition, these envi- Scale (SSSS), in addition to supplementary questions related to ronments can also provide an inadequate opinion in the social the subject of the study, such as amount of meaningful friend- or behavior point of view. Yet, Johnsen, Rosenvinge, and Gam- ships made in the group, suggestions for improvement for future mon7 state that in specific communities for online support in the groups, positive and negative criticism regarding the network, field of mental health, there are, sometimes, negative comments suggestions for new activities, degree of involvement with the that are strengthened by other participants, thus creating a de- group, among others. structive line of negativity. However, despite the weaknesses, van All the 444 respondents who had completed the social support Uden-Kraan et al.8 indicate that, when put on the scale, the posi- electronic survey signed the free and informed consent before tive effects tend to overcome the possible negative contributions. answering the research. Only five subjects refused to sign the Frost and Massagli9 point out that talking in online environments electronic consent, being excluded from the statistical analysis. of dialogue and questioning the behaviors of other members that To reach the described sample, the main researcher sent inbox suffer from the same disease, with the possibility of exchanging messages on Facebook to most of the group members, informing personal experiences, locate other people and offer knowledge on about the research and inviting them to collaborate with the study. health management tend to solidify relationships. But few stud- The sample of 444 respondents was established as representative ies have examined the details in using these mechanisms. of the studied universe. As a calculation basis, it was used the In this sense, understanding the patterns of interactive behavior, estimate of 8,000 patients in the network as the study universe the themes of interest and the profile of patients with chronic because it was identified that approximately 5% of the partici- pain (in this case, fibromyalgia) who attend online discussion pants of the online group were health professionals, family mem- groups, as well as to identify ways to enhance such groups are bers, friends or people interested in the subject. To establish the important research steps. sample calculation with a confidence level of 95% and 5% of The objective of this study was to analyze the interactive behav- error margin, the sample size required was 367 respondents. ior, characteristics, the perception of social support and the inter- It is important to highlight that before the application of the ests of patients with FM in online discussion groups. social support electronic survey; the group coordinator initiated an opinion poll with the participants of online communities on METHODS Facebook connected to the institution that she runs in order to characterize the patients with FM that participate in these discus- An exploratory survey was initially conducted to identify rel- sion settings. Then, in order to complement the present article, evant discussion groups on Facebook addressing the subject of the author of the survey was invited to present part of her data. FM. More than 100 communities of virtual support for FM in The group coordinator used the Google Form tool for the survey Portuguese were found. The community selected for the netnog- and shared the results with the main researcher of the present ar- raphy has a high number of members (8,197 on 10/14/2015) ticle. The questionnaire consisted of questions about age, gender, and a nationwide patients’ association connected to the group medical specialty who provided the FM diagnosis, most unpleas- and to a complementary information channel that has already ant symptoms, place of residence, monthly income, treatments, been awarded by the public with the Top Blog Award in the the amount spent with treatments, among others. health category. Despite her participation in co-authorship of the manuscript, Other reasons that guided the selection were the fact that the since some of the descriptive data were collected by her, the sur- community is closed and has many active individuals, clear par- vey coordinator had no interference in the article writing, nor in ticipation rules, and 14 administrators in the occasion (what was the form the data is presented, since this could represent a con- 5 Br J Pain. São Paulo, 2018 jan-mar;1(1):4-8 Moretti FA, Silva SS and Novoa CG flict of interest in the form of presentation of the netnography However, although few significant friendships were made, the ma- results and of the social support survey. jority of the respondents (>60%) miss somebody truly close to vent This study was approved by the Committee of Ethics of the their feelings, and approximately 70% miss social activities a lot. institution under record number in Plataforma Brasil: CAEE When it comes to the question of how engaged the users were 47925615.8.0000.5505. with the activities of the group, most of the participants reported a low involvement, and only 22.8% had an involvement above RESULTS the average of 5 (in a scale where 10 was the maximum involvement), 19.4% (86) reported an average involvement (that is, By the netnography, it was possible to observe that many par- score 5) and the remaining of respondents (57.9%) reported a ticipants pointed out the online environment as the only place low or very low involvement with the activities. to vent their feelings with intimate, deep, suffered reports and However, despite this low involvement with the group’s activi- broad exposure of personal data. ties, in reply to an open question - where participants were in- With such stories, we observed empathy behaviors from the group vited to speak freely about the virtual group they participate, and active contribution from the moderators with affectionate and the positive comments were more frequent than the negative, constructive comments. Similarly, it was also observed slightly dis- with frequent reports expressing the importance of the group connected contributions, for instance likes for extremely sad/hard for the day-to-day, compliments to the great efforts, encouraging situations, as well as abrupt changes of topics discussed. Regular speeches and a lot of gratitude. statements were recorded about social discrimination due to the As for the most frequent suggestions about what could be im- disease - coming from family, friends and health professionals - proved in these virtual FM groups, virtual conferences appeared who often question the veracity of the symptoms, alleging to be in first among the given answers. Ways to help and provide in- a purely psychological syndrome, and also showing discredit and teraction among users were also some of the main topics, as well ignorance. The discrimination posts generally get a lot of likes, as the support of more healthcare professionals, the need of psy- shares, and comments reinforcing that this is absolutely common- chological and legal support, and also the creation of regional place. The group has characteristics very similar to mutual help discussion forums. Other frequent suggestions were: dissemina- associations, where there is collaboration among peers with the tion of trustworthy research, a listing of medical experts, physical exchange of experiences, recognition, and appreciation of the dif- attendance meetings and more technical videos on the subject. ficulties of others. There are also congratulation posts on birthdays, The state of health the patients attributed themselves is usually for overcoming challenges, in addition to the intense and relevant from regular to very bad. Of the 444 respondents, 51.1% (227) participation of the moderators. considered their health bad or very bad. Yet, 37.8% (168) con- The coordinator told that the moderators are regularly trained sidered their health state reasonable; 10.6% (47) reported a good due to the high turnover of volunteers in this function. health state and 0.5% (2) said they were in very good health. Improper Posts receive a warning message when they do not fol- Other complementary data from the 444 respondents are that low the rules, and members can be excluded or blocked. The veto 73.9% (328) are married or in a steady relationship, and 71.6% and the exclusion of some freer manifestations of the collective (318) have children. Other characterization data of the 444 re- sometimes imply in dissatisfaction and disengagement of certain spondents (such as gender, age, education level, and income) are people of the community. very similar to the results collected in the questionnaire applied There are also reading suggestions, news highlights and criticism by the coordinator, described below. to articles deemed of low credibility when they are posted to the The questionnaire applied by the coordinator of FM virtual group. groups had 3,217 respondents. It was instructed that only in- Regular comments on difficulties to get people to help in the dividuals that have already received a previous diagnosis of FM group moderation, as well as frequent requests for more engage- from a physician should answer the online questionnaire. How- ment of the users. ever, it is important to highlight that when refining the answers To evaluate possible topics to be debated, the members receive database, some duplicates and errors were found in approximate- surveys to state their interest, questionnaires to evaluate the par- ly 3% of the fields. Therefore, it is suggested to consider such ticipants’ degree of knowledge about the syndrome, and ques- margin of error in the interpretation of the data of this article. tions so that they can express their personal feelings about the Of the total of 3,217 respondents, 97.5% were female and participation in a collective digital environment. 86.2% with age between 31 and 60 years. Of the total of re- Patients’ rights and new treatments are among the topics of spondents, 60.1% received the diagnosis from a rheumatologist, greatest interest expressed by the participants. 16.5% from an orthopedist and 6.8% from a general practioner. In the survey answered by 444 individuals, 72.1% (320) of the The five major unpleasant symptoms reported were pain, anxi- participants said they did not make any significant friends in ety, memory problem, irritability, and tingling. the group, followed by 7.9% (35) who made just one friend, As for the education level of the sample, 26.7% (859) have com- 6.1% (27) who made two friends and 4.7% (21) who made three pleted high school, 22% (707) had superior education, 19.8% friends. The remaining percentage of those who said they have (637) had a post-graduation, and 15.5% (499) had an incom- made more than four friends was always below 2.9% for the oth- plete superior education. These were the first 4 categories with er categories that ranged from four to 10 (or more) friends made. the highest number of respondents. 6 Characteristics and perception of social support by Br J Pain. São Paulo, 2018 jan-mar;1(1):4-8 patients with fibromyalgia in Facebook

Of the total sample, 44.7% (1,437) were from the Southeast bers); “I have fibromyalgia (13,600 members); “Commission of of Brazil, 19.8% (636) from the South, 18% (578) from the Fibromyalgia patients - Pro National Association” (11,600); “I Northeast, 10.8% (357) from the Midwest, 4.2% (134) from the have Fibromyalgia, what now?” (10,500); “Knowing more about North, and the others from other regions/countries. fibromyalgia (10,300); “Fibromyalgia Association” (9,000); “Fi- The personal monthly income that predominated was between bromyalgia – sharing experiences” (8,800); “Friends with Fibro- R$ 1.001,00 and 3.000,00 - with 31.4% (1,010) respondents myalgia” (4,300); “Positivism in Fibromyalgia (880). self-reporting such income. Followed by 21.2% (682) who As a counterpoint, it is worth pointing out that the format of the did not have any remuneration (being financially dependent self-management education programs for rheumatology men- on someone else). Then, 20.2% (650) reported a monthly in- tioned in the first paragraph of this discussion, give as a meth- come up to R$ 1.000,00; 13% (419) between R$ 3.001,00 and odological model the creation of small groups of patients (up to 5.000,00; and 4.6% (149) between R$ 5.001,00 and 7.000,00. 25 members). The others fell into other categories. As for the findings on low social support reported by the 444 individuals in the electronic survey and the small number of us- DISCUSSION ers with FM that made friendship bonds online, some possible hypothesis was proposed for this apparent fragility in building Web-based education strategies for rheumatic patients have already stronger social bonds, such as isolation due to the disease itself15 shown to be promising for diseases as RA and FM1,5. A renowned (since more than 50% of the respondents said their health was education program for self-management for rheumatology12, rep- very bad and bad, which makes social interaction more difficult), licated in several countries with the support of the American Col- the presence of a certain invisibility in a ocean of so many mem- lege of Rheumatology, was structured online and showed to be bers16, and a postmodern culture of liquidity - which stimulates superior to the conventional treatment in a randomized study with weak social bonds17,18, and the current monetary and social log- 855 patients with FM, RA, and osteoarthrosis13. ic that values more the quantity at the expense of intimacy or It is important to say that the online education format proposed depth of human relations. However, the construction of closer by Lorig et al.13 was exactly an attempt to give support to a broad interpersonal relations is a process that is highly desired by the universe of patients who enter the virtual environment searching members, and more than 60% of the participants miss some- for health information. In these virtual searches, such patients body truly close to vent their feelings, and approximately 70% end up in discussion groups on Facebook and other interactive miss social activities a lot. In addition, ways to help and provide platforms. In an online search on Facebook in August 2017, we interaction among users were also topics suggested as improve- found 98 FM groups, 102 pages on FM and other dozen groups ments to these FM groups. that appeared in the personal profile category when running the With regard to this analysis, the studied group showed to have search with only the “Fibromyalgia” keyword in Portuguese. social repercussion and impact in the life of its members. How- As a suggestion for a higher possibility of success of these com- ever, it faces difficulties to motivate the users to have more active munities, van Uden-Kraan et al.6 point out that the moderators participation and interpersonal involvement. However, to build of these online groups should dedicate 10 to 15 hours weekly strategies that drive the social support within these communities due to the wide demand required by the users of these com- is something that deserves attention, because it is exactly in the munities. networks with strong bonds that there is a common identity, Camerini, Camerini and Schultz5 also mention the importance and it is where people search for references in their decision- to provide personalized content with individualized attention as making process. According to Granovetter (apud Kaufman)17, it a way to increase the global efficacy of these groups. is with strong bonds that comes the feelings of trust among the In spite of these considerations in the present study and the ac- members of a community. Granovetter says that the stronger the tive and intense contribution from the moderators, it was ob- bonds in their networks, more consistent are the decisions they served the difficulty in sending individualized messages to the make. According to Kaufman: users, due to reasons usually associated with the high number of “The new digital informative architecture provided an exponen- members, because it is an action that requires a lot of work to tial growth of ‘Weak Bonds’ networks, with the formation of the be performed without automation, it is a voluntary work (which so-called ‘Virtual Communities’, around 1985, that expanded dedication tends to be compromised by the fragile functional after 1994 with the advent of the web and boosted after 2004 bond) and due to lack of financial resource to provide better with the social networks. By looking at the profile of the mem- structured activities. Such difficulties have already been observed bers of the key communities, we found participants with more in other research on rheumatic patient associations14 and must than a thousand ‘friends’ with, apparently, no kind of social in- be taken into account when opening new groups. teraction among those involved”. As part of the research, when interviewing an active patient of However, several international studies suggest that it is exactly these FM groups and questioning her about the most relevant in the strong interpersonal and intimate relations that we see the initiatives she has participated, it catches the attention that the most significant benefits in terms of prevention and promotion majority she listed has thousands of users. Below is the list sent of health. The strong and consistent inverse association of social by the patient in June 2017 with the respective number of users bonds and the general mortality rate was one of the first effects listed by the patient. “Fibromyalgia I have friends” (17,600 mem- identified among the benefits of a good social network on health19. 7 Br J Pain. São Paulo, 2018 jan-mar;1(1):4-8 Moretti FA, Silva SS and Novoa CG

In this sense, educational activities that foster greater interaction REFERENCES and personal relationship among the members of the group can be important actions to be considered for future experiences in 1. Murray E, Burns J, See TS, Lai R, Nazareth I. Interactive Health Communica- tion Applications for people with chronic disease. Cochrane Database Syst Rev. FM online groups. 2004;18(4):CD004274. It is also worth mentioning that among the initiatives of greater 2. Andrade GR, Vaitsman J. Apoio social e redes: conectando solidariedade e saúde. Ciênc Saúde Coletiva. 2002;7(4):925-34. interest for the patients are conferences with healthcare profes- 3. Luciano JV, Sabes-Figuera R, Cardeñosa E, T Peñarrubia-María M, Fernández-Vergel sionals, something possible to be explored with more emphasis R, García-Campayo J, et al. 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8 Br J Pain. São Paulo, 2018 jan-mar;1(1):9-14 ORIGINAL ARTICLE

Association between musculoskeletal symptoms and perceived stress in public servants of a Federal University in the South of Brazil Associação entre sintomas osteomusculares e estresse percebido em servidores públicos de uma Universidade Federal do Sul do Brasil

Letícia Maria da Silva Almeida1, Samuel de Carvalho Dumith2

DOI 10.5935/2595-0118.20180004

ABSTRACT RESUMO

BACKGROUND AND OBJECTIVES: In view of the high JUSTIFICATIVA E OBJETIVOS: Diante da alta prevalência prevalence of pain complaints among workers in the country das queixas de dor entre os trabalhadores no país e suas conse- and their consequences in the quality of life and work, the objec- quências para qualidade de vida e no trabalho. O objetivo deste tive of this study was to investigate the association between the estudo foi investigar a associação entre o estresse percebido e a perceived stress and the presence of musculoskeletal symptoms presença de sintomas osteomusculares entre servidores públicos among public servants of the Federal University of Rio Grande. da Universidade Federal do Rio Grande. METHODS: Observational, transversal and quantitative study. MÉTODOS: Estudo observacional, transversal e quantitativo. The survey population comprised all active servants in the se- O público da pesquisa foi todos os servidores efetivos que es- cond semester of 2016 in any campuses of the Federal University tavam em atividade no segundo semestre de 2016 de qualquer of Rio Grande. Participants received a digital invitation to par- dos campi da Universidade Federal do Rio Grande. Os partici- ticipate in the survey containing a link that would lead to the pantes receberam, por via digital, um convite para participar da questionnaire generated by Google Docs. The questionnaire was pesquisa contendo um link que remetia ao questionário, gerado composed of questions on demographic data, and two standardi- pelo Google Docs. O questionário foi composto por perguntas zed instruments: the Nordic Musculoskeletal Questionnaire and que inquiriam dados demográficos e duas avaliações padroni- the Perceived Stress Scale. The descriptive analysis was done by zadas: Nordic Musculoskeletal Questionnaire e Escala de Estresse absolute and relative frequency. For the bivariate analysis, it was Percebido. A análise descritiva tratou-se da frequência absoluta used the Fisher’s Exact test. P values were reported for the linear e relativa. Para análise bivariada, utilizou-se o Exato de Fisher. trend test on associations between stress and pain. Foram reportados os valores p para o teste de tendência linear nas RESULTS: Of the total number of eligible servants (n=717), associações entre o estresse e a dor. 36.6% participated in the study. The spine was the most repor- RESULTADOS: Participaram do estudo 36,6% do número to- ted area of the body with pain symptoms in the last 12 months, and in the last seven days. The least prevalent region of pain was tal dos servidores (n=717). A região das costas foi a mais preva- hips / thighs. It was observed that the greater the perceived stress, lente de dor quanto aos sintomas nos últimos 12 meses, e nos the greater was the prevalence of musculoskeletal symptoms. It últimos sete dias. A região menos prevalente foi quadril/coxas. was observed a statistically significant linear trend in almost all Verificou-se que quanto maior o estresse percebido, maior foi a assessed anatomic regions. prevalência de sintomas osteomusculares. Observou-se tendên- CONCLUSION: There was a high prevalence of musculoskeletal cia linear com significância estatística em quase todas as regiões symptoms in the analyzed population, as well as a strong association anatômicas analisadas. between the perceived stress and the presence of these symptoms. CONCLUSÃO: Constatou-se elevada prevalência de sintomas Keywords: Musculoskeletal pain, Psychological stress, Universi- osteomusculares na população estudada, além da forte associação ties, Workers. entre o estresse percebido e a presença destes sintomas. Descritores: Dor osteomuscular, Estresse psicológico, Trabalha- dores, Universidade. 1. Universidade Federal do Rio Grande, Faculdade de Medicina, Rio Grande, RS, Brasil. 2. Universidade Federal de Rio Grande, Faculdade de Medicina, Programa de Pós-Gradua- INTRODUCTION ção em Saúde Pública. Rio Grande, RS, Brasil.

Submitted in August 26, 2017. Pain is pointed out as one of the most common complaints Accepted for publication in January 05, 2018. Conflict of interests: none – Sponsoring sources: none. among the reasons for seeking care in healthcare services and one of the reasons for self-medication in the country1,2. The preva- Correspondence to: Rua Visconde de Paranaguá 102 – Centro – Campi Saúde lence of chronic pain in the general population, investigated in 96203-900 Rio Grande, RS, Brasil. a multicenter study, with 42,249 people older than 18 years, in E-mail: [email protected] 17 countries, was 38.4%3. Another study, which assessed 46,394 © Sociedade Brasileira para o Estudo da Dor people in 15 European countries and Israel, found that 19% had 9 Br J Pain. São Paulo, 2018 jan-mar;1(1):9-14 Almeida LM and Dumith SC moderate or severe pain lasting at least six months, had pain in servant, that is, to work as an administrative technician and/or the last month and had pain at least twice a week4. teacher at the Federal University of Rio Grande (FURG), in the Several factors are related to the triggering, development, and second half of 2016 and work on the FURG campuses. FURG maintenance of musculoskeletal pain. When it comes to acute has campuses in the cities of Rio Grande (Carreiros Campus and pain, it is understood as a response to the stimuli on the surface Health Campus), Santa Vitória do Palmar, Santo Antônio da Pa- of the skin, since it is a physiological pain that triggers a protecti- trulha, and São Lourenço do Sul. As exclusion criterion, the civil ve reaction, such as the withdrawal reflex to stop the exposure to servant should be on leave of absence. noxious stimulus5. However, the persistent pain picture cannot There was no calculation of sample size since all the institution’s be considered an adaptive response when nociceptive afferent servants were eligible and were invited to participate in the study. stimuli induce changes leading to the deleterious effects of chro- The survey was of the census type, and the sample was not by nic pain5. Individual factors (age, gender, life habits), sociode- convenience. mographic, psychosocial, physical and organizational factors are The data collection was from October to November 2016. All mentioned6. In addition, the perception of stress and the relation eligible employees received an individual invitation to partici- with mental health are indicated as important impact factors on pate in the survey, via the university system, and by e-mail. In pain in many systems of the human body6. addition, the university staff was briefed on the survey by a post The relationship between the psychosocial aspects of work and mus- on the news page of the FURG website. The invitation had a link culoskeletal symptoms are studied in several professions7. It is recog- to the questionnaire used in the survey. This questionnaire was nized that some professional categories are more exposed to the onset generated by Google Docs and was answered on the computer, of these symptoms8,9. Psychosocial work factors have been pointed only needing an internet connection to open and send. Before out for many years because they are related to a large amount of answering the questionnaire, teachers had to indicate that they health complaints10. Occupational stress can also affect and promote agreed to participate in the study. No personal information as the prevalence of musculoskeletal disorders and symptoms10. the name or school registration number was collected, keeping It is known that stress leads to symptoms in the body, similar to the answers anonymous. The average time to fully complete the the reactions caused by toxic-chemical substances. This picture is questionnaire was 5 to 7 minutes. associated with sensations of discomfort that disturb the home- The questionnaire was composed of blocks of questions. The ostasis of the human body11. The stages of stress evolution, such first with demographic data including gender, age group, time of as alarm, resistance and adaptation, and finally the exhaustion in work, institute and function in the university. The second blo- most severe and persistent situations are also mentioned11. ck was composed by the Nordic Musculoskeletal Questionnaire Musculoskeletal pain is reported in several studies with teachers (NMQ) and the third block consisting of the Perceived Stress as a relevant health problem12-14. The diseases caused by injuries Scale (PSS). to the musculoskeletal system appear as the main causes of leave The NMQ is a standardized, self-applied instrument, already of absence and occupational diseases in this category8. It is also validated in the country and developed with the intention to a contributing factor in mental disorders and increase of absen- standardize the measurement of symptoms reported19,20. The teeism resulting in countless consequences, such as cost increase authors of this questionnaire do not indicate it as the base for in the economy around the world15,16. clinical diagnosis, but to identify musculoskeletal disorders and, The high prevalence of pain in the population, the high costs therefore, be an important instrument of diagnosis of the work imposed on society, insurance companies and healthcare servi- environment to elaborate prevention measures19. The instrument ces, as well as the negative impact on the daily activities of those consists of binary choices referring to the occurrence of symp- who live with such experience, put it as a public health problem2. toms in last the 12 months and in the seven preceding days, in Musculoskeletal symptoms are important causes of absenteeism, nine anatomical regions and the report of leave of absence of and in Brazil, it is the second most prevalent health problem routine activities in the last year20. The anatomical regions sur- to receive social benefits for temporary and permanent disabili- veyed are the neck, shoulders, back (upper part), elbows, wrists/ ty17. Over the last decade, Social Security numbers indicate that hands, back (lower) hips/thighs, knees and ankles/feet. among the most prevalent diagnostic groups of sick benefit be- The main exposure variable in this study was stress, which was nefits are musculoskeletal diseases18. associated with musculoskeletal symptoms, mainly muscle pain The objective of this study was to investigate the association be- in different anatomical regions. The Perceived Stress Scale, also tween the presence of musculoskeletal symptoms and the percei- called PSS, was used to assess stress. It consists of a general scale ved stress among public servants in the extreme south of Brazil. that can be used with different age groups, already translated into The hypothesis of the study was based on the fact that adverse Portuguese and validated in Brazil21. Its objective is to measure the life events can trigger central sensitization and aggravate the im- perceived stress, so it evaluates the degree in which the individuals pact of biological stress systems dysfunction on chronic pain. perceive situations as stressing ones22. It is composed of 14 questions in simple language that use the following answers as options: METHODS (zero) never; (1) almost never; (2) sometimes; (3) almost always or (4) always21. The PSS scores are obtained by the inversion (zero=4, This study was cross-sectional, observational, with a quantitati- 1=3, 2=2, 3=1) of the scores of the seven positive items (items 4, ve approach. The inclusion criteria were to be an active public 5, 6, 7, 9, 10 and 13), and then by summing all the 14 items22. 10 Association between musculoskeletal symptoms and perceived stress Br J Pain. São Paulo, 2018 jan-mar;1(1):9-14 in public servants of a Federal University in the South of Brazil

For the analysis of the scores of this questionnaire, the results were in the associations between pain and stress were tested for the divided into quartiles, being the first quartile the group with lesser variables gender, age group, position and time of work in the exposure to stress and the last quartile, greater exposure. institution. When the p value of the interaction test was lower The study was approved by the Committee on Ethics for Re- than 0.10, the results were duly reported in the text. search in the Health Area (CEPAS) of the Federal Universi- ty of Rio Grande (FURG) under number 72/2015 (CAAE: RESULTS 48819115.1.0000.5324). A total of 717 public servants of FURG, which represents 36.6% Statistical analysis of the total number of servants (1960), answered the question- The answers were exported to an Excel file and later transferred to naire. Most of the participants were female (60%) with ages be- the statistical package Stata, version 11.2, where data cleansing, tween 30 and 49 years (65.6%), with the position of University variable creation, and data analysis were performed. The absolute technician (54.7%) and working for less than 10 years in the and relative frequency of variables were applied for the descripti- institution (63.5%) (Table 1). There was no significant statistical ve analysis. Fisher’s Exact test was used for the bivariate analysis. correlation between these variables and the perceived stress. The p values for the linear trend test in the associations between stress average of the stress score was 42.8±3.2, varying from 31 to 53 and pain were reported. The statistical significance level used was points, with a median of 43. 5% for two-tailed tests. It is worth to mention that interactions Table 2 shows the data referring to the presence of the musculoskeletal symptoms assessed by the NMQ and its distribution Table 1. Description of the sample of teachers and technicians of the in the different anatomical regions surveyed in this study. These Federal University of Rio Grande, Rio Grande, RS, 2016 (n=717) items were described in the last 12 months and in the last seven Variables n % Stress p value days. Data on those subjects who had the need to seek health (%) professionals help or who reported impairment to carry an acti- Gender 0.06 vity were also reported. The back region was the most prevalent Female 430 60.0 21.8 for pain symptoms in the last 12 months, and 55.7% in the Male 287 40.0 15.8 lower back and 54.1% in the upper part. The region with lesser Age group (years) 0.71 prevalence was the hip/thigh (24.3%). In terms of pain symp- 20-29 73 10.1 18.3 toms in last the seven days, the anatomical region most pointed 30-39 282 39.1 21.7 as the cause of musculoskeletal symptoms remained to be the lower back (33.2%) and less pointed the hip/thigh (13.7%). 40-49 191 26.5 19.2 Still on table 2, with regard to preventing the performance of 50-69 175 18.3 17.2 any activity, the region most cited was also the back, the lower Position 0.92 part (22.2%) and the less reported was the hip/thigh (7.6%). Teacher 312 43.5 20.1 And, as the reason to seek a health professional, the most indica- Technician 393 54.7 19.6 ted anatomical region continued to be the back, the lower part Both 13 1.8 10.0 (29.0%) and the less reported was ankles/feet (12.0%). Most of Working in the 0.30 the sample reported musculoskeletal symptoms in at least one re- institution (years) gion assessed in the last year (85.6%), being slightly less frequent Up to 4 285 39.6 21.6 concerning the last seven days (70.4%). Almost half of the servants had some kind of impairment in their activities as a result 5 to 9 172 23.9 21.0 of these symptoms in at least one region (45.7%), and more than ≥10 263 36.5 16.6 half had to seek a health professional due to this pain (58.0%).

Table 2. Distribution of musculoskeletal symptoms by anatomical region in teachers and technicians of the Federal University of Rio Grande, Rio Grande, RS, 2016 (n=717) Anatomical regions Pain in the last 12 Prevented any Consulted a Pain in the last months (%) activity (%) professional (%) seven days (%) Neck 49.9 13.4 24.9 31.9 Shoulders 51.3 15.3 26.6 31.7 Back (upper part) 54.1 15.4 26.9 31.1 Back (lower part) 55.7 22.2 29.0 33.2 Wrists/hands 45.7 13.9 18.1 22.6 Hips/thighs 24.3 7.6 12.2 13.7 Knees 32.7 12.7 16.3 18.7 Ankles/feet 30.5 9.2 12.0 16.2 In some regions above 85.6 45.7 58.0 70.4

11 Br J Pain. São Paulo, 2018 jan-mar;1(1):9-14 Almeida LM and Dumith SC

Table 3. Association between musculoskeletal pain, as to anatomical region in the last year, and stress (in quartiles) of teachers and technicians from the Federal University of Rio Grande, Rio Grande, RS, 2016 (n=717) Stress scale in quartile Neck Shoulders Back Back (lower Hand/ Hip Knees Feet Any region (upper part) part) wrist 1st (less stressed) 46.6 48.5 47.0 44.7 43.1 21.7 29.5 27.3 81.9 2nd 46.5 46.2 53.5 53.9 37.9 24.1 26.8 23.2 82.3 3rd 50.0 57.7 54.8 62.9 48.9 19.4 36.6 35.9 88.0 4th (more stressed) 63.4 59.5 66.9 70.1 53.1 32.0 38.2 40.7 92.5 p trend <0.01 0.02 <0.01 <0.01 0.03 0.12 0.04 <0.01 <0.01

Table 3 shows the analysis of the association between the repor- the 12 months and the presence of the perceived stress between ted anatomical regions with the musculoskeletal symptoms and teachers and technicians of the university. It was observed that the its relation to the perceived stress. The relation between stress higher the frequency of musculoskeletal symptoms, the higher the and the presence of the reported symptoms in at least one of the prevalence of the perceived stress among the participants. assessed regions was also analyzed. It can be observed that for this variable, the higher the perceived stress, the higher was the DISCUSSION prevalence of musculoskeletal symptoms (p<0.01). We observed a positive linear association between the level of perceived stress It was found that most of the participants in the study reported and the presence of symptoms in almost all the analyzed varia- musculoskeletal symptoms in at least one region assessed in the bles, except for the hip region (p=0.12). last year (85.6%), being slightly less frequent concerning the last It was found that for the neck and lower back regions, this asso- seven days (70.4%). However, it is important to highlight the ciation with stress was more pronounced in the administrative high number of servants with musculoskeletal complaints. The technicians. The numbers also pointed out that there was a statis- back region was the most prevalent in terms of pain symptoms in tically significant linear association only for teachers in the case the last 12 months, 55.7% in the lower back and 54.1% in the of pain in the knee region. Among participants with 50 years or upper part. When the perceived stress variable was analyzed, it older, the data were statistically significant for the wrist/hands was observed that the higher the stress score, the higher the pre- and feet anatomical regions. The association between pain and valence of musculoskeletal symptoms (92.5%), while the group stress in the wrist/hands regions was stronger for servants with with the lowest stress level had 81.9% rate. These differences working period equal or longer than 10 years in the university. were observed for almost all the anatomical regions analyzed. A multivariable analysis was conducted between the level of With respect to the involvement of musculoskeletal symptoms stress and pain considering the gender, age group, position (tea- in teachers’ population, some studies addressing this subject cher or administrative technician) and time of work in the insti- were conducted in Brazil with percentages ranging from 40.9 tution (data not presented). However, the association remained 12 statistically significant. and 90.4% . These are numbers similar to those found in the Figure 1 shows the distribution of participants in accordance with present study, showing that 85.6% of the sample of the Uni- the frequency (in quartiles) of musculoskeletal symptoms in last versity staff reported some musculoskeletal symptom last year. Even the number being slightly smaller concerning the last seven days (70.4%), it was still noted a high prevalence. Almost half of the servants had some kind of impairment in their activities as a result of these symptoms in at least one region (45.7%), and more than half had to seek a health professional due to this pain (58.0%). These numbers translate the high negative impact of musculoskeletal pain in the studied population, and they are corroborated by the literature1,2,18,29. Chronic diseases that have musculoskeletal relation are one of the major health problems in Brazil in the productive phase of life23. Musculoskeletal diseases are pointed as frequent causes of retirement and disability in the country24. Statistics of the Na- tional Institute of Social Security (INSS) indicate an increase in benefits granted, including sick pay, besides being the second major cause of leave of absence14. The incidence is higher among the young (20 to 39 years old) and the women25. Available data Figure 1. Distribution of the perceived stress in accordance with the musculoskeletal symptoms (in quartiles) in last the 12 months betwe- indicate that more than 80% of the diagnostic of these disorders en teachers and technicians of the Federal University of Rio Grande, have resulted in accident allowance and disability retirement by (n=717). Fisher’s Exact test 0.001 the INSS26. 12 Association between musculoskeletal symptoms and perceived stress Br J Pain. São Paulo, 2018 jan-mar;1(1):9-14 in public servants of a Federal University in the South of Brazil

Servants of the FURG presented a higher prevalence of muscu- lack of a specific place to rest, bad remuneration, a high number loskeletal symptoms in the lumbar region, being the major cause of students, inadequate body posture, job dissatisfaction, conflict to seek health care (29.0%) or limitation in the performance of with students31. It is worth mentioning that these causes impact activities (22.2%), regardless the studied period - last 12 months mental health and act as a trigger of stress to teachers18,27,32. (55.7%) or seven days (33.2%). These results are corroborated The experience of pain sensation is known as a cortical function. by other studies with university teachers or basic education tea- The nerve impulse travels in the spinal cord up to the basal part chers, which indicated rates of 63.127 and 51.5%14. of the brain, where it makes the second synapsis. The signals For the technicians, studies point the prevalence of musculoske- can go directly to the cortex or stimulate the autonomic nervous letal pain or discomfort among nursing workers, 96.3% in last system (ANS). The nociceptive stimuli are also directed to the 12 months and 73.1% in the last seven days, being more fre- limbic system (amygdala), that defines the affective characteris- quent the symptoms in the back region (71.5%), neck (68%) tic of pain. The stimulation finally reaches the posterior parietal and shoulders (62.3%)26. In another study with public servants area, where the integration of the nociceptive neural network working on hospital cleaning and hygiene, in the last 12 mon- happens, leading to the perception (interpretation) of pain33,34. ths, 87% of the sample reported some symptom and half of the Acute pain usually occurs right after a trauma to the soft tissues workers indicated the shoulders as the part of the body most or by inflammation, when inflammatory mediators are released, involved in musculoskeletal symptoms28. being related to an adaptation of the body to protect and facili- Still, in one study with office workers of a public university in tate tissue repair and healing5,34. Therefore, acute pain is a symp- Minas Gerais, 39.3% reported localized pain, being the back re- tom that is rarely the cause to seek medical care35. On the other gion, shoulders, forearms a, d hands the most cited sites29. It was hand, chronic pain, without known pathological source, can be possible to observe that the back region was cited as the cause of the consequence of changes in the functioning of the biological symptoms in these servants analyzed in the present study. Mo- stress systems, resulting in abnormal pain perception. The main reover, more than two thirds of the employees had musculoske- hypothesis suggests that the disruptions in the hypothalamic- letal symptoms in the last 12 months and/or in the prior week, -pituitary-adrenal axis, the immune system, and the ANS con- in accordance with the data of the Brazilian population where, tribute to the onset of chronic pain. This can occur by means of according to the National Health Research of 2013, chronic ba- central sensitization, a process of hypersensitization of the neural ckbone diseases registered a prevalence of 18.5% among adults, nociceptive pathways36. that is, almost one fifth of the Brazilian population23. The high However, other authors suggest that the well-documented asso- percentage of reports of musculoskeletal symptoms signals a se- ciation between occupational stress and musculoskeletal pain is rious health problem in the studied population, consonant with not fully explained by a stress effect on pain report. Moreover, the literature18,23,29. it seems that the workers who report musculoskeletal pain are As for the association between stress and musculoskeletal pain more prone to develop subsequent perceptions of stress. This can in public servants of the studied sample, it was observed that the occur because pain makes people less tolerant to work psycholo- higher the perceived stress, the higher the prevalence of mus- gical demands37. culoskeletal symptoms. It was also observed a linear association In this way, stress can also be a consequence of the musculoske- with statistical significance in almost all areas of the body, except letal pain. Any painful stimulation can activate the sympathe- the hip (p=0.12). It is important to consider the emotional and tic nervous system and the hypothalamic-pituitary-adrenal axis, psychological factors involved with the work, the psychosocial which constitutes the regulating axis of the stress reaction38. factors related to the work organization, the individual psycho- Among the limitations of the present study, it is observed that logical factors like repetitive, monotonous tasks, work overload, when considering only the active servants performing their pro- lack of autonomy, low job satisfaction, and low social support30. fession, we could have had the presence of underestimated data These factors are singled out as indicators of stress and associa- in terms of the prevalence of musculoskeletal pain. Probably, tion with musculoskeletal problems30. those with more serious symptoms of pain and/or stress are on In relation to the trend observed in the sample, it stands out the a leave of absence or have refused to participate in the study. stronger association among workers in terms of symptoms in the Therefore, the low participation (36.6%) of the institution’s em- neck and the lower back, while the teachers showed a significant ployees may have underestimated the occurrence of both pain trend only for the knee region, contradicting previous studies and stress as well as the association measures. However, all the that point the back, cervical, and upper limbs31. Among parti- servants of the institution, active in the period, were invited to cipants with 50 years or older, the data were statistically signi- participate in the study with the purpose to not generate a bia- ficant for the wrist/hands and feet. Yet, the association between sed sample. The non-discrimination between chronic and acute pain and stress in the wrist/hands was stronger in servants with a pain is pointed as another limitation of the study. The tool used, working period equal to or longer than 10 years in the university. although standardized and validated, does not make this distinc- This period is lower than the one reported by Sanchez et al.31 tion. Therefore, we can only talk about pain knowing that it can that presented in their study that among the occupational risk be chronic or acute. factors in the involvement of the musculoskeletal system among As strengths of this study, it is the use of questionnaires validated teachers is a period longer than 15 years. Among the causes cited in the country and translated to Portuguese, as well as the prac- for the increased risk are: little or no time to rest between classes, tical and economical way of application. 13 Br J Pain. São Paulo, 2018 jan-mar;1(1):9-14 Almeida LM and Dumith SC

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14 Br J Pain. São Paulo, 2018 jan-mar;1(1):15-20 ORIGINAL ARTICLE

Detection of pain with neuropathic characteristics in patients with diabetes mellitus assisted in primary care units Detecção de dor com características neuropáticas em pacientes com diabetes mellitus atendidos na atenção básica

Francisca Lidiane Ximenes da Silva Aguiar1, Luciana Fernandes Pastana Ramos2, Cléa Nazaré Carneiro Bichara3

DOI 10.5935/2595-0118.20180005

ABSTRACT RESUMO

BACKGROUND AND OBJECTIVES: There is a lack of epi- JUSTIFICATIVA E OBJETIVOS: Há uma carência de dados demiological data on neuropathic pain in Brazil. Thus, the pres- epidemiológicos sobre dor neuropática no Brasil. Assim, o pre- ent study aimed to detect the presence of pain with neuropathic sente estudo teve por objetivo detectar a presença de dor com characteristics in people with diabetes mellitus, assisted by the características neuropáticas em pessoas com diabetes mellitus, at- Hiperdia program in Santarém-Pará. endidos pelo programa Hiperdia, em Santarém-Pará. METHODS: A cross-sectional study was carried out between MÉTODOS: Estudo transversal, realizado no período de abril a April and November of 2016 in seven Primary Care Units of novembro de 2016, em sete Unidades Básicas de Saúde de San- Santarém. Patients with types 1 and 2 diabetes mellitus enrolled tarém. Foram incluídos pacientes com diabetes mellitus tipos 1 in the Hiperdia program, who answered a clinical and sociode- e 2, cadastrados no programa Hiperdia, que responderam a um mographic questionnaire were included. All those who reported questionário clínico e sociodemográfico. Todos que relataram pain responded the Douleur Neuropathique 4 questions and the dor responderam aos questionários Douleur Neuropathique 4 visual analog pain scale. Data were tabulated and statistically questions e a escala analógica visual. Os dados foram tabelados e analyzed using the software Bioestat® 5.0. analisados estatisticamente através do software Bioestat® 5.0. RESULTS: The sample consisted of 129 patients, all of whom RESULTADOS: A amostra foi composta por 129 pacientes, os with type 2 diabetes mellitus. Of these, 67 (51.9%) reported quais todos possuíam diabetes mellitus tipo 2. Dentre eles, 67 pain. Of these, 34.1% were detected with pain of neuropathic (51,9%) referiram dor. Desses, 34,1% foram detectados com characteristics, with a predominance of pain in lower limbs and dor de características neuropáticas, com seu predomínio nos moderate intensity. The most reported symptoms were: tingling, membros inferiores e de intensidade moderada. Os sintomas pinching/needling and numbness. mais relatados foram formigamento, alfinetada/agulhada e CONCLUSION: An expressive prevalence of people with neu- adormecimento. ropathic pain was obtained through the application of the Dou- CONCLUSÃO: Obteve-se uma prevalência expressiva de pes- leur Neuropathique 4 questions questionnaire, which proved to soas com dor de características neuropáticas, por meio da apli- be an effective and easily applied tool. It is suggested that the cação do questionário Douleur Neuropathique 4 questions, que neuropathic pain should be identified in the primary care unit demonstrou ser um instrumento eficaz e de fácil aplicação. Sug- and that studies with greater population coverage be performed ere-se que seja feita a identificação da dor neuropática na aten- in Santarém-Pará and in the Northern region, due to the scarcity ção básica e que sejam realizados estudos de maior abrangência of data in Brazil. populacional em Santarém-Pará e na região norte, em razão da Keywords: Diabetes mellitus, Pain, Primary care. escassez de dados no Brasil. Descritores: Atenção básica, Diabetes mellitus, Dor.

INTRODUCTION

1. Universidade Federal do Pará, Programa de Pós-Graduação em Saúde na Amazônia, Belém, PA, Brasil. Epidemiological data on the frequency and consequences of 2. Universidade Federal do Oeste do Pará, Instituto de Saúde Coletiva, Santarém, PA, Brasil. neuropathic pain (NP) in patients with diabetes mellitus (DM) 3. Universidade do Estado do Pará, Centro de Ciências Biológicas e da Saúde, Belém, PA, Brasil. is scarce. Studies on this subject are important drivers to im- Submitted in May 06, 2017. prove the treatment of these patients. NP is defined as a chronic Accepted for publication in January 08, 2018. pain caused by injury or illness, that involves the somatosensory Conflict of interests: none – Sponsoring sources: none. system1. It is considered to be more serious than other types of Correspondence to: pain. It is clinically characterized as continuous pain, lacerating, Francisca Lidiane Ximenes da Silva Aguiar Avenida Magalhães Barata, 790 of moderate to severe intensity, with a pricking sensation, the 68030-700 Santarém, PA, Brasil. presence of tingling, numbness, and burning. It is preferential- E-mail: [email protected] ly located in the extremities, symmetrically and bilateral, with © Sociedade Brasileira para o Estudo da Dor changes on local sensitivity2. 15 Br J Pain. São Paulo, 2018 jan-mar;1(1):15-20 Aguiar FL, Ramos LF and Bichara CN

In addition to its extremely unpleasant symptoms, NP is of- low-up System (HIPERDIA), responsible for tracking patients ten associated with anxiety disorder, depression, sleep disorders with diabetes and hypertension was also created and became a and sexual dysfunction, which leads to significant decrease in fundamental instrument to know the users, map the risks, pre- the quality of life and functionality, as well as contributing to vent and minimize the complications of these diseases14. social isolation and generating high costs to health services due Therefore, the Department of Health is fostering new studies to disability and absence from work3. on NP in order to meet the demand for epidemiological data Amongst the main causes of NP is diabetic peripheral neuropa- and studies about pain management15. In this sense, the present thy4, and it is estimated that at least 10% of people with DM study aimed to detect the presence of pain with neuropathic type 1 (DM1) and 20% of the people with DM type 2 (DM2) characteristics in people with DM, assisted by the Hiperdia have severe pain2, which is of concern since, according to the program, in Santarém-Pará. International Diabetes Federation5 it is expected that the number of diabetic people goes up from 387 million recorded until METHODS 2014 to 592 million until 2035. NP pathogenesis in diabetics is not yet fully known and may be A prospective cohort cross-sectional study was carried out from related to prolonged hyperglycemia, which leads to the accu- April to November 2016, in seven Primary Care Units (UBS in mulation of toxic substances derived from glucose in body tis- Portuguese) of the district Grande Área da Aldeia, in Santarém- sues6. When the neurological damage occurs, the transmission Pará. Patients enrolled in the population of this study fulfilled and perception of painful stimulus in the spinal cord change, the following inclusion criteria: (a) to have DM1 and 2; (b) of modifying nerve conduction and its control, both in the ascen- both the gender; (c) older than 18 years; (d) registered in the dant and descendant pathways, with the consequent increase in Hiperdia program of the UBS of the district of the Grande the spinal sensory neuron excitability7. Área da Aldeia; (e) were present at the data collection moment The diagnosis of NP is complex, since it is a subjective assess- and (f) signed the Free and Informed Consent Form (FICT). ment, difficult to be described and measured, with no consen- Patients who did not meet the inclusion pre-requirements were sus yet on the diagnosis of this type of pain1. However, it is excluded, the ones who did not regularly attend the Hiperdia believed that for a proper assessment, it should be considered meetings (at least 3 meetings in last the 6 months) and those the clinical history of the patient, the physical examination who did not have time to participate in the assessment. with quantitative sensitivity tests, and the use of instruments Patients were approached randomly and individually by one specific for NP8. of the researchers, while waiting for the distribution of drugs, Besides these diagnosis methods, it is extremely important to consultation with a nurse or doctor, in the hall of the UBS carry laboratory and image tests, essential to differentiate from where the Hiperdia meetings take place once a month in the other types of pain, in order to have a possible, probable or morning. definitive NP diagnosis9, which classification was developed All subjects were informed about the objectives and procedures for clinical and investigation purposes to obtain a trustworthy of the study and invited to participate in the study after sign- diagnosis1. ing the FICT, elaborated in accordance with the Resolution The International Association for the Study of Pain (IASP) 196/1996 of the National Health Council (CNS)16, ensuring suggests the use of some instruments to detect PN, such as the bioethics principles (beneficence, non-maleficence, justice the NP questionnaire in four questions, known as Douleur and autonomy) throughout all the steps of this study, as well Neuropathique 4 questions (DN4); the Pain ID; the Leeds As- as the guarantee of the confidentiality of the information pro- sessment of Neuropathic Symptoms and Signs (LANSS); the vided by the participants. questionnaire for pain detention, PainDETECT; and the Neu- In the city of Santarém, according to City Department of ropathic Pain questionnaire4. Health, there are 5,100 people with DM diagnosis registered It is worth mentioning that it is usually through the primary care in the Hiperdia, being the great majority with DM2 (4,610 unit that people with diabetes enter the Unified Health System people). The District Grande Área da Aldeia, chosen for this (SUS), responsible for the care of all the users with quality and study has 60,859 inhabitants and eight UBS. However, only resolvability10. Given the breadth and capacity of the primary seven were conducting monthly Hiperdia meetings. care, it is important that the detention of pain with neuropathic According to the information given by the nurses of each health characteristics occurs in the primary care unit since it is a condi- unit, in the seven UBS surveyed there were 1,389 patients regis- tion of highly disabling degree that requires distinct treatment, tered with diabetes. However, the data was not updated in terms that can be provided by the primary care physician11. of the number of deceased and people who no longer attend the Several programs were created to improve primary care services meetings. When analyzing the attendance list of the three last such as the Family Health Strategy (ESF in Portuguese), respon- months, we had a monthly average of 47 people with DM at- sible for the reorganization of the healthcare model, with the tending the Hiperdia meetings in the studied Health Units. creation of multi-professional teams12, the Family Health Sup- For the sample calculation, the parameters used were confidence port Center (NASF in Portuguese), that gather professionals of level of 95%, error of 5% and expected prevalence of 10%. several specialties to work with the family health and primary Participants were selected by means of simple random sampling. care teams13. The Hypertensive and Diabetics Record and Fol- The instruments used in this study were: the clinical and sociode- 16 Detection of pain with neuropathic characteristics in patients Br J Pain. São Paulo, 2018 jan-mar;1(1):15-20 with diabetes mellitus assisted in primary care units mographic questionnaire, prepared by the researchers of this The average time of the DM diagnosis was higher in people who study; DN4 questionnaire17; and the visual analog scale (VAS)18. reported pain with neuropathic characteristics (10.05±7.07). Initially, the clinical and sociodemographic questionnaire was People with non-neuropathic characteristics pain had an average applied to collect information about the Health Unit where of 7.67±5.48, and individuals with no pain, 7.55±6.21. the follow-up is carried, age, gender, place of birth, race/color, The most referred pain location by patients was the feet, both marital status, education and occupation, clinical diagnosis of for people with neuropathic characteristics and those with non- DM1 or 2, disease duration, pain complaint, drugs in use, and neuropathic characteristics, as shown in table 2. questions about the site of pain and treatment for the patients who have reported the symptom. Table 2. Site of pain among patients with pain with neuropathic and Patients who reported pain answered the DN4 questionnaire, non-neuropathic characteristics considered an effective tool to detect NP in people with dia- Site of pain Neuropathic pain Total x² n(%) betes. It has four questions; the two first include seven sen- Yes (%) No (%) sorial descriptors that characterize NP (burning; painful cold Hands 2 (4.55) 3 (13.04) 5 (7.46) p=0.1634 sensation; electric shock; tingling; pricking tugging; numbness and itching). The other two questions relate to the physical Legs 3 (6.82) 2 (8.70) 5 (7.46) examination to assess the indicative signs of neurological injury Feet 22 (50) 16 (69.57) 38 (56.72) (hypoesthesia to the touch; hypoesthesia to needle stick and Hands and feet 10 (22.73) 2 (8.70) 12 (17.91) brushing)19. Participants answered “yes” or “no” to all items. Legs and feet 6 (13.64) 0 (0) 6 (8.96) Each positive answer received a “1”, and the negative, “0”. The Arms and legs 1 (2.27) 0 (0) 1 (1.49) result was obtained by adding the 10 items, and the presence of Total 44 (100) 23 (100) 67 (100) 17 NP was confirmed with scores≥4 . Assessed using the clinical and sociodemographic questionnaire elaborated by Then, patients were evaluated regarding the intensity of pain by the author. VAS, considering a score from zero to 2 for mild pain, 3 to 7 for moderate pain, and 8 to 10 for severe pain8. According to the data of the DN4 questionnaire (Table 3), pa- The project was approved by the Ethics and Research Commit- tients with NP (n=44) presented a higher number of complaints tee involving humans (CEP) of the Tropical Medicine Center (n=279) related to soreness, especially in relation to the tingling, of the Federal University of Pará, with number 2.003.985. pricking/tugging, and numbness.

Statistical analysis Table 3. Distribution of the Douleur Neuropathique 4 questions A descriptive analysis of the data was performed, showing the questionnaire items among patients with neuropathic and non-neu- absolute and relative frequency, central trend measures (mean, ropathic pain minimum and maximum) and dispersion measures (standard Sensory descriptors Neuropathic pain Total deviation). The information was recorded in a database created Yes (%) No (%) n(%) ® ® in the Excel 2010 software and imported into Bioestat 5.0, Tingling 42 (15.05) 9 (3.33) 51 (15.55) where possible associations between NP and related factors, such Pricking/tugging 41 (14.70) 10 (3.70) 51 (15.55) as time of the diagnosis of DM, pain intensity, location, and pain Numbness 39 (13.98) 8 (2.96) 47 (14.33) treatment were analyzed. The analysis was conducted using the Chi-square test with significance level values of p≤0.05 values. Electric shock 32 (11.47) 5 (1.85) 37 (11.28) Itching 17 (6.09) 3 (1.11) 20 (6.10)

RESULTS Burning 25 (8.96) 7 (2.59) 32 (9.76) Painful cold sensation 25 (8.96) 2 (0.74) 27 (8.23) The sample had 129 patients, with 100% of patients with Physical sensitivity examination DM2. There was a predominance of females (76.7%); with Hypoesthesia to touch 30 (10.75) 4 (1.48) 34 (10.37) an average age of 65.1±9.4 years; married (54.3%) and with Hypoesthesia to pricking 19 (6.81) 1 (0.37) 20 (6.10) incomplete basic education (45%). The pain scenario was re- Brushing 9 (3.23) 0 (0) 9 (2.74) ported by 51.9% (n=67) of participants, being NP the major Total 279 (100) 49 (100) 328 (100) type of pain (Table 1).

Table 1. Prevalence of pain with neuropathic characteristics in pa- Table 4 shows VAS results with moderate pain intensity being tients with diabetes mellitus included in the Hiperdia program the most frequent. The present study shows that there is no statistically significant difference in the association between NP and Type of pain n % intensity of pain. Non-neuropathic (DN4<4) 23 34.3 When asked about any treatment for pain, a great part of the Neuropathic (DN4≥4) 44 65.7 individuals with neuropathic characteristics confirmed the use Total 67 100 of conventional painkillers as the pharmacological treatment Assessed by the Douleur Neuropathique 4 questions questionnaire. (52.27%), as shown in table 5. 17 Br J Pain. São Paulo, 2018 jan-mar;1(1):15-20 Aguiar FL, Ramos LF and Bichara CN

Table 4. Distribution of pain intensity in patients with pain with neuro- poor glycemic control, since hyperglycemia for a prolonged pe- pathic and non-neuropathic characteristics riod can cause irreversible tissue damages31. Neuropathic pain We can observe a wide variety in the prevalence of NP in the Pain intensity Yes (%) No (%) x² world. This is because the epidemiological studies are carried out Mild (0-2) 9 (20.45) 6 (26.09) with different methodologies, sample selection, diagnostic cri- Moderate (3-7) 19 (43.18) 14 (60.87) p= 0.1307 teria and assessment tools, not to mention the influence of the 8,32 Severe (8-10) 16 (36.36) 3 (13.04) cultural and sociodemographic diversity . Another important factor observed in the studies on NP is that Total 44 (100) 23 (100) many researchers carried their research with samples composed Assessed by the visual analog pain scale. of people with the clinical diagnosis of diabetic neuropathy. It Table 5. Distribution of patients with pain with neuropathic and non- is believed that the pain associated with diabetic polyneuropa- -neuropathic characteristics regarding pain treatment thy is clearly neuropathic, and it is possible to have neuropathy 1,33 Pain Neuropathic pain Total x² with and without NP , suggesting that there is no relation- treatment n (%) Yes (%) No (%) ship between the presence of neuropathy and a higher risk of developing NP34. As observed in a study with diabetic patients, No 21 (47.73) 17 (73.91) 38 (56.72) p=0.0400 with and without neuropathy, in a sample of 15,692 people, Yes 23 (52.27) 6 (26.09) 29 (43.28) where the NP prevalence was 34%35. In this study, the group Total 44 (100) 23 (100) 67 (100) without neuropathy was the one that presented the highest fre- Assessed using the clinical and sociodemographic questionnaire quency of NP. elaborated by the author. From this result, the authors highlight the importance to assess the signs and symptoms related to pain in all the patients, DISCUSSION and not only in those with confirmed neuropathy, indicating that the painful neuropathic symptoms are neglected by the In this research, the sample was entirely composed of people healthcare services. It is worth mentioning that the current with DM2. Two similar studies also showed a high prevalence of study did not investigate the presence of neuropathy, searching DM2, one study with 90.4% of the sample20 and the other with only for pain with neuropathic characteristics in individuals 86.3%21. The high frequency observed of type 2 can be explained with diabetes, since the NP can occur even in the absence of by the fact that this classification represents, in adults, about 90 neuropathy23. to 95% of all the diagnosed cases22. In the current study, there was a predominance of females in The result has also revealed that 51.9% of the sample subjects 76.74% of the sample, a fact corroborated in other studies with complained of pain, with a global prevalence of 34.1% of pain 60 to 70% of women27,36. Other studies, however, reported lit- with neuropathic characteristics and 17.8% non-neuropathic. In tle difference between gender, but still with a female predomi- a similar study conducted in the United Kingdom with 326 dia- nance20,21,24. A higher prevalence of men has also been observed betics, 63.8% reported pain, distributed in 19% with NP (less in people with diabetes and NP25,37. than the observed in the results of this survey) and 36.8% with Some time ago, women prevalence was expressly higher, ex- non-neuropathic pain23. plained by the fact that they seek for health services more often The prevalence of NP observed in this study is similar to the ones than men, getting the diagnosis at an early stage. This scenario is conducted in other countries, like in the South Africa24 in people changing with the advance of active search for diabetes, reducing with DM1 and 2, also using the DN4 questionnaire, showing a the difference between gender38. frequency of 30.3% of NP in a sample of 1,046 people. In the The average of age of the sample population was 65.1±9.4 years, northeast of England, a study with 204 people with DM1 and with little difference between the groups. It is believed that a 2, in which the LANSS pain scale was applied, the global preva- higher occurrence of NP increases with age35. Some authors lence of painful diabetic neuropathy was 30.4%25. highlighted the predominance of people above of 60 years of age On the other hand, the literature shows a lower prevalence of in the composition of their samples21,25-27,29, pointing that senior NP compared to this study. In Nigeria, in a study conducted people have a higher risk to develop NP, since, a great part of the with 250 diabetics, applying the painDETECT questionnaire, diseases that cause this type of pain has greater incidence with showed a prevalence of 21.6%26. Such situation also was ob- aging39. served in studies with the DN4 in Istambul20, Turkey, with 1,357 However, some studies showed the prevalence of NP in people diabetics and the prevalence was 23%. In the city of Tubarão27 with diabetes with an average age below 60 years20,36. This reduc- in Santa Catarina, with 72 people, it was 16.7%; and in Ko- tion of the age group shows that, although the evidence points rea28 14.4%. On the other hand, a study conducted with 2,358 to the increased prevalence of diabetes in the elderly (≥65 years), diabetics Chinese, showed a value below what it is seen in the there is an increase of the disease in middle-aged adults (35-64 literature, only 7.6%29. years)40, justified by the sedentary lifestyle and bad dietary habits In Saudi Arabia30, where 1,039 diabetic patients were evaluated adopted by great part of the population, leading to obesity5. using the DN4, the prevalence of NP was higher than expected In terms of educational level, incomplete basic education was (65.3%), explained by the researchers as a consequence of the more prevalent in the sample, showing significance between the 18 Detection of pain with neuropathic characteristics in patients Br J Pain. São Paulo, 2018 jan-mar;1(1):15-20 with diabetes mellitus assisted in primary care units groups, as observed in another study with 62%41. These results ture, religious beliefs, and even different forms of health percep- are in accordance with the Brazilian reality, registered by the tion48. A study conducted with Asians showed that this popula- Brazilian Institute of Geography and Statistics that the elderly tion reported less serious problems when compared with people population has up to 4 years of education42. This occurrence can from Latin America and the Middle East36. be related with the profile of the users who use the services of All the participants in the present sample reported taking some the ESF, characterized by senior people, of low income and low medication for diabetes, indicating good treatment compliance. educational level, that have a poor perception of their health and However, it is important to remember that although the treat- need more care since they are more susceptible to illness43,44. ment of diabetes is fundamental to prevent complications and As for the marital status, more than half of the sample was the onset of NP, the control of the underlying disease should married (54.26%), a fact considered positive because it is be- not to be the only form to fight the NP since it has an adjuvant lieved that the individual inserted in a family environment action in its treatment49. However, when asked about following tends to receive greater support and help during treatment a pain treatment, 52.27% of the people with neuropathic pain and self-care41. reported having some type of intervention, while within people In the present study, the global average of time of the diabetes with non-neuropathic pain it was only 26.09%, showing asso- diagnosis was 8.09±6.55 years. People with pain with neuropath- ciation (0,0400). It is believed that this difference among the ic characteristics had a higher average (10.05±7.07). However, groups may have occurred due to the extremely unpleasant char- there was no statistical significance between the studied groups, acteristics of the NP, frequently reported by the patients2, that as well as in the research conducted in Korea28. However, many makes them seek treatment. authors have reported that the time of the diabetes diagnosis is Likewise, a study showed that the group of patients with diabetic related to the development of NP25,27,29,45. neuropathy and NP was more medicated in comparison with the The sample was composed of 92.54% of individuals that re- group with neuropathy, but without pain33. Similarly, in a study ported pain in the lower limbs, the majority in the feet, in both conducted in Brazil, 72% of the patients with NP had some type groups. However, there was no association between the site of of analgesic treatment, indicating that adults with NP seek for pain and pain with neuropathic characteristics (p=0.1634). Usu- care more than the people who do not have this symptom47. ally, pain affects the lower extremities with higher frequency, Another possibility would be the high pain intensity observed characterizing the “stocking pattern”46. in patients with neuropathic characteristics in this study, since Concerning the DN4, the item “tingling” was the most reported 36.36% of the individuals reported severe pain according to the by those who have reported pain (15.55%), together with the VAS, whereas in patients with non-neuropathic characteristics, symptom “pricking and tugging” with the same percentage. only 13.04%. Finally, “numbness” with 14.33%. These three symptoms were Although more than half of the sample (52%) reported pain, we also the most frequent among people with pain with non-neu- noticed that the only treatment provided in the healthcare units ropathic characteristics, with higher ratio observed in those with surveyed was the treatment of the underlying disease. When neuropathic pain. asked about the treatment they were following to alleviate pain, A similar result was observed in South Africa24, where “burning” the surveyed patients reported the use of ordinary painkillers as- (36.5%) was the most reported complaint, followed by “pricking sociated with muscle relaxants, teas, and massage gels. and tugging” (35.4%) and “numbness” (31.2%). These results In a study conducted in Nigeria26, 81.5% used painkillers. How- are in agreement with the literature, pointing tingling, numb- ever, only 20.5% were using the ones recommended for NP. In ness, burning, continuous, lacerate pain with needle stick sensa- some epidemiologic studies, the majority of the people with NP tion as clinical manifestations of the NP2,47. were using analgesics not suitable for this type of pain, such as In terms of intensity of pain, it was observed that 36.36% of nonsteroidal anti-inflammatory drugs and paracetamol21,24. the volunteers reported severe pain according to the VAS, while The use of conventional analgesics is ineffective in the treat- people with pain with non-neuropathic characteristics, only ment of NP, being necessary the administration of proper drugs 13.04%. However, there was no significant difference in rela- as antidepressants, anticonvulsants and opioids50. Although the tion to the intensity among the researched groups (p=0,1307). World Health Organization has included drugs for the NP in its French researchers had also observed that the intensity of pain list of essential drugs, in the majority of the emergent and devel- was significantly higher in individuals with NP (p<0.001)37. oping countries, this list model is deficient in terms of efficient In the current study, moderate pain was more frequent in both drugs for the NP51. groups, corroborating the findings in South Africa, where the majority of the participants (67.7%) have also reported moder- CONCLUSION ate pain24. The results of these studies are different from other authors who reported sever pain as the most frequent in their With the results obtained in this study, it is clear the need to samples36. identify pain with neuropathic characteristics in the primary It is known that the clinical manifestations of the NP are pre- care units so that, through an active search, it will be possible to sented with intensity from moderate to severe2. However, the elaborate strategies for the prevention of this type of pain, estab- painful experience varies according to the perception of each lishing an adequate intervention and generating epidemiological individual, and it can be associated with the aspects of each cul- information to assist the management of pain. 19 Br J Pain. São Paulo, 2018 jan-mar;1(1):15-20 Aguiar FL, Ramos LF and Bichara CN

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20 Br J Pain. São Paulo, 2018 jan-mar;1(1):21-8 ORIGINAL ARTICLE

The effect of the Pilates method on the treatment of chronic low back pain: a clinical, randomized, controlled study Efeito do método Pilates no tratamento da lombalgia crônica: estudo clínico, controlado e randomizado

Pedro Henrique Brito da Silva1, Dayane Ferreira da Silva1, Jéssyka Katrinny da Silva Oliveira1, Franassis Barbosa de Oliveira1

DOI 10.5935/2595-0118.20180006

ABSTRACT RESUMO

BACKGROUND AND OBJECTIVES: Low back pain is de- JUSTIFICATIVA E OBJETIVOS: A lombalgia crônica é defin- fined as a painful disorder located between the first and the fifth ida como um distúrbio doloroso localizado entre a primeira e a lumbar vertebra, and it is considered to be an important public quinta vértebra lombar, considerada um importante problema health problem. In Brazil, approximately 10 million people are de saúde pública, sendo que no Brasil, aproximadamente 10 mil- disabled as a result of this condition. The objective this study was hões de pessoas são incapacitadas em consequência desta afecção. to assess the effects of the Pilates method on the treatment of O objetivo deste estudo foi avaliar o efeito do método Pilates no chronic low back pain. tratamento da lombalgia crônica. METHODS: The present study is based on a randomized, con- MÉTODOS: Estudo clínico, controlado e randomizado, com trolled clinical trial involving 16 individuals, aged 30-60 years, participação de 16 indivíduos com lombalgia crônica, de ambos of both gender, with chronic low back pain, divided into con- os sexos, com idade entre 30 e 60 anos, divididos aleatoriamente trol group and experimental group, with eight individuals each. em grupo controle e grupo experimental, com oito indivíduos Twelve sessions of 40 minutes were performed, in which nine cada. Foram realizadas 12 sessões, de 40 minutos, em que foram positions of the Pilates method were applied within the experi- aplicadas, no grupo experimental, nove posturas do método Pi- mental group. The control group performed kinesiotherapeutic lates. O grupo controle realizou exercícios cinesioterapêuticos conventional exercises. The visual analog scale and the Oswestry convencionais. Foram utilizados um questionário sociodemográ- Disability Questionnaire were used before and after the study fico, a escala analógica visual e o Questionário de Oswestry, pré e period in both groups. pós o período do estudo, em ambos os grupos. RESULTS: The assessment of pain and disability in the pre- and RESULTADOS: A avaliação da dor e incapacidade no momento post-evaluation periods showed no statistically significant differ- pré e pós entre os grupos não apresentou diferença estatística sig- ence. The control group also showed no statistical difference for nificativa. O grupo controle também não apresentou diferença the visual analog scale and Oswestry scores between the pre- and estatística para os valores das escalas analógica visual e Oswestry post-evaluation periods, whereas the experimental group showed entre os momentos pré e pós e o grupo experimental apresentou a significant difference between the scores obtained in these two significância entre os valores obtidos nos dois momentos de cole- different periods for the Oswestry and visual analog scores. ta pré e pós para os escores de Oswestry e escala analógica visual. CONCLUSION: It is suggested that the method was effective CONCLUSÃO: Sugere-se que o método foi efetivo para o gru- for the group studied and proved to be suitable for the treatment po estudado e adequado ao tratamento da dor lombar crônica, of low back pain, but it did not prove superior to conventional porém não se mostrou superior à fisioterapia convencional. physical therapy. Descritores: Coluna vertebral, Dor, Lombalgia. Keywords: Low back pain, Pain, Spine. INTRODUCTION

Chronic back pain is a musculoskeletal problem with a prevalence of approximately 11.9% in the world population and high costs related to losses in productivity, leave of absence

1. Universidade Estadual de Goiás, Curso de Fisioterapia, Goiânia, GO, Brasil. and expenses to the healthcare system in the economically advanced societies of the present time1. Anatomically, it can Submitted in October 25, 2017. be defined as a pain present from the last costal arch until the Accepted for publication in January 09, 2018. Conflict of interests: none – Sponsoring sources: none. gluteal fold, persisting for more than 12 weeks and frequently not resulting from specific diseases but from of a set of causes, Correspondence to: Avenida Anhanguera – Setor Vila Nova as sociodemographic factors (age, gender, income), behavior 74605-085 Goiânia GO, Brasil. factors (smoking and lack of physical exercises), ergonomic E-mail: [email protected] exposure (stressful physical work, vicious working positions, © Sociedade Brasileira para o Estudo da Dor repetitive movements), among others2,3. 21 Br J Pain. São Paulo, 2018 jan-mar;1(1):21-8 Silva PH, Silva DF, Oliveira JK and Oliveira FB

It was the first cause of disability retirement in Brazil, in The prescription of Pilates exercises for patients with chronic 20074. Therefore, there is a great amount of time and re- back pain is justified by the fact that this method is based on sources spent with patients with this type of musculoskeletal exercises that emphasize body stretching and strengthening. disease and about 50 billion dollars per year are directed to Therefore, the method jointly works isometric strengthening, expenses related to low back pain around the world5. global stretching, breathing, and proper positioning of the Disability, when associated with chronic back pain, can be spine promoting a broader body awareness and propriocep- explained as the difficulty or impossibility to accomplish dai- tion in the exerciser14. ly tasks and activities due to the painful picture. Self-care, The exercises proposed by the Pilates method are commonly household chores, work, social and leisure activities can be af- used in the clinical practice of physiotherapists with satisfac- fected or even impaired, because of the pain. Other variables tory results. However, there is little evidence in the scientific involved in defining disability are anxiety, stress, and fear6,7. literature on its effectiveness in patients with chronic low There are many physiotherapeutic resources for the treatment back pain15. of chronic back pain proposed in the literature. However, The objective of this study was to evaluate the effect of Pi- the one with better evidence is physical exercise8. Treatments lates exercises in the treatment of the chronic back pain in based on exercises to improve trunk muscle strength and re- individuals attending the Physiotherapy sector of the Medical sistance are important to reduce the intensity of pain and Specialties Center of Senador Canedo (CEMSC), Goiás, GO. the functional impairment9. Another treatment approach for chronic back pain is the Postural School, a multidisciplinary METHODS program based on health education aiming to facilitate the acquisition of healthier postural habits. The benefits of this This is a clinical, controlled and randomized study. The technique are not limited to the musculoskeletal disorder, but sample was composed of patients with a clinical diagnosis also to the quality of life and psychosocial aspects3. of chronic back pain (with painful symptoms for more than In this context, among the kinesiotherapy methods to pa- three months) that were in the waiting line of the public tient’s global approach is Pilates. This method reduces pain physiotherapeutic service at CEMSC. The participants were levels and, consequently, the damages caused by the painful referred to the study according to the inclusion and exclusion picture in daily life activities (DLA) and practical life ac- criteria, soon after an individualized clinical evaluation per- tivities (PLA), since the exercises created by Josef Pilates in formed by the researchers. 1918, can be considered as the torso stabilization. The Pilates The inclusion criteria of the study were a clinical diagnosis of method requires contractions of the abdominal muscles (rec- chronic back pain by the physicians of the different Primary tus abdominis, transverse abdominis, internal and external Care Units of Senator Canedo - Goiás; with age from 30 to 60 oblique), gluteus, perineal and lumbar paravertebral muscles, years; of both gender; voluntary participation in the study; be the so-called powerhouse, responsible for the static and dy- literate and able to communicate verbally. The exclusion cri- namic core stabilization9,10. teria were: individuals with hypertension, severe neurologic, Moreover, resistance exercise and dynamic stretching, asso- respiratory, cardiac, orthopedic diseases (fractures, instability, ciated with breathing during the execution of the exercises hernias, stenosis, and tumors), diagnosed by any clinical way promote a uniform strengthening the powerhouse, providing and following a physiotherapeutic treatment in parallel to the more core-stabilization, thus being effective in the elimina- present study. tion of the painful low back syndrome11. The participants were duly informed by the researchers about The Pilates method is based on a concept called “Contrology,” the purpose of the study and its relevance to the society. In- which consists of the conscious control of all body muscle formation was given in writing and orally and was detailed in movements with the correct use and application of the most the Free and Informed Consent Form (FICT). The subjects important principles of the forces acting on the musculoskel- who agreed to participate in the study signed the FICT and etal system, with the full knowledge of the functional body then the 16 participants were referred to the physiotherapeu- mechanisms. Pilates exercises are performed, in its great ma- tic treatment at CEMSC. jority, in the lying position, resulting in less overload in the The size of the sample was calculated using 50% of the statis- joints of the body support in orthostatism, enabling the re- tical power, 30% of improvement in the experimental group covery of muscle, joint, and ligament structures, particularly (visual analog scale - VAS), the Oswestry questionnaire, and of the lumbar segment12. a standard deviation of two points, giving the number of 15 In addition, Pilates is characterized by a set of movements participants in each group. It was used 5% of significance. where the neutral position of the spine is always respected, Thirty subjects were on the waiting list for physiotherapeutic aiming to improve the coordination of breath with the body treatment at CEMSC, and all of them were evaluated accord- movement, the general flexibility, muscle strength, and pos- ing to the eligibility criteria of the study. Of those, eight were ture, which are important factors in the posture-re-education excluded, and 22 participated in the study. The 22 subjects process. When performing these low-impact exercises, it is were randomly divided into two groups by means of a simple recommended to use six principles: concentration, control, raffle, where the participants’ names were in a dark envelope, precision, flow, breath, and centering13. and their names were taken one by one. The first 11 names

22 The effect of the Pilates method on the treatment of chronic Br J Pain. São Paulo, 2018 jan-mar;1(1):21-8 low back pain: a clinical, randomized, controlled study were allocated in the control group (CG) and the other 11 in 1) in the first session, to ensure a basic level of execution of the experimental group (EG). However, only 16 participants movements before applying the Pilates method to the EG, the concluded the treatment, as illustrated in figure 1. participants became familiar with the exercises; 2) nine exercises were adopted in each session, and each of them was repeated 10 times with an interval of one minute Assessed according between each posture; to the eligibility 3) the postures adopted favored the respiratory chain, anterior, criteria (n=30) anterointernal hip, and the posterior chain, since it is observed a greater involvement due to muscle weakness and shortening 14 Excluded (n=8) in these chains in patients with chronic lower back pain ; Did not meet the 4) there was no posture progression, that is, the exercises did inclusion criteria not change in terms of positioning. Moreover, the postures selected did not use balls or equipment, so that the interven- Randomized (n=22) tion protocol could be applied in any situation; 5) The postures were maintained in accordance with the respiratory rhythm of each participant, determined by the time Control Group (n=11) Experimental of forced and prolonged exhalation that should last about 10 Conventional Group (n=11) seconds; Physiotherapy Pilates Method 6) before the Pilates exercises, the volunteers received verbal instructions on how each exercise should be performed with a Excluded (n=3) Excluded (n=3) demonstration by the researcher; 2 drop-outs 1 drop-out without 7) during the postures, the researcher corrected the partici- without reason; reason; pants who were not doing the exercise correctly by tactile or 1 due to 3 absences. 2 due to 3 absences. verbal stimulation. In the CG, resistance exercises were applied jointly with Assessed at the end Assessed at the end stretching exercises in a protocol of general exercises, with of treatment (n=8) of treatment (n=8) the purpose to simulate the common practice of exercises usually prescribed by physiotherapists in patients with low Figure 1. Representation of groups division back pain16. The protocol consisted of stretching exercises n = sample size. with three repetitions, keeping the stretching stimulus for 30 seconds with a 30-second pause between each repetition. It was used a sociodemographic questionnaire, structured by Strengthening exercises were performed in a series of 10 rep- the researchers, with items related to personal data and some etitions, using only the body load and handspikes to promote clinical information of the subjects of the study. The subjects endurance, with a 30-second pause in each position17. informed their weight and height for the calculation of the The protocol of the CG comprised of the following exercises, body mass index (BMI). The VAS was also used to assess the gluteus strengthening, abdominal strengthening, hamstrings subjects’ pain intensity. And finally, the Oswestry Disability strengthening, torso strengthening, anterior torso stretching, Questionnaire was applied to identify the impact of pain in and torso extensor strengthening, hip adductors stretching, participants’ DLA and PLA. knee rocking, abdominal with a partial lift of the torso and The EG participated in the Pilates Method exercises. The CG rotation, piriformis stretching, knee to chest unilateral16-18. performed conventional stretching and strengthening exer- The study was conducted in accordance with the Guide- cises for the spine and lower limbs. Both the CG and the lines and Regulatory Standards for Research Involving Hu- EG had 12 sessions between April and May 2016, twice a man Subjects (Resolution 466/2012, of the National Health week, with 40 minutes duration of individualized sessions. Council). It was duly submitted, reviewed and approved by The place selected for the data collection was a large and ven- the Research Ethics Committee of the Faculdades Integradas tilated room located in the CEMSC premises. The researcher de Santa Fé do Sul (FISA/FUNEC), with opinion number conducted the treatment and evaluation sessions and also ap- 1.772.749. plied and analyzed the questionnaires and the VAS, before and after the intervention. Statistical analysis The exercises of the Pilates method selected for this study Descriptive analyses were performed using frequency and per- were: breathing with activation of transverse abdominis, in centage measures, central tendency (average) and variability addition to the following postures: Spine Stretch, The Spine (standard deviation) of the VAS score and the questionnaires. Twist, The Hundred, The one leg circle, The Plank, Leg Pull The inferential statistical analysis was performed using the Bio Front, Swimming, Rocking, Swan. (Annex 1). Estat 5.0 software, and the distribution normality was performed The postures selected are described in the literature10,16 and using the Shapiro-Wilk test. The differences in the average of the followed these directions: variables of the levels of pain and disability intragroup were ana-

23 Br J Pain. São Paulo, 2018 jan-mar;1(1):21-8 Silva PH, Silva DF, Oliveira JK and Oliveira FB lyzed using the Student’s t-test for paired samples, and the CG With regard to the Oswestry questionnaire, the pre and post mo- and EG intergroup variables were analyzed using the Student’s ments between the groups did not present significant statistical t-test for independent samples. The significance level considered difference. The CG did not present statistical difference between was alpha=0.05. the pre and post moments, while the EG showed a statistically significant difference between the pre and post moments, with a RESULTS p-value of 0.0021 (Table 3).

The CG had an average age of 44.87±11.07 years, with BMI of Table 3. Average values and standard deviation, p values between intergroups and intragroup moments 25.49±3.70kg/cm2, with seven female subjects and one male. In the group, five subjects (62.5%) of the sample were Caucasian and 3 Groups Pre-Oswestry Post-Oswestry p value were brown. Three subjects were married, three single and one di- CG 47.25 ± 17.13 37.75 ± 19.25 0,069 vorced. Regarding the educational level of the CG, only one partici- EG 36.75 ± 7.70 24.75 ± 11.56 0.0021* pant had a complete higher education (12.5%), two had complete p value 0.1362 0.1238 elementary school, two had complete high school, two had incom- * Significant difference between the averages; CG = control group; EG = expe- plete elementary school and one had incomplete high school. rimental group. Source: the author (2016). The average age of EG was 47±8.48 years, average BMI of 25.96±3.55kg/cm2, with seven female subjects and one male. In DISCUSSION the group, four subjects were married, and four were single. The educational level of the group was characterized by three individuals (57.12%) with incomplete elementary education, three It was observed higher participation of women with low back with complete elementary education, one with incomplete high pain in the present study. This can be attributed to women’s school and one with complete high school. greater awareness facing the signs and symptoms, who fre- The age and BMI values between the CG and EG groups had quently seek more health services. In addition, household no statistically significant difference. The average values, standard chores added to paid employment can lead to an overload on deviation and p values for the Student’s t-test are shown in table 1. the lumbar segment due to repetitive work, in a non-ergonomic position and at high speed19. However, the meaning of Table 1. Average values, standard deviation between the studied pain for men can be influenced by social and cultural factors groups that allow the woman to express their pain while men are Groups Age (years) BMI (kg/cm2) encouraged to ignore it, since insensitivity in the face of pain may be related to issues of manhood, which can justify the CG 44.87±11.07 25.49±3.70 reduced number of male participants in the study20,21. EG 47.00±8.48 25.96±3.55 In relation to age, in this study, there were individuals in p value 0,6732 0,8000 the age group between 30 and 60 years, corroborating with CG = control group; EG = experimental group; BMI = body mass index. 22 Source: the author (2016). similar results in the literature . This is the age group of economically active individuals, which reduces their functional capacity to work and to perform their DLA with an impact As for participants’ working activity of the CG, six of them had 23 paid employment jobs. In the EG, six participants did not have on the quality of life of these individuals . Aging can result paid employment jobs. Both in the CG and the EG, participants in progressive degenerative changes in the spine with the wear reported having back pain for more than 24 months, with sev- of musculoskeletal structures of the lumbar segment, bringing 24 en and six participants, respectively. It was observed that seven pain as a consequence . members of the CG and five individuals in the EG did not per- The BMI results obtained for the CG and EG subjects point form physical exercises. out an overweight of the studied sample. When there is an Pain assessment by VAS, before and after between the groups excessive load that the musculoskeletal structure is required showed no significant statistical difference. The CG also showed to sustain, this can result in changes in the biomechanical 25 no statistical difference for the VAS values pre and post-assessment balance of the lumbar spine . moments, and the EG presented significance between the values The data indicate that in both groups there was a prevalence obtained in both pre and post moments of collection (table 2). of individuals with low schooling, corroborating the studies conducted in the South and Southeast of the country26,27. In- Table 2. Average values and standard deviation of the groups studied dividuals with lower levels of education have professions that Groups Pre-VAS Post-VAS p value have a higher physical demand, which may explain the rela- 24 CG 5.75 ± 2.81 3.25±3.37 0,1006 tionship between the educational level and low back pain . Only the EG showed improvement of the VAS and Oswestry EG 5.00±2.00 2.00±2.56 0.0031* scores when comparing the pre and post-intervention results. p value 0.5489 0.4177 In the comparison of the VAS and Oswestry results between * Significant difference between the averages; CG = control group; EG = experimental group; VAS = visual analog scale. the CG and the EG, there was no difference between before Source: the author (2016). and after the kinesiotherapy and the Pilates exercises. A com- 24 The effect of the Pilates method on the treatment of chronic Br J Pain. São Paulo, 2018 jan-mar;1(1):21-8 low back pain: a clinical, randomized, controlled study parative study of the Pilates method and traditional exercises vention34,35, or with a Back-School approach - an educational for the stabilization of the lumbar spine was conducted in program which objective is to provide guidance on ergonomic the State of Tennessee, in the United States, in individuals posture to subjects with episodes of back pain36. This can be with chronic lower back pain28. The interventions occurred exemplified by a controlled and randomized study37 in which twice a week, totaling 12 sessions of 30 to 45 minutes, and 39 subjects were divided into two groups, with ages between the groups had six participants in each session. The pain was 20 and 55 years in Hong Kong, China. The experimental assessed by the VAS using Oswestry to analyze the functional group worked with Pilates exercises for four weeks, in order to impairment. The results showed a difference between the be- confirm its influence in reducing the pain of the participants, ginning and the conclusion of treatment only in the Pilates since low back pain may be related to a decreased joint mobil- group. However, there was no difference between the groups, ity due to joint stiffening and changes in the ability of muscle corroborating the results of this study recruitment. While the CG participants had only a medical Therapeutic exercises focusing on the stabilization of the lum- follow-up in the same period. In this context, they noted a bar spine, involving muscle strengthening and stretching in decrease in the level of pain in addition to a significant gain order to rebalance the tension of the muscle chains of the in muscle strength, stretching, and flexibility, determining lumbo-pelvic-hip complex may justify the positives results the effectiveness of the Pilates exercises for the treatment of found in the EG in this study because the pain and the im- chronic low back pain when compared with the CG. pairment faced by individuals with chronic lower back pain As to the application of postures, they recommended postures can be a result of muscle weakness, especially in the abdomi- focusing on the muscle chains which were compromised in nal region and the low joint flexibility on the back and in the patients with low back pain. The postures applied to partici- 29 lower limbs . pants in some studies showed an improvement in the flexibili- In addition, Pilates is among the several physical therapy re- ty of the muscles that make up the respiratory chain, anterior, sources able to reduce back pain and provide a functional re- anterointernal hip chain, and the posterior chain14,16. With education of this dysfunction, which may promote physical, the extensibility gain in these muscle chains, by maintaining mental and social well-being, encouraging the return to DLA the stretching position while performing the Pilates postures, and PLA30. Resistance exercise and dynamic stretching, as- there is an increase in the number of serial sarcomeres and sociated with breathing during the execution of the exercises connective tissue remodeling, providing a gain in ROM and promote a uniform strengthening of the powerhouse muscles, decreased muscle tension, which can also justify the improve- providing more core-stabilization, thus being effective in the ment of pain and disability scores in the EG38,39. elimination of the painful low back syndrome31. The treatment with Pilates can vary in terms of frequency In a study conducted in Melbourne32, Australia, they com- and duration of the sessions, with no consensus in the litera- pared an exercise program based on the Pilates method with ture. This study was conducted during two sessions per week, a general exercise program in patients with chronic low back for 40 minutes, totaling 12 sessions. Other studies followed pain, between 18 and 70 years of age, for six weeks. They the same frequency and duration with results similar to this assessed the intensity of pain by the numeric scale and the 10,16 functional impairment using the Quebec questionnaire. study . General stretching techniques, such as Pilates, ap- Eighty-three participants were randomized into two groups: plied twice or three times during 10 to 12 sessions, provided The Pilates group with 41, and the exercise group with 42. benefits regarding flexibility, the range of motion, pain reduc- 40 The results showed a reduction in low back pain and improve- tion and improvement in the quality of life . ments in the functional impairment in both groups, but with The present study showed the importance of the Pilates exer- no statistical difference between them. Although the exercise cises in the treatment of low back pain. Somehow, these exer- is the physiotherapeutic resource with the best evidence15,16,28, cises can improve the patient’s painful picture, relieving pain it is not established in the literature which is the best method and the functional limitations imposed on these individuals. to handle chronic low back pain. Therefore, the Pilates meth- However, limitations in the conduction of this research can od was not considered superior to the other forms of exercise, be identified, such as the small sampling and loss of partici- corroborating the present research. pants in both groups during the execution of the physiothera- This can be explained by the relation between the chronic peutic treatments. back pain, the lack of physical knowledge, and the reduction of the neuromotor control. The general physical fitness and CONCLUSION endogenous factors, such as the release of endorphins, can be associated with the pain modulation central mechanisms, This study showed that the Pilates method can be an effective acting on its perception. Thus, the therapeutic exercise can tool for the physiotherapist in the management of patients reduce the painful disorder and the consequent functional with chronic low back pain to reduce pain and disability. limitations33. However, when comparing with the CG subjects who had Other studies based on Pilates exercises directed to the treat- conventional physiotherapy activities in the same period, the ment of chronic back pain were reported in the literature Pilates method did not prove to be superior to the intensity compared with control groups with none or minimum inter- of pain and functional impairment scores. 25 Br J Pain. São Paulo, 2018 jan-mar;1(1):21-8 Silva PH, Silva DF, Oliveira JK and Oliveira FB

Annex 1. Description of the Pilates method postures 1. Breathing For a correct execution of the Pilates exercises, proper breathing is paramount because with it comes the contraction of the deep muscles. When starting with the method, the patient was instructed to breathe properly, with deep and complete inhalation and exhalation. The directions on how to breathe properly were provided in the first treatment session. The transverse muscle contraction must be the result of forced exhalation, therefore favoring the stability of the entire lumbar spine and pelvis, favoring the relaxation of the inhalation muscles and cervical muscles. The proper breathing can be described by the synchronized motion in the following order: 1. Chest inhalation; 2. Upper chest exhalation; 3. Lower chest exhalation; 4. Abdominal exhalation. Those moments must occur together with the muscle action. 2. Spine Stretch The patient sat on the sit bones, keeping the alignment of the physiological curves of the spine. With knees in extension and the hip in the maximum abduction. The hands were in front of the body, on the floor. The patient inhaled in this posture, followed by a forced exhalation taking the hands ahead of the body. At that moment, the movement started from the cervical vertebrae. The command given to the patient was to “roll up” the vertebrae and later to “roll down,” returning to initial posture. 3. The Spine Twist In this exercise, the initial posture is similar to the one of the Spine Stretch. What differs is the positioning of the arms. The arms were in a 90° alignment of flexion and shoulder abduction with the extension of the elbows, keeping proper alignment in order to avoid bending the knees. In this posture, the patient inhaled. Followed by a forced exhalation while taking one of the hands towards the opposite foot, stretching the trunk rotators. 4. The Hundred The patient remained in the supine position, with hip and knees bent, both at 90º; and plantarflexion. The arms were resting alongside the body, with the extension of elbows and palms on the supporting surface. Then, the patient inhaled. Exhalation occurred right after when the patient moved the arms in the air quickly and in sync with the breath, while remaining with a cervical flexion, lifting the scapulae off the floor. 5. The one-leg circle The patient was in the supine position with the lower limbs extended, feet in plantarflexion, with the upper limbs resting alongside the torso and hands on the support surface. The patient performed rotation movements with one of the legs, with the iliac spines facing up all the time. Inhalation was made at the moment of the highest instability of the exercise, that is, during the rotation of one of the legs. 10 repetitions were performed for each side. 6. The Plank This exercise consists of a lateral plank where the patient lies sideways putting the weight on the forearm at a 90º angle. The knees remained in a 90° flexion. The hip in a neutral position and lifted in the air, only supported by the forearm and knee. The opposite arm, the one that does not receive weight, rested alongside the body. The patient performed the isometric exercise for no more than 10 repetitions. Followed by a sequence on the opposite side. 7. Leg Pull Front (Cat or four-support) In this exercise, the patient was positioned in four-supports: the hips in a 90º flexion to the thighs and the thighs in 90º with the legs. The shoulders, elbows and wrists remained similarly in the same direction. After positioning, and with the torso well stabilized, concomitantly, the patient performed the extension of one leg and the extension of the contralateral arm. The alignment of all structures was important to maintain a posture similar to the plank and always preserving the physiological curvature of the spine. The move was performed during exhalation. 8. Swimming To perform this exercise, the patient lay on the stomach, with knees and shoulders extended (arms stretched overhead). Alternately, dissociating the upper and lower limbs, the patient performed a movement similar to swimming. The exercise activates the paravertebral. While raising one of the upper limbs, there was the hyperextension of the contralateral hip. The move was performed during exhalation. The return to the starting position was during inhalation. 9. Rocking The patient was in the prone position, with knees in maximum flexion (stretching the quadriceps muscle). The hands held the feet, keeping elbows in flexion. The patient extended the elbows and the knees. At that time, the patient took a forced exhalation. 10. Swan The patient was in the prone position, with the hands on the floor in the direction or above the shoulders. Then, the patient raised the chest off the supporting surface. The pelvis remained in contact with the floor during the performance. When pushing the floor with the hands, the patient took a forced exhalation.

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26 The effect of the Pilates method on the treatment of chronic Br J Pain. São Paulo, 2018 jan-mar;1(1):21-8 low back pain: a clinical, randomized, controlled study

Annex 1. Description of the Pilates method postures – continuation Description of conventional stretching and strengthening exercises These postures were based on Kisner and Colby17 and selected according to studies by Macedo and Briganó18 and Franco16. 1. Strengthening glutes The patient stayed in the supine position with the knees bent and feet in parallel on the floor. The exercise was done with the patient pressing the upper part of the spine against the floor, without lifting the heels. 2. Strengthening ABS The patient stayed in the supine position with knees bent and feet on the floor with the lumbar spine rectified and supported on the same surface. It started with a posterior tilt of the pelvis, raising the head from the floor, which causes a stabilizing contraction of the abdominal muscles. Then, the chest was raised until the shoulder blades were out of the floor. 3. Stretching hamstrings The patient stayed in the supine position with the hip and knee extended and the contralateral leg flexed supported on the floor. Then, the stretched leg was raised towards the chest. 4. Strengthening the torso The patient was on all fours with the hands on the floor. The participant was instructed to perform a pelvic tilt before extending the lower limb. This limb would be stretched to align the hip, and the opposite arm extended overhead simultaneously with the leg extension. While the leg was stretched, the arm raised up to the shoulder. 5. Stretching the anterior torso and strengthening torso extensors The patient was in the prone position, with the hands on the floor in the direction or above the shoulders. After that, the individual raised its chest, keeping the pelvis in contact with the floor. When pushing the floor with the hands, the patient also pushed the shoulder to depress the scapula. 6. Stretching hip adductors With the patient in the supine position, with knees bent and tights in adduction and the feet with the posterior face one against the other. The subject stretched with the arms in shoulder flexion above of the head. 7. Rocking the knees The patient, in the supine position, performed moves from one side to the other with the knees bent and thighs in adduction and bent. 8. Abdominal with partial torso lift and rotation The patient stayed in the supine position with knees bent and feet on the floor with the lumbar spine rectified and supported on the same surface. It started with a posterior tilt of the pelvis, then raising the head off the floor. Then, the chest was raised until the ipsi- lateral scapula left the floor, rotating the torso towards the opposite knee. 9. Piriformis stretching The patient, in the supine position, crossed one leg over the other with the ankle on the knee, bringing the opposite knee towards the chest to create the stretching. 10. Knee to chest unilateral The patient was in the supine position, with the hip and knee bent unilaterally with the opposite leg extended took the bent limb towards the chest.

These postures were based on Franco16 and Pinheiro et al.10

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28 Br J Pain. São Paulo, 2018 jan-mar;1(1):29-32 ORIGINAL ARTICLE

Pain and musculoskeletal discomfort in military police officers of the Ostensive Motorcycle Patrol Group Dor e desconforto musculoesquelético em policiais militares do Grupamento de Rondas Ostensivas com Apoio de Motocicletas

Katianna Karolinna Fernandes Maia Braga1, Francis Trombini-Souza1, Michele Vantini Checchio Skrapec1, Diego Barbosa de Queiroz1, Andréa Marques Sotero1, Tarcísio Fulgêncio Alves da Silva1

DOI 10.5935/2595-0118.20180007

ABSTRACT RESUMO

BACKGROUND AND OBJECTIVES: Work-related muscu- JUSTIFICATIVA E OBJETIVOS: Os distúrbios osteomuscula- loskeletal disorders have shown a high prevalence among work- res relacionados ao trabalho têm apresentado alta prevalência nos ers, among these, law enforcement officers have been greatly trabalhadores, dentre esses, a classe de policiais tem sido bastante affected. The aim of this study was to analyze the occurrence acometida. O objetivo deste estudo foi analisar a ocorrência de of musculoskeletal disorders symptoms in the Ostensive Motor- sintomas de distúrbios osteomusculares em policiais do Grupa- cycle Patrol Group of the Military Police of Pernambuco, PE. mento de Rondas Ostensivas Com Apoio de Motocicletas da METHODS: This was a cross-sectional study developed from Polícia Militar de Pernambuco, PE. February to June 2016. The subjects were 28 police officers from MÉTODOS: Trata-se de um estudo do tipo transversal, desen- the Ostensive Motorcycle Patrol Group, of the 5th Battalion of volvido entre os meses de fevereiro a junho de 2016, com 28 the Military Police. Data was collected through a self-admin- indivíduos da Rondas Ostensivas Com Apoio de Motocicletas da istered questionnaire with sociodemographic variables and pro- Polícia Militar do 5° Batalhão de Polícia Militar. Os dados foram fessional characteristics. The Nordic Musculoskeletal Question- obtidos por meio de um questionário autoaplicável com variáveis naire and the visual analog scale were used. sociodemográficas, características profissionais, Questionário RESULTS: In the study sample, most of the individuals were Nórdico de Sintomas Osteomusculares e escala analógica visual. male with an average of 62±8 working hours per week. Regard- RESULTADOS: Dentre a amostra estudada, a maioria dos in- ing the presence of musculoskeletal symptoms, the most affected divíduos era do sexo masculino, sendo observada uma média de anatomical region was the back, followed by the knees and then 62±8 horas trabalhadas por semana. Em relação à presença de the chest. As for the pain perception of the subjects, the spine sintomas osteomusculares, a região anatômica mais acometida and lower limbs showed higher pain intensity when compared foi a lombar, seguida pelos joelhos e região torácica. Quanto à to other regions. Most of the sample believe that musculoskeletal percepção de dor dos policiais, a coluna vertebral e os membros symptoms are related to work. inferiores apresentaram maior intensidade de dor quando com- CONCLUSION: The findings in this study demonstrate the parados às outras regiões avaliadas. A maioria dos indivíduos da presence of musculoskeletal symptoms in the studied popula- amostra relatou que os sintomas osteomusculares estavam relation. The analysis of the musculoskeletal disorders of these police cionados ao trabalho. officers will serve as an input for the planning of intervention CONCLUSÃO: Os resultados deste estudo demonstram a presen- actions to improve the general conditions of the service provided ça de sintomas osteomusculares na população estudada de forma by the Ostensive Motorcycle Patrol Group. unânime. A análise dos distúrbios osteomusculares desses policiais Keywords: Chronic pain, Military personnel, Motorcycles, servirá como subsídio para o planejamento de ações de intervenção Musculoskeletal pain, Police. voltados para a melhoria das condições gerais de prestação de ser- viços da Rondas Ostensivas Com Apoio de Motocicletas. Descritores: Dor crônica, Dor musculoesquelética, Militares, Motocicletas, Polícia.

INTRODUCTION 1. Universidade de Pernambuco, Petrolina, PE, Brasil.

Submitted in July 07, 2017. Work-related musculoskeletal disorders (WRMD) are common Accepted for publication in January 21, 2018. Conflict of interests: none – Sponsoring sources: none in several professions and result in a high proportion of injuries. Among the risk factors for WRMD are the repetitive, forceful Correspondence to: Rodovia BR 203, Km 2, s/n - Vila Eduardo or uncomfortable movements, as well as continuous pressure, 56328-903 Petrolina, PE, Brasil. excessive use of specific anatomical structures or region, posture E-mail: [email protected] alteration or inadequate positioning, excessive force, tension ex- © Sociedade Brasileira para o Estudo da Dor treme and vibrations imposed to the body1. 29 Br J Pain. São Paulo, 2018 jan-mar;1(1):29-32 Braga KK, Trombini-Souza F, Skrapec MV, Queiroz DB, Sotero AM and Silva TF

Of the several classes of workers, we can highlight those re- METHODS sponsible for the preservation of the public order: the police officers. These professionals can constantly be exposed This is a cross-sectional study conducted from February to to countless risk factors to development WRMD. A recent June 2016 at the Polyclinic of the MPPE. According to the Canadian study where 3,589 vehicle patrolling police officers sample size calculation done by the GPower 3.0 software, in were evaluated using an online questionnaire, showed that which it was adopted an X statistics of2, with effect size of 67.7% reported chronic low back pain (CLBP) and 96.5% W=0.8, α=0.05, test power β=0.90 and a population of 33 noticed that the CLBP presence was partially related to their members that compose the ROCAM of the 5th Battalion of work in the Canadian police corporation2. the Military Police (BMP), we came up with a sample of 26 In Brazil, motorcycles are another patrolling modality. The police officers necessary for the conclusions of the present Ostensive Motorcycle Patrol Group (ROCAM, in Portuguese) study. However, when considering a possible sample loss of of the Military Police of Pernambuco (MPPE) was created an 5%, it was necessary to evaluate 28 police officers, and the innovative patrolling model specifically to combat crimes by single eligibility criterion was to be in the motorcycle patrol- criminals using motorcycles3. ling function for at least 12 months. Among the activities performed by ROCAM police officers, Data collection was conducted in accordance with the work we can list get on and off the bike in due course, approach schedule of the police officers at the beginning of the shift, suspects while riding, dangerous overtaking and maneuvers, which was previously authorized by ROCAM chief officer, attention to the traffic and the patrol team, considering that with no harm to the course of the work. the operational job must be carried by, at least, two police- The data was obtained after consent, by means of a self- men on each patrol3. The physical and mental stress inherent applicable questionnaire including the following variables: to this work activity, the weight of the weapons, the uniform sociodemographic characteristics (gender, marital status, and the equipment, as well as the overload on the spine, up- age and education); professional characteristics (tenure, per and lower limbs and the emotional stress due to the patrol time with ROCAM, hours worked per week and overtime); riding and the heat of the bike engine can be responsible for other information (performance of physical exercises and the high levels of absenteeism of these workers4,5. diagnosis of any disease in the last 12 months). The Nor- All these mechanical aspects of the motorcycle and the roads, dic Musculoskeletal Questionnaire (NMQ) was used. This as well as the emotional and biomechanical aspects on these tool was validated and adapted for the Brazilian population motorcycle professionals, can contribute to the increasing by Pinheiro, Troccoli, and Carvalho9, containing multiple world public health problem in this segment of military choices for musculoskeletal symptoms in several anatomic workers. regions as well as the visual analog scale (VAS) that assesses However, in Brazil, especially related to the important and in- the perception of pain intensity. The final pain score, vary- dispensable work of the ROCAM officers, there is not yet an ing from zero to 10, where zero means the absence of pain epidemiological panorama about WRMD. Moreover, there and 10 the worse pain possible, was categorized according are no studies that evidence if this type of work activity, in to Boonstra et al.10 as mild (scores≤5), moderate (scores 6 or fact, can influence the pain perception and body discomfort 7) and severe (scores ≥8). suffered by these police officers. Five of the 33 ROCAM police officers were not included in In case this is confirmed by the present study, some determi- the present study because they were in the motorcycle patrol nants for disability and absenteeism of these workers6-8 can activity for less than one year. be better approached to minimize the subsequent damages This project was approved by the Research Ethics Com- from the imposed extreme use to the musculoskeletal system, mittee of the University of Pernambuco (UPE), according mainly when associated to the lack of time for recovery af- to Resolution number 466, of December 12, 2012, of the ter long hours of work on motorcycles. In a complementary National Health Council/Department of Health (CAAE: form, with the results of this study, it will be possible to pub- 53811816.5.0000.5207). lish scientific information that can serve as input for an inter- ventional action plan to improve the general conditions of the Statistical analysis services provided by ROCAM. It was used the Statistical Package for Social Sciences software The hypothesis was: (i) the type of work activity performed by (SPSS), version 22.0. ROCAM police officers could evidence the higher prevalence of pain and body discomfort, mainly, in the low back region RESULTS (lumbar region) and wrist/hands; (ii) the working period of the ROCAM police officers could be associated with higher The studied sample was composed of 28 ROCAM police of- prevalence of pain and discomfort in the above-mentioned ficers of the 5th BPM, with age of 34±5 years, varying be- regions. tween 24 and 48 years, with a predominance of males, 82.1% The objective of this study was to analyze the occurrence married. In the studied sample, the majority reported being of WRMD symptoms in the ROCAM police officers of the working at MPPE for less than 10 years and as a motorcycle MPPE in Petrolina. patrol officer at ROCAM for less than 5 years. As for the 30 Pain and musculoskeletal discomfort in military police Br J Pain. São Paulo, 2018 jan-mar;1(1):29-32 officers of the Ostensive Motorcycle Patrol Group working time, it was observed an average of 62±8h per week, Table 2. Frequency of intensity of musculoskeletal symptoms repor- of which 14.28% of the sample reported no overtime in other ted by the ROCAM police officers, according to the analog visual scale activities of the PMPE. When questioned about the practice Anatomical regions Mild Moderate Severe of physical exercises, the majority told to do it three times Spine (19) 0 84.2% 15.8% per week with minimum duration of 30 minutes, including UL (04) 0 100% 0 bodybuilding, jogging, and martial arts (Table 1). LL (16) 0 81.2% 18.8% Table 1. Characterization of the sample, according to sociode- UL = upper limbs; LL = lower limbs. mographic variables, professional characteristics, and practice of physical exercise. Petrolina, PE, 2016 As for the characterization of pain, according to the “almost al- Variables n % ways” and “always” frequency, 46.4% reported pain when work- Gender ing as shown in table 3. When questioned if the symptoms wors- Female 01 3,6 ened when working, 28.6% of the subjects had musculoskeletal Male 27 96,4 symptoms. Marital status Single 04 14,3 Table 3. Characterization of the pain, according to the frequency Married 23 82,1 Divorced 01 3,6 Pain frequency Comes before work Comes during work Job tenure at MPPE (years) Never 10.7% 0 <10 22 78,6 Almost never 14.3% 3.6% >10 06 21,4 Sometimes 53.6% 50% Job tenure at ROCAM (years) <5 15 53,6 Almost always 14.3% 21.4% >5 13 46,4 Always 7.1% 25% Physical exercise Total 100% 100% Yes 19 67,8 No 09 32,2 MPPE = Military Police of Pernambuco. DISCUSSION

Figure 1 shows that the anatomical region most involved by It was observed that most subjects were predominantly male. Ac- 11 pain and discomfort in the studied sample was the lower back cording to Capelle , the Military Police is considered an orga- with a prevalence of 50%, followed by the knees with 43%. nization of masculine character, where it is necessary to act with The less involved body segments were the shoulder (7%) and energy in situations of urban violence, conveying a representa- wrist/hand (7%). tion market by aggressiveness. Ferreira, Bonfim, and Augusto12 According to the intensity of musculoskeletal symptoms re- affirmed in their study with police officers in Pernambuco, that ported by the ROCAM police officers, in accordance with the this is a predominantly masculine environment, with a recent VAS, we identified that the anatomical regions with higher and gradual presence of females in the military career. intensity of severe pain were the spine and the lower limbs With respect to job tenure, most of the interviewed subjects in- (Table 2). dicate a relatively recent staff, less than 10 years in the corpora-

50%

43%

36%

29%

18% 14% 7% 7%

Neck Shoulder Upper Wrist/ Lower Hip/Thigh Knees Ankle/Feet Back Hands Back

Figure 1. Prevalence of the anatomical regions most involved in pain and discomfort

31 Br J Pain. São Paulo, 2018 jan-mar;1(1):29-32 Braga KK, Trombini-Souza F, Skrapec MV, Queiroz DB, Sotero AM and Silva TF tion, which corresponds to about one-third of the total time in The relatively small sample poses some limitations to this study the military career, reflecting a policy of maintenance and sub- imply that can be justified by the small staff of theth 5 BMP RO- stitution of the operational staff of the military organization5. CAM. Since it is a descriptive study, it was not possible to make In relation to the hours of work, it was observed an average of a correlation with posture assessment, requiring new studies on 62 hours per week, including weekly work hours and overtime. the subject. With the data obtained, we can identify musculo- According to Minayo, Assis, and Oliveira5, the workload of these skeletal symptoms in the police officers of ROCAM. professionals is enlarged since they work on their day off as a way to complement their income. CONCLUSION In the police activity, specifically, it is essential the practice of physical exercises, since due to their function, it is necessary to The results of this study corroborate the notorious presence of have good physical performance in order to ensure the public musculoskeletal symptoms in the studied population, where the order4,5. Among the studied police officers, the majority reported lumbar spine was the region with the highest number of pain the practice of physical exercises. However, an important per- complaints that aggravated when working, suggesting possible centage said not having any physical activity at all, which can work-related musculoskeletal disorders. harm the professional performance, since a sedentary person has a less physical capacity to do functional movements in their REFERENCES Daily Life Activities (DLA) and work activities, being exposed to musculoskeletal symptoms13,14. 1. Melhorn JM. Cumulative trauma disorders and repetitive strain injuries. The future. Clin Orthop Relat Res. 1998;(351):107-26. Among the regions involved, the lower back was predominant 2. Benyamina Douma N, Côte C, Lacasse A. Quebec serve and protect low back pain in terms of more pain complaint among the police officers inter- study: a web-based cross-sectional investigation of prevalence and functional impact 15 among police officers. Spine. 2017;42(19):1485-93. viewed. Oliver and Middledith presented some effects on the 3. Brasil, 2010. Ministério da Justiça. Secretaria Nacional de Segurança de Pública. De- lumbosacral curve and found that when sitting at 90º, there is partamento Nacional de Policiamento com motocicletas. 2010; Belém-PA, maio. 4. Costa M, Júnior HA, Oliveira J, Maia E. [Stress: diagnosis of military police personnel the rectification of the lumbar curve. These results corroborate in a Brazilian city]. Rev Panam Salud Publica. 2007;21(4):217-22. Portuguese. the study by Marques, Hallal, and Gonçalves16. This might have 5. Minayo MC, Assis SG, Oliveira RV. Impacto das atividades profissionais na saúde happened with the studied population, since during the work física e mental dos policiais civis e militares do Rio de Janeiro (RJ, Brasil). Ciênc Saúde Coletiva. 2011;16(4):2199-209. hours the ROCAM police officers remain sitting for 16 to 18 6. Trindade LL, Schuh MC, Krein C, Ferraz L, Amestoy SC. Dores osteomusculares em hours at 90° of hip and knees, adding the additional load of the trabalhadores da indústria têxtil e sua relação com o turno de trabalho. Rev Enferm UFSM. 2012;2(1):108-15. equipment, weapons and the uniform, as well as the impact of 7. Vitta A, Canonici AA, Conti MH, Simeão SF. Prevalência e fatores associados à the motorcycle when riding over obstacles on highways, alleys, dor musculoesquelética em profissionais de atividades sedentárias. Fisioter Mov. 5 2012;25(2):273-80. and streets. Minayo, Assis, and Oliveira in, their study with 8. Lima Júnior JP, Silva TF. Análise da sintomatologia de distúrbios osteomuscu- military and civil policemen, observed that back pain is among lares em docentes da Universidade de Pernambuco – Campus Petrolina. Rev Dor. the most frequent musculoskeletal injury in this population. 2014;15(4):276-80. 9. Pinheiro FA, Troccoli BT, Carvalho CV. [Validity of the Nordic Musculoskeletal 17 18 Santos et al. , Gonçalves, Trombetta and Gessinger , reported Questionnaire as morbidity measurement tool]. Rev Saude Publica. 2002;36(3):307- the prevalence of musculoskeletal disorders in the spine of mo- 12. Portuguese. 10. Boonstra AM, Stewart RE, Köke AJ, Oosterwijk RF, Swaan JL, Schreurs KM, et al. torcycle taxi drivers, which corroborates the results of this study. Cut-off points for mild, moderate, and severe pain on the numeric rating scale for Oliveira and Santos19, when studying police officers, noticed that pain in patients with chronic musculoskeletal pain: variability and influence of sex and catastrophizing. Front Psychol. 2016;7(1466):1-9. most of the studied population, always or sometimes, felt physi- 11. Capelle MC. Mulheres policiais, relação de poder e de sexo na Polícia Militar de Minas cally and emotionally tired after the work day. In this study, we Gerais. Rev Adm Mackenzie. 2010;11(3):71-99. t can observe that musculoskeletal symptoms were common, al- 12. Ferreira DK, Bonfim C, Augusto LG. Condições de trabalho e morbidade referida de policiais militares, Recife-PE, Brasil. Saúde Soc. 2012;21(4):989-1000. ways or sometimes when working and that they worsened with 13. Tavares Neto A, Faleiro TB, Moreira FD, Jambeiro JS, Schulz RS. Lombalgia na ativi- the execution of movements. Low back pain in police officers dade policial militar: análise da prevalência, repercussões laborativas e custo indireto. Rev Baiana de Saúde Pública. 2013;37(2):365-74. is frequent due to the overload on the musculoskeletal system, 14. Calasans DA, Borin G, Peixoto GT. Lesões musculoesqueléticas em policiais militares. sometimes requiring the use of the force and agility during the Rev Bras Med Esporte. 2013;19(6):415-8. 13 15. Oliver J, Middledith A. Anatomia funcional da coluna vertebral. Rio de Janeiro: situations inherent to the profession . Revinter; 1998. It was also observed that the majority of the ROCAM police 16. Marques NR, Hallal CZ, Gonçalves M. Características biomecânicas, ergonômicas e officers believe that the musculoskeletal symptoms are related clínicas da postura sentada: uma revisão. Fisioter Pesq. 2010;17(3):370-6. 17. Santos LB, Amorim CR, Vilela AB, Rocha SV, Cardoso JP. Prevalência de sintomas to the work activities. It is worth mentioning that the physical osteomusculares e fatores associados entre mototaxistas de um município brasileiro. trauma experienced by police officers are closely linked to the Rev Baiana de Saúde Pública. 2014;38(2):417-31. 8,19 18. Gonçalves EC, Trombetta JB, Gessinger CF. Prevalência de dor na coluna vertebral em professional activity which requires them to run, approach, motoboys de uma cooperativa de Porto Alegre, RS. Rev AMRIGS. 2012;56(4):314-9. jump, ride, requiring a major physical demand and a good fit- 19. Oliveira KL, Santos LM. Percepção da saúde mental em policiais militares de força 20 13 tática e de rua. Sociologias. 2010;12(25):224-50. ness level . According to Tavares Neto et al. , the work activity 20. Jesus GM, Jesus EF. Nível de atividade física e barreiras percebidas para a prática de of police officers tends naturally to complaints of low back pain. atividades físicas entre policiais militares. Rev Bras Cienc. 2012;34(2):433-48.

32 Br J Pain. São Paulo, 2018 jan-mar;1(1):33-9 ORIGINAL ARTICLE

Pain self-efficacy questionnaire and its use in samples with different pain duration time Questionário de autoeficácia relacionado à dor e seu uso em amostra com diferentes durações de ocorrência de dor

Fernanda Salloume Sampaio Bonafé1, João Marôco2, Juliana Alvares Duarte Bonini Campos3

DOI 10.5935/2595-0118.20180008

ABSTRACT CONCLUSION: There is evidence of a relationship between the self-efficacy belief and the pain characteristics, where the BACKGROUND AND OBJECTIVES: The pain self-efficacy presence of pain and length of time living with pain might be questionnaire has been frequently used in several languages, important factors in the study of the concepts involved in the but its use is limited to chronic pain. This study aimed to i) perceptions of pain and self-efficacy. evaluate the properties of the pain self-efficacy questionnaire Keywords: Pain, Pain measurement, Psychometrics, Scale, Self- among Brazilians with different durations of pain occurrence; -efficacy, Validation. ii) present a new proposal for estimation of the overall self-efficacy belief score; and iii) compare such score among different RESUMO pain duration time. METHODS: A total of 1,155 adults (79.0% women; 38.6±10.8 JUSTIFICATIVA E OBJETIVOS: A utilização do questioná- years) participated, 337 had no pain, 386 reported pain for less rio de autoeficácia relacionado à dor tem sido frequente, po- than 3 months, 253 reported pain for more than 3 months with rém, limitada ao contexto da dor crônica. Os objetivos deste a recurrent pattern, and 179 reported continuous pain for more estudo foram: i) avaliar as propriedades psicométricas do ques- than 3 months. The confirmatory factor analysis was performed tionário de autoeficácia relacionado à dor para amostra de in- to check the pain self-efficacy questionnaire unifactorial model divíduos brasileiros com diferentes durações da ocorrência de good-fit. The pain self-efficacy questionnaire invariance was tes- dor, ii) apresentar uma nova proposta de estimativa do escore ted in independent samples using multigroup analysis. We pro- global da crença de autoeficácia e iii) comparar esse escore entre posed the calculation of the self-efficacy belief score from the fac- grupos com diferentes durações de dor. tor score obtained in the confirmatory factor analysis. The score MÉTODOS: Participaram 1.155 adultos (79,0% mulheres; was compared among groups (ANOVA, alpha=5%). 38,6±10,8 anos). Do total, 337 não apresentavam dor, 386 RESULTS: After inserting four correlations between errors of relataram dor há menos de 3 meses, 253 relataram dor recor- items, the pain self-efficacy questionnaire model shows to be rente há mais de 3 meses e 179, dor contínua há mais de 3 fit to the sample (X2/df=7.059; CFI=0.978; GFI=0.964; RM- meses. Realizou-se análise fatorial confirmatória para verificar SEA=0.072). The model was invariant between independent o ajustamento do modelo do Questionário de Autoeficácia re- samples. Lower self-efficacy belief was found among participants lacionado à Dor. A invariância do questionário de autoeficácia with pain for less than three months (p<0.05). relacionado à dor foi testada utilizando análise multigrupos. Foi proposto cômputo do escore global da crença de autoeficá- cia a partir da matriz dos pesos de regressão da análise fatorial

1. Universidade de Araraquara, Faculdade de Odontologia, Araraquara, SP, Brasil. confirmatória. O escore de autoeficácia foi comparado entre 2. Instituto Superior de Psicologia Aplicada, Lisboa, Portugal. grupos (ANOVA, alfa=5%). 3. Universidade Estadual Paulista, Faculdade de Ciências Farmacêuticas de Araraquara, Ara- RESULTADOS: Após inserção de quatro correlações entre raquara, SP, Brasil. os erros dos itens, o modelo do questionário de autoeficácia Submitted in August 29, 2017. relacionado à dor apresentou ajustamento adequado à amos- Accepted for publication in January 22, 2018. Conflict of interests: none – Sponsoring sources: The authors would like to thank the fi- tra (X2/gl=7,059; CFI=0,978; GFI=0,964; RMSEA=0,072). nancial support provided by the São Paulo Research Foundation (FAPESP) and the Coor- O modelo foi invariante entre as amostras independentes. dination for the Improvement of Higher Education Personnel (CAPES) in form of grants #2014/00874-3; #2014/17624-0; #2014/23611-8; #2015/23126-5, and the National Menor escore de crença de autoeficácia foi encontrado en- Council for Scientific and Technological Development, Brazil (301611/2015-7). tre os participantes com dor presente há menos de 3 meses (p<0,05). Correspondence to: Juliana A D B Campos CONCLUSÃO: Há evidências da relação entre a crença de au- Departamento de Alimentos e Nutrição, Faculdade de Ciências Farmacêuticas de Ara- toeficácia e as características da condição dolorosa, o que per- raquara, Universidade Estadual Paulista – UNESP Rodovia Araraquara-Jaú, Km 01, Campos Ville mite discussões acerca das conceituações teóricas envolvidas na 14800-903 Araraquara, São Paulo, Brasil. percepção da dor e autoeficácia dos indivíduos. E-mail: [email protected] Descritores: Autoeficácia, Dor, Escala, Mensuração da dor, © Sociedade Brasileira para o Estudo da Dor Psicometria, Validação. 33 Br J Pain. São Paulo, 2018 jan-mar;1(1):33-9 Bonafé FS, Marôco J and Campos JA

INTRODUCTION METHODS

Self-efficacy can be defined as an individual’s degree of belief/ This is an observational study (with non-probability sampling by trust to perform an activity or specific behavior required to convenience) that relied on the participation of adults seeking achieve a goal/outcome, considering the effort being expended dental care at the School of Dentistry of Araraquara (UNESP), by the individual and his/her persistence in the face of obstacles/ in 2015 and 2016. The sample was composed only of indivi- aversive experiences1-3. duals with ages 18 and above who agreed with and signed the Nicholas2,4 identified chronic pain as one of such obstacles/aver- Free Informed Consent Form (FICT). Individuals that sought sive experiences, and proposed an instrument to assess the self- assistance at the special patients’ clinic were excluded. -efficacy belief. The pain self-efficacy questionnaire (PSEQ) is The minimum sample size was estimated considering the pro- composed of 10 items arranged in a unifactorial model and was posal of Hair et al.18, who suggest the need of 5 to 10 subjects developed to investigate the degree of trust that patients with per model parameter. Considering that the factorial models chronic pain have on themselves to perform daily activities or to be tested for the PSEQ could have up to 20 parameters, it functions. was verified that the estimated minimum sample size was from The use of PSEQ has grown with the increase in translations and 100 to 200 subjects. Considering that this study also aimed at adaptations to different languages3,5-12. In spite of its wide use, comparing individuals with different pain conditions (without few studies5,7,8,11 have shown evidence of the instrument’s psycho- pain, pain for less than 3 months, recurrent pain for more than metric properties in different samples based on a confirmatory 3 months, and continuous pain for more than 3 months), each analysis of the psychometric properties. group should have this sample size. Further, considering the li- As the PSEQ was developed to assess the self-efficacy belief in kelihood of refusal to participate in the study, we have increased individuals with chronic pain, its use is still aimed mainly to this this estimate in 30%, obtaining the result that at least 1,040 sub- pain condition13. However, Rokke et al.14 pointed out the im- jects should be invited to participate. Thus, 1,426 individuals portant role that the self-efficacy belief plays on other pain con- were invited. Of these, 1,214 consented to participate and 1,155 ditions such as, for example, acute pain tolerance. Thus, a space answered all items of the PSEQ. is open to the need for research and discussion of this concept in different contexts, such as acute pain and recurrent pain. The Sample characterization assessment of the self-efficacy belief can also be suggested with For the sample characterization, we collected information individuals without pain, aiming to carry out discussions that such as gender, age, marital status, and economic level. The allow evaluating aspects of the operationalization and/or proces- economic level was estimated by means of the Brazil Econo- sing of the memorization of pain, which can also be relevant in mic Classification Criteria19. Information related to the pain the clinical context. characteristics was also collected. Considering the proposal of Originally, the strategy proposed to calculate the overall self- the International Association for the Study of Pain (IASP)20,21 -efficacy belief score was the sum of the responses provided the information collected were presence/lack of pain (in the by individuals to 10 PSEQ2,4 items. From the sum, there is last 24 hours), pain onset and pattern of pain (crises/episodes a minimum-maximum value that can be obtained, and it is or continuous). Such information helped in classifying parti- considered that all items have the same weight in the opera- cipants into 4 groups. Individuals who did not have pain in tionalization of the construct being measured. However, va- the 24 hours before the study were included in group G0 (wi- lidation studies have been pointing out that the sum can be a thout pain). Individuals who reported pain in the 24 hours and fragile strategy to calculate a construct’s overall score, because the pain started within the 3 previous months were included during the refinement of the model to the different samples, it in group G1 (pain <3 months). For individuals who reported is possible to exclude items, which will inevitably compromise pain beginning before the 3 previous months we considered the points of reference adopted to calculate the overallscore15. the pattern of the pain (recurrent/continuous). Thus, indivi- Another aspect to be taken into consideration is that, when duals with recurrent pain for more than 3 months were inclu- the sum is used, the same weight is assigned to each item to ded in G2 (recurrent pain ≥3 months,), while individuals with calculate the overall score, which is not realistic. Thus, in this continuous pain for more than 3 months were included in G3 work, we will present a new proposal to calculate the overall (continuous pain ≥3 months). Participants also reported the self-efficacy belief score based on the factor score weight ob- place of the worse pain (orofacial/body). Those who reported tained in the confirmatory factorial analysis. This strategy pre- no pain in the last 24 hours before the interview also answered served the instrument’s operationalization in the capture of the the questions “When was the last time you felt pain”? sample’s construct; therefore, the resulting score is estimated The PSEQ was used is composed of 10 items distributed in a with less error15-17. single factor called “Pain Self-Efficacy Belief”. The options for Thus, this study aimed at assessing the psychometric properties the responses varied from zero (not confident at all) to 6 (com- of the PSEQ with a sample of Brazilian adults with different pletely confident). The reference period used for the response to durations of pain occurrence; ii) proposing a new method to cal- the items of the instrument was the individual’s general pain ex- culate the overall self-efficacy belief score; and iii) comparing the perience. The Portuguese version used was based on the proposal score among groups with different durations of pain. of Sardá et al.3. 34 Pain self-efficacy questionnaire and its use in Br J Pain. São Paulo, 2018 jan-mar;1(1):33-9 samples with different pain duration time

The PSEQ version proposed by Sardá et al.3 was analyzed in Reliability comparison with the instrument’s original version2, 4 by the The reliability was estimated by means of standardized Cronbach’s study’s researchers and a bilingual translator, independently. To alpha coefficient (a) and composite reliability (CR). Values of that end, we have used the orthographic agreement established and CR≥0.70 indicated adequate reliability15,18. among Portuguese speaking countries in 2009. The word “posso” was changed to “consigo” at the beginning of each item of the ins- Factorial invariance trument, and item 3 has undergone grammatical reconstruction The factorial invariance was carried out using the multigroup to ensure its standardization in relation to the other items of the analysis with the Chi-square difference test (Dc2)15. instrument. After these changes, the adapted Portuguese version The factorial invariance of the model’s parameters was estimated of the PSEQ (Table 1) was tested by means of a Pilot Study. between independent samples to ascertain the result’s external vali- The adapted Portuguese version of the PSEQ was applied dity. To assess the factorial invariance in independent samples, the to 25 adult patients (81% women) with average age of 45.73 sample was divided in half; each subsample was called “Test Sam- (SD=10.41) years, seeking care at the School of Dentistry of ple” (n=577) and “Validation Sample” (n=578). It should be clari- Araraquara (FOAR-UNESP), Brazil. The average time to com- fied that such samples were randomly selected using the program plete the PSEQ was 2.67 (SD=0.97) minutes. To check the par- IBM SPSS Statistics (v.22, SPSS an IBM Company, Chicago, IL). ticipants’ understanding in relation to the terms/words of each The invariance test was performed by the imposition of equality item, we estimated the lack of understanding (II). All items were constraints to the models of both subsamples. The model presen- understood by all participants (II=0). ted metric invariance when the factorial loading were invariant The content validity ratio (CVR) was carried out for the adapted (Dc2l; p≥0.05), which represents weak metric invariance. It was Portuguese version, by adopting Lawshe22 proposal. In this pha- considered that the scalar invariance was present when the fac- se, 8 pain/psychometrics experts participated, who classified each torial loading and intercepts did not statistically differ between item of the PSEQ according to their essentiality into “essential”, independent samples (Dc2land Dc2i; p≥0.05), which represents “useful, but not essential” and “not necessary”. For the decision strong metric invariance. When the factorial loading, intercepts taking, the proposal of Wilson et al.23 was used considering a and residual variances/covariances did not statistically differ be- Dc2l Dc2l Dc2 significance level of 5% (CVR8;0.05 = 0.693). tween subsamples ( , and Res; p≥0.05), there was strict invariance. The external validity was considered adequate Analysis of psychometric properties when at least strong metric invariance was observed. Psychometric sensitivity The psychometric sensitivity of the PSEQ items was evaluated Overall score using the measures of central tendency, variability and shape of To calculate the overall score of the PSEQ factor, the regression the distribution of responses provided by the participants. The weight matrix (W) obtained in the confirmatory factorial analy- kurtosis (Ku)<7 and skewness (Sk)<3 absolute values were consi- sis was used, considering the covariance matrix between manifest dered as indicators of psychometric sensitivity15,24. (items) and the covariance matrix between latent (factor and errors) and manifest variables15. Thus, a weight was estimated for Construct validity each item of the instrument. To keep the exact metric of the The factorial and convergent validities were estimated to assess instrument’s items, such weights were adjusted to the minimum- the construct validity. -maximum of the response’s options (zero to 6). The overall self-efficacy belief score for each individual was obtai- Factorial validity ned by multiplying the weight of each item by the response pro- A confirmatory factorial analysis (CFA) was performed using the vided by the individual to that same item. At the end, all values maximum likelihood estimation method. The chi-square ratio were summed to obtain the overall weighted score. by degrees of freedom (c2/df), the comparative fit index (CFI), the goodness of fit index (GFI), and the root mean square error Comparison between groups (Criterion Discriminant Validity) of approximation (RMSEA) were used as goodness-of-fit indices To compare the overall score of “Pain Self-Efficacy Belief” among of model15,24. groups with different pain conditions, the one-way ANOVA was The model’s fit was considered adequate when c2/df≤2.00, CFI and performed. The data homocedasticity was evaluated by the Leve- GFI≥0.90, and RMSEA<0.10. Items whose factorial loadings (l) ne test. The Tukey post hoc test was used to multiple compari- were <0.50 were excluded. Correlations among items’ errors were sons. The significance level adopted was 5%. included when pointed out by the modification indices calculated Programs IBM SPSS Statistics (v.22, SPSS an IBM Company, from the method of Lagrange Multipliers (LM>11, p<0.001)15. Chicago, IL) and AMOS 22.0 (SPSS an IBM Company, Chica- go, IL) were used to carried out the analysis of the study. Convergent validity The data collection was carried out at the waiting room of the Convergent validity was assessed according to the proposal of FOAR-UNESP clinics before the beginning of the care. Indivi- Fornell and Larcker25, which recommend the estimation of the duals were interviewed (face to face) individually. This study was average variance extracted (AVE). AVE≥0.50 were deemed as approved by the Human Research Ethics Committee of the Scho- adequate15,18. ol of Dentistry of Araraquara (CAAE 14986014.0000.5416). 35 Br J Pain. São Paulo, 2018 jan-mar;1(1):33-9 Bonafé FS, Marôco J and Campos JA

RESULTS groups. Most participants of group G1 reported orofacial pain as the worst pain, while group G3 reported body pain, this fact may The adapted Portuguese version of the PSEQ and the content be related to the place of data collection. validity ratio are presented in table 1. With regard to pain characteristics, individuals who reported no The study sample characteristics are presented in table 2. pain in the 24 hours have had their last pain 47.09 (SD=112.82) It should be noted that in all groups, most participants were wo- days before. men, married/in common-law marriage, with economic level C. The descriptive statistics of responses provided by participants to There is a different prevalence of men and women in different the PSEQ items are found in table 3.

Table 1. Adapted Portuguese version and content validity ration of items of the pain self-efficacy questionnaire Face Validity Content validity Item Original Versiona Adapted Portuguese Versionb Essential CVRd Pain self-efficacy questionnaire Pain self-efficacy questionnaire (nc) 1 I can enjoy things, despite the pain. Consigo apreciar/aproveitar as coisas, apesar da dor. 8 1,00 2 I can do most of the household chores (e.g., tidying- Consigo fazer a maior parte das tarefas domésticas (ex: La- 7 0,75 -up, washing dishes, etc.), despite the pain. var a louça, arrumar a casa, lavar o carro....), apesar da dor. 3 I can socialize with my friends or family members as Consigo encontrar meus amigos e familiares com a mesma 8 1,00 often as I used to do, despite the pain. frequência que antes, apesar da dor. 4 I can cope with my pain in most situations. Consigo lidar com a minha dor na maior parte das situações. 8 1,00 5 I can do some form of work, despite the pain. Consigo fazer alguns trabalhos (ex: trabalhos de casa e em- 8 1,00 (“work” includes housework, paid and unpaid work). prego remunerado ou não), apesar da dor. 6 I can still do many of the things I enjoy doing, such Consigo fazer muitas coisas que aprecio (ex: lazer, artesa- 8 1,00 as hobbies or leisure activity, despite pain. nato, esporte...) apesar da dor 7 I can cope with my pain without medication. Consigo lidar com a dor sem usar remédios. 8 1,00 8 I can still accomplish most of my goals in life, des- Consigo alcançar a maior parte dos meus objetivos de vida, 8 1,00 pite the pain. apesar da dor. 9 I can live a normal lifestyle, despite the pain. Consigo viver uma vida normal, apesar da dor. 8 1,00 10 I can gradually become more active, despite the pain. Consigo aos poucos me tornar mais ativo, apesar da dor. 8 1,00 a 2 b 3 c d Nicholas ; Adapted of the Sardá et al. version; number of experts that deemed the item as essential; critical value of the CVR8;0.05 = 0.693. All items were considered as “essential” by experts.

Table 2. Sample characterization Groups* Characteristics G0 G1 G2 G3 Total n 337 386 253 179 1,155 Age (mean, SD) 38.15±10.75 36.60±9.92 38.06±11.09 44.67±10.20 38.62±10.79 Gender Male 84 105 32 21 242 Female 253 281 221 158 913 Marital status Single 101 141 64 31 337 Married/common-law marriage 197 203 158 111 669 Widow 10 8 9 7 34 Divorced 29 34 22 30 115 Economic level A/B 146 131 94 57 428 C 171 218 129 107 625 D/E 20 37 30 15 102 Place of the worst pain Orofacial 170 320 121 34 645 Body 167 66 132 145 510 *G0 (without pain), G1 (pain <3 months), G2 (pain ≥3 months, recurrent), G3 (pain ≥3 months, continuous).

36 Pain self-efficacy questionnaire and its use in Br J Pain. São Paulo, 2018 jan-mar;1(1):33-9 samples with different pain duration time

Table 3. Descriptive statistics (mean, standard-deviation, kurtosis and skewness) of responses provided by participants to items of the pain self- -efficacy questionnaire for the different groups Groups* Mean(standard-deviation)/kurtosis/skewness Item G0 G1 G2 G3 Total 1 3.93(1.68)/-0.10/-0.70 3.19(1.89)/-0.87/-0.32 3.67(1.73)/-0.43/-0.54 3.73(1.88)/-0.51/-0.68 3.59(1.82)/-0.56/-0.54 2 4.13(1.66)/0.10/-0.85 3.50(1.89)/-0.85/-0.43 3.92(1.80)/-0.48/-0.69 3.89(1.89)/-0.41/-0.79 3.84(1.82)/-0.50/-0.66 3 3.82(1.91)/-0.66/-0.61 2.92(2.13)/-1.37/-0.09 3.38(1.97)/-1.09/-0.29 3.34(2.14)/-1.18/-0.40 3.35(2.06)/-1.15/-0.34 4 4.13(1.62)/-0.11/-0.72 3.42(1.94)/-0.88/-0.49 3.78(1.73)/-0.42/-0.63 3.92(1.80)/-0.18/-0.80 3.78(1.80)/-0.45/-0.66 5 4.20(1.65)/0.15/-0.90 3.66(1.84)/-0.55/-0.66 4.11(1.58)/-0.14/-0.74 3.99(1.88)/-0.29/-0.83 3.97(1.75)/-0.21/-0.79 6 3.55(2.01)/-0.94/-0.51 2.66(2.09)/-1.35/0.02 3.28(2.09)/-1.18/-0.31 2.87(2.32)/-1.54/-0.05 3.09(2.13)/-1.30/-0.22 7 2.53(2.05)/-1.28/0.12 1.84(2.12)/-1.08/0.66 1.97(2.12)/-1.12/0.58 2.01(2.17)/-1.19/0.53 2.09(2.12)/-1.24/0.45 8 4.04(1.72)/0.03/-0.87 3.32(1.97)/-0.95/-0.42 3.78(1.92)/-0.56/-0.70 3.45(2.00)/-0.86/-0.50 3.65(1.92)/-0.65/-0.62 9 4.09(1.76)/-0.07/-0.88 3.19(2.15)/-1.28/-0.33 3.82(1.87)/-0.51/-0.68 3.66(1.99)/-0.64/-0.70 3.66(1.99)/-0.77/-0.63 10 3.93(1.80)/-0.24/-0.82 3.12(2.09)/-1.23/-0.30 3.62(1.84)/-0.59/-0.58 3.40(2.01)/-0.87/-0.54 3.51(1.97)/-0.84/-0.55 *G0 (without pain), G1 (pain <3months), G2 (pain ≥3 months, recurrent), G3 (pain ≥3 months, continuous).

All items of the PSEQ had adequate psychometric sensitivity in all groups; therefore, there was no severe violation of the normality of the distribution of responses. However, it should be highlighted that the individuals’ responses to item 7 had a different pattern from the remaining items, being below the scale’s mean point. The unifactorial model of the PSEQ did not present adequate fit to the sample (l=0.54-0.83;c2/df=25.575; CFI=0.900; GFI=0.848; RMSEA=0.146; AVE=0.60; CR=0.94; a=0.93). The modification indices pointed out the existence of correlations between items’ errors 2-5 (LM=224.490), 8-9 (LM=118.953), 8-10 (LM=67.088) and 9-10 (LM=230.740). After inclusion of these correlations, the model presented adequate fit to the sample (l=0.54-0.85; ∆c2/df=7.059; CFI=0.978; GFI=0.964;

RMSEA=0.072) and was called refined model (MR). The model also presented adequate convergent validity (AVE=0.59) and reliability (CR=0.93; a=0.93).

Figure 1 shows the structure and factorial loadings of the MR for the sample. The comparison of the self-efficacy belief score among groups with different pain conditions is found in table 4. ANOVA shows that the self-efficacy belief significantly differs among the different groups, showing the validity of the scale’s criterion to differentiate groups of patients with different pain conditions.

Table 4. Comparison of means ± standard-deviation of overall p self- -efficacy belief scores among groups with different pain conditions Figure 1. Refined model (MR) of the pain self-efficacy questionnaire for the sample Groups* Self-efficacy belief ANOVA (mean ± standard deviation) This model also presented adequate fit for the different pain conditions (G0: c2/df=3.324; CFI=0.972; GFI=0.942; RMSEA=0.083; G1: c2/df=4.318; G0 3.89±1.47ª F=14.663; p<0.001 CFI=0.962; GFI=0.936; RMSEA=0.090; G2: c2/df=1.711; CFI=0.989; GFI=0.959; b RMSEA=0.053; and G3: c2/df=2.435; CFI=0.964; GFI=0.928; RMSEA=0.090). G1 3.13±1.60 This model presented strict invariance in independent samples (Test G2 3.59±1.54a.c Sample vs Validation Sample: Δc2l(10)=2.574; p=0.990; Δc2i(10)=16.507; p=0.086; Δc2Res(14)=14.737; p=0.396). G3 3.50±1.61c Equation 1 presents the weights of each item for the calculation of the overall score of self-efficacy belief for the sample, considering the minimum-maximum Total 3.51±1.58 value from 0 to 6. *G0 (without pain), G1 (pain <3months), G2 (pain ≥3 months, recurrent), G3 (pain ≥3 months, continuous); a,bdifferent letters indicate significant statistical diffe- Self-Efficacy Belief= 0.12PSEQ1 + 0.08PSEQ2 + 0.17PSEQ3 + 0.19PSEQ4 rence. Tukey post hoc test (a=5%). + 0.10PSEQ5 + 0.13PSEQ6 + 0.04PSEQ7 + 0.08PSEQ8 + 0.05PSEQ9 + Individuals who reported pain with duration of less than 3 months believe to 0.04PSEQ10 (1) have less self-efficacy in relation to pain than the other individuals.

37 Br J Pain. São Paulo, 2018 jan-mar;1(1):33-9 Bonafé FS, Marôco J and Campos JA

DISCUSSION one’s capacity to organize and perform the necessary behaviors to reach objectives and resist when facing obstacles and difficul- This study aimed to contribute with the expansion of the inves- ties. For this reason, when facing recent event (pain for less than tigations of self-efficacy in different pain contexts beyond chro- 3 months: G1) the individual might present lower self-efficacy nic pain. For the first time, evidence of the validity, reliability belief score than when facing an already-known pain (G2 and and invariance of the PSEQ for a Brazilian sample with different G3), or in view only of a memory of pain (G0). However, it pain conditions was presented in the literature. Furthermore, should be noted that this study has a limitation related to the this study brings a new proposal to estimate the overall score of interpretation of cause and effect results due to the study design the “Pain Self-Efficacy Belief” to minimize errors of the measu- adopted. It is expected that longitudinal studies be carried out to rement obtained with the PSEQ. prove this suggestion. The PSEQ unifactorial model2,4, was confirmed in this Brazilian The calculation of the overall self-efficacy belief score, it should sample composed of individuals with different pain conditions. be emphasized that, from the use of the confirmatory factorial For adequate fit, the model was refined with the inclusion of analysis, it is possible to estimate a measure more adequate to the correlations between items’ errors (2-5, 8-9, 8-10, and 9-10). sample, complying with the implicit characteristics of the opera- Such correlations were included due to the theoretical approach tionalization of the PSEQ15-17. Thus, the proposal to calculate the among these items. Items 2 and 5 address issues regarding work- overall weighted score (Equation 1) allows estimating the pain self- -related everyday activities, either developed at home (item 2: -efficacy belief score in a more accurate manner. It should be no- household chores) or any other activity (item 5: work at home ted, however, that the values presented are estimates for a sample or paid employment). Items 8, 9 and 10 somehow complement representing a certain population; therefore, it is not necessarily each other by carrying concepts related to abstract situations reproducible with other samples with different characteristics15,26. of life such as the achievement of life goals (item 8), becoming Others limitations and proposals for future studies can be lis- more active (item 10), and living a normal lifestyle (item 9). It ted. It should be noted that, although this study has presented should be emphasized that, in addition to presenting adequate a Portuguese version of the PSEQ, adapted in accordance with validity and reliability, this new structure also presented adequate the orthographic agreement among Brazil and other Portuguese- invariance with independent samples, which points out to the -speaking countries, this version was not tested abroad. Thus, adequate external validity of the results presented. we suggest that future studies be carried out to evaluate the pos- Further, in relation to the items of this instrument, we should sibility of using a single Portuguese version in different Portu- refer to our observation of the response pattern of item 7 (Table guese-speaking countries (transnational validation). It is further 3). Most items usually point out a beliefs level to carry out daily expected that other studies consider this method to investigate activities/chores higher than the scale’s mean point; item 7 points the psychometric properties, invariance of the PSEQ model’s pa- out the individuals’ lower beliefs level when dealing with pain rameters, and the estimates of the Pain Self-Efficacy Belief factor without using medicines. In view of a similar result, Di Pietro et in samples representing other populations, so that discussions real.10 and Chiarotto et al.11 proposed that this item could present garding the operationalization of the construct self-efficacy belief a high potential to differentiate the individuals’ behaviors when are encouraged. Furthermore, it is expected that further studies facing pain, as it approaches the self-efficacy belief in dealing take into account the relation between self-efficacy belief and the with pain using no medicines. Thus, this item could have clinical presence/lack of pain and the pain characteristics, so that new aggregate value in the assessment of pain-related self-efficacy. evidence is presented that might bring about new discussions Although assessments of self-efficacy are widely carried out, about the theoretical concepts involved in the perception of pain such assessments are often made with samples of individuals and self-efficacy. with chronic pain13. To the extent of our knowledge, this is the first study that proposed evaluating the psychometric proper- CONCLUSION ties of the PSEQ model in a sample of individuals with other pain profiles. Thus, new possibilities are opened to investigate It is concluded that the PSEQ was valid and reliable for the this construct. Among such possibilities, we can mention the sample of Brazilian adults with different pain conditions. Thus, influence and importance of self-efficacy in the handling and the possibility of extending the use of this instrument to clinical success of the treatment of patients with different types of pain and/or epidemiological contexts that go beyond the chronic pain or, in another perspective, the influence of pain characteristics in should be considered. In addition, there is evidence of a rela- pain self-efficacy belief. It is speculated, from the comparison of tionship between the self-efficacy belief and the pain characte- the self-efficacy belief scores between groups with different pain ristics, where the presence of pain and length of time living with conditions, that the characteristics of the pain can be relevant. pain might be important factors in the study of the concepts Table 4 shows that the self-efficacy belief was lower in group G1, involved in the perceptions of pain and self-efficacy. which can indicate that the individual’s reaction/behavior when facing a recent event can be different from his/her reaction after ACKNOWLEDGEMENT living with the pain, believing that the time of living with a certain condition, summed to the individual cognitive-behavioral The authors would like to thank psychologist Fernanda Cristina tools and/or strategies could result in the increase of the belief on Maurício for her collaboration in data collection. 38 Pain self-efficacy questionnaire and its use in Br J Pain. São Paulo, 2018 jan-mar;1(1):33-9 samples with different pain duration time

REFERENCES 12. Rasmussen MU, Rydahl-Hansen S, Amris K, Samsøe BD, Mortensen EL. The adaptation of a Danish version of the Pain Self-Efficacy Questionnaire: reliability and construct validity in a population of patients with fibromyalgia in Denmark. Scand J 1. Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev. Caring Sci. 2016;30(1):202-10. 1977;84(2):191-215. 13. Jackson T, Wang Y, Wang Y, Fan H. Self-efficacy and chronic pain outcomes: a meta- 2. Nicholas MK. The pain self-efficacy questionnaire: taking pain into account. Eur J -analytic review. J Pain. 2014;15(8):800-14. Pain. 2007;11(2):153-63. 14. Rokke PD, Fleming-Ficek S, Siemens NM, Hegstad HJ. Self-efficacy and choice of 3. Sardá J, Nicholas MK, Pimenta CA, Asgharl A. Pain-related self-efficacy beliefs coping strategies for tolerating acute pain. J Behav Med. 2004;27(4):343-60. in a Brazilian chronic pain patient sample: a psychometric analysis. Stress Health. 15. Maroco J. Análise de equações estruturais: fundamentos teóricos, software & aplica- 2007;23(3):185-90. ções. Pero Pinheiro: ReportNumber; 2014. 374p. 4. Nicholas MK. Self-efficacy and chronic pain. Paper presented at the annual conference 16. da Silva WR, Marôco J, Ochner CN, Campos JA. Male body dissatisfaction scale of the British Psychological Society; 1989. (MBDS): proposal for a reduced model. Eat Weight Disord. 2017;22(3):515-25. 5. Asghari A, Nicholas MK. An investigation of pain self-efficacy beliefs in Iranian chro- 17. Campos JA, Zucoloto ML, Bonafe FS, Maroco J. General oral health assessment in- nic pain patients: a preliminary validation of a translated English-language scale. Pain dex: a new evaluation proposal. Gerodontology. 2017;34(3):334-42. Med. 2009;10(4):619-32. 18. Hair JF, Black WC, Babin B, Anderson RE, Tatham RL. Multivariate data analysis. 6th 6. Vong SK, Cheing GL, Chan CC, Chan F, Leung AS. Measurement structure of the ed. Prentice Hall; 2005. 928p. Pain Self-Efficacy Questionnaire in a sample of Chinese patients with chronic pain. 19. ABEP. Associação Brasileira de Empresas de Pesquisa. Critério de Classificação Eco- Clin Rehabil. 2009;23(11):1034-43. nômica Brasil. 2015 [21 janeiro 2016]; Available from: http://www.abep.org/new/ 7. Ferreira-Valente MA, Pais-Ribeiro JL, Jensen MP. Psychometric properties of the criterioBrasil.aspx. Portuguese version of the Pain Self-Efficacy Questionnaire. Acta Reumatol Port. 20. International Association for the Study of Pain (IASP). Classification of chronic pain: 2011;36(3):260-7. description of chronic pain syndromes and definitions of pain terms. Seattle: IASP 8. van der Maas LC, de Vet HC, Koke A, Bosscher RJ, Peters ML. Psychometric proper- Press; 1994. ties of the Pain Self-Efficacy Questionnaire (PSEQ) validation, prediction, and discri- 21. International Association for the Study of Pain (IASP). Pain terms: a list with defini- mination quality of the Dutch version. Eur J Psycholog Assess. 2012;28(1):68-75. tions and notes on usage. Pain. 1979;6(3):249-52. 9. Adachi T, Nakae A, Maruo T, Shi K, Shibata M, Maeda L, et al. Validation of the Ja- 22. Lawshe CH. Quantitative approach to content validity. Pers Psychol. 1975;28(4):563-75. panese version of the pain self-efficacy questionnaire in Japanese patients with chronic 23. Wilson FR, Pan W, Schumsky DA. recalculation of the critical values for lawshe’s pain. Pain Med. 2014;15(8):1405-17. content validity ratio. Measurement and evaluation in counseling and development. 10. Di Pietro F, Catley MJ, McAuley JH, Parkitny L, Maher CG, Costa Lda C, et al. 2012;45(3):197-210. Rasch analysis supports the use of the Pain Self-Efficacy Questionnaire. Phys Ther. 24. Kline RB. Principles and practice of structural equation modeling. New York: The 2014;94(1):91-100. Guilford Press; 1998. 354p. 11. Chiarotto A, Vanti C, Ostelo RW, Ferrari S, Tedesco G, Rocca B, et al. The Pain Self- 25. Fornell C, Larcker DF. Evaluating Structural Equation Models with Unobservable -Efficacy Questionnaire: cross-cultural adaptation into Italian and assessment of Its Variables and Measurement Error. J Marketing Res. 1981;18(1):39-50. measurement properties. Pain Pract. 2015;15(8):738-47. 26. Anastasi A. Psychological testing. Ed T. (editor). New York City: Macmillan; 1988.

39 Br J Pain. São Paulo, 2018 jan-mar;1(1):40-5 ORIGINAL ARTICLE

Scapular dyskinesis was not associated with pain and function in male adolescent athletes Discinese escapular não está associada à dor e função no ombro dos adolescentes atletas

Valéria Mayaly Alves de Oliveira1, Hitalo Andrade da Silva2, Ana Carolina Rodarti Pitangui1, Muana Hiandra Pereira dos Passos1, Rodrigo Cappato de Araújo2

DOI 10.5935/2595-0118.20180009

ABSTRACT RESUMO

BACKGROUND AND OBJECTIVES: Scapular dyskinesis has JUSTIFICATIVA E OBJETIVOS: A discinese escapular tem been associated to shoulder injuries and pain. However, this rela- sido associada a lesões e dor no ombro, no entanto essa relação tionship with adolescent athletes is not well established. The ob- em adolescentes atletas ainda não é bem definida. O objetivo jective of this study was to evaluate scapular dyskinesis in young deste estudo foi avaliar a prevalência de discinese escapular em athletes and its association with pain or shoulder function. adolescentes atletas amadores e sua associação com a dor e medi- METHODS: 178 male adolescent athletes (14.58±2.16 years) das de função no ombro. were evaluated. The subjects completed the Quick Disability MÉTODOS: 178 adolescentes do sexo masculino (14,58±2,16 Arm Shoulder Hand questionnaire. Body mass, height, shoul- anos) participaram do estudo. Os sujeitos responderam ao ques- der internal rotation and Closed Kinetic Chain Upper Extremity tionário Quick Disability Arm Shoulder Hand. Também foram Stability test were measured. A dynamic visual method was ap- avaliados massa corporal, estatura, rotação interna do ombro e plied to assess dyskinesis. Binary logistic regression was applied Closed Kinetic Chain Upper Extremity Stability. Para avaliação da to analyze the association between dyskinesis and other variables. discinese escapular, utilizou-se o método visual dinâmico. A re- The comparison between groups with and without dyskinesis gressão logística binária foi utilizada para analisar a associação was made by the Mann-Whitney and t-test, accepting a statisti- entre discinese e as demais variáveis. A comparação entre os gru- cal significance of p<0.05. pos com e sem discinese foi feita pelo teste t e Mann-Whitney, RESULTS: The dyskinesis prevalence was 56.7% and this condi- sendo aceito significância estatística quando p<0,05. tion was not associated with shoulder pain. Younger athletes are RESULTADOS: A prevalência de discinese foi de 56,7% e essa 159% more likely to have dyskinesis, while those who practice condição não teve associação com dor no ombro. Atletas mais jo- more than one hour a day for three times a week are 77% more vens têm 159% mais chances de apresentar discinese, enquanto likely to have the same outcome. No difference in shoulder func- aqueles que treinam mais de uma hora por dia, durante três vezes tion was found. por semana, têm 77% mais chances de ter o mesmo desfecho. CONCLUSION: Scapular dyskinesis is not associated with Nenhuma diferença na função do ombro foi encontrada. pain and does not affect shoulder function in adolescent ath- CONCLUSÃO: A discinese escapular não está associada à dor e letes. Sports modality, age and training volume seem to induce não altera medidas de função no ombro em adolescentes atletas. changes in scapula movement. Modalidade, idade e volume de treinamento parecem induzir Keywords: Adolescents, Athletes, Athletic performance, Pain, mudanças na movimentação escapular. Shoulder. Descritores: Adolescente, Atletas, Desempenho atlético, Dor, Ombro.

INTRODUCTION

Sports modalities requiring constant use of the upper limb increase the joint overloads on this segment, especially in the shoulder complex.1. It has been well documented in the litera- 1. Universidade Federal da Paraíba, Departamento de Fisioterapia, João Pessoa, PB, Brasil. ture that movements at high speed, repetition, and load trigger 2. Universidade de Pernambuco, Programa de Hebiatria, Recife, PE, Brasil. joint adaptations such as disproportion between internal and Submitted in September 03, 2017. external shoulder rotation amplitudes and changes in humeral Accepted for publication in January 22, 2018. 1-5 Conflict of interests: none – Sponsoring sources: none and scapular positioning . Specifically, the modification in the scapula positioning, called scapular dyskinesis, has been studied Correspondence to: Avenida Umbuzeiro, 581 – Manaíra because it presents possible relations with the presence of pain 58038-180 João Pessoa, PB, Brasil. and shoulder injuries in athletes2,6-8. E-mail: [email protected] Most of the studies state the relation between shoulder pain/ © Sociedade Brasileira para o Estudo da Dor injury and scapular dyskinesis2,7,9-11. Such research ensures that 40 Scapular dyskinesis was not associated with pain Br J Pain. São Paulo, 2018 jan-mar;1(1):40-5 and function in male adolescent athletes changes in scapular kinematics may result in structural and func- presents internal consistency of α=0.9120. The anthropometric tional changes in the glenohumeral and acromioclavicular joints, variables (body mass and height) according to the International decreased subacromial space, changes in the scapular muscles Society for the Advancement of Kinanthropometry (ISAK) stan- activation and, consequently, leading to dysfunctions such as dardization and body mass index (BMI) were calculated using shoulder-rotator cuff syndrome, rotator cuff tendinopathies, gle- the equation BMI = Body Mass/(Height)2. The criteria suggested nohumeral instability, and other conditions. On the other hand, by the International Obesity Task Force (IOTF) were used to there is evidence that scapular asymmetries are also observed in classify adolescents’ nutritional status21. asymptomatic subjects, and for this reason, it is not possible to The range of motion of the internal shoulder rotation was mea- clearly and accurately infer a cause-effect relationship between sured using the passive motion technique with a goniometer. For pain and dyskinesis, making it impossible to state which of these this, the subjects remained in the supine position bent knees and factors precedes the other12-16. It is noteworthy that a good part hips, abducted arm and elbow bent at 90°21,22. The goniometer of these studies12-16, stating that there is a relationship between axis was aligned in the olecranon process, the arm fixed perpen- pain and dyskinesis, refers to the adult population or high-level dicularly to the floor and the mobile in parallel to the styloid competition athletes, which, possibly, by the repetitive motor process of the subject’s ulna. The final range of motion criteria movements and training overload may make this association for internal rotation was the combination of end feel and visu- more evident. Thus, it is possible to speculate if younger athletes, alization of scapular compensation (anterior tilt). In the cases of and with fewer sports requirements, would behave similarly to subjects with shoulder pain, the range limit was established by previous studies, but evidence that supports this inquiry is still the initial (reported or expressed) sensation of pain. The measure- insufficient17,18. ment was performed by a single evaluator. Three measurements Therefore, this study aimed at estimating the scapular dyskine- were performed on both limbs, and a final value was taken from sis prevalence in young amateur athletes, as well as evaluating the angles average. The calculation of the glenohumeral internal the possible association between scapular dyskinesis and shoul- rotation deficit was taken by subtracting the internal rotation der pain and identifying whether this condition influences the values of the dominant and non-dominant limbs. According to shoulder function of adolescent athletes. Wilk et al.24, it was established a difference greater than 18° to categorize the volunteers with internal rotation deficits. METHODS Scapular movement was evaluated by the dynamic observational method. In this method, the volunteer was asked to remain in This is a cross-section, observational, descriptive and correlation- the orthostatic position and perform three repetitions of the al study. The sample consisted of male adolescents, practicing the bilateral arm elevation movement in the scapular plane up to following sports: volleyball, swimming, handball, basketball, and 90°. The movement speed was standardized in three seconds for judo from the city of Petrolina, PE. The inclusion criteria were: concentric phase and three seconds for eccentric phase through be between 10 and 19 years old and have been practicing sports examiners verbal command. The movement execution was re- for at least one year. Exclusion criteria were not submitting the corded in a posterior view by a digital camcorder with a sampling Informed Free and Informed Consent Form (FICT) signed by frequency of 60 Hz (SONY model DCR-SX21), positioned on the legal representatives together with the Free and Informed Ac- a tripod 1.00m high in relation to the floor and at 2.85 meters knowledgment Form, who refused to perform the tests and/or from the subject. Ground markings were used to standardize the inadequately completed the questionnaire. position of the camcorder and the volunteers25. Three hundred and seventeen adolescents were evaluated, aged The categorization of the scapular dyskinesis type was performed between 10 and 19 years, of both genders, randomly selected af- according to Kibler et al.26 guidelines. The visualization of the ter a probabilistic sampling procedure, determining a minimum prominence of the scapula’s lower angle was interpreted as type I; sample of 290 athletes based on the representativeness of the five type II, those representing the medial edge prominence increase; modalities. However, this study’s sample was composed only of type III those characterized by upper angle excessive elevation; male adolescents (n=180), since the female athletes did not feel and type IV those indicating the absence of scapular dyskine- comfortable to perform the dyskinesis evaluation. Therefore, for sis. Once the asymmetry was identified in several planes, a duly the purpose of this analysis, the sampling power calculation was qualified evaluator classified dyskinesis in one of these four types, performed posteriori using the GPower software. based on the predominant pattern13. In a second moment, all the Initially, a questionnaire containing personal and sports data volunteers classified with scapular dyskinesis (types I to III) were (age, sports modality, total sports practice time, training frequen- grouped into a single category: “with scapular dyskinesis” and cy on days per week, duration of the training session in hours per those classified as type IV were included in the “without scapular day, the presence of shoulder pain) was applied. The subjects an- dyskinesis” category13. swered questions from the Corlett’s Body Diagram19 to check for Finally, to assess the upper limb stability, the volunteer was asked the presence or absence of shoulder pain. In addition, the Quick- to perform the Closed Kinetic Chain Upper Extremity Stability DASH (Quick Disability Arm Shoulder Hand) questionnaire Test (CKCUES-Test). In that test, the volunteers remained in was applied with its optional practicing module (Quick-DASH the push-up position with their hands resting on two tapes fixed optional). This instrument was translated and validated for ado- to the ground at a distance of 36 inches (91.4cm). The volunteer lescents20 which evaluates the upper limb as a functional unit and should hold this position while alternately performing the move- 41 Br J Pain. São Paulo, 2018 jan-mar;1(1):40-5 Oliveira VM, Silva HA, Pitangui AC, Passos MH and Araújo RC ment of touching the opposite hand for 15 seconds. Three maxi- observe the differences between the analyzed variables and sub- mal repetitions with a 45-second interval between trials were jects with and without scapular dyskinesis. In order to verify the performed. Before performing the test, the volunteers performed association between the dyskinesis presence and the personal, three submaximal tests in order to familiarize them with the task. sports and pain characteristics, a bivariate model of association One evaluator was responsible for counting the touch number between dyskinesis presence and each independent variable was and the other for measuring time and verbally informing the first constructed in order to observe which variables would enter the evaluator of the test start and end. The touch mean obtained was model (p<0.20). In this analysis, odds ratios (ORs) and 95% multiplied by 68% of the body weight in kilograms and divided confidence intervals were used to express the association degree by 15 to obtain the test power score27. between variables. Then, binary logistic regression was performed Prior to data collection, a pilot test was conducted with 25 ado- to explore possible confounding and interaction factors, and to lescents to verify the level of agreement between the measures identify the need for analyzes statistical adjustment. (with a one-week interval between evaluations). For the nu- Binary logistic regression with a step-by-step strategy for the analy- merical variables we used the Intraclass Correlation Coefficient sis was chosen. Only the variables presenting p<0.20 were inserted (ICC) test, and for the dyskinesis categorization, the Kappa’s into the final model. Omnibus test and Hosmer-Lemeshow value index. Numerical variables showed coefficient body mass and were analyzed to confirm the model’s validity. Finally, for shoulder height of 0.99, Quick-DASH of 0.81, optional Quick-DASH function measurements comparison in adolescents with and with- 0.73, CKCUES-test of 0.87 and internal rotation of 0.82 for the out scapular dyskinesis, the Mann-Whitney test was used. All tests right shoulder and 0.91 for the left shoulder. Kappa’s index for considering a level of significance of less than 5%. scapular dyskinesis presence or absence was 0.99. All measurements indicate excellent reliability. These 25 volunteers were not RESULTS part of the final sample of the study, and the same evaluator who performed those measurements was responsible for them out in One hundred and eighty male adolescent athletes were included the larger study. in the study. However, two volunteers were excluded by the ex- This study was approved by Ethics Committee of the University clusion criteria because they refused to perform scapular dyski- of Pernambuco CAAE 38321114.0.0.0000.5207. nesis assessment, totaling 178 subjects. Theposteriori sampling power, based on the final logistic regression model, indicates Statistical analysis that for a α=0.05 with four predictors in the final model and Data’s statistical analysis was performed using the Statistical R2=0.227, the statistical power of this study represents 99%. The Package for the Social Sciences (SPSS) software version 20. average age was 14.58±2.16 years, and the most practiced sports Categorical data description was represented by absolute and by adolescents were handball and basketball. The description of relative frequency and mean/median values and interquartile the anthropometric data, sports characteristics and their respec- standard deviation/range were used to describe the numerical tive frequencies according to the presence or absence of scapular data depending on the normality of data distribution. For this, dyskinesis is presented in table 1. the data distribution inferential analysis was carried out by the The prevalence of scapular dyskinesis in this sample was 56.7%. Kolmogorov-Smirnov test. In addition, the Chi-square test, t- From these, 46.5% were classified with type I dyskinesis, 43.6% test for independent samples and Mann-Whitney were used to with type II and 9.9% with type III. Table 2 shows the associa-

Table 1. Personal and sports characteristics of the total sample and stratified by absence and presence of scapular dyskinesis. Numerical values represented in average and standard deviation and categorical in absolute and relative frequency (n=178) Personal characteristics Total Without dyskinesis With dyskinesis p value Age (years) 14.58 (2.16) 14.78 (2.26) 14.44 (2.07) 0.206 Body mass, (kg) 63.27 (15.52) 65.10 (15.03) 61.88 (15.82) 0.167 Height (m) 1.70 (0.12) 1.70 (0.12) 1.70 (0.12) 0.639 Body mass index (kg/m2) 21.62 (3.92) 22.39 (3.94) 21.03 (3.81) 0.011* Sports characteristics Modalities Basketball 44 (24.7%) 13 (16.9%) 31 (30.7%) Handball 48 (27.0%) 21 (27.3%) 27 (26.7%) 0.012* Judo 18 (10.1%) 7 (9.1%) 11 (10.9%) Swimming 32 (18.0%) 14 (18.2%) 18 (17.8%) Volleyball 36 (20.2%) 22 (28.6%) 14 (13.9%) Practice time 1 year 43 (24.2%) 25 (32.5%) 18 (17.8%) 0.037* More than 1 year 135 (75.8%) 52 (67.5%) 83 (82.2%) Years of practice 4.76 (2.99) 4.77 (3.04) 4.75 (2.98) 0.980 Continue...

42 Scapular dyskinesis was not associated with pain Br J Pain. São Paulo, 2018 jan-mar;1(1):40-5 and function in male adolescent athletes

Table 1. Personal and sports characteristics of the total sample and stratified by absence and presence of scapular dyskinesis. Numerical values represented in average and standard deviation and categorical in absolute and relative frequency (n=178) – continuation Personal characteristics Total Without dyskinesis With dyskinesis p value Frequency of training (times/week) Up to 3 135 (75.8%) 58 (75.3%) 77 (76.2%) 1.000 More than 3 43 (24.2%) 19 (24.7%) 24 (23.8%) Duration of training session (hours/day) Up to 1 hour 30 (16.9%) 16 (20.8%) 14 (13.9%) 0.308 More than 1 hour 148 (83.1%) 61 (79.2%) 87 (86.1%) *Statistical difference. tion between dyskinesis presence and the independent variables. 95% = 0.08 - 0.66) remained in the final model. No confound- Only the variables age (10 to 14: OR = 2.59; CI 95% = 1.27 ing variable was found. The model validity was confirmed by - 5.26); BMI (eutrophic: OR = 2.43; CI 95% = 1.16 - 5.09); the Omnibus test (p=0.001) with explanatory power of 89% by modality (basketball: OR = 3.82; CI 95% = 1.41 - 10.35; hand- Hosmer-Lemeshow. ball: OR = 2.92; CI 95% = 1.09 - 7.80; judo: OR = 4.45; CI The comparison between upper limb function variables and 95% = 1.20 - 16.52 and swimming: OR = 2.95; CI 95% = 0.96 scapular dyskinesis can be observed in table 3. No statistical dif- - 9.05); and practice time and session duration (OR = 0.23; CI ferences were found between groups.

Table 2. Association of independent variables with the presence of scapular dyskinesis in adolescent athletes (n=178) Independent variables Dyskinesis presence Dyskinesis absence Bivariate OR Multivariate OR n (%) n (%) [CI 95%] [CI 95%] Age (years) 10 to 14 51 (50.5) 29 (37.7) 1.69 [0.92 – 3.09] 2.59 [1.27 – 5.26] 15 to 19 50 (49.5) 48 (62.3) 1 Body mass index Under weight 7 (6.9) 1 (1.3) 8.46 [0.97 – 73.64] 2.43 [1.16 – 5.09] Eutrophic 70 (69.3) 47 (61.0) 1.8 [0.94 – 3.47] Overweight 24 (23.8) 29 (37.7) 1 Modality Basketball 31 (30.7) 13 (16.9) 3.75 [1.48 – 9.52] 3.82 [1.41 – 10.35] Handball 27 (26.7) 21 (27.3) 2.02 [0.84 – 4.87] 2.92 [1.09 – 7.80] Judo 11 (10.9) 7 (9.1) 2.47 [0.77 – 7.88] 4.45 [1.20 – 6.52] Swimming 18 (17.8) 14 (18.2) 2.02 [0.77 – 5.32] 2.95 [0.96 – 9.05] Volleyball 14 (13.9) 22 (28.6) 1 Practice time 1 year 18 (17.8) 25 (32.5) 0.45 [0.22 – 0.91] More than 1 year 83 (82.2) 52 (67.5) 1 Frequency of training Up to 3 times 77 (76.2) 58 (75.3) 1.05 [0.53 – 2.10] 0.23 [0.08 – 0.66]* More than 3 24 (23.8) 19 (24.7) 1 Duration of session (hours/day) Up to 1 hour 14 (13.9) 16 (20.8) 0.61 [0.28 – 1.35] Over than 1 hour 87 (86.1) 61 (79.2) 1 Shoulder pain No 46 (45.5) 33 (42.9) 1.12 [0.61 – 2.03] Yes 55 (54.5) 44 (57.1) 1 GIRD Absence 92 (91.1) 67 (87.0) 1.70 [0.67 – 4.34] Presence 9 (8.9) 10 (13.0) 1 *Value generated from the interaction “Duration per Frequency”; GIRD = glenohumeral internal rotation deficit.

Table 3. Median (interquartile range) of shoulder function measurements among adolescents with and without scapular dyskinesis (n=178) Function measurement With dyskinesis Without dyskinesis p value Quick – DASH 6.80 (9.10) 9.10 (11.30) 0.288 Optional Quick – DASH 0.00 (12.50) 0.00 (12.50) 0.979 CKCUES-test 69.20 (35.60) 60.40 (25.40) 0.079 Internal rotation deficit 8 (8) 9.00 (10.00) 0.563 Quick-DASH = Quick Disability Arm Shoulder Hand; CKCUES-Test = Closed Kinetic Chain Upper Extremity Stability Test.

43 Br J Pain. São Paulo, 2018 jan-mar;1(1):40-5 Oliveira VM, Silva HA, Pitangui AC, Passos MH and Araújo RC

DISCUSSION sis. This condition’s presence was not enough to reflect on upper limb functional impairment according to the questionnaires Differences regarding the relationship between dyskinesis and applied. In addition, the CKCUES-test power values and the shoulder pain motivated this study. Results indicate that for a internal rotation deficit, conditions that are related to the pres- population of adolescent athletes with an amateur sports level, ence of shoulder pain in previous studies3,24,27 were not different the dyskinesis prevalence is high; however, it is not associated between the groups with and without scapular dyskinesis. Thus, with pain and does not seem to affect measures of upper limb it is speculated that functional alterations may be related to pain function. complaint and not to changes in scapular positioning. However, Although some studies support the relationship between pain/ the absence of studies regarding the influence of scapular dyski- lesion and scapular dyskinesis2,7-11, more than half of the current nesis on indicators of upper limb function in adolescent athletes sample (56.7%) presented changes in scapular movement with- limits the in-depth discussion of these results. out, however, being associated with shoulder pain. The results Since motor skills can be influenced by factors such as strength, of this study corroborate those of Oliveira et al.28 who analyzed flexibility and muscular endurance, and these are improved amateur male athletes with shoulder injury syndrome and ob- over time, kinematic differences in the scapula and muscle ac- served no association between dyskinesis and shoulder pain. In tion are found in children and adolescents athletes compared to addition, Uhl et al.13 analyzed the scapular dyskinesis presence adults17,18,29. In the present sample, younger athletes (10 to 14 through the observational and kinematic 3D method between years old) were 159% more likely to have dyskinesis. This rein- groups with and without shoulder pain. The authors reveal that forces the hypothesis that scapular dyskinesis in adolescents may the dyskinesis prevalence between the two groups was similar be once again attributed to compensatory actions through motor and concluded that the presence of this condition should not be action in sport combined with immaturity in motor skills. How- considered a pathological sign, but a compensatory mechanism ever, the appearance of a medium- or long-term pain as a result for individuals who use the upper limb intensely. In addition, of this scapular dysrhythmia is still a limited and inconclusive it is suggested that the asymmetry presence should not be the questioning. only factor that determines the clinical significance of scapular In the current sample, underweight and eutrophic adolescents dyskinesis and that bilateral asymmetries are frequent. Thus, it is were more likely to be classified with scapular dyskinesis. These speculated that the scapular dyskinesis in amateur athletes may results may not be related to the anthropometric characteristics be attributed more to the adaptive attitudes of the sports move- themselves, but rather to the limitations of a proposed instrument than to the presence of pain itself. ment for scapular dyskinesis analysis. Because it is a visual meth- Indeed, the lack of longitudinal studies makes it difficult to dis- od, Uhl et al.13 confirm the difficulty in accurately observing the cern whether the observed changes in the scapular movement scapular movements under the underlying muscle and soft tis- are compensatory attitudes of an already installed lesion or if sues. It implies, therefore, that subjects with less tissue adjacent the uncoordinated movement results in injurious mechanisms. to the scapula, either subcutaneous or muscular, allow a better Under this perspective, Myers, Oyama e Hibberd16 proposed visualization of the bony prominences, which has justified the to prospectively evaluate if scapular dyskinesis identified in the high odds of identifying dyskinesis in these subjects in the cur- pre-season of adolescent baseball athletes could be a predispos- rent study. Although the observational method presents some ing factor to the risk of shoulder injuries in athletes and could limitations, it is considered the most applicable for clinical and conclude that the dyskinesis presence does not increase the risk sportive practice and presents good reliability and validity com- of upper limb lesions. pared to the kinematic 3D analysis method13,16. Sports factors are associated with scapular changes presence. This study was concerned with reducing possible biases due to In this study, it was possible to observe that adolescent athletes the limitations found. The cross-sectional delineation is a factor are more likely to be classified with dyskinesis according to the that restricts further conclusions about cause-and-effect. How- greater training volume, and in general, sports modalities also ever, information obtained through a representative sample may increase the probability of individuals having dyskinesis. Adoles- serve as a subsidy for future studies with longitudinal designs cents training in smaller magnitude (up to three times a week for in adolescents. Another limitation refers to the extrapolation of less than one hour per day) are 64% less likely to have scapular the results found, which is directed to male amateur athletes of dyskinesia. In the same vein, Madsen et al.15 proposed to evalu- the evaluated modalities. This second limitation offers a field of ate the evolution of the scapular dyskinesis prevalence during a study with both genders and/or with different sports levels. Oth- single training session in asymptomatic elite young athletes (14 er variables, which were not measured in this study, could also to 22 years old). Authors used the observational method to eval- have influenced scapular dyskinesis, such as rotator cuff strength uate the dyskinesis occurrence before, and at 25, 50, 75 and 100 or cervicothoracic motion. Thus, not all potential variables were minutes of training. Their results showed a cumulative dyskinesis or could not be measured, but there may be evidence of its as- prevalence of 82% in the last session interval (100 minutes of sociation with dyskinesis. Finally, another limitation is related to training), and suggest that scapular dyskinesis may be a result of not having established a moment of pain symptoms occurrence muscle fatigue as a consequence of the high volume of training15. in the shoulder. In this study, any occurrence of shoulder pain It was also found in this study that measures of shoulder function during the subject’s life was analyzed, which may have overesti- are similar among athletes with and without scapular dyskine- mated the results. 44 Scapular dyskinesis was not associated with pain Br J Pain. São Paulo, 2018 jan-mar;1(1):40-5 and function in male adolescent athletes

CONCLUSION scapular posture in healthy overhead athletes. J Athl Train. 2008;43(6):565-70. 13. Uhl TL, Kibler W Ben, Gecewich B, Tripp BL. Evaluation of clinical assessment methods for scapular dyskinesis. Arthroscopy. 2009;25(11):1240-8. Scapular dyskinesis is not associated with pain and does not alter 14. Struyf F, Nijs J, Meeus M, Roussel NA, Mottram S, Truijen S, et al. Does scapular positioning predict shoulder pain in recreational overhead athletes? Int J Sports Med. measures of shoulder function in amateur adolescent athletes. 2014;35(1):75-82. Specific sports for upper limbs, age, and training volume may 15. Madsen PH, Bak K, Jensen S, Welter U. Training induces scapular dyskinesis in pain- increase the chances of scapular movement, so the dyskinesis free competitive swimmers: a reliability and observational study. Clin J Sport Med. 2011;21(2):109-13. presence can be attributed to the compensatory mechanisms of 16. Myers JB, Oyama S, Hibberd EE. 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45 Br J Pain. São Paulo, 2018 jan-mar;1(1):46-50 ORIGINAL ARTICLE

Parafunctional habits and its association with the level of physical activity in adolescents Hábitos parafuncionais e sua associação com o nível de atividade física em adolescentes

Gabriela Navarro1, Aline Fernanda Baradel1, Larissa Canzanese Baldini1, Natália Navarro2, Ana Lúcia Franco-Micheloni3, Karina Eiras Dela Coleta Pizzol4

DOI 10.5935/2595-0118.20180010

ABSTRACT RESUMO

BACKGROUND AND OBJECTIVES: Physical activities are JUSTIFICATIVA E OBJETIVOS: A prática de atividades físi- considered beneficial to reduce daily stress. If not eliminated, cas é considerada uma forma benéfica de redução de estresse stress is able to promote large increases in muscle tension, hy- diário. Quando não eliminado, o estresse é capaz de promover pertension, asthma, heart arrhythmia and the development of grande aumento de tensão muscular, hipertensão, asma, arrit- parafunctions. Then, the aim of this study is to evaluate the as- mias cardíacas e desenvolvimento de parafunções. Assim, o obje- sociation between the presence of parafunctional habits and the tivo deste estudo foi avaliar a associação entre a presença de hábi- practice of physical activity in adolescence. tos parafuncionais e a prática de atividade física na adolescência. METHODS: The sample comprised of 200 adolescents, boys MÉTODOS: A amostra foi composta por 200 adolescentes, and girls, from 10 to 19 years old, recruited from the clinics of de ambos os sexos, com idade entre 10 e 19 anos, recrutados the Dentistry Course of the University of Araraquara or from das clínicas do Curso de Odontologia da Universidade de Ara- public and private schools from the city. The presence of para- raquara ou de escolas públicas e particulares do município. A functional oral habits, daytime teeth clenching, and sleep brux- presença de hábitos parafuncionais orais, apertamento diurno e ism was obtained through a self-report questionnaire (yes/no). de bruxismo do sono foram rastreados por meio de um question- The individuals answered a questionnaire to identify the practice ário de autorrelato (sim/não). Os indivíduos responderam a um of physical activity according to the instrument adopted in the questionário para a identificação da prática de atividade física National School Health Survey (PeNSE - 2012). For the associa- de acordo com o instrumento adotado na Pesquisa Nacional de tions, subjects were divided according to the practice of physi- Saúde do Escolar (PeNSE - 2012). Para o estudo de associação, cal activity into active (>300 minutes of activity in the week) or os indivíduos foram divididos em relação à prática de atividade inactive (≤300 minutes of activity in the week). física em ativos (>300 minutos de atividade na semana) e inati- RESULTS: It was observed that boys practiced more physical activ- vos (≤300 minutos de atividade na semana). ity and for a longer period when compared to girls. However, the RESULTADOS: Observou-se que os meninos praticam mais practice of exercises did not present a significant association with the atividade física e por mais tempo quando comparado às meni- presence, quantity or type of the oral parafunction (p>0.05). nas, entretanto, a prática de exercícios não apresentou associa- CONCLUSION: The level of physical activity is not associated ção significativa com a presença, quantidade ou o tipo de hábito with oral parafunction nor with extrafacial pain areas. parafuncional, e nem com a presença de dor extrafacial (p>0,05). Keywords: Adolescent, Exercise, Habits. CONCLUSÃO: O nível de atividade física não se associou à parafunção oral nem com pontos de dor extrafacial. Descritores: Adolescente, Exercício, Hábitos.

INTRODUCTION

1. Universidade de Araraquara, Faculdade de Odontologia, Araraquara, SP, Brasil. The World Health Organization (WHO) defines adolescence 2. Universidade de Araraquara, Faculdade de Odontologia, Programa de Pós-graduação em Ciências Odontológicas, Área de Concentração em Ortodontia, Araraquara, SP, Brasil. as the period of life that starts at the age of 10 and finishes at 3. Universidade de Araraquara, Disciplinas de Oclusão, Terapêutica, Prótese Total e Re- complete 19 years. It is a period characterized by great physical, movível, Araraquara, SP, Brasil. psychological, and social transformations1 that can lead to para- 4. Universidade de Araraquara, Disciplinas de Ortodontia e Oclusão, Araraquara, SP, Brasil. functional habits2,3. When such habits exceed the limit of physi- Submitted in June 23, 2017. ological tolerance of the individual, it can result in aggression to Accepted for publication in January 23, 2018. 4,5 Conflict of interests: none – Sponsoring sources: none the stomatognathic system . According to the American Academy of Orofacial Pain (AAOP) Correspondence to: Av. Maria Antônia Camargo de Oliveira, 170 – V. Suconasa and the American Association of Sleep Disorders, bruxism is 14807-120 Araraquara, SP, Brasil. characterized by an involuntary sleep/awake parafunctional ac- E-mail: [email protected] tivity of the masticatory muscles, rhythmic or in spasm, and may © Sociedade Brasileira para o Estudo da Dor present teeth clenching and/or grinding6. Currently, publications 46 Parafunctional habits and its association with the Br J Pain. São Paulo, 2018 jan-mar;1(1):46-50 level of physical activity in adolescents suggest that bruxism should be considered separately from para- of communication skills; the presence of large cavities or lesions functions, as well as daytime clenching, due to their different in oral mucosa, able to mimic the TMD pain; history of recent pathophisiology7. Both conditions generate peripheral sensitiza- trauma on the face; absence of parental consent and/or its own tion leading to acute local pain due to the release of inflamma- acknowledgement. tory substances in muscle and joint tissue. Peripheral sensitization, when not resolved (by the absence of effective treatment), The following protocol was used: becomes a source of continuous pain in the tissue that leads to Tracking the presence of daytime parafunctional habits, day- central sensitization4,8-12. time clenching, and sleep bruxism Although daytime bruxism and clenching have a multifactori- It was conducted using a self-reporting questionnaire (yes/not) al origin, psychoemotional aspects, such as stress, anxiety, and about the habits of nail biting, chewing gums with frequency, depression are directly linked to their onset and maintenance4. biting objects, biting lips/cheeks, support the chin with the There is no doubt that the practice of physical exercises is an hand (adapted from the protocol proposed in the Bonafé16 excellent method to vent daily stress. When not released, the study). To identify the awake teeth clenching and sleep teeth state of tension and stress can increase muscle tone/craniocer- grinding parafunctions, we selected questions 15c and 15d (re- vical tension, hypertension, asthma, cardiac arrhythmias and spectively, “Have you noticed or did someone tell you that you the development of parafunctions4. Sedentariness is currently grind or clench your teeth when sleeping?” and “During the one of the major problems of modernity, and it also reaches day, do you grind or clench your teeth”?, from the Research the teenager directly. Unfortunately, the compliance with ex- Diagnostic Criteria for Temporomandibular Disorders (RDC/ ercise programs is still a fundamental problem. The lack of TMD)17, in its Portuguese version18). In addition to these re- time, lack of interest and lack of social support are the most ports, the number of extra facial pain complaints were also common indicators of this problem13. Physically active ado- studied, asking about the presence of pain in the last 3 months lescents may have reduced risk of chronic diseases (diabetes, in the following areas: neck/shoulders, arms/legs, back, chest/ hypertension, obesity) in adulthood since the practice of reg- abdomen. For this study, the answer alternatives were: “yes, al- ular physical activity helps to control the body mass, to lower ways” (2), “yes, sometimes” (1) “no, never” (0). The answers blood pressure, improve psychological well-being, and bring “yes, always” or “yes, sometimes” were considered positive re- social benefits in all life stages14. Studies involving the prac- ports. A sum of positive self-reports was obtained. Separately, tice of physical activity in childhood and adolescence, and its were also evaluated the reports of sleep bruxism and daytime relationship with the onset of parafunctional habits, bruxism clenching, dichotomously grouping the answers in yes (“yes, or even temporomandibular disorders (TMD) are still very always” or “yes, sometimes”) or not. scarce and show the importance to detect and intervene early to minimize possible losses15. Questionnaire to identify the practice of physical activity Given the scarcity of information and scientific evidence about The information on the practice of physical activity was gath- this theme, the present study aimed at identifying the presence ered in accordance with the tool proposed in the National of parafunctional habits in teenagers and confirm its possible as- Research on Students’ Health (PeNSE - 2012)19. From this sociation with the practice of physical activity. questionnaire, we obtained the absolute sum and the results, grouped according to the variables: days of exercise, hours of METHODS exercise and hours of reported sedentary activities. The days of exercise were grouped in less than 2 days/week, 2 to 4 days/ The sample was composed of 200 teenagers, aged between 10 week and 5 or more days/week. The hours of exercise were and 19 years, of both genders, registered for dental care at the grouped into inactive (less than 300h/week) and active (more University of Araraquara (UNIARA), or recruited in public and than 300h/week). The hours of sedentary activities were private schools of the municipality. grouped in less than 2h/day, 3-5h/day and 6 or more hours For the sample calculation, it was considered the confidence per day. For data tabulation, the number of days of exercise level of 95%, a sampling error of 5% and minimum percentage practiced by the adolescent was multiplied by the time spent of 88.0%, considering the prevalence of parafunctional habits for its execution. observed in a national study with similar methodology. Accord- This study was approved by the Committee of Ethics of the In- ing to the software (http://www.publicacoesdeturismo.com.br/ stitution (CAAE 45104615.1.0000.5383). calculoamostral/), the minimum n proposed for this study was 163 teenagers. The minimum n stipulated was 171 participants Statistical analysis considering a 5% absenteeism. The data were computed by the software SPSS para Windows, All adolescents and their responsible who accepted to participate version 21, in a spreadsheet especially developed for this pur- in the study received clear oral and written instructions about the pose. The descriptive statistics were performed, and for the inter- methodology and objectives of the study and signed the Free and est associations, we used the Qui-square test adopting a level of Informed Consent Form (FICT) and the FIAF. significance of 5% (p<0.05). For the quantitative variables, the The adolescents with the following conditions were not included statistical tests were defined in accordance with the distribution in the sample: changes in cognitive functions and impairment patterns (normal and not normal). 47 Br J Pain. São Paulo, 2018 jan-mar;1(1):46-50 Navarro G, Baradel AF, Baldini LC, Navarro N, Franco-Micheloni AL and Pizzol KE

RESULTS facial points of pain (p=0.094), sleep bruxism (p=0.124)) e daytime clenching (p=0.128), and for this reason, tables 4 to 8 were In the sample, we evaluated 76 adolescent boys (38%) and 124 worked with the total sample, without grouping by gender. girls (62%), with an average age of 14.07±2.789 years, girls 14.31 The statistical analyses demonstrated that there was a statistically years and boys 13.66 years. Most of the adolescents were Cau- significant difference between genders in terms of days (Table 1), casian (n=117, 58.5%), followed by brown (n=54, 27%), black hours of exercise (Table 2) and hours of sedentary activity (Table 3). (n=27, 13.5%) and yellow (n=2, 1%). There was no difference There were no statistically significant differences between the between boys and girls as for the race (Qui-square, p=0.300), and number of points of extra facial pain nor the number of reported age (Mann-Whitney, p=0.093). Also, there was no statistically parafunctional habits in the categories of days of exercise (Table significant difference between genders for the following variables: 4), hours of exercise (Table 5) and hours of sedentary activities number of parafunctional habits (Mann-Whitney: p=0.5), extra (Table 6).

Table 1. Days of exercise according to gender Gender Days of exercises/weeks n (%) Total Less than 2 weeks 2 to 4 weeks 5 or more weeks Male 10 (13.1) 25 (32.8) 41 (53.9) 76 (100) Female 38 (30.6) 42 (33.8) 44 (35.4) 124 (100) Total 48 (24) 67 (33.5) 85 (42.5) 200 (100) p=0.007, significance by the Chi-square test.

Table 2. Hours of exercise according to gender Gender Minutes of exercises/weeks n (%) Total Less than 300 min/week More than 300min/week Male 54 (71.1) 22 (28.9) 76 (100) Female 107 (86.2) 17 (13.7) 124 (100) Total 161 (80.5) 39 (19.5) 200 (100) p=0.008, significance by the Chi-square test.

Table 3. Hours of inactivity according to gender Gender Hours of inactivity/day n (%) Total Less than 2 days 3-5 days 6 or more days Male 27 (35.5) 22 (28.9) 27 (35.5) 76 (100) Female 33 (26.6) 38 (30.6) 53 (42.7) 124 (100) Total 60 (30) 60 (30) 80 (40) 200 (100) p=0.008, significance by the Chi-square test.

Table 4. Descriptive values and statistical difference of the variables studied regarding the categories of days of exercise Days of exercise/week Points of extra facial pain Number of parafunctional habits Average±SD Average±SD Less than 2 days/week 1.35 (1.08) 3.38 (1.39) 2-4 days/week 1.16 (0.96) 3.55 (1.19) 5 or more days/week 1.11 (1.11) 3.36 (1.39) p value 0,98 0,61 Total 1.19 (1.05) 3.43 (1.32) p= significance by the Kruskal-Wallis test.

Table 5. Descriptive values and statistical difference of the variables studied regarding the categories of minutes of exercise Minutes of exercises/week Points of extra facial pain Number of parafunctional habits Average±SD Average±SD Less 300min/week 1.22 (1.03) 3.48 (1.33) More than 300min/week 1.05 (1.14) 3.21 (1.30) p value 0,25 0,13 Total 1.19 (1.05) 3.43 (1.32) p= significance by the Mann-Whitney test.

48 Parafunctional habits and its association with the Br J Pain. São Paulo, 2018 jan-mar;1(1):46-50 level of physical activity in adolescents

Table 6. Descriptive values and statistical difference of the variables studied regarding hours of inactivity Hours of inactivity/day Points of extra facial pain Number of parafunctional habits Average±SD Average±SD Less than 2 h/day 1.22 (1.12) 3.12 (1.23) 3-5h/day 1.03 (0.97) 3.53 (1.33) 6 or more h/day 1.28 (1.06) 3.59 (1.36) p value 0,42 0,08 Total 1.19 (1.05) 3.43 (1.32) p= significance by the Kruskal-Wallis test.

Table 7. Descriptive values and difference of the variables studied regarding sleep bruxism Sleep bruxism Days of physical activity/week Minutes of physical activity/week Hours of inactivity/day Average±SD Average±SD Average±SD No 3.76 (2.42) 214.10 (225.74) 267.20 (143.39) Yes 3.72 (2.67) 196.08 (213.03) 283, 08 (129.82) p value 0,82 0,350 0,493 Total 3.75 (2.46) 210.59 (222.91) 270.30 (140.68) p= significance by the Mann-Whitney test.

Table 8. Descriptive values and difference of the variables studied regarding daytime clenching Daytime clenching Days of physical activity/week Minutes of physical activity/week Hours of inactivity/day Average±SD Average±SD Average±SD No 3.79 (2.50) 220.52 (237.18) 267.47 (144.51) Yes 3.56 (2.33) 162.06 (124.23) 284.12 (121.18) p value 0,62 0,10 0,47 Total 3.75 (2.46) 210.59 (222.91) 270.30 (140.68) p= significance by the Mann-Whitney test.

There was no statistically significant difference among the aver- Since physical activity reduces the stress that aggravates psy- ages of the values of the sum of the days of physical activity, the chophysical problems4, our hypothesis was that physically less minutes of physical activity and the hours of inactivity in terms active adolescents could present more parafunctions and extra of specific reports of sleep bruxism (Table 7) and daytime clench- facial pain. However, in this study, the presence and the time of ing (Table 8). physical activity practiced by adolescents had no significant association with the parafunctional habits, sleep bruxism, daytime DISCUSSION clenching, and points of extra facial pain. It was not found in the literature studies confronting the same variables analyzed in In general, studies using questionnaires to classify the level of ha- the present study correlating to the practice of physical activi- bitual physical activity of the population have some operational ties. However, in a slightly broader context, authors as Tavares advantages, such as reaching large groups, be precise, easy to ap- et al.26 and Bonafé16, studied the practice of physical activity and ply and low cost. However, such tools usually do not have good the presence of TMD, not observing any significant association sensitivity to all the components of the physical activity. There between both, in line with, even distantly, with our findings. is a need for more information regarding the use of question- Moreover, although the physical activity in adolescence brings naires with Brazilian adolescents. However, we can cite PeNSE, innumerable health benefits, preventing diseases, obesity, insom- IPAQ, and PAQ-C as methods used in previous studies16,19-25. nia, and stress13,20,25 it seems to have little influence on extra facial In the present study, we preferred to use the PeNSE since it is a pain and the presence of parafunctional habits. National Research on Students’ Health developed by the Depart- Since bruxism/clenching have a multifactorial origin27-31, they ment of Health, with nationwide coverage. must be analyzed with caution because many factors can trig- Although both genders showed a low level of physical activity, ger the onset and not only the absence of physical activity. It the boys were more active than the girls since they devoted more is worth mentioning that bruxism, as well as parafunctions, hours of physical activity, during more days of the week, and generate peripheral sensitization and can lead to local acute this difference is statistically significant. The high level of physi- pain resulting from the release of inflammatory substances in cal inactivity found in the present study, mainly in females, cor- the muscle and joint tissue. The peripheral sensitization can roborates the literature data21,23,25 and seems to be a trend in the become a continuous source of pain in the tissue, thus leading young generation. to central sensitization4,8-12. 49 Br J Pain. São Paulo, 2018 jan-mar;1(1):46-50 Navarro G, Baradel AF, Baldini LC, Navarro N, Franco-Micheloni AL and Pizzol KE

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50 Br J Pain. São Paulo, 2018 jan-mar;1(1):51-4 ORIGINAL ARTICLE

Comparison of combined therapy with ultrasound-associated interferential current in healthy subjects Comparação da terapia combinada com corrente interferencial associada ao ultrassom em indivíduos saudáveis

Bárbara Caroline Royer1, Carla de Fátima Albuquerque1, Cecília Felix da Silva1, Gabriela Walker Zancanaro1, Gustavo Kiyosen Nakayama1, Gladson Ricardo Flor Bertolini2

DOI 10.5935/2595-0118.20180011

ABSTRACT RESUMO

BACKGROUND AND OBJECTIVES: Although used in the JUSTIFICATIVA E OBJETIVOS: Apesar de utilizada no cam- therapeutic field, there is a shortage of studies that evaluate po terapêutico, há escassez de estudos que avaliem a terapia combined therapy or the association of electrical currents with combinada ou a associação de correntes elétricas ao ultrassom therapeutic ultrasound, the present study aimed to compare the terapêutico. O objetivo deste estudo foi comparar as duas formas two forms in healthy individuals, analyzing the pain, number of em indivíduos saudáveis, analisando o limiar de dor ao frio e à accommodations and current intensity. pressão, número de acomodações e intensidade da corrente. METHODS: Thirty healthy volunteers took turns for three weeks MÉTODOS: Trinta voluntários saudáveis revezaram em três gru- in three groups. Nociception was evaluated by means of pressure pos de forma cruzada durante três semanas. A nocicepção foi ava- and thermal stimuli in the lumbar spine and respective dermato- liada por meio de estímulos pressóricos e térmicos na coluna lom- mes. Then, the volunteer’s dominant foot was submerged in cold bar e dermátomos. Em seguida, o voluntário teve seu pé submerso water to evaluate the threshold of pain and its intensity. Shortly em água fria, e avaliado o limiar e a intensidade da dor. Logo após after, electroanalgesia (combined therapy, only current association foi aplicado a eletroanalgesia (terapia combinada, apenas asso- with ultrasound, or placebo) was applied for 15 minutes. The ap- ciação da corrente com ultrassom, ou placebo), por 15 minutos. plication of the bipolar interferential current used a frequency of Para corrente interferencial bipolar, foram utilizados frequência de 4kHz, and amplitude modulation frequency of 100Hz, with one 4kHz e frequência modulada pela amplitude de 100Hz, com um electrode on L3 and the other on S1. When combined therapy was eletrodo sobre L3 e o outro sobre S1. Quando se utilizou a tera- used, the ultrasound head (1MHz) played the role of the electrode pia combinada, o cabeçote do ultrassom (1MHz) fez o papel do positioned over the L5-S1 region, in continuous form, at a dose eletrodo posicionado sobre a região de L5-S1, na forma contínua, of 0.4W/cm2. The intensity of the initial and final current was com dose de 0,4W/cm2. Foi avaliada a intensidade da corrente evaluated, as well as the number of accommodations. inicial e final, além do número de acomodações. RESULTS: There was no significant difference between the pain RESULTADOS: Não houve diferença significativa entre os li- thresholds of pressure and cold, but the combined therapy re- miares dolorosos à pressão e ao frio, mas a terapia combinada, quired more current intensity despite having a smaller number apesar de ter apresentado menor número de acomodações, ne- of accommodations. cessitou maior intensidade da corrente. CONCLUSION: None of the therapies produced a difference CONCLUSÃO: Nenhuma das terapias produziu diferença nos in pain thresholds, but the combined therapy had fewer accom- limiares dolorosos, mas a terapia combinada apresentou menor modations. número de acomodações. Keywords: Analgesia, Pain measurement, Physical therapy modali- Descritores: Analgesia, Estimulação elétrica nervosa transcutâ- ties, Transcutaneous electric nerve stimulation, Ultrasonic therapy. nea, Mensuração da dor, Modalidades de fisioterapia, Terapia por ultrassom.

INTRODUCTION 1. Universidade Estadual do Oeste do Paraná, Departamento de Fisioterapia, Cascavel, PR, Brasil. 2. Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto, SP, Brasil. Nociception can be defined as the mechanism responsible for protecting the body against injuries, whereas acute pain occurs Submitted in November 30, 2017. when it fails in preventing the injury, with the transformation Accepted for publication in February 07, 2018. Conflict of interests: none – Sponsoring sources: none of the nociceptive activity in conscious pain. Adaptations in the nociceptive threshold are critical for the development of chronic Correspondence to: 1,2 Rua Universitária, 2069 – Jardim Universitário pain that is produced by the reorganization of the brain matrix . 85819-110 Cascavel, PR, Brasil. The interferential current is an electrostimulation that basically aims E-mail: [email protected] at the reduction of pain. It is generated from two alternating cur- © Sociedade Brasileira para o Estudo da Dor rents of medium frequency, which by interference, generate a re- 51 Br J Pain. São Paulo, 2018 jan-mar;1(1):51-4 Royer BC, Albuquerque CF, Silva CF, Zancanaro GW, Nakayama GK and Bertolini GR sultant with the average frequency between the two initial ones3. Based on the initial assessment data of the pressure threshold, However, the interferential can be applied in other clinical condi- with a standard deviation of 328, the difference to be detected of tions, such as muscle re-education, strengthening, and reduction of 210, a significance level of 5%, with the size of the sample used, edema4. One of the main characteristics of the interferential current the power of the test was of 80%. is to generate amplitude modulation frequency (AMF), stimulating the depolarization of afferent fibers as a low frequency current5. Nociceptive evaluation Another modality that also aims at pain control is the therapeutic The nociception was evaluated using pressure and thermal sti- ultrasound that usually works with 1MHz and 3MHz frequen- muli in the lumbar spine and respective dermatomes. To evaluate cies, with a deep or superficial action, respectively. It is common- the pain threshold to pressure it was used a pressure algometer ly used in clinical practice, also with the objective of speed up (Kratos®), with a tapered tip, applied on the paravertebral region the metabolic and inflammatory processes in cells and tissues6,7. (3cm lateral to the spinous process) of the 5th lumbar vertebra These two modalities can be combined into one single therapy (L5). It was also evaluated the pressure threshold in the L4 and to amplify the therapeutic results, called combination therapy8. L5 dermatome corresponding region in the lower limb. After Thus, it is necessary to have one fixed electrode and one mobi- the measurements, the force (gf) needed to cause the painful le (the ultrasound header), and its simultaneous use with low stimulus was recorded. to medium current. This modality increments the effects of the Then, the volunteer submerged the dominant foot in a bucket therapy, with reports that there is no need to work with high cur- with water controlled at 5ºC, up to the intermalleolar region. rents. On the other hand, over time, the patient has the sensation The volunteer was requested to indicate the moment when it felt that the current increases9, in contrast to what is usually observed pain and this moment was timed. This was considered the cold with the use of currents aiming at electroanalgesia, which cha- pain threshold. However, the subject kept the limb immersed racteristic is the accommodation when there is a repetitive ap- in cold water, until completing 60 seconds, and after this pe- plication of the same stimulus, thus decreasing the physiological riod, the subject was asked to indicate on the visual analog scale response10. This form of therapy, however, is still little explored (VAS), the intensity of the pain felt during the 30 seconds. The by the scientific literature. Regarding the intensity for the elec- evaluations were performed before the electrostimulation (AV1), trostimulation, the basis is generally perception capacity of the right after the therapy (AV2), and 30 minutes after (AV3). individual, that is, this is an abstract sensation11. Due to the scarcity of studies addressing the combination therapy, Electrostimulation protocol the objective of the present study was to compare the combination Soon after the initial nociceptive evaluation (AV1), the subject therapy (jointly therapies) and the interferential current associated went to the therapy application, which lasted 15 minutes. At the with ultrasound (isolated therapies applied simultaneously) in he- beginning of the protocol, the current intensity was raised until althy individuals, analyzing the cold pain threshold and pressure, the sensation of intense paresthesia, but without reaching the number of accommodations and current intensity. nociceptive threshold. During the electric stimulation, the time was counted until the subject (previously guided) indicated the METHODS reduction of the paresthesia sensation of the current (accommodation threshold). Then, the intensity was adjusted to return to This is a cross-sectional, randomized and quantitative study. The the initial paresthesia sensation. The number of accommodations sample was composed of 30 volunteers, students of the State Uni- was recorded in all moments when the volunteer reported such versity of the West of Paraná (UNIOESTE), healthy, without any need, and the current intensity was marked at the beginning and type of pain in the assessed region. There were 22 female volun- at the end of the therapy. teers and 8 male volunteers with ages between 18 and 33 years For the application of the CT we used the ultrasound header (average of 21.37±3.16 years), weighting 62.82±10.05kg, a height (1MHz) in the continuous form, with a dose of 0.4W/cm2, whi- of 1.68±0.08m, and body mass index (BMI) of 22.27±3.05. All ch played the role of an electrode, with slow and rhythmic mo- participants in the study signed the Free and Informed Consent vements on the L3-L5 region, while only one electrode of the form (FICT) before the beginning of the study. interferential current in the bipolar form, 4kHz, 100Hz AMF, The subjects performed the same activities, randomly, in three were placed on the of S1 region. consecutive weeks, that is, each individual was chosen to recei- When the AT was used, an electrode was placed on the L3 re- ve one current in each week. The three currents used were the gion and the other on S1, the intensity was strong, however, not combination therapy (CT - ultrasound + interferential current), painful. Yet, in AT the ultrasound header was placed between L3 associated therapy (AS- ultrasound and interferential current) and S1. Both therapies were used simultaneously, with the same and the placebo treatment (PT) in which the volunteers did not parameters of the combination therapy. receive any type of electrostimulation. There was no type of electrostimulation in the PT, just the pla- Individuals with any contraindication to electrostimulation or cement of the ultrasound header with gel, performing circular therapeutic ultrasound, such as the use of a pacemaker, metallic movements onto the lumbar region for 15 minutes, simulating synthesis, sensation alterations, hemorrhagic processes, as well as the therapy. the contraindication to cold therapy (cold hypersensitivity and This study it was approved by the Research Ethics Committee of hives) were excluded. UNIOESTE, with report number 1.696.921. 52 Comparison of combined therapy with ultrasound- Br J Pain. São Paulo, 2018 jan-mar;1(1):51-4 associated interferential current in healthy subjects

Statistical analysis RESULTS The data are presented in average and standard deviation, or median and quartiles. In order to evaluate data normality, we used In the comparison of the pain threshold to the pressure betwe- the Shapiro-Wilk test, and for the comparison of the results ob- en AV1, AV2, and AV3, no significant difference was found tained in the evaluation with the pressure algometer and current when compared with the L5 (Lumbar) regions and the L4 and intensity we used the unidirectional ANOVA with Bonferroni L5 dermatomes (F=0.5015; p=0.8553, F=0.549; p=0.8198 and post-test. The Friedman test was used for the evaluations perfor- F=0.9719; p=0.5409, respectively) (Table 1). med at low temperature, and for the accommodations, we used Also, for the cold pain threshold and VAS, there was no signifi- the Wilcoxon test. In all the cases, the accepted level of significant difference in all the groups (Table 2). cance was 5%. There was a significant difference in the number of accommodations between the combined and associated currents (p=0.0054) Table 1. The pain threshold to the pressure of the L5 region (lumbar) (CT Md=1.5; Q1=1; Q3=3 and AT Md=3; Q1=2; Q3=4, res- and the L4 and L5 dermatomes, in the evaluations of combined and pectively). In the evaluation of the combined and associated associated currents and placebo current intensities, initial (CT 62.96±24.34; AT 35.3±20.42) Region Therapies Evaluations Pressure threshold (gf) and final (CT 74.36±23.77; AT 72.43±27.40), there was a sig- L5 (lumbar) CT AV1 560±218.15 nificant difference (p<0.0001), with differences between the CT AV2 658.66±319.07 AV3 659.66±275.26 with initial ATs, and initial and final AT. AT AV1 696.66±420.19 AV2 642.33±347.68 DISCUSSION AV3 678.33±278.03 PT AV1 669.33±345.21 In spite of being a resource used in the clinical practice, the CT is AV2 688.66±297.26 little explored in scientific research, we tried in the present study AV3 648±244.26 to evaluate the effects of cold and pressure induced pain, as well L4 (dermatome) CT AV1 509.8±226.83 as the own characteristics of the current, such as the necessary AV2 615.33±196.76 intensity for therapy and the number of accommodations. The AV3 634.46±304.34 main justification for the CT is that the beneficial effects of the AT AV1 565.2±331.39 two modalities can be achieved at the same time, and even the AV2 604.66±407.47 AV3 543±189.53 possibility of an amplifying effect of one therapy with the other, and time efficiency for the therapist and the patient12. PT AV1 596.76±285.49 AV2 597.2±275.06 No significant difference between the pressure and cold-induced AV3 594.86±287.62 pain threshold was found in the L5 (lumbar) and in the L4 and L5 (dermatome) CT AV1 803±496.72 L5 dermatomes regions, regardless the therapy delivery (combined, AV2 880.13±478.70 associated or placebo). This corroborates the data from another stu- AV3 940.06±490.93 dy that used as an electrostimulation method the transcutaneous AT AV1 1029.86±666.04 electrical nerve stimulation, which similarly found no difference in AV2 1039.66±825.18 pressure and cold pain thresholds. This study, however, evaluated AV3 1057.7±886.26 the thenar and hypothenar region using the transcutaneous electri- PT AV1 866.56±333.77 cal nerve stimulation as a form of current13. Silva et al.11 also compa- AV2 869.56±444.61 AV3 997±503.73 ring different interferential base frequencies, did not observe rising AV1 = first evaluation, AV2 = second evaluation, AV3 = third evaluation. TC = effects on the pressure and cold pain induced threshold. Similarly, combined therapy, YOU = associated therapy, PT = placebo therapy. Claro et al.14 did not evidence alterations in the thresholds when

Table 2. The cold pain threshold and the visual analog scale of the L5 region (lumbar) and the L4 and L5 dermatomes, in the evaluations of combined and associated currents and placebo Therapies Evaluations Cold pain threshold (seconds) Visual analog scale Md Q1 Q3 Md Q1 Q3 CT AV1 14,5 8,25 41,25 6,5 4,57 7,97 AV2 10,5 7 59,75 7 5,2 7,72 AV3 14 7,25 53 6,75 5 8,37 AT AV1 14 7,25 32,25 6 4,5 7 AV2 12 8 27 6,25 5 7,5 AV3 18 9 43,75 6 4,5 7,37 PT AV1 21 10,25 38,75 6,65 4,5 7,5 AV2 19,5 10,25 58,75 7,25 5 8 AV3 20,5 9,25 44,75 6,5 4,12 7,95 Av1 = first evaluation; Av2 = second evaluation; Av3 = third evaluation; Md = median; Q1 = first quartile; Q3 = third quartile; CT = combination therapy; AT = associated therapy; PT = placebo therapy.

53 Br J Pain. São Paulo, 2018 jan-mar;1(1):51-4 Royer BC, Albuquerque CF, Silva CF, Zancanaro GW, Nakayama GK and Bertolini GR varying the interferential AMF. It is worth mentioning that in all the CONCLUSION studies the individuals submitted to the evaluations were healthy, that is, the stimulation purpose was to increase the pain threshold There was no significant difference between the pain thresholds and not necessarily to produce analgesia, and we should keep in but between the intensity and accommodation of the currents. mind that pain assessment is a subjective process, with differences in The combination therapy, although presenting a fewer number physical, psychological and social nature15. This was considered the of accommodations also produced this phenomenon, and requi- major limitation of the present study and a suggestion to others to red, initially, a higher current intensity. focus on patients with existing painful pictures. 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54 Br J Pain. São Paulo, 2018 jan-mar;1(1):55-9 REVIEW ARTICLE

Post-traumatic stress disorder and temporomandibular dysfunction: a review and clinical implications Transtorno de estresse pós-traumático e disfunção temporomandibular: uma revisão e implicações clínicas

Dyna Mara Araújo Oliveira Ferreira1, Camila Cristine de Oliveira Vaz2, Juliana Stuginski-Barbosa1, Paulo César Rodrigues Conti1

DOI 10.5935/2595-0118.20180012

ABSTRACT RESUMO

BACKGROUND AND OBJECTIVES: Post-traumatic stress JUSTIFICATIVA E OBJETIVOS: Transtorno de estresse pós- disorder is a disabling disorder that can be developed after a per- traumático é um transtorno incapacitante que pode se desen- son has experienced or exposed to a traumatic event. The evi- volver após exposição ou testemunho de um evento traumáti- dence shows the coexistence between post-traumatic stress dis- co. Evidências demonstram a coexistência entre transtorno de order and chronic painful conditions as the temporomandibular estresse pós-traumático e condições dolorosas crônicas como a dysfunction. This study aimed to review the literature to describe disfunção temporomandibular. Este estudo teve como objetivo the coexistence relation between post-traumatic stress disorder revisar a literatura para descrever a relação de coexistência entre and temporomandibular dysfunction. transtorno de estresse pós-traumático e disfunção temporoman- CONTENTS: A non-systematic search was carried on the dibular. Pubmed, BVS and LILACS databases on studies evaluating the CONTEÚDO: Foi realizada uma busca não sistemática nas relationship between post-traumatic stress disorder and temporo- bases de dados Pubmed, BVS e LILACS para estudos avaliando mandibular dysfunction. Clinical studies published in the last 10 a relação entre transtorno de estresse pós-traumático e disfun- years that presented a diagnostic criterion validated for temporo- ção temporomandibular. Foram selecionados estudos clínicos mandibular dysfunction and the post-traumatic stress disorder publicados nos últimos 10 anos e que apresentassem critério were selected. Six studies were included in the review. The results diagnóstico validado para a disfunção temporomandibular e o showed that the post-traumatic stress disorder often occurs in transtorno de estresse pós-traumático. Seis trabalhos foram in- patients with temporomandibular dysfunction and, at the same cluídos na revisão. Os resultados demonstraram que transtorno time, a higher prevalence of temporomandibular dysfunction is de estresse pós-traumático ocorre frequentemente em pacientes found in individuals with post-traumatic stress disorder. There com disfunção temporomandibular e ao mesmo tempo, uma is a trend for a larger connection between post-traumatic stress maior prevalência de disfunção temporomandibular é encon- disorder and muscular pain than pain in the temporomandibular joint. The presence of post-traumatic stress disorder modulates trada em indivíduos com transtorno de estresse pós-traumático. the level of physical, psychological and behavioral involvement Há uma tendência indicando uma associação maior entre tran- in individuals with temporomandibular dysfunction, and can storno de estresse pós-traumático e dor muscular que dor na ar- predict the onset of this painful conditions. ticulação temporomandibular. Presença do transtorno de estresse CONCLUSION: The review shows a complex coexistence be- pós-traumático modula o nível de comprometimento físico, psi- tween post-traumatic stress disorder and painful temporoman- cológico e comportamental em indivíduos com disfunção tem- dibular dysfunction. poromandibular e pode predizer início desta condição dolorosa. Keywords: Psychological trauma, Stress disorders, Temporo- CONCLUSÃO: A revisão demonstra uma relação de coexistên- mandibular joint dysfunction syndrome, Trauma. cia complexa entre transtorno de estresse pós-traumático e dis- função temporomandibular dolorosa. Descritores: Síndrome da disfunção da articulação temporomandibular, Transtornos de estresse pós-traumáticos, Trauma, 1. Universidade de São Paulo, Faculdade de Odontologia de Bauru, Departamento de Pró- Trauma psicológico. tese e Periodontia, Bauru, SP, Brasil. 2. Instituto de Ensino Odontológico de Bauru, Bauru, SP, Brasil. INTRODUCTION Submitted in September 25, 2017. Accepted for publication in January 15, 2018. Conflict of interests: none – Sponsoring sources: none. Temporomandibular disorder (TMD) comprises a group of musculoskeletal conditions involving the temporomandibular Correspondence to: 1 Al. Octávio Pinheiro Brisola, 9-75 joint (TMJ), masticatory muscles and associated structures . It 17012-901 Bauru, SP, Brasil. is an important public health problem affecting 5 to 12% of E-mail: [email protected] the world population and represents the most common chronic © Sociedade Brasileira para o Estudo da Dor painful condition in the orofacial region2,3. 55 Br J Pain. São Paulo, 2018 jan-mar;1(1):55-9 Ferreira DM, Vaz CC, Stuginski-Barbosa J and Conti PC

Post-traumatic stress disorder (PTSD) is a relatively common anxi- CONTENTS ety disorder and can be defined as a set of symptoms that manifests itself after exposure to a stressful or traumatic event4. According to A non-systematic literature search for studies on the relationship the 5th edition of the Diagnostic and Statistical Manual of Men- between PTSD and TMD published between 2007 and June tal Disorders (DSM), PTSD diagnosis requires that the subject 2017 was performed in Pubmed, BVS and LILACS databases. be exposed to a stressful event such as death, death threat, actual The search included the following keywords: temporomandibu- or possible serious injury, actual or possible sexual violence in the lar joint; temporomandibular joint disorders; temporomandibu- following forms: direct exposure, trauma testimony, knowledge lar joint dysfunction syndrome; craniomandibular disorders that a family member or friend was exposed to trauma, or indirect combined with stress disorders, traumatic; stress disorders, post- exposure to trauma details4. PTSD is characterized by symptoms traumatic; combat disorders and psychological trauma. The ar- of negative and inopportune thoughts about trauma, nightmares, ticles’ titles and abstracts were evaluated to identify the inclusion emotional distress, increased reactivity to stressful stimuli, and criteria. There was no restriction for participants’ age and gender. dodge/avoidance behavior4. These symptoms’ persistence is what The papers should present primary results and written in Portu- characterizes the pathological picture; i.e., PTSD reflects a failure guese or English. The following criteria were adopted to verify of physiological and psychological adaptation, in which normal the coexistence relationship between PTSD and TMD: acute reactions to a stressor are not corrected over time5. 1. Cross-sectional, case-control, randomized clinical trial or co- Evidence shows that chronic painful TMD pictures often coexist hort studies; with PTSD. Epidemiological studies have indicated that PTSD 2. TMD diagnosis based on validated criteria (RDC/TMD13, is more prevalent in TMD patients when compared to the gen- DC/TMD14 or AAOP guidelines15); eral population6,7 and PTSD subjects also presented more TMD 3. Medical PTSD diagnosis, or based on a structured question- than subjects without the disorder8. In addition, the comorbidity naire defined by DSM4,16. relationship between TMD and PTSD may be a complicating factor for TMD handling, as it reduces the efficacy of commonly RESULTS used therapeutic interventions9. The clinically observable relationship’s reasons between TMD The databases search resulted in 116 articles. After sorting the and PTSD are not fully understood, but some theoretical models titles and abstracts, 12 articles were selected for a complete read- have been proposed to explain the relationship between chronic ing of the texts. From these, six meet the inclusion criteria6-8,17-19. pain and PTSD10-12. Among them, the mutual maintenance One paper was excluded because it did not evaluate the relation- model10 is the most widespread and suggests that components ship between TMD and PTSD20 and five because they did not related to PTSD and painful condition exacerbate and maintain use diagnostic criteria validated for TMD, only evaluating signs one another. Considering the negative impact of PTSD in the and symptoms of dysfunction in the studied population21-25. The TMD patients handling, this study aims to describe the rela- flowchart with the article selection process is shown in figure tionship of coexistence between TMD and PTSD, as well as the 1, and the information of the studies included in the review is clinical implications involved in this relationship. shown in table 1.

Table 1. Information of the included studies Authors Study types Studied population Main results Bertoli et al.6 Cross-sectional 445 patients with painful TMD 46% reported at least one traumatic stressor event. 91% women 12.6% with PTSD. PTSD prevalence is higher in the muscle pain group (14.9%) than in the joint pain group (9.9%); although not statistically different. Positive association between PTSD and disability, psychological dysfunction, difficulty coping with pain and sleep problems. Burris et Cross-sectional 411 patients with orofacial pain re- 23,6% with PTSD. al.17 porting traumatic life events prior to PTSD was associated with greater severity of pain, daily interferences, pain psychological dysfunction, reduced levels of daily activity and sleep 100% women problems. Porto et al.7 Cross-sectional 81 patients with myofascial pain 43.2% reported at least one traumatic stressor event. type TMD 14.8% with PTSD. 73% women Weber et Cross-sectional 610 patients with TMD reporting PTSD predicts pain severity, psychological dysfunction, and interfer- al.18 traumatic life events ence in daily activities in TMD patients. 85% women Muhvić-Urek Case-control 50 war veterans with PTSD TMD prevalence was 48% in the veterans and 8% in the control group. et al.8 50 healthy subjects The most common diagnosis was myofascial pain among veterans 100% men and disc displacement in the control group. Fillingim et Cohort 3,263 healthy subjects monitored for PTSD was associated with a higher incidence of painful TMD (risk ratio al.19 2.8 years = 1.38). TMD = temporomandibular disorder; PTSD = post-traumatic stress disorder.

56 Post-traumatic stress disorder and temporomandibular Br J Pain. São Paulo, 2018 jan-mar;1(1):55-9 dysfunction: a review and clinical implications

dence, and correlation between the two conditions. Approx- Articles recovered from imately half of the TMD patients reported at least one life- databases 6,7 (n=116) threatening traumatic event and 12,6 to 23,6% fulfilled the criteria for PTSD6,7,17. Epidemiological studies show that 30 Articles deleted after reading to 90% of the population report a traumatic events history; titles and abstracts however, the PTSD prevalence is less than 10%27,28. Therefore, (n=104) the included studies indicated a higher PTSD prevalence in Selected articles for TMD subjects than in the general population. These results detailed evaluation corroborate a recently published systematic review demonstrat- (n=12) ing that there is sufficient evidence to confirm the association 29 Articles excluded (n=6) between PTSD and chronic painful conditions . In addition, No evaluation of the PTSD seems to be strongly associated with certain conditions relationship between of chronic pain in the craniofacial segment than other condi- TMD and PTSD (n=1) Diagnostic criteria not tions. In a subgroup analysis, the PTSD prevalence was higher validated for TMD (n=5) among subjects with a headache and facial pain (9 to 25%) than in subjects with lumbar pain (0.3 to 0.7%)29,30. Deleted articles (n=6) TMD patients reported traumatic stressors of different natures. Knowing that a family member or friend was injured or killed; experiencing automobile accidents and suffering from violent at- Figure 1. Study selection process flowchart TMD = temporomandibular disorder; PTSD = post-traumatic stress disorder. tacks were the most commonly reported traumatic experiences and of important personal significance for TMD patients17. PTSD prevalence for different TMD subgroups was investi- The relationship between PTSD and TMD was investigated gated by Bertoli et al.6. Although not statistically significant, through cross-sectional, case-control, and cohort studies. Among the values indicated a higher PTSD prevalence in subjects with TMD patients, 43 to 46% reported at least one traumatic stress- masticatory muscles pain when compared to TMJ pain. An ex- or event6,7. PTSD prevalence in TMD patients ranged from 12.6 planation for these results is the greater psychological vulner- to 23.6% in the studies6,7,17. The sample of TMD patients was ability found in subjects with myalgia. These patients present composed mostly of women, with an average age ranging from high levels of anxiety, depression, pain-related disability, and 37 to 47 years old. One paper evaluated only subjects with mas- report a greater number of stressful events than subjects with ticatory muscle myofascial pain7 and three studies investigated arthralgia31,32. Additional studies investigating the PTSD prev- populations with painful muscle and joint TMD6,17,18. In these alence in subgroups of TMD patients are needed to elucidate papers6,7,17,18 the participants were not formally diagnosed (medi- this outcome. cal diagnosis) with PTSD but had symptoms consistent with From another perspective, the TMD prevalence is higher in PTSD diagnosis identified by Post-Traumatic Stress Disorder PTSD subjects when compared to subjects without PTSD8. Check List-Civilian (PCL-C)26, a structured questionnaire, de- Studies of this nature are carried out mainly in at-risk popula- veloped according to the DSM, and validated to investigate the tions for PTSD, such as war veterans or natural disasters victims. PTSD prevalence in epidemiological surveys. PTSD development after traumatic events is associated with in- Only one paper investigated the TMD prevalence in PTSD sub- creased risk of musculoskeletal pain and functional somatic syn- jects8. TMD prevalence was 48% in PTSD subjects and 8% in dromes (FSS)33,34. healthy subjects. The most common TMD diagnosis was myo- In addition, subjects with both conditions, TMD and PTSD, fascial pain among PTSD subjects, while in the control group it presented greater pain intensity, psychological dysfunction, in- was disc displacement. The PTSD population studied consisted terference with daily activities, sleep problems and pain coping of war veterans with an average age of 42 years and with medical difficulties when compared to subjects without PTSD6,17,18. PTSD diagnosis. These results may be reflective of changes in pain processing The positive association between PTSD symptoms and variables found in PTSD subjects. such as pain intensity, disability, psychological dysfunction, diffi- A recent study with quantitative sensory tests demonstrated culties in coping with pain, interference with daily activities and increased pain sensitivity (hyperalgesia) possibly related to pro- sleep problems were found in three studies6,17,18. cesses of central sensitization in these subjects35. On the other Finally, a cohort study reported that PTSD predicted the inci- hand, PTSD was associated with reduced sensitivity to noxious dence of painful TMD in healthy populations with a risk ratio stimuli (hypoalgesia)36. This pattern type suggests preservation of 1.3819. of the sensory pathways and absence of central sensitization and indicates that the pain perception in these patients is modulated DISCUSSION centrally by emotional factors36. However, it is still uncertain whether alterations in pain processing are pre-existing risk fac- The bidirectional relationship between PTSD and painful tors for PTSD development or whether they are consequences of TMD is supported by studies evaluating the prevalence, inci- exposure to trauma and its neurobiological implications. 57 Br J Pain. São Paulo, 2018 jan-mar;1(1):55-9 Ferreira DM, Vaz CC, Stuginski-Barbosa J and Conti PC

A set of physiological and psychological processes is triggered Clinical implications when the human being experiences stressful or traumatic events. Psychiatric disorders related to traumatic events usually go unno- For many, these physiological changes return to normal once the ticed when evaluating TMD subjects. Considering the high PTSD stressor or trauma is ceased. However, the initial state of hyperex- prevalence in these patients, especially in cases of masticatory citation may become chronic for some subjects. Chronic hyper- muscle myalgia, it is prudent to adopt screening instruments for excitation leads to physiological stress system dysregulation and PTSD, since there is a chance of this condition being present. An- to the development of several changes. other implication is that treatments for chronic pain are time-con- Studies have demonstrated dysfunction in the hypothalamic- suming and require patient adherence. Subjects diagnosed with pituitary-adrenal (HPA)37 axis and abnormal activation patterns PTSD are three times more likely not to adhere to treatment40. in frontal-limbic brain areas (prefrontal cortex, hippocampus, In addition, individuals with painful TMD who report high lev- insula, and amygdala) in PTSD subjects38. In addition, the trau- els of psychiatric symptoms make up a subgroup of patients for ma experience may also affect the interpretation of a potentially whom conventional treatments are ineffective9. In such cases, ef- threatening stimulus. This interpretation bias may then result in fective interventions for both TMD and PTSD, including psy- dodge behavior, catastrophic symptoms, and amplification of the chiatric and psychological therapies, should be considered in the disease state34. treatment plan. Studies investigating the temporal relationship between TMD and PTSD are scarce in the literature and this review identified only CONCLUSION one cohort study19. Fillingim et al.19 reported that the PTSD presence in healthy subjects predicts the risk for developing painful This review described a complex coexistence relationship between TMD (Risk Rate 1.38). This result corroborates with retrospective PTSD and painful TMD. PTSD frequently occurs in patients studies outcomes. A recent meta-analyzes has shown that expo- with TMD, and at the same time, a higher TMD prevalence is sure to traumatic life events such as physical, sexual, emotional found in PTSD subjects. There is a trend indicating a greater abuse, war combat or PTSD diagnosis increases by 2.7 times the relationship between PTSD and muscle pain than TMJ pain. chance of a subject developing FSS such as TMD, fibromyalgia, PTSD presence modulates the level of physical, psychological generalized chronic pain, chronic fatigue syndrome and irritable and behavioral impairment in TMD subjects and can predict the bowel syndrome34. 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59 Br J Pain. São Paulo, 2018 jan-mar;1(1):60-5 REVIEW ARTICLE

Inflammatory mediators related to arthrogenic temporomandibular dysfunctions Mediadores inflamatórios relacionados às disfunções temporomandibulares artrogênicas

Rodrigo Lorenzi Poluha1, Eduardo Grossmann2

DOI 10.5935/2595-0118.20180013

ABSTRACT RESUMO

BACKGROUND AND OBJECTIVES: Inflammatory dis- JUSTIFICATIVA E OBJETIVOS: As desordens inflamatórias orders of the temporomandibular joint present a high preva- da articulação temporomandibular apresentam alta prevalência lence in the population. The knowledge about inflammatory na população. O conhecimento sobre os mediadores inflamatóri- mediators, such as histamine, serotonin, kinins, eicosanoids, os, tais como histamina, serotonina, cininas, eicosanoides, fator platelet-activating factor, nitric oxide, tumor necrosis factor and de ativação plaquetária, óxido nítrico, fator de necrose tumoral e interleukins, may contribute to a better understanding of these interleucinas, pode contribuir para melhor entendimento dessas disorders. The objective of this study was to review the literature desordens. O presente trabalho objetivou revisar a literatura a on the major inflammatory mediators involved in temporoman- respeito dos principais mediadores inflamatórios envolvidos nas dibular arthralgia. artralgias temporomandibulares. CONTENTS: A search was made in the LILACS, Pubmed/ CONTEÚDO: Foi realizada uma busca nas bases de dados Medline, Scielo and Science direct databases, crossing the fol- LILACS, Pubmed/Medline, Scielo e Science direct, cruzando- lowing descriptors in the English and Portuguese language: se os seguintes descritores em língua inglesa e portuguesa: in- inflammation, temporomandibular joint, inflammatory media- flammation, temporomandibular joint, inflammatory mediators, tors, inflammation, temporomandibular joint and inflammatory inflamação, articulação temporomandibular e mediadores infla- mediators. Articles of literature review, systematic review, me- matórios. Foram incluídos artigos de revisão de literatura, revisão ta-analysis and randomized clinical trials, as well as books with sistemática, meta-análise e estudos clínicos randomizados, bem compatible themes, published between September 1990 and como livros com temática compatível, publicados no período de June 2017 were included. Clinical reports, open label studies, setembro de 1990 a junho de 2017. Foram excluídos casos clíni- animal model studies, were excluded. cos, estudos abertos «open-label» e estudos em modelos animais. CONCLUSION: The knowledge of the inflammatory process, CONCLUSÃO: O conhecimento do processo inflamatório, with the different mediators and mechanisms, can contribute to com os diferentes mediadores e mecanismos, pode contribuir a better understanding, allowing the selection of the best therapy para um melhor entendimento do mesmo, possibilitando a to be used clinically in cases of arthrogenic temporomandibular seleção da melhor terapêutica para ser empregada clinicamente joint disorders. nos casos de artralgias temporomandibulares. Keywords: Inflammation, Inflammatory mediators, Temporo- Descritores: Inflamação, Mediadores inflamatórios, Transtornos mandibular joint disorder. da articulação temporomandibular.

INTRODUCTION

Temporomandibular dysfunction (TMD) is a set of functional and pathological changes that affect the masticatory muscles, associated structures, and the temporomandibular joint (TMJ)1. The TMJ is considered a ginglymoarthrodial joint that allows rotational and translational motion. These movements are essential in mastication, speech, and swallowing2,3. 1. Universidade Estadual de Maringá, Maringá, PR, Brasil. 2. Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil. TMJ inflammatory disorders have a 34.2% prevalence in the population4. It can occur due to trauma or an intrinsic and/or Submitted in September 01, 2017. extrinsic joint overload that exceeds the adaptive capacity of the Accepted for publication in January 10, 2018. 5,6 Conflict of interests: none – Sponsoring sources: none. joint tissues, generating an inflammation as a consequence . In- flammation is a set of homeostatic phenomena in the vascular- Correspondence to: Rua Coronel Corte Real, 513 - Petrópolis ized tissues to remove harmful agents and to restore their normal 90630-080 Porto Alegre, RS. functions. These phenomena are coordinated by the action of E-mail- [email protected] inflammation mediators (IM)7-9. Histamine, serotonin, kinins, © Sociedade Brasileira para o Estudo da Dor eicosanoids, platelet activating factor, nitric oxide, tumor ne- 60 Inflammatory mediators related to arthrogenic Br J Pain. São Paulo, 2018 jan-mar;1(1):60-5 temporomandibular dysfunctions crosis factor, and interleukins are among the main IM of TMJ intracapsular pain that is intensified with the jaw movement14. disorders10,11. When intense, necrosis and fibrin deposition in the joint surface Therefore, understanding these IM can contribute to a better un- may occur which reduces the joint space and eventually leading derstanding the disorders, as well as to select the proper therapy, to a TMJ fibrous ankylosis18. as the anti-inflammatory pharmacology, intra-articular injec- The inflammation of the TMJ capsular ligament (capsulitis), is tions, arthrocentesis, and arthroscopy12,13, in order to optimize clinically manifested by pain on palpation of the lateral head pole the clinical outcome. of the jaw when in static joint position and in motion. The most The objective of the present study was to review the literature frequent etiologic factor is the macro trauma when the capsular about the main IM involved in temporomandibular arthralgia. ligament is abruptly stretched14,15. During the healing process, the joint capsule can adhere to adjacent structures (adhesive cap- CONTENTS sulitis) or heal with loss of length (capsular fibrosis18. The inflammation of the TMJ retrodiscal tissue (retrodiscitis) Literature search strategies is characterized by a pulsating pain15, which can lead to acute A search was conducted in the LILACS, Pubmed/Medline, Scie- malocclusion in the contralateral anterior jaw due to local ede- lo, and Science direct databases, crossing the following keywords ma. Macro and microtrauma that force the mandibular condyle in English and in Portuguese: “inflammation”, “inflammation towards the innervated and vascularized retrodiscal tissues may mediators”, “temporomandibular joint” “temporomandibular cause a retrodiscitis14. The intensity of the trauma and the pro- joint disorders,” “inflamação”, “mediadores da inflamação”, “ar- gression of the inflammatory process can cause the perforation ticulação temporomandibular” and “transtornos da articulação of retrodiscal tissues and put the mandibular condyle in direct temporomandibular”. We included review articles, systematic contact with the mandibular fossa18. review, meta-analysis and randomized clinical studies, as well as The inflammation of the disc ligaments (ligamentitis) is a re- books on compatible themes published from September 1990 to sult of macro or microtrauma, bruxism and/or functional acts of June 2017. Reports of clinical cases, “open-label” studies, stud- broad magnitude in an attempt to move the disc of the mandib- ies with animal models were excluded. We found a total of 95 ular condyle. Usually, it results in intermittent pain, increasing study materials (articles and books). Of these, after reading the by maximum intercuspation and reducing by the interposition summary, 50 articles and 6 books met the inclusion criteria and of a dental spatula. It can be associated with pain, protective provided the basis for the writing of the present study. muscle co-contraction, and limitation of jaw movements14. The inflammation of the joint surfaces (arthritis) is a group of Inflammatory joint disorders of the temporomandibular disorders in which we observe changes in the morphology of the joint bone tissue. Several types of arthritis can impact the TMJ (os- It is a series of alterations in which some tissues that compose teoarthritis, osteoarthrosis, and polyarthritis). The level of pain the joint structure suffer an inflammatory process, being classi- and the clinical and image findings vary tremendously in the fied according to the structures affected in synovitis, capsulitis, different types14. retrodiscitis, ligamentitis, and arthritis14,15. Usually, it is difficult to make a differential diagnosis of these arthrogenic alterations INFLAMMATION MEDIATORS due to their clinical similarities16. The inflammation of the synovial membrane that lines the TMJ Inflammation mediators are substances released in an injured tis- (synovitis) results in changes in the composition and amount of sue area or by properly activated cells that coordinate the process the synovial fluid17. Clinically, it is characterized by a persistent of the inflammatory response19 (Table 1).

Table 1. Summary of the key inflammation mediators found in arthrogenic temporomandibular dysfunctions Mediators Sources Actions Histamine Mast cells, basophils, platelets, epidermal cells Vasodilation; vascular permeability increase; endothelial activation and and neurons of the central nervous system. stimulation of the serotonin release. Serotonin (5-HT) Serotonergic neurons of the central nervous Vasodilation; increased vascular permeability and nociception. system and enterochromaffin cells. Platelets (that capture 5-TH in the circulation). Kinins (bradykinin) Plasma substrate, by the metabolization of Vasodilation; increased vascular permeability; promotion of the IL-1 and

kininogen by kallikrein. TNF synthesis and activation of phospholipases A2 and C.

Prostacyclin (PGI2) Mast cells from membrane phospholipids. Increment the effect of histamine and kinins. Prostaglandins Mast cells from membrane phospholipids. Increment the effect of histamine and kinins; nerve endings hyperalgesia.

(PGE2, PGF2)

Thromboxane (TxA2) Mast cells from membrane phospholipids. Intravascular coagulant; keep intravascular normality.

Leukotrienes (LTB4) Leucocytes. Chemotaxis, polymorphonuclear leukocytes aggregation, and degranulation. Continue...

61 Br J Pain. São Paulo, 2018 jan-mar;1(1):60-5 Poluha RL and Grossmann E

Table 1. Summary of the key inflammation mediators found in arthrogenic temporomandibular dysfunctions – continuation Mediators Sources Actions Platelet activation Leukocytes, mast cells, and platelets. Vasodilation; an increase of capillary permeability, chemotaxis, aggrega- factor (PAF) tion, and degranulation of polymorphonuclear leukocytes. Nitric oxide Macrophages, endothelial cells. Vasodilation; reduction of platelet aggregation. Tumor necrosis fac- Monocytes, macrophages, and T-lym- Coagulation activation; stimulation of the expression of adhesion mo-

tor (TNF-α) phocytes. lecules, PGE2, PAF, glucocorticoids, eicosanoids, besides influencing cellular apoptosis. Interleukin-1 (IL-1) Macrophages, monocytes, fibroblasts, den- An important marker of the inflammatory response associated with acu- dritic cells, B lymphocytes, NK cells and epi- te Infection. thelial cells. Interleukin-1 (IL-6) Monocytes, macrophages, fibroblasts, en- Regulation of immune reactions, inflammation, hematopoiesis, and car- dothelial cells. cinogenesis; maturation and activation of several inflammatory cells.

Histamine vial fluid of the temporomandibular arthralgias, in patients with Histamine is a vasoactive amine formed by the histidine decar- arthritis, show that it is significantly increased and related to pain boxylation by the l-histidine enzyme decarboxylase, found in the during the movement of the joint and the reduction of the man- mast cells, basophils, platelets, cells of the human epidermis, gas- dibular mobility25. 5-HT also induces nociception in the TMJ tric mucosa, and neurons of the central nervous system (CNS)20. region by the activation of β1 and β2 adrenoreceptors located The tissue aggression leads to the degranulation of the mast cells8, in this joint, and also the local release of adrenergic amines and usually found in the retrodiscal zone and contributes to the TMJ prostaglandins. Therefore, high levels of 5-HT in the synovial inflammation mainly through the release of histamine21. In the fluid of patients with TMJ inflammatory pain can contribute to inflammatory process, histamine promotes the vasodilation, in- the maintenance of the painful picture26. creasing vascular permeability, and endothelial activation, and its effects are mediated by the interaction with four receptors Kinins (H1, H2, H3, and H4). H1 receptors are essentially found in Kinins (bradykinin, lysyl-bradykinin, and methionyl-lysyl-bra- blood vessels, and they promote vasodilation, bronchoconstric- dykinin) keep the exudative phenomena after the hypersensitization, and modulation of the circadian rhythm. H2 receptors are tion to histamine, with effectiveness 10 times higher8. Kinins in the intestine and induce the secretion of gastric acid. The H3 interact with specific receptors (B1 and B2), present in inflamma- predominates in the CNS acting as neurotransmitters. H4 is tory cells, like macrophages, promoting the synthesis of interleu- widely expressed in the bone marrow and leukocytes and medi- kin-1 and the tumor necrosis factor (TNF) (when coupled to B1) 7 ates the mast cells chemotaxis . Following one to two hours after receptors, activating A2 and C phospholipases (when coupled to 24 the aggression, the receptors of the endothelial cells become hy- B2receptors) . Bradykinin has been implied in the pathogenesis posensitive to the histamine action, and the exudative phenom- of the TMJ inflammatory conditions due to its pro-inflammato- ena continue by other mediators8. Histamine inactivation occurs ry properties27. The increase of bradykinin levels in the synovial by for methylation in the liver, or oxidation in the kidneys and fluid of patients with temporomandibular dysfunction (TMD) intestines through histaminase7. Histamine concentration tends can indicate the lower effectiveness of using arthrocentesis in this to be higher in patients with osteoarthritis than with other TMJ joint28 since there is a positive correlation between the concentra- disorders, having, in addition, a positive correlation between the tion of bradykinin and the synovitis degree29. pain and the concentration of this amine22. Histamine induces the nociception through an indirect mechanism stimulating the Eicosanoids 5-hydroxytryptamine release (5-HT, serotonin)23. Eicosanoids are composites with great potency and a broad spectrum of biological activity, being originated by the oxygenation Serotonin (5-HT) of long-chain polyunsaturated fatty acids19. The arachidonic acid 5-HT is an amine found in the animal and vegetal kingdoms. It (AA), present in cell membranes, is the most abundant and im- is synthesized in the serotonergic neurons of the CNS and in the portant eicosanoid precursor20. AA is present in the membranes enterochromaffin cells (Kulchitsky cells) of the gastrointestinal of the body cells. It is an essential fatty acid, of the Omega-6 tract of the animals. In the human body, 5-HT is synthesized family, formed by a 20-carbon chain with four double bonds from the tryptophan amino acid by short metabolic pathway, (allowing several areas of the molecule to be oxidized)7. The that involves two enzymes: tryptophan hydroxylase and aromatic cell stress resulting from the injury generates, as a consequence, L-amino acid descarboxylase7. Although being better known by an increase of calcium permeability with higher inflow to the its action as a neurotransmitter in the CNS, 5-HT contributes to interior of the cell, activating the action of the acyl-hydrolases vasodilation and the increase of vascular permeability, in inflam- enzymes (phospholipase A2 and C) that breaks up the phospho- mation, being released by platelets (that take 5-TH from of the lipids and promotes the generation of AA molecules available in circulation, storing in secretory granules by active transport) at the cytosol8. AA is oxidized, mainly, by five enzymatic pathways the moment of its aggregation24. The levels of 5-HT in the syno- (two cyclooxygenases and three lipoxygenases) producing eico- 62 Inflammatory mediators related to arthrogenic Br J Pain. São Paulo, 2018 jan-mar;1(1):60-5 temporomandibular dysfunctions sanoids (prostaglandins, thromboxanes, leukotrienes), that play Pro-inflammatory cytokines a fundamental role in the inflammatory process20. The migration of cells to the region where the inflammation is oc- curring is also strongly influenced by the cytokines action35. These Cyclooxygenase products are peptides or polypeptides produced by the inflammatory or tis- Cyclooxygenase (COX), enzymes present in the cytosol and bond sue cells, in conditions of normality, but also, especially, in cell to the endoplasmic reticulum of the cells, generate the synthesis of mechanic, biochemical and/or functional cell stress as it is charac- 8 prostaglandins (PGE2, PGF2), prostacyclins (PGI2) and thrombox- terized in an area with an inflammatory process . Besides stimulat- 20 anes (TxA2) . Prostaglandins and prostacyclins act as modulators ing the leukocyte cell adhesion to the vascular endothelium and of the exudative phenomena in late periods (after some hours of inducing the synthesis and release of prostaglandins, the increase the onset of the inflammatory process) incrementing the histamine in the concentration of pro-inflammatory cytokines has been as- and kinins effect on the specific receptors, by increasing its sensitiv- sociated to the reabsorption of bone tissue in the TMJ36. Among ity24. Moreover, prostaglandins promote nerve endings hyperalgesia the cytokines in the TMJ inflammation are the tumor necrosis making them more sensitive to the action of pain mediators (hista- factor (TNF-α) and the interleukins (especially IL-1 and IL-6)37. mine, serotonin, and kinins) which makes the local pain, induced 8 by mechanical and chemical agents, stronger . PGE2 is present in Tumor necrosis factor high concentrations in the synovial fluid of TMJ involved in an in- TNF-α is a pro-inflammatory cytokine mainly produced by flammatory process, playing an important role in the development monocytes, macrophages, and T-linphocytes35. After traumas, sur- and maintenance of the inflammation30, such as the allodynia in- gical procedures or during infections, the TNF-α is one of the volved in these processes through the regulation of the 1.7 voltage- earliest and potent mediators of the inflammatory response. Its dependent sodium channels that have a modulating function in this plasma half-life is only 20 minutes, enough to cause metabolic 31 type of pain . The TxA2 is an important intravascular coagulant, and hemodynamic important changes and to activate other cyto- 38 α being physiologically inhibited by PGI2(vasodilator). This constant kines . TNF- acts activating coagulation, stimulating the expres- 8 opposition maintains the intravascular normality . sion or release of adhesion molecules, PGE2, PAF, glucocorticoids, eicosanoids and influencing cell apoptosis39. This cytokine plays a Lipoxygenase products key role in the development of TMD40. Its increased expression In the leukocytes, part of the AA molecules is submitted to the promotes the beginning and progression of multiple inflamma- action of lipoxygenases (5-, 12- and 15-LOX), resulting in the tory diseases, including the ones that involve the TMJ41. This fact formation of leukotrienes (LT)7. Leukotrienes have a chemotac- is confirmed by results in which high TNF-α levels in the TMJ are tic function, aggregation, and degranulation of polymorpho- positively correlated with acute and chronic joint inflammation, nuclears, as well as the stimulation of leukocytes adherence to destruction of the connective tissue and pain in this joint42,43. the endothelial wall during the formation of the inflammatory 8 infiltrate . High concentrations of leukotrienes (LTB4) are found Interleukin-1 (IL-1) in the synovial fluid of inflamed TMJ32, having a positive cor- IL-1 is intensely produced by macrophages, monocytes, fibro- 29 relation between the degree of synovitis and the level of LTB4 . blasts and dendritic cells, but it is also expressed by B lymphocytes, NK cells, and epithelial cells, and it is one of the most Platelet activating factor important markers of induction of the inflammatory response As a response to specific stimuli (immune, tissue injuries), during associated with acute infection44. The IL-1 system includes, at the phosphorylation of phospholipids in phospholipase2, there is least, 21 different molecules represented by the IL-1 receptors, also the formation of the platelet activating factor (PAF) that is co-receptors, antagonists, and endogenous ligands. There are released by leukocytes, mast cells, and platelets8. PAF induces the three types of ligands: IL-1α and IL-1β (both have an almost in- expression of adhesion molecule that recruits the inflammatory distinguishable pro-inflammatory effect), and the IL-1 receptor cells to the endothelium, in addition to contributing to the in- antagonist (IL-1RA) that inhibits the pro-inflammatory func- flammation exudative phenomena when produced by mast cells tions acting as a competitive inhibitor of the receptor. There are and leukocytes24. High concentrations of PAF are found in in- also two different IL-1 receptors: the type 1 and type 2. The type flammatory processes involving the TMJ32. 1 IL-1 receptor is responsible for the induction of intracellular signal transductions after binding with IL-1. The type 2 IL-1 Nitric oxide receptor acts binding to IL-1 without producing any effect, thus Nitric oxide (NO) is a free radical that is formed from the con- reducing its general availability to bind and to initiate an inflam- version of L-arginine and L-citrulline by nitric oxide enzymes matory response45. The intricate balance of molecules and recep- synthetases, in endothelial cells in the CNS, the cardiac muscle, tors of the IL-1 family has a deep effect on the TMJ homeostasis. and macrophages24. NO promotes muscle relaxation of blood Many studies indicated that higher levels of IL-1α and IL-1β are vessels leading to vasodilation (a process that culminates in the present in the synovial fluid of patients with TMD46. formation of hyperemia and hyperthermia in inflammatory processes), besides reducing platelet aggregation8. 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65 Br J Pain. São Paulo, 2018 jan-mar;1(1):66-71 REVIEW ARTICLE

Osteoarthritis of the hands and muscle strengthening exercises: an integrative update and review of the literature Osteoartrite de mãos e exercícios de fortalecimento muscular: uma atualização e revisão integrativa da literatura

Isabelle Ferreira da Silva Souza1, Rosa Sá de Oliveira Neta1, Renata Trajano Jorge Caldas2, Michely Nery3, Marcelo Cardoso de Souza1

DOI 10.5935/2595-0118.20180014

ABSTRACT RESUMO

BACKGROUND AND OBJECTIVES: Osteoarthritis of the JUSTIFICATIVA E OBJETIVOS: A osteoartrite de mãos é uma hands is a highly prevalent disease that can lead to significant doença altamente prevalente que pode levar à importante defor- deformity and disability. The therapeutic approach in the ma- midade e incapacidade. A abordagem terapêutica no seu manu- nagement of osteoarthritis of the hands is based on pharmaco- seio baseia-se em condutas farmacológicas e não farmacológicas; logical and non-pharmacological approaches. However, none of no entanto, nenhum desses tratamentos demonstrou redução da these treatments demonstrated a reduction of joint damage, and lesão articular e apresenta-se de maneira puramente sintomática. it presents itself in a purely symptomatic way. Yet, expert practi- Contudo, profissionais especializados recomendam e utilizam tioners strongly recommend and use hand muscle strengthening amplamente o fortalecimento da musculatura das mãos em pain patients with hand osteoarthritis, but there is no consensus cientes com osteoartrite de mãos, mas não há um consenso para for such conduct. The objective of the study was to review the tal conduta. O objetivo do estudo foi revisar os conceitos sobre a concepts about hand osteoarthritis as well as to bring the current osteoartrite de mãos, bem como trazer as evidências atuais sobre evidence on muscle strengthening as a non-pharmacological tre- o fortalecimento muscular como forma de tratamento não medi- atment for this disease. camentoso para esta doença. CONTENTS: The study reviewed the United States National CONTEÚDO: O estudo foi realizado na base de dados “United Library of Medicine database (Pubmed). The words used were: States National Library of Medicine” (Pubmed). As palavras uti- hand osteoarthritis, exercises, physiotherapy and rehabilitation. lizadas foram: “hand osteoarthritis”, “exercises”, “physiotherapy We included 5 articles in English, published in the last 10 years, and rehabilitation”. Foram incluídos 5 artigos em inglês, publi- focused on muscle strengthening exercises for osteoarthritis pa- cados nos últimos 10 anos, cujo foco fosse exercícios de fortaleci- tients. mento muscular para pacientes com osteoartrite de mãos. CONCLUSION: There is no consensus, nor a more effective CONCLUSÃO: Não existe consenso, nem um protocolo de exercise protocol, although exercises and physiotherapy are still exercícios mais efetivos, embora os exercícios e a fisioterapia ain- recommended. We suggest conducting randomized controlled da sejam recomendados. Sugere-se a realização de estudos clíni- clinical trials to improve the evidence on this subject. cos controlados e randomizados para melhorar a evidência sobre Keywords: Hands, Muscle strengthening, Osteoarthritis. este assunto. Descritores: Fortalecimento muscular, Mãos, Osteoartrite.

INTRODUCTION

According to the American College of Rheumatology (ACR), osteoarthritis (OA) is defined as a heterogeneous set of conditions, causing signs and symptoms of joint origin associated to joint integrity defects and changes in the subchondral bone1. Among 1. Universidade Federal do Rio Grande do Norte, Faculdade de Ciências da Saúde do Trairi, the rheumatological diseases, OA is the most common and fre- Programa de Pós-Graduação em Saúde Coletiva, Santa Cruz, RN, Brasil. quently involves the hand joints2. 2. Faculdade Santa Terezinha, São Luís, MA, Brasil. 3. Universidade Federal de São Paulo, Disciplina de Reumatologia, São Paulo, SP, Brasil. Characterized by the gradual injury to the joints associated to pain, degeneration of the subchondral bone, joint cartilage, and adjacent Submitted in April 16, 2017. structures; OA of the hands involves mainly the proximal interphalan- Accepted for publication in January 29, 2018. 2,3 Conflict of interests: none – Sponsoring sources: none geal joints (PIJ) and distal (DIJ) and carpometacarpal joint (CMC) . The alterations present in the joint cartilage and the subchondral Correspondence to: Rua Vila Trairi, S/N, Centro bone result from the deficient function of chondrocytes to main- 59200-000 Santa Cruz, RN, Brasil. tain the necessary balance of the extracellular matrix. However, the E-mail: [email protected] cause of the cartilage destruction is still unknown. Chemical and © Sociedade Brasileira para o Estudo da Dor mechanical factors are associated with the onset of this condition4. 66 Osteoarthritis of the hands and muscle strengthening exercises: Br J Pain. São Paulo, 2018 jan-mar;1(1):66-71 an integrative update and review of the literature

Some risk factors are related to the development of the OA of Table 1. Recommendations for the treatment of osteoarthritis inclu- hand, as for example age, female gender, family history, trauma, ding the involvement of the hands 3,5,6 Pharmacological recommendations: mechanical work factors and obesity . Moreover, it is a highly prevalent disease, affecting between 55 and 70% of the adult po- • The use of topical capsaicin and NSAIDs, oral NSAIDs, including pulation above 55 years, varying from 70 to 80% in individuals selective COX-2 inhibitors, and tramadol; above of 75 years, and about 75% of the women between 6th • No use of intra-articular therapies, analgesics, and opioids; and 7th life decade6,7. • The use of NSAIDs in patients with and above 75 years of age. The involvement of the PIJ, DIJ, and CMC can be characterized Non-pharmacological recommendations: by some degrees of deformities, reduction of grasp and prehension muscle strength, reduction of the range of motion (ROM), • To assess the ability of the patient to perform daily life activities; the presence of pain and joint stiffness, reducing the capacity to • Teach joint protection techniques; 8,9 perform basic daily activities . • Teach the use of thermal modalities; The classification of OA of the hand is made according to the • Making prothesis for patients with OA CMC. ACR criteria, defined for symptomatic hands, based on the phy- *These recommendations have a small to moderate level of evidence; NSAIDs sical examination of the patient with pain in the hands, provi- = nonsteroidal anti-inflammatory drugs; OA = osteoarthritis, CMC = carpome- ding 92% of sensitivity and 98% of specificity. This proposed tacarpal joint. classification is based on the pain in the hands or joint stiffness in most of the days of the previous month, with 3 or 4 characteristics presented below: (paraffin, hot bandage, ultrasound therapy), use of prosthesis, to- • Joint swelling in two or more than 10 selected joints: second pical NSAIDs and capsaicin, paracetamol, oral NSAIDs effective and third PIJ and DIJ or CMC of the hands; low doses, extended-release symptomatic drugs for osteoarthri- • Joint swelling in two or more DIJ; tis, intra-articular injections with corticoids, especially for CMC • Less than three swollen metacarpophalangeal joints; joint, and surgery, for severe OA of the hands when the conser- • Deformity in two or more than 10 PIJ, DIJ and CMC joints. vative treatment is unsuccessful. It is important to highlight that The selected joints bilaterally include the PIJ, DIJ of nd2 and 3rd most of this evidence is based on the guidelines of experts in the fingers and CMC1. management of OA of the hands14. The classification of OA of hands, according to the European With regard to the measures to protect the joint, we can include League Against Rheumatism (EULAR), assesses the following the strengthening of the of the extensor muscles of the wrist and items: associated risk factors, mechanical pain and joint stiffness, the intrinsic muscles of the hand. However, the best protocol is presence of Heberden’s and Bouchard’s nodes, with or without still unknown, especially because of the different methods to as- joint swelling, reduction in hand function, association with sess its efficacy and the great amount of selected exercises4,8,9,11,12. other joints involved (knees and/or hip), evaluation of a diffe- Among the group of non-pharmacological measures, it is also rential diagnosis and x-ray of the hands10. necessary to mention the importance of a diet standard and the The therapeutical management of the OA of the hands is based nutritional state of the individual in the prevention and the tre- on pharmacological and non-pharmacological approaches. Ho- atment of OA. The advantage of the nutritional therapy can be wever, none of these treatments showed a reduction of the joint obtained with a balanced and adjusted diet, with the habitual injury and presented in purely symptomatic way8. emphasis on micronutrients, fatty acids, flavonoids and phyto- In most of the cases, the pharmacological treatment of OA of the chemicals that can be acquired eating fruits, fresh vegetables, hands is directed by the symptoms presented by the patients, in- skimmed dairy products, olive oil, and oil seeds. This can help cluding analgesic, nonsteroidal anti-inflammatory drugs (NSAI- to maintain the weight and bring antioxidant and anti-inflam- Ds), glucosamine sulfate, intra-articular injections and surgery matory benefits for the individual, allowing the reduction of the in cases of severe OA of the hands. However, there are few dise- incidence or the progression of the musculoskeletal injury15,16. ase-modifying drugs for OA of the hands, and the non-pharma- The objective of this study was to update the concepts on OA of cological measures are strategies to manage this condition8,11,12. the hands and to review the studies that have used the strengthe- In 2012, the ACR published some recommendations for the use ning of the hand muscles as a non-pharmacological treatment of pharmacological and non-pharmacological therapies for OA, for this disease. including the treatment of the hands. However, these guidelines do not present an expressive degree of support, being conditio- CONTENTS ned to the patient’s response. These recommendations13 are described in table 1. This is a literature review study conducted in the United States According to Zhang et al.14, the proper treatment for OA of the National Library of Medicine Database (PubMed). The follo- hands is based on the combination of individualized pharmaco- wing Health Sciences Descriptors (DeCS) and their combina- logical and non-pharmacological modalities, in accordance with tions were used: hands osteoarthritis, exercises, physiotherapy, the patient’s need. and rehabilitation. Among this group of measures, the presented guidelines are: The determinant inclusion criteria for the selection were full education of the patient, joint protection, local thermotherapy articles, available on the Internet and published in last the 10 67 Br J Pain. São Paulo, 2018 jan-mar;1(1):66-71 Souza IF, Oliveira Neta RS, Caldas RT, Nery M and Souza MC years. The exclusion criteria were descriptive studies that did not RESULTS offer precise information on the methodology employed and/or results obtained, as well as abstracts of congresses, incomplete or Of the 925 articles initially found in the database, 721 were ex- paid articles, and those that did not have the terms used in the cluded because they did not meet the inclusion criteria. search as the main object of the study. After that, of the 204 eligible articles, 66 were removed due to After the consultation to the database and the refinement of the duplicity, and 133 were excluded after the search refinement. searches, the studies in duplicate were identified and excluded. Thus, we had 5 articles in this review. Figure 1 summarizes the Then, all the remaining abstracts were read. In addition, in the process of articles selection. cases where the reading of the abstract was insufficient to esta- The selected articles had been published in 4 reputable journals: blish the inclusion of the article, considering the defined inclu- Journal of Rehabilitation Medicine (1) Annals of the Rheumatic sion criteria, the article was read in full to determine its eligibility Diseases (1), Osteoarthritis and Cartilage (2) and The Journal of for later inclusion in the study. The search was conducted from Rheumatology (1). December 2016 to January 2017, resulting in 925 articles, of Table 2 shows the articles, their authors, objectives, type of stu- which 5 about hand muscle strengthening exercises for patients dy and conclusions. Table 3 shows the sample size, the exercises with OA of the hands were included. performed and the results.

Studies identified by the search in the database (Pubmed) (n=925)

Reasons for the exclusion: Not published in the period selected in the review (n=314). The full article was not available for free on the Internet (n=407).

Articles excluded after the application of the inclusion criteria (n=721)

Eligible articles (n=204)

Articles removed in duplicate (n=66)

Articles excluded after the search refinement (n=133)

Studies included in the review (n=5)

Figure 1. Flowchart of articles identification and selection

Table 2. Objectives and conclusions of the clinical trials on osteoarthritis of the hands and exercises for muscle strengthening in last the 10 years Authors Objective of the studies Types of studies Conclusion Østerås To determine the clinical efficacy of an exer- Clinical trial The exercise program was well tolerated by the individuals et al.12 cises program on the function of the hand in with OA of hands, but in comparison with the usual care, patients with OA of hands. it produced only a slight improvement in short-term (after 3 months). Stukstette To examine the efficacy of a multidisciplinary Clinical trial There is not enough evidence to confirm a clinically relevant et al.17 non-pharmacological intervention in patients effect in short-term in the patients followed in the multidis- with OA of hands. ciplinary treatment program and those that have just received information in writing. Carreira, To evaluate the efficacy of a functional trape- Clinical trial The results indicate that the use of the functional splint du- Jones and ziometacarpal splint in patients with trapezio- ring daily life activities reduced pain in short- and long-term, Natour18 metacarpal OA. but did not change the function, the prehension strength, the grasping strength or the dexterity in individuals with OA. Dziedzic To report the results of a broad randomized Clinical trial The results show that occupational therapies can support et al.19 study to investigate the clinical efficacy of two the treatment of the elderly with OA. Moreover, the joint programs for adults over 50 years with OA of protection provides an effective intervention in mid-term. hands. Oppong To evaluate the cost-effectiveness of combi- Clinical trial The results offer a choice for the patient and the health pro- et al.20 ned protective exercises for OA of hands. fessional when selecting the best approach to manage OA of the hands. OA = osteoarthritis.

68 Osteoarthritis of the hands and muscle strengthening exercises: Br J Pain. São Paulo, 2018 jan-mar;1(1):66-71 an integrative update and review of the literature

Table 3. Sample size, exercises performed and results of the clinical trials on osteoarthritis of hands and muscle strengthening exercises in last the 10 years Authors Sample size Performed exercises Results Østerås et al.12 CG (n=65) Shoulder extension; biceps bending; Small significant differences found in the IG for IG (n=65) shoulder flexion; movements with the fingers pain in the hands, stiffness and daily activities; and the wrist; abduction/extension of the No significant differences observed in manual thumb and squeezing strength. dexterity or maximum prehension strength. Stukstette et CG (n=75) Exercises with the wrist and fingers. No significant differences observed between the al.17 IG (n=76) groups. Carreira, Jones CG (n=20) Use of an orthosis for daily life activities. The pain was significantly different between the and Natour18 IG (n=20) groups over time. Dziedzic et al.19 IG (n=65) Joint protection Flexion and extension of the wrist, pronation and Significant differences were found in the impro- recommendation (n=62) supination; sliding tendon, radial finger walking; vement of pain to joint protection. exercises CG (n=65) pro- doing an “O” with the thumb and the index fin- tection + exercises (n=65) ger, and extension of the thumb, abduction and opposition to the base of the 5th finger. Oppong et al.20 Recommendation (n=65) Flexion and extension of the wrist, pronation and Hand exercises were the most cost-effective joint protection (n=62) supination; sliding tendon, radial finger walking; treatment strategies over 12 months when com- exercises (n=65) protec- doing an “O” with the thumb and the index fin- pared to alternative methodological approach- tion + exercises (n=65) ger, and extension of the thumb, abduction and es. opposition to the base of the 5th finger. CG = Control Group; IG = Intervention Group.

DISCUSSION have shown the beneficial effect of physiotherapy to improve pain and functionality of OA in the lower limbs, especially for The objective of this review was to update the concepts on OA the knees. However, the recommendation of exercises for OA of the hands and analyze the studies that used the strengthe- of the hands is still based on recommendation guides on the ning of the hand muscles as a non-pharmacological treatment clinical experience in the treatment of the disease21,23. In 2009, for this disease. This compilation can help health professio- a study concluded that there is no evidence in high-quality nals in making decisions about the best approach to monitor studies that validate the use of non-pharmacological and non- OA and may be used in further studies for comparison of -surgical interventions for OA of the hands. These interven- results. Studies addressing this subject are scarce in the litera- tions, despite the small size of the effect, caused less adverse ture21, and the limited amount of studies make it difficult to implications for the patient21. discuss the subject. A current study showed that three distinct latent functional OA of the hands is a progressive and irreversible disease that domains must be evaluated in elderly with OA of the hands: increases fatigue, reduces muscle strength, the range of motion strength, coordinated function of upper extremity and sensori- and the resistance of the individual due to the pain and inflam- motor processing24. mation caused by the disease7. Kjeken et al.25 described a treatment program with hand exer- Stukstette et al.17 state that studies on OA of the hands fre- cises for patients with OA. The program had three exercises to quently relate the reduction of the range of motion and pal- increase strength and stability of the shoulder, arm and wrist mar prehension strength with the difficulties presented by the muscles, and four exercises to keep or to increase the range of studied patients. Furthermore, they commonly analyzed the motion, prehension and joint stability of the finger joints. The disease self-management, exercises for the range of motion, program started with a warm-up and stretching period, and the increment of muscle strength, education and ergonomic finished with a finger exercise, following the recommendations principles. of the American College Sports Medicine, on the intensity of One study included 150 patients with OA of the hands where the exercise, the frequency of the session and the duration of the effect of the exercise associated with multiple interventions the exercise period. compared to joint protection recommendation. The patients According to Carreira, Jones and Natour18, the effect of the of the control group had only one session on OA recommen- muscle strengthening exercises for OA of the hands, combined dations, and the intervention group had recommendation with other non-pharmacological alternatives, as for example, sessions on self-management, ergonomics, home exercises to the use of orthosis and joint protection techniques have its evi- improve strength and the range of motion, and the use of the dence based on the literature which results are still doubtful. orthosis. After a three-month follow-up, the results were insu- A systematic review analyzed the effect of non-surgical therapies fficient to confirm the importance or the clinical relevance of for OA of the hands. of the 44 studies assessed, only four were the short-term treatment in a multidisciplinary program17. selected due to poor methodological quality and plurality in the Other authors reported the increase of palmar prehension af- interventions (exercises for OA of the hands, including Yoga, re- ter an intervention with education, a set of exercises associated sistance exercises, and occupational therapy). The result of the with joint protection8,22. Systematic reviews and meta-analyses analysis of these studies showed “some” evidence for muscle 69 Br J Pain. São Paulo, 2018 jan-mar;1(1):66-71 Souza IF, Oliveira Neta RS, Caldas RT, Nery M and Souza MC strengthening exercises because the methods used for randomi- to Kjeken et al.11, the conclusion of the evidence on the use zation, blindness and allocation hiding were rarely described and of exercises in the treatment of OA of the hands still presents a meta-analysis could not be performed since most of the studied studies with a high bias risk that do not allow the conduction treatments were not similar to allow data grouping26. of meta-analyses to confirm the effect of exercises in the reduc- In the systematic review by Valdes and Marik27, of the 204 tion of pain, improvement of strength and range of motion articles recovered dated between 1986 and 2009, 21 studies since the studies have demonstrated a lack of consensus in the were included for full analysis and it was observed the effect outline of exercise programs for OA of the hands. Therefore, of exercises for OA of the hands, with a moderate level of evi- considering the insufficient amount of studies addressing OA dence for the increase in palmar prehension, function, range of of the hands21 and in view of the prevalence and impact of the motion and reduction of the pain picture. However, the evalua- disease, there is a need for more studies on this subject23. ted studies used multiple treatment interventions, for example, strengthening and range of motion exercises associated with CONCLUSION recommendations to protect the joint and application of heat (thermotherapy). Even though muscle strengthening exercises are recommen- In 2011, a systematic review evaluated pain and function im- ded for the functional improvement of patients with OA of provement in individuals with OA of the hands. In this review, the hands, very few studies support this affirmation. We found 10 studies with an evidence level of 2b or higher, that compa- studies with low methodological quality, amount of distinct red a rehab intervention with a control group and evaluated at exercise protocols and lack of systematic reviews with assertive least one of the following result measures: pain, hand function conclusions for the use of muscle strengthening exercises in the or other measures of hand impairment. In addition, the eli- treatment of OA of hands. gibility and the methodological quality of the trials were systematically evaluated by two independent reviewers using the REFERENCES Physiotherapy Evidence Database (PEDro). After the analysis, the authors concluded that in relation to the studies that used 1. Altman R, Alarcón G, Appelrouth D, Bloch D, Borenstein D, Brandt K, et al. The American College of Rheumatology criteria for the classification and reporting of os- the exercise as a treatment technique, no significant effect was teoarthritis of the hand. 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71 Br J Pain. São Paulo, 2018 jan-mar;1(1):72-6 REVIEW ARTICLE

Tapentadol: what every doctor needs to know about this new drug Tapentadol: o que todo médico precisa saber sobre esse novo fármaco

Bernardo De Marchi Mosele1, Daniel Benzecry de Almeida2, Válery Baggio Hess3

DOI 10.5935/2595-0118.20180015

ABSTRACT CONTEÚDO: Foi realizada uma pesquisa na base de dados Pubmed utilizando os descritores “tapentadol” e “opioides” para BACKGROUND AND OBJECTIVES: Acute and chronic revisão da literatura mundial sobre esse novo fármaco, avaliando pain is a major problem with repercussion in our society, causing as características farmacológicas e aspectos clínicos do seu uso na impairment in the quality of life of patients as well as socioeco- realidade atual, em comparação com os fármacos já existentes nomic losses, due to work absenteeism. This review aims to ana- no mercado, assim como suas indicações e contraindicações no lyze the use of tapentadol, an analgesic not yet available in Brazil, manuseio do paciente com dor. with a dual mechanism of action, in the treatment of acute and CONCLUSÃO: O tapentadol se mostrou eficaz no tratamento chronic pain syndromes. de dores agudas e crônicas, com potência equiparável aos opioi- CONTENTS: A review about this new drug was made on the des já comercializados. Além disso, desenvolveu menos tolerân- Pubmed database using the keywords “tapentadol” and “opi- cia, menos efeitos adversos e melhor resposta terapêutica na dor oids,” evaluating its pharmacological and clinical aspects com- crônica neuropática quando comparado com agonistas recep- paring with other current drugs in pain treatment, as well as its tores opioides tipo μ puros. indications and contraindications in the management of patients Descritores: Duplo mecanismo de ação, Opioides, Tapentadol. with pain disorders. CONCLUSION: Tapentadol has been shown to be effective in INTRODUCTION the treatment of acute and chronic pain, with potency equivalent to the opioids currently used. In addition, it developed less Pain is a problem of great proportion, involving 20 to 25% of tolerance, less adverse effects and better therapeutic response in the population with an increasing incidence. Despite the ex- chronic neuropathic pain when compared to pure μ-opioid re- traordinary advances in anatomy, physiology, diagnosis and pain ceptors agonists. management, more than 50% of patients report improper re- Keywords: Dual mechanism of action, Opioids, Tapentadol. lief. This can be related to the neuroplasticity process of the pain pathways1, creating a persistent “memory” of the aggressive event RESUMO and neuronal hiperexcitability2,3. Understanding chronic pain neurobiology is fundamental to target the treatment. Thus, the JUSTIFICATIVA E OBJETIVOS: A dor aguda e crônica con- use of drugs that act on more than one pathophysiologic mecha- siste em um problema de grande repercussão em qualquer so- nism, as tapentadol, can be a new weapon in the therapeutic ciedade atual, causando degradação na qualidade de vida dos armamentarium against acute pain and especially chronic ones. próprios pacientes e comprometimento socioeconômico pelo absenteísmo laboral. O objetivo deste estudo foi analisar o uso The objective of this study was to analyze the use of tapentadol, do tapentadol, um analgésico ainda não disponível no Brasil e an analgesic not yet available in Brazil, with a dual mechanism com duplo mecanismo de ação, no tratamento das síndromes of action, in the treatment of acute and chronic pain syndromes. dolorosas agudas e crônicas. CONTENTS

Tapentadol is a single non-racemic molecule (Figure 1) with a dual central mode of action, available in the United States of Ameri- 1. Santa Casa de Santos, Centro de Ensino e Treinamento em Anestesiologia, Santos, SP, Brasil. ca (USA) and in Europe for the treatment of acute and chronic 2. Instituto de Neurologia de Curitiba, Grupo de Tratamento de Dor, Curitiba, PR, Brasil. 1.4 3. Hospital Estadual Guilherme Álvaro, Departamento de Residência Médica em Aneste- pain . It is in available in the U.S. since 2008 for the treatment of siologia, Santos, SP, Brasil. moderate acute to severe pain, in its immediate release (IR) formu- Submitted in August 15, 2017. lation, and since 2011 for the treatment of moderate chronic to Accepted for publication in January 05, 2018. severe pain in its extended release (ER) formulation, after approval Conflict of interests: none – Sponsoring sources: none by the Food and Drug Administration (FDA)5,6. In the European Correspondence to: market, the IR and ER formulations of the drug were approved by Instituto de Neurologia de Curitiba, Grupo de Tratamento de Dor 7,8 Rua Jeremias Maciel Perretto, 300 - Campo Comprido – Ecoville the European Medicines Agency (EMA) in 2010 . 81210-310 Curitiba, PR, Brasil. Its central analgesic action occurs by means of two mechanisms: E-mail: [email protected] 1) as an agonist of the μ-opioid receptors (MOR), with the same © Sociedade Brasileira para o Estudo da Dor affinity or 10 times higher on KOR receptors (k-opioid receptor) 72 Tapentadol: what every doctor needs to know about this new drug Br J Pain. São Paulo, 2018 jan-mar;1(1):72-6

travenous administration, it is widely distributed, and only 20% bind to plasma proteins4. The main metabolic pathway occurs through glucuronic acid binding, 97% due to phase 2 reactions. The main metabolite is tapentadol-O-glucuronide4,8, which does not exercise any activity on opioid receptors or reuptake systems of synapses or other junction9. Ninety seven percent of the drug delivered is trans- formed into inactive metabolites4. No significant induction or inhibition of the P450 cytochrome (CYP) was reported11. There was no relevant clinical change in the pharmacokinetic properties when delivered concomitantly with non-opioids, as well as with omeprazole and metoclopramide10,11. The elimination half- life is of approximately 4 hours9, and the metabolites are excreted in 24 hours and completely eliminated in 5 days, almost apart through the kidneys. The fecal excretion is negligible, approximately 1%4,12,14,15. Figure 1. Molecular formula C H NO.HCl4 14 23 Tapentadol IR is available in 50, 75 and 100mg tablets. The recommended dose is at every 4-6h, depending on criteria such and DOR (delta opioid receptor)4; 2) as a norepinephrine reup- as the intensity of pain, tolerability, and response to treatment. take inhibitor (NRI). The MOR affinity is considered modest Total doses higher than 700mg in the first day or 600mg in the when compared to pure agonists, such as morphine9,10, whose subsequent days were not studied6. affinity is 44 to 50 times higher2,4. Tapentadol ER is available in 50, 100, 150, 200 and 250mg tab- Its NRI action increases the norepinephrine release by the pain lets. In Spain, there is the 25mg presentation for more precise descending inhibitory pathways in the dorsal horn of the spi- dose adjustments in senior and liver disease patients. The ER nal cord, allowing the substance to accumulate in the synapses. formulation is indicated for the treatment of moderate to severe

Norepinephrine binds to the alpha2-adrenergic inhibitors of the chronic pain and cannot be used without a ceiling dose as the pre- and post-synaptic neurons, inhibiting the action potential other opioids. It is recommended 100 to 250mg BD (at every by MOR identical mechanisms (Figure 2), blocking the pre- 12 hours)16. In patients who had never used opioids, the initial synaptic calcium channels and activating the post-synaptic po- dose is 50mg. For patients taking another opioid, the initial dose tassium channels, hyperpolarizing the membrane1. In models will depend on the type and daily dose of the drug in use. In of visceral, neuropathic and inflammatory pain, all of acute and these cases, titration to increase the 50mg BD should occur every chronic nature, the NRI dose-dependent action was reported11. 3 days, until the adequate pain control. Due to the tolerability It was observed, in vitro, a weak action on the serotonin reuptake profile, especially the gastrointestinal, tapentadol ER allows for with no apparent analgesic effect4,9. relatively fast titration with effective pain control. Daily doses It has fast oral absorption, reaching its maximum serum con- higher than 500mg are not recommended. Like other formula- centration in less than 2 hours, and can be taken disregarding tions of extended release opioids, tablets shall not be broken or meals12,13. The bioavailability is of 32% due to first pass effect. crushed6,10. Plasma concentration in stationary state occurs in approximately Tapentadol IR presented great efficacy in acute pain after a 4,11,14 25-30h with the administration at every 6 hours . After in- bunionectomy and dental surgery, in back pain, and knee and hip joint pain. Tapentadol ER was also effective in chronic back pain, fibromyalgia, neuropathic and osteoarthritis-related pain12,17,18. Also, it had benefits in injury and nerve inflammation models, with predictability in the management of bone cancer pain, a state of mixed, nociceptive and neuropathic pain19. Its broad therapeutic spectrum makes it effective in nociceptive 9 Tapentadol and neuropathic acute and chronic pain . Moreover, the synergic dual mechanism reduces the drug-drug interaction risk associ- Receptor m ated with the polypharmacy approach6. Tapentadol was also effective in patients with hyperalgesia due to central sensitization who have already tried multiple subtypes of opioids5. It is suggested that the combination of tapentadol ER Potential for action with pregabalin is well tolerated and effective, being this association more favorable than the pure agonist opioids10. The relevance of the dual mechanism of action was investigated

Figure 2. Agonist mechanism of action on μ-opioid receptors and by combining tapentadol with naloxone or alpha2 yohimbine in inhibitory action on norepinephrine reuptake (MOR-NRI) models of acute and chronic pain. It was noted that the opi- 73 Br J Pain. São Paulo, 2018 jan-mar;1(1):72-6 Mosele BM, Almeida DB and Hess VB oid agonist contributes to analgesia in acute pain, whereas the As for the development of withdrawal symptoms, one must fol- NRI action played a fundamental role in chronic pain2. Another low the same protocol as any other opioid, with gradual and important factor related to the NRI action is its usefulness in regressive discontinuation. The symptoms after abrupt discon- chronic neuropathic pain20. Additional evidence of the efficacy tinuation of the drug are minimal10,11. in states of neuropathic pain comes from a study in diabetic neu- Tapentadol ER is well tolerated and effective up to 2 years of ropathy models, in which tapentadol inhibited thermal hyperal- treatment in patients with chronic pain, with no development of gesia and morphine did not. Pure opioids lose power and efficacy acquired tolerance to the analgesic effects in this period10. in neuropathic pain due to an unsatisfactory therapeutic win- Concerning drug abuse rate, evidence from monitoring systems dow, while the noradrenergic drugs become more efficient. Even suggests low rate in the clinical practice10. During the first 24 being 2 to 3 times less potent than morphine in a series of acute months after the initial release and commercialization of tapent- models, tapentadol became at least equipotent in neuropathic adol IR in the U.S., the abuse rates found were much lower than models, ratifying the reason for opioids not be considered the those for oxycodone or hydrocodone, through a system called first line of treatment for this type of pain and its use be preferred RADARS12. A cohort study showed that the risk of abuse with for refractory neuropathic pain2,20,21. The FDA approved the use tapentadol was lower when compared to oxycodone8. of tapentadol for the treatment of diabetic neuropathic pain A study with rats and mice studied the acute toxicity by oral and in 2012 due to its proved efficacy when compared to placebo. venous administration. The average values of lethality were above However, we still lack evidence of clinical relevance comparing 300mg/kg for oral administration and 40mg/kg for venous ad- tapentadol with first-line drugs, such as pregabalin, duloxetine, ministration. The most common effects after the administration and tricyclic antidepressants22,23. of high doses were central, such as sedation, excited behavior, and Another use of tapentadol would be in acute pain after an outpa- respiratory depression12. On the abuse by humans, a retrospective tient surgical procedure. Despite the improvements in protocols study compared the tapentadol toxicity with tramadol using the structure, pain - in the outpatient surgery context - remains a information of the U.S. National Poison Data System. The reasons challenge due to the limitation of the analgesic techniques when for exposure include the non-intentional (iatrogenic and improper compared with hospitalized patients. Pain killers with multi- use) and intentional ones (suspicion of suicide and abuse). The modal actions can improve the postoperative analgesia and the exposure to tapentadol was associated with the significantly high- functionality of outpatient surgeries24. er risk of a serious clinical outcome, like respiratory depression, The most frequent adverse effects reported associated with the coma, lethargy, slurred speech, hallucination, and confusion. Tra- continuous opioid therapy are a problem for patients with madol was associated with higher convulsion and vomiting rates. chronic pain, such as nausea in 6 to 42%, vomit in 8 to 33% and Although these drugs have similar mechanisms of action, tapent- constipation in 3,1 to 95% of patients18. The main adverse effects adol was associated with clinical effects significantly more toxic27. of tapentadol are gastrointestinal and central, the most common A case report was published about the death of a 34-year male after being nausea (30%), followed by vomiting (18%), drowsiness the use of endovenous tapentadol. The patient was found with (15%) and dizziness (24%). Of these, the ones that have really gasping-like respiratory pattern28. In a cohort study carried out led to treatment discontinuation were dizziness (2.6%), nau- with children with an average age of 4.17 years, drowsiness and sea (2.3%), vomiting (1.4%), drowsiness (1.3%) and headache lethargy were the most observed adverse effects (28.8%). More (0.9%)14,17. Tapentadol was associated with the reduction of important adverse effects such as respiratory depression, coma and 50% in treatment discontinuation when compared with similar dyspnea only happened in 7.7% of the sample29. drugs7. On the other hand, there were more treatment discon- To compare drugs with a dual mechanism of action, as tapentadol, tinuations due to lack of effect than morphine, oxycodone, and it is essential to consider the analgesic equivalence and not the opi- fentanyl patch, but also fewer discontinuations due to the same oid equivalence19. Considered tapentadol closest competitor, since reasons for placebo25. Another recognized adverse effect due to they share certain chemical superficial structural similarities30, tra- the continuous use of MOR agonists in men is the opioid-in- madol also has more than one mechanism of action, with agonist duced androgen deficiency, leading to erectile dysfunction, reaction on opioid receptors, minimum NRI effect and significant duction in sperm counts, testicular atrophy, and hair rarefaction. effect in inhibiting serotonin reuptake (SSRI)6, binding to MOR, Studies have shown that tapentadol presented a relatively lesser KOR and DOR with low affinity, being, therefore, less effective magnitude of these effects. Reports of reduction of some typi- than other opioids to treat intense pain6,9. However, tapentadol is cal opioid-induced secondary adverse effects in comparison with pharmacologically very different from tramadol. Many pharmaco- doses of the same analgesic potency of classic opioids corroborate logical interactions can be triggered by tramadol since some antiar- the hypothesis that this higher analgesic efficacy of tapentadol is rhythmic, antidepressants, antipsychotics, antiparasitic drugs and only partially mediated by opioid agonist mechanisms, which are tamoxifen are a substrate for CYP9,24. In animal models, tapent- spared by the drug NRI action19. adol showed to be 2 to 5 times more potent than tramadol. Even Studies that evaluated the long-term tolerability, corroborated by assuming a conservative conversion rate of 1:2 between tapentadol meta-analysis results, indicated that tapentadol is not associated and tramadol based on the maximum daily recommended dose with laboratory alterations for liver or kidney function, and did of 400mg for tramadol, this dose would reach only 40% of the not affect the ECG, blood pressure or heart rate parameters since analgesic effect of the maximum daily dose of tapentadol. Conse- the NRI action increases the chances of cardiovascular effects14,17,26. quently, an intermediate daily dose of 250mg of tapentadol would 74 Tapentadol: what every doctor needs to know about this new drug Br J Pain. São Paulo, 2018 jan-mar;1(1):72-6 extend over the effect of the maximum dose of tramadol. A factor a neuronal injury. Neuropathy powers its actions in low doses, that could explain the lower potency and clinical efficacy of tra- although its affinity with MOR is smaller9. madol, in spite of its affinity with MOR be more intense, would Tapentadol is prohibited in patients with paralytic ileum, im- be the fact that tramadol does not cross the blood-brain barrier in paired pulmonary function or in places with no monitoring or the same ratio that its dose is increased, while tapentadol crosses resuscitation equipment6. In obese patients with obstructive sleep it, following its concentration gradient2,30. Tapentadol showed a apnea syndrome, caution should be even higher. The concomitant greater benefit in several pain scenarios, mainly due to the reduc- use of central nervous system depressants can foster the effects of tion of the pro-nociceptive effect of the neuropathies, the increase sedation, respiratory depression and decreased vigilance10. Due to of norepinephrine in the dorsal horn of the spinal cord, and the the NRI action, with the NRI coadministration, norepinephrine reduction of the inconvenient adverse effects in similar analgesic reuptake inhibitors, tricyclic antidepressants and primarily with doses, like nausea and vomiting, caused by the 5-HT serotonin monoamine oxidase inhibitors (MAOI) may trigger cardiovascu- receptor antagonist9. lar effects such as hypertensive crises and even serotonin syndrome, Thus, we can conclude that the comparison between these drugs being contraindicated the use of MAOI in the last 14 days6,11. is inappropriate since their potency and analgesic efficacy are dis- The incidence of chronic pain proportionally increases with the proportional. This higher tapentadol efficacy led the majority of age23. Dose adjustment is not required with tapentadol ER10. the studies to consider oxycodone as the benchmark30. Studies However, it is advisable to start with low doses in patients older have shown that in the acute postoperative pain, the analgesic ef- than 65 years4. ficacy of the 50-75mg tapentadol IR is not inferior to oxycodone It is not recommended in patients with less than 18 years of IR 10mg and that 100mg of tapentadol IR is equivalent to 15mg age10,11, pregnant and breastfeeding women (category C)11, with of oxycodone IR19,31. Another comparative study of 10 days on severe liver or kidney failure6. Dose adjustment in liver and kid- the management of acute back pain showed that tapentadol IR ney failure is not required4,6,10,17. has analgesic efficacy and global security comparable to oxycodone Tapentadol has unique pharmacological characteristics. Some IR for the relief of moderate to severe acute back pain, as well as authors suggest that it should be considered the first of a new more flexibility in the dose regimen to improve gastrointestinal pharmacologic class, the MOR-NRI20,30. It was the first analge- tolerability, especially related to vomiting and constipation11,31. A sic with MOR and NRI agonist action released in the global systematic review used 7 clinical assays with a direct comparison market. It showed to be effective in the treatment of innumer- between tapentadol ER 100-250mg BD and oxycodone ER 10- able situations of acute and chronic pain, with good tolerability 20mg BD, as well as the immediate release formulations, tapent- and low potential of pharmacological interactions, becoming the adol IR, and oxycodone IR in the doses of 50-100mg versus 10- preferred choice in the pain control in the outpatient setting11. 15mg every 4-6 hours, respectively, to manage severe chronic pain. It is worth mentioning the major limitations as to the quantity At the end of the treatment, significant differences were found in and quality of clinical trials. In addition, the manufacturer has pain relief, between 30 and 50% favoring tapentadol, as well as been responsible for, or the sponsor of many of studies and re- a significant advantage of tapentadol over oxycodone in terms view articles published23. of patient’s general impression and improvement of the quality The main advantages are the analgesic potency comparable to of life. The grouped analysis on the number of serious adverse pure agonist opioids in the treatment of nociceptive, neuropath- events showed boundary significance for tapentadol over oxyco- ic and mixed types of chronic pain, as well as the tolerability done. With regard to specific adverse events, there were significant profile due to the low incidence of gastrointestinal and central differences favoring tapentadol with respect to the incidence of adverse effects and the prolonged relief of the symptoms with a constipation, nausea, and vomiting. Oxycodone groups showed low addiction rate10,16. a lower incidence of discontinuation to due lack of efficacy, while treatment discontinuation for any reason and adverse events were CONCLUSION significantly more frequent25. The superiority of tapentadol over oxycodone can, in part, to be related to the higher tolerability, Since tapentadol maximizes the advantages of the multimodal reducing the number of patients who discontinue the treatment, therapy, mitigates the adverse effects and drug interactions, its mainly during dose titration. It is possible to establish a total thera- entry in the Brazilian market should be evaluated by the compe- peutic effect more frequently with tapentadol. tent agencies. Tapentadol ER showed higher tolerability compared to morphine, specifically in the reduction of the incidence of nausea, ACKNOWLEDGMENTS vomiting, dizziness, and constipation10. Its analgesic potency in nociceptive pain models would be around 2,5 times lower than To Mrs. Marli Uchida for the revision and Dr. Erasmo Barros da morphine2. In animal models with equianalgesic doses of tapen- Silva Júnior for providing figure 2. tadol and morphine, the complete tolerance was significantly decreased in the tapentadol group (23 days) in comparison to REFERENCES the morphine group (10 days), what seems to be due to its dual 1. Fornasari D. Pain pharmacology: focus on opioids. Clin Cases Miner Bone Metab. mode of action. The first group also showed a lower physical de- 2014;11(3):165-8. pendence2,15. Unlike morphine, tapentadol keeps its efficacy after 2. Pergolizzi J, Alegre C, Blake D, Alén JC, Caporali R, Casser HR, et al. Current con- 75 Br J Pain. São Paulo, 2018 jan-mar;1(1):72-6 Mosele BM, Almeida DB and Hess VB

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76 Br J Pain. São Paulo, 2018 jan-mar;1(1):77-9 CASE REPORT

Personality, coping and atypical facial pain. Case reports Personalidade, enfrentamento e dor facial atípica. Relato de casos

Ludmila Maria Christofolleti1, Maria de Fátima Vidotto Oliveira2, Silvia Regina Dowgan Tesseroli de Siqueira1,2

DOI 10.5935/2595-0118.20180016

ABSTRACT RESUMO

BACKGROUND AND OBJECTIVES: Idiopathic facial pain JUSTIFICATIVA E OBJETIVOS: Dor facial idiopática per- is a chronic condition with unknown etiology and pathophy- sistente é uma condição crônica cujas etiologia e fisiopatologia siology. Its diagnostic criteria depend on the exclusion of any permanecem obscuras. Os critérios diagnósticos dependem da somatic cause of orofacial pain. Several studies have investigated exclusão de todas as possíveis causas somáticas de dor orofacial. anxiety and depression, but there is a lack of publications about Vários estudos investigaram frequentes comorbidades psiquiátri- personality. The objective of this study was to describe three ca- cas como ansiedade e depressão, mas há carência de estudos que ses of patients with idiopathic facial pain that had their tempe- tenham observado aspectos de personalidade nesses doentes. O rament and character evaluated in order to verify the relation objetivo deste estudo foi descrever três casos de pacientes com between the findings with pain behavior and pain characteristics. dor facial idiopática persistente que foram avaliados quanto a tra- The instruments used were a free interview and the Tempera- ços de personalidade e de caráter, bem como a associação desses ment and Character Inventory. traços com as características da dor e o comportamento doloroso. CASE REPORTS: Case 1 was proactive and had high scores of Os instrumentos utilizados foram a entrevista livre e o Inventário cooperativity and self-transcendence correspondent to the well- de Caráter e Temperamento de Cloninger. -coping behavior. On the other side, cases 2 and 3 showed simi- RELATO DOS CASOS: O caso 1 apresentava traços de proa- larities about their harm avoidance, novelty seeking and poor tividade e altos índices de cooperatividade e autotranscendên- coping, correspondent to a self-protective insecure personality. cia, correspondentes com seu perfil de bom enfrentamento. Por CONCLUSION: These cases show the importance of personali- outro lado, os casos 2 e 3 apresentaram similaridades quanto à ty assessment in order to determine coping strategies in complex evitação de dor, busca por novidades e enfrentamento pobre, o chronic facial pain such as idiopathic facial pain. que correspondeu a uma personalidade insegura e autoprotetora. Keywords: Atypical facial pain, Persistent pain, Personality. CONCLUSÃO: Esses casos mostram a importância de abordar a personalidade do paciente para que estratégias de enfrentamento adequadas sejam estabelecidas para a dor facial crônica complexa. Descritores: Dor facial atípica, Dor persistente, Personalidade.

INTRODUCTION

Pain is a sensory and emotional experience (International Asso- ciation for the Study of Pain, 1996)1 that after 6 months becomes chronic, losing its biological function and causing permanent or transitory incapacities2. Subjective psychic factors play a major role in pain chronification and pain crises, especially when pain is located at the head and / or face, because of the psychic and social importance of this body area. Among orofacial pain diagnosis, atypical facial pain or persistent idiopathic facial pain (PIFP) remains as one of the most complex to evaluate and treat, 1. Universidade de São Paulo, Escola de Artes, Ciências e Humanidades, São Paulo, SP, Brasil. with the compulsory need of psychological assessment3. 2. Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia e Hos- PIFP is characterized as diffuse deep and constant chronic pain pital das Clínicas, Centro Interdisciplinar de Dor, São Paulo, SP, Brasil. (International Headache Association, 2013)4 that has no etiolo- Submitted in August 08, 2017. gy behind it and the exclusion of other pathologies is necessary Accepted for publication in January 22, 2018. Conflict of interests: none – Sponsoring sources: none before final diagnosis. It is usually unilateral, located in the ma- xillary region, described as dull, aching, throbbing or burning5. Correspondence to: Avenida Dr. Enéas de Carvalho Aguiar 255 – 5º andar – Cerqueira César In 50% of the cases, there are initial physical or emotional trau- 05403-000 São Paulo, SP, Brasil. mas and the pathophysiology is associated, at least in part, with E-mail: [email protected] deafferentation3. Anxiety, depression and pain behaviors are very © Sociedade Brasileira para o Estudo da Dor common in these patients and can be part of the multifactorial 77 Br J Pain. São Paulo, 2018 jan-mar;1(1):77-9 Christofolleti LM, Oliveira MF e Siqueira SR aspects involved in pain onset or can be a consequence of chronic Case 1. Male patient, 58 years old started the treatment at the pain as a secondary comorbidity5. Anxiety can be due to the fear Orofacial Pain Clinic because of a persistent pain in his face and or lack of knowledge of the diagnosis. Despite the wide range of neck, which was causing difficulties to work. He was a house- studies investigating emotional issues of chronic pain, there is a -builder, and at that moment he was working as a painter. The lack of studies that evaluated the personality of these patients. pain was so intense that he could not paint the ceiling of the The behavior pattern and its motor, psychological, affective and houses. Although suffering, he loved his job and did not want to relational reactions are based on the personality that can alter stop. He wanted a painkiller to come back to normal activity. He according to the exposure of cultural, social and environmental was married and lived with his wife. His pain was bilateral and aspects6. Personality is a complex adaptive system directed by had started 10 years ago. When asked, he described it as throb- internal and external factors that produce the behavior6. Thus, bing and jumping, with an intensity of 8 on a scale from zero to even patients with anxiety or depression traits deserve special at- 10 (visual analog scale). He had been diagnosed with PIFP and tention about their personality and character that can influence was treated with antidepressants, neuroleptics, and anticonvul- their coping reaction to chronic conditions such as pain. Perso- sant drugs, with partial improvement. nality disorders are associated with low cooperation with treat- His medical history included poliomyelitis when a child which ment7. Besides, reward dependence, novelty seeking, and harm resulted in a sequela at his left arm. He was a former drug addic- avoidance have been associated with the anxiety trait of patients ted and reported the cure by faith when he started to go to the with chronic pain. Moreover, cooperativity and self-transcen- church. He said he is happy to work as a painter, having many dence are directly or indirectly associated with coping7-12. clients and felt bad because he could not keep on working becau- The Temperament and Character Inventory (TCI) is an interna- se of the pain. He also had dizziness and was diagnosed with la- tional instrument to evaluate personality, validated to the Por- byrinthitis. Because of it, he was afraid of falling while working. tuguese Language13. It is considered one of the most complete He was very collaborative, communicative and proactive, telling and trustable tools to evaluate temperament and character in several details. He told that he loved to help other people. In detail, and with an interactive and nonlinear way, with a dimen- the analysis of the instrument, his profile was according to the sional assessment14. It has also been used in patients with chronic findings of a moderate reward dependence and persistence and a pain8,10,11 and thus, it was chosen for this study)13. high level of cooperativeness and self-transcendence. Identifying and assessing the temperament and character is determinant in the follow-up of patients with chronic pain, and Case 2. Female patient, 51 years old with pain on the right side there is a lack of studies in orofacial conditions. Thus, the objec- of the face that started 10 years ago. She was a housekeeper and tive of this case series was to describe the narrative of personality reported intensity of 7 by the visual analogue scale. The pain was traits of three individuals with PIFP. very intense, and she said that the sensations were burning and pressing. She told that she lives with the husband and the son CASE REPORTS and that her work is affected by the pain symptom. However, she needed to keep on working and was avoiding stopping because Three patients with PIFP were included. They were under tre- of the pain. She was discrete, little talking and asked for help to atment at the Orofacial Pain Clinic of a General Hospital in complete the inventory. She also informed that she was frequen- a multidisciplinary team, and they were diagnosed with PIFP tly insecure and shy, especially when in front of other people, according to the IHS criteria (International Headache Society, and that she was not used to telling other people (even the close 2013)4. The local ethics committee approved this project (CA- ones) about her feelings or personal problems. Her fear was that PPesq - HCFMUSP). The patients were informed about the pur- they would think her problems are insignificant. After the analy- poses of the research, and all agreed to participate. All signed the sis of the TCI result, she had a high level of harm avoidance and informed consent. There was no other pain complaint in these novelty seeking, highlighting a compulsive behavior while shop- patients, except the face. ping. She had very low cooperativeness and self-transcendence. A trained researcher that followed the international TCI application guidelines evaluated the patients. It was performed in a si- Case 3. Female patient, 37-year-old was under treatment at the lent room, and only the subject and the researcher were present, orofacial pain clinic. She was single and lived alone. Her pain was after the regular appointment of the patient for follow-up and on the right side of the face, and it started 5 years ago. The des- treatment of pain. The patients underwent an interview in order criptor was jumping pain, and the intensity was 7 by the visual to access psychological characteristics such as anxiety, depression, analogue scale. She reported that the pain was impairing her daily pain behavior, coping and personality. After, they were also eva- activities, especially work. She was a children’s teacher and did not luated by Cloninger’s TCI14, adapted and validated for the Portu- want to talk about her personal life. She was quiet and bored, not guese language13. This inventory consists of 240 self-completed interested at all in the evaluation, and she was ashamed to ask ‘true’ or ‘false’ questions subdivided into seven personality traits, about her doubts while completing the inventory. She was com- four temperaments (novelty seeking, harm avoidance, reward pletely uncomfortable with the interview. Her results in the TCI dependence, persistence) and three characters (self-directedness, were compatible with this description and showed low socializa- cooperativeness, self-transcendence). tion, discretion, insecurity. She had high harm avoidance and no- The results were presented by the method of narrative description. velty seeking and very low cooperativeness and self-transcendence. 78 Personality, coping and atypical facial pain. Case reports Br J Pain. São Paulo, 2018 jan-mar;1(1):77-9

DISCUSSION pain management. Besides, in chronic pain, individuals need a deep comprehension of their unique condition. Psychiatric morbidities are frequent in patients with chronic pain, and the evaluation of anxiety and depression has been ex- ACKNOWLEDGMENTS tensively discussed in the literature. However, there is a lack of studies that analyzed the role of personality. Fibromyalgia syn- All authors participated in the design, discussion, writing and drome is associated with high scores of harm avoidance with a final revision of the manuscript. Dr. Christofoletti evaluated the tendency to pessimism, insecurity, uncontrollable fear, shame patients, Dr. Oliveira with Dr. Siqueira analyzed the results. and timidity in the majority of social circumstances besides a chronic sensation of tiredness and fatigue14. The cases 2 and 3 REFERENCES are in accordance with the findings of fibromyalgia and other chronic pains7-11. They showed shame, timidity, harm avoidance 1. Classification of chronic pain. Descriptions of chronic pain syndromes and definitions of pain terms. Prepared by the International Association for the Study of Pain, Sub- and novelty seeking, aspects that are associated with the anxie- committee on Taxonomy. Pain Suppl. 1996;3:S1-226. ty traits in chronic conditions. However, case 1 is the opposite, 2. Watson JC, Sandroni P. Central neuropathic pain syndromes. Mayo Clin Proc. 2016;91(3):372-85. with a proactive and extroverted personality, having high levels 3. Siqueira SR, Siviero M, Alvarez FK, Teixeira MJ, Siqueira JT. Quantitative sensory of cooperation and self-transcendence. Part of these aspects may testing in trigeminal traumatic neuropathic pain and persistent idiopathic facial pain, Arq Neuropsiquiatr. 2013;71(3):174-9. be related to the religious behavior of the patient. In any case, it 4. The nternationalI Classification of Headache Disorders. International Headache So- calls for attention to this type of patient that is also representa- ciety 3rd ed. (beta version). Cephalalgia. 2013;33(9):629-808. tive and relevant, deserving individual assessment and different 5. Zakrzewska JM. Multi-dimensionality of chronic pain of the oral cavity and face. J Headache Pain. 2013;14:37. coping strategies. Moreover, the self-transcendence can become 6. Cloninger CR. A unified biosocial theory of personality and its role in the develop- a coping tool for the other patients represented by cases 2 and 3. ment of anxiety states: a reply to commentaries. Psychiatr Devel. 1988;6(2):83-120. 7. Conrad R, Schilling G, Bausch C, Nadstawek J, Wartenberg HC, Wegener I, et al. They have an excessive self-centrism, which amplifies the atten- Temperament and character personality profiles and personality disorders in chronic tion to pain, an old-known aspect that triggers pain crises and pain patients. Pain. 2007;133(1-3):197-209. 8. Boz C, Velioglu S, Ozmenoglu M, Sayar K, Alioglu Z, Yalman B, et al. Temperament chronification. Patients in pain can be more focused on details and character profiles of patients with tension-type headache and migraine. Psychiatry about themselves, and they might have perfectionist personali- Clin Neurosci. 2004;58(5):536-43. ties. On the other side, self-directedness (not present in this sam- 9. Knaster P, Estlander AM, Karlsson H, Kaprio J, Kalso E. Temperament traits and chronic pain: the association of harm avoidance and pain-related anxiety. PLoS One. ple) is also another issue associated with self-centrism when there 2012;7(10):e45672. is no self-transcendence14. 10. Malmgren-Olsson EB, Bergdahl J. Temperament and character personality dimensions in patients with nonspecific musculoskeletal disorders. Clin J Pain. The case series and the narrative description with a qualitative 2006;22(7):625-31. analysis is crucial when individualized aspects, such as persona- 11. Nylander PO, Schlette P, Brändström S, Nilsson M, Forsgren T, Forsgren L, et al. lity, are under investigation. Although the majority of patients Migraine: temperament and character. J Psychiatr Res. 1993;30(5):359-68. 12. Pud D, Eisenberg E, Sprecher E, Rogowski Z, Yarnitsky D. The tridimensional perso- have self-centrism, high levels of insecurity, shame, novelty se- nality theory and pain: harm avoidance and reward dependence traits correlate with eking and harm avoidance, we have a lot to learn from the mi- pain perception in healthy volunteers. Eur J Pain. 2004;8(1):31-8. 13. Fuentes D, Tavares H, Camargo CH, Gorestein C. Inventário de Temperamento e nority. The attention to pain and to themselves can play a role Caráter de Cloninger - validação para a versão em português. In: Andrade LH, Zuardi in the chronification and in the triggering of pain crises or treat- AW, Gorenstein C. (Eds), Escalas de Avaliação Clínica em Psiquiatria e Psicofarmaco- logia. São Paulo: Lemos Editorial; 2000. ment resistance. The study of these cases helps in the understan- 14. Cloninger CR, Svrakic DM, Przybeck TR. A psychobiological model of temperament ding of coping tools in order to keep the high quality of life and and character. Arch Gen Psychiatry. 1993;50(12):975-90.

79 Br J Pain. São Paulo, 2018 jan-mar;1(1):80-6 CASE REPORT

Orofacial myofunctional disorder, a possible complicating factor in the management of painful temporomandibular disorder. Case report Distúrbio miofuncional orofacial, um possível fator complicador no manuseio da disfunção temporomandibular dolorosa. Relato de caso

Melissa de Oliveira Melchior1, Laís Valencise Magri1, Marcelo Oliveira Mazzetto1

DOI 10.5935/2595-0118.20180017

ABSTRACT disorder signs and symptoms. In this sense, the importance of dental and speech therapy interventions in patients with orofa- BACKGROUND AND OBJECTIVES: The clinical associa- cial myofunctional disorders as possible comorbidity to painful tion between painful temporomandibular disorder and orofacial temporomandibular disorder is highlighted. myofunctional disorders is frequent and requires attention. The Keywords: Comorbidity, Speech therapy, Temporomandibular objective of this study was to describe a clinical case of pain- joint dysfunction syndrome. ful temporomandibular disorder in association with orofacial myofunctional disorders that evidence the importance of dental RESUMO and speech therapy approaches involving myofunctional orofacial limits, as well as to discuss whether the presence of orofacial JUSTIFICATIVA E OBJETIVOS: A associação clínica da disfun- myofunctional disorders can be a comorbidity that hinders the ção temporomandibular dolorosa com distúrbios miofuncionais temporomandibular disorder management. orofaciais é bastante frequente e requer atenção. O objetivo deste CASE REPORT: Female patient, 35 years old, complaining of estudo foi mostrar um caso de disfunção temporomandibular do- pain in the orofacial region and joint noises during high ampli- lorosa com associação de distúrbios miofuncionais orofaciais que tude mandibular movements for 17 years. She was diagnosed evidenciou a importância do manuseio terapêutico odontológico with myofascial pain and arthralgia (RDC/TMD) and orofacial e fonoaudiológico, com abordagens que envolveram limites mio- myofunctional disorders (phonoarticulation with deviations funcionais orofaciais, bem como discutir se a presença de distúr- and lingual interposition, atypical swallowing, oromandibular bios miofuncionais orofaciais pode ser uma comorbidade que difi- incoordination and mandibular hyperexcursion with eminence culta o manuseio da disfunção temporomandibular. noise). Complementary tests (electromyography and electro- RELATO DO CASO: Paciente do sexo feminino, 35 anos, com vibratography) were performed in the pre- and post-treatment queixa de dor na região orofacial e ruídos articulares durante movi- moments (1 year after). The treatment consisted of self-manage- mentos mandibulares de grande amplitude há 17 anos. Diagnosti- ment and mindfulness orientations, stabilizing occlusal splint cada com dor miofascial e artralgia (RDC/TMD) e distúrbios mio- and speech therapy. After the treatment, there was an improve- funcionais orofaciais (fonoarticulação com desvios e interposição ment in pain and mandibular range of motion, with consequent lingual, deglutição atípica, descoordenação oromandibular e hiper- reduction of noise, better electromyographic balance and reduc- excursão mandibular com ruído de eminência). Foram realizados tion of orofacial myofunctional disorders scores. exames complementares (eletromiografia e eletrovibratografia) nos CONCLUSION: The case report has suggested that the presence momentos pré e pós-tratamento (1 ano após). O tratamento consis- of orofacial myofunctional disorders in association with painful tiu de orientações de automanuseio e de atenção plena nas funções temporomandibular disorder could interfere in the management orofaciais (mindfulness), placa oclusal estabilizadora e terapia fono- of pain and the balance of the stomatognathic system because audiológica. Após o tratamento, houve melhora da dor e da ampli- it seems to act as a worsening factor to the temporomandibular tude dos movimentos mandibulares, com consequente redução dos ruídos, maior equilíbrio eletromiográfico dos músculos e redução dos escores dos distúrbios miofuncionais orofaciais. 1. Universidade de São Paulo, Faculdade de Odontologia de Ribeirão Preto, Departamento CONCLUSÃO: O presente caso sugere que a presença dos dis- de Odontologia Restauradora, Área de Oclusão, Disfunção Temporomandibular e Dor Oro- túrbios miofuncionais orofaciais em associação com a disfun- facial, Ribeirão Preto, SP, Brasil. ção temporomandibular dolorosa pode interferir no manuseio Submitted in October 25, 2017. da dor e no equilíbrio do sistema estomatognático, pois parece Accepted for publication in January 29, 2018. atuar como fator de piora dos sinais e sintomas da disfunção Conflict of interests: none – Sponsoring sources: none temporomandibular. Neste sentido, ressalta-se a importância de Correspondence to: intervenções odontológicas e fonoaudiológicas em pacientes que Avenida do Café, s/n, Monte Alegre Faculdade de Odontologia apresentem os distúrbios miofuncionais orofaciais como possível 14040-904 Ribeirão Preto, SP, Brasil. comorbidade à disfunção temporomandibular dolorosa. E-mail: [email protected] Descritores: Comorbidade, Fonoaudiologia, Síndrome da dis- © Sociedade Brasileira para o Estudo da Dor função da articulação temporomandibular. 80 Orofacial myofunctional disorder, a possible complicating factor in the Br J Pain. São Paulo, 2018 jan-mar;1(1):80-6 management of painful temporomandibular disorder. Case report

INTRODUCTION were trigger points that reproduced the reported pain (familiar pain) in the masseter and anterior temporal muscles, and local- Currently, temporomandibular dysfunctions (TMD) are defined ized pain in the temporomandibular joint (TMJ). as a set of signs and symptoms that indicate a painful musculo- The phonological evaluation evidenced severe mandibular right- skeletal syndrome associated to multisystemic changes, as well ward deviation when speaking, together with ceceo, interfering as changes in behavior, in the emotional state and social interac- in the speech intelligibility and coinciding with the side of the tions, recognized as manifestations of deregulation of the central prevalence of spontaneous pain (right). Moreover, other myo- nervous system1-3. Among the key predictors for the develop- functional disorders were found such as chewing side preference ment of TMD is the presence of comorbidities, non-painful to the right, atypical deglutition, oral-motor incoordination for orofacial symptoms (such as self-report of parafunctions), the isolated movements, mandibular rest with no free functional frequency of somatic symptoms, poor sleep quality, and genetic space, and deleterious oral habits. The situation found character- and epigenetic factors1,2. The most common signs and symptoms ized the diagnosis of OMD. are the orofacial pain, joint noises and changes in jaw mobility4. The TMD diagnosis was carried by an experienced dental sur- The presence of comorbidities associated with painful TMD geon based on the revised protocol Research Diagnostic Criteria makes the diagnosis and management difficult, in special in the for Temporomandibular Disorders (RDC/TMD)10 and the pho- presence of other dysfunctional syndromes, such as headaches, nological by an expert in orofacial kinetics, based on the Oro- fibromyalgia, and cervicalgia5,6. These comorbidities can be a facial Myofunctional Evaluation Protocol with Scores (AMIO- huge challenge in specific clinical cases since the physiopatho- FE)11, that allowed to quantify the perceptive evaluation (clinical logical mechanisms, and the site of pain involvement or percep- examination) and compare with the evolution obtained after the tion can be very similar to the TMD6. The central sensitization, therapeutic process. The instrumental evaluation was performed the involvement of the pain descending inhibitory systems and to complement the diagnosis and was composed by surface elec- the neural convergence are phenomena that contribute to this tromyography (SEMG) and electrovibratography (EVG). overlapping of conditions in the orofacial region5,6. The initial treatment plan included the use of an occlusal splint, The orofacial myofunctional disorders (OMD) are defined as any speech therapy and directions for self-management. Speech alteration that involves the orofacial muscles generating unfavor- therapy, as previously described12, included strategies to elimi- able forces to the balance of the stomatognathic system7. Some nate the deleterious oral habits, to self-manage pain (step 1), to TMD situations present a pain that is triggered or worsened by coordinate and strengthen the orofacial and masticatory muscles jaw movements. In this sense, the performance of orofacial func- to allow flexible and symmetrical jaw movements, avoiding actions that respect the functional balance is of utmost importance cidental bites in the cheeks and tongue (step 2-myotherapy)12. for a favorable prognostic of its signs and symptoms8,9. The con- As the sessions evolved with improvement in the patient’s condi- comitant presence of these two clinical conditions (TMD and tions, strategies were included and trained to balance chewing OMD), although independent, can reveal overlapping signs and and swallowing and to promote a more intelligible phonoarticu- symptoms that characterize a challenge for their diagnosis and lation, in addition to the mandibular rest with free mandibu- management. lar functional space preserved (step 3 orofacial myofunctional The objective of this study was, by reporting a clinical case, to therapy) (Table 1). present a possible clinical association between painful TMD After 13 weekly sessions, other 10 sessions were carried for 6 and the presence of OMD, and to discuss if they can act as fortnightly sessions and 4 monthly ones, in which were included complicating factors in TMD management. Moreover, to ad- in the therapeutic process complementary mindfulness practices dress the importance of the therapeutic dental management that constitute an important group of meditation practices used and speech therapy with strategies that involve orofacial myo- as a tool to reduce stress and anxiety, also being recognized to functional limits. contribute in the reduction of painful pictures2,13. Since the phonological approach was directed to the stomatognathic system, CASE REPORT the exercises, guided by the therapist, focused on the rhythm of breathing and attention to the orofacial structures (anchor of the Female patient, 35 years, percussionist, complaining about mindfulness practice: aspect or object to which the targeting - or strong joint noises and pain in the orofacial region for 17 years focus - is exercised). The detailed therapeutic plan is shown in that worsened in the last 3 months. She also reported a strong table 1. discomfort with accidental bites that frequently occurred in the Table 2 also shows the data of the clinical evaluations at the ini- cheeks and tongue when chewing and speaking; history of teeth tial evaluation and after the treatment. According to the diagnos- clenching (sleep bruxism) and pain in the shoulders related to tic criteria of the RDC/TMD, the patient presented myofascial her occupational activities. A clinical dental evaluation was con- pain without limitation of mouth opening (Ia), and arthralgia ducted. During the occlusal examination, it was noticed a bilat- (IIIa). The intensity of the overall experience of the initial pain eral posterior crossbite and mild dental crowding in the lower was 9 (visual analog scale, VAS) and after the treatment, it was anterior region; and in the muscle evaluation, it was observed 2. There was also a reduction of pain on palpation in the mas- an intense pain to palpation according to the numerical scale seter, anterior temporal and the TMJ region, which initially was from zero (absence of pain) to 10 (worse possible pain). There reported with a strong intensity (variation between 8 and 10)

81 Br J Pain. São Paulo, 2018 jan-mar;1(1):80-6 Melchior MO, Magri LV and Mazzetto MO

Table 1. Phonological therapeutic plan: intervention target, objective, management and strategies/actions8 Intervention Objective Management Strategies/actions target Pain Pain remission/reduction; Self-management direc- Thermotherapy for 20 to 30 minutes followed by self-massage, Reduction of related emo- tions awareness about habits and behaviors that contribute to pain, di- tional aspects (anxiety) Mindfulness practices rections about sleep hygiene and regular physical exercises. 13 we practices focusing breathing and orofacial structures, with the therapist’s assistance. Masticatory Coordinate/strengthen Mandibular exercises Lower and raise the jaw gently with the support of the apex of the muscles jaw movements tongue on the hard palate, aiming at a rectilinear motion (3 sequences of 10 movements each); gently press a rubber band (latex) of 5 mm in diameter, placed between the posterior teeth, varying at each bite between premolar and molar teeth (3 sequences of 10 bites each), 1 to 3 times a day. TMJ Lubricate Mandibular exercises as- Mandibular excursive movements for mouth opening, as already sociated with the use of described, right and left laterality, protrusion. (Exercises with oc- the occlusal splint clusal splint) Tongue Coordinate Stimulate the sensitivity, Concomitant mechanical stimulation on the sides of the tongue mobility, increase tension, using toothbrushes, lightly passing the bristles in posteroanterior favor habitual position direction for approximately 15 seconds, repeating 5 times in sequence, with 3 to 5-second intervals; Lingual movements to the sides, up and down, slowly, with instruction to touch the apex of the tongue in the labial commissures, in the center of the upper lip and in the center of the lower lip, respectively; Use of the pró-fono* lingual appliance in accordance with the protocol suggested in the instruction manual Pass the apex of the tongue gently and continuously in back and forth movements for approximately 5 minutes* and then, remain resting keeping this contact of the tongue against the hard palate consciously for an indeterminate time, without the interposition of the tongue between the dental arches (several times per day)**. Speech Eliminate ceceos and Mandibular exercises, and Lower and raise the jaw gently with the support of the apex of mandibular deviations speech and articulation the tongue on the hard palate, aiming at a rectilinear motion (3 exercises sequences of 10 movements each); symmetrically right and left laterality exercise, protrusion exercise trying not to create deviations. (Exercises with occlusal splint); tongue exercises described above; repetition of syllables, words, texts, phonetically balanced with phonemes where the ceceo and mandibular deviations occurred. Chewing Balance Create awareness about Common chewing exercises of different food, consciously, broade- the mode used, expanding ning the perceptions about the sensations caused, such as pain, the attention and percep- easiness, difficulty, the difference between the sides, physical food tions during this function characteristics and taste perception; simultaneous bilateral chewing with different food, esta- exercise, that is, chewing a portion in each side of the mouth simul- blish chewing without pain taneously. and without aggravating the problem (Mindfulness) Swallowing Eliminate compensations Tongue and swallowing Tongue exercises described above and swallowing exercises of exercises water and food, with the instruction to position the apex of the tongue opposed to the anterior region of the hard palate, performing a waving movement of the body of the tongue in the anteroposterior direction propelling the food bolus into the pharynx. Resting Keep the functional space Awareness and relaxation, Enhance the attention (Mindfulness) in the day-to-day for perception free/prevent teeth clen- positioning the tongue and awareness of the teeth clenching events, using reinforcement ching properly, strengthen the strategies as reminders such as self-adhesive notes in different pla- levator muscles of the jaw ces in the house and at work; gently and countinuously pass the apex of the tongue in back and forth movements for approximately 5 minutes (RLPM)* and then, to rest and counsciously keep this contact of the tongue against the hard palato for an undetermina- te time, without the interposition of the tongue between the dental arches (several times per day**; gently press a rubber band (latex) of 5mm of diameter, placed between the posterior teeth, varying, at each bite, between the pre-molar and molar teeth (3 sequences of 10 bites each), 1 to 3 times per day. *(This exercise was described previously for the relaxation of the levator muscles of the jaw, called lingual-papilla-mandibular reflex (RLPM in Portuguese)8; ** (the exercise was also performed with the occlusal splint, that had an orifice for memorization in the palate region corresponding to the one described in table 1)8.

82 Orofacial myofunctional disorder, a possible complicating factor in the Br J Pain. São Paulo, 2018 jan-mar;1(1):80-6 management of painful temporomandibular disorder. Case report

Table 2. Initial and post-treatment results of the intensity of the overall pain experience in the last month (visual analog scale), pain on palpation (VAS), the range of mandibular motion (mm), joint noises and diagnosis according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Intensity of the overall pain experience in the last month (VAS) Initial Post-treatment 9 2 Pain on palpation (VAS) Masseter R-10/L-10 R-6 /L-8 Anterior temporal R-10/L-10 R-6 /L-4 Temporomandibular joint R-8/L-10 R-4 /L-2 Mandibular movements Opening 52 45 (mm) R laterality 8,5 10 L laterality 10 11 Protrusion 8 7,5 Joint Noises Total integral R-45.5/L-43.9 R-4.2/L-3.9 >;300 Hz R-4.2/L-6.3 R-0.8/L-0.5 <300 Hz R-41.3/L-37.6 R-3.4/L-3.4 Diagnosis by RDC/TMD Myofascial pain without mouth opening limitation(Ia) and arthralgia (IIIa). Source: Authors elaboration. R = right side; L = left side; Hz = Hertz (unit of measure); Ia and IIIa = RDC/TMD categories. and after the treatment was referred to as a light/moderate pain. cited muscles. Initially, in the left chewing, there was a greater ac- With regard to mandibular movements, the mouth opening was tivity at the work side and the anterior temporal; whereas in the trained to reduce its range in order to avoid the eminence crack, right chewing, the balance side was more active, and the tempo- which resulted in a variation of 52 to 45 mm. Thus, the intensity ral muscles also had greater activity. After the speech therapy for of joint noise was reduced, as shown by the EVG. both chewing, the electromyographic activity at the balance side The electromyographic activity of the anterior temporal and was slightly greater than the work side, and there was a reduction masseter muscles when chewing with raisins was analyzed by of the temporal muscle activity and an increase in the masseter the relation between the work side and balance and between the activity, tending to a better balance (Figure 1).

Left chewing Right chewing Electromyographic activity (mv) Electromyographic Pre Post Pre Post Work side Balance side

Anterior temporal Masseter Electromyographic activity (mv) Electromyographic Pre Post Pre Post Work side Balance side

Figure 1. Electromyographic activity in chewing raisins

83 Br J Pain. São Paulo, 2018 jan-mar;1(1):80-6 Melchior MO, Magri LV and Mazzetto MO

The static surface EMG showed that after the treatment there In the initial evaluation, all scores of the AMIOFE protocol was a reduction in the electric activity of the anterior tempo- were below the cut-off values of normality. After the speech ral and masseter muscles in the resting, swallowing, clenching therapy, the scores related to the aspect/posture, mobility, with cotton and clenching in maximum habitual intercuspation and the total score reached the cut-off of normality. The (MHI). In addition to a trend of a better balance between the left analysis of the orofacial functions also showed an improve- and right sides, as well as between the pairs of evaluated muscles ment after the treatment, reaching the standard values of (Figure 2). normality (Figure 3).

At rest Swallowing

Pre Pre Post Post Electromyographic activity (mv) Electromyographic activity (mv) Electromyographic LT RT LM RM LT RT LM RM

Clenching with cotton Clenching MHI

Pre Pre Post Post Electromyographic activity (mv) Electromyographic activity (mv) Electromyographic LT RT LM RM LT RT LM RM

Figure 2. Static electromyography at rest, swallowing, clenching with cotton and clenching in maximum habitual intercuspation MHI = Maximum Habitual Intercuspation; LT = Left Temporal; RT = Right Temporal; LM = Left Masseter; RM = Right Masseter.

Pre Post Normality Maximum score AMIOFE score

Aspect/Posture Mobility Functions Total score

Figure 3. Scores of the orofacial myofunctional evaluation with scores for aspect/posture, mobility, functions and total score

84 Orofacial myofunctional disorder, a possible complicating factor in the Br J Pain. São Paulo, 2018 jan-mar;1(1):80-6 management of painful temporomandibular disorder. Case report

DISCUSSION states of anxiety, but it was possible to obtain favorable reports from the patient regarding this aspect, raising the possibility of Painful TMJ treatment approaches are increasingly targeting edu- new investigations that contribute to the inclusion of speech cational efforts about pain, mandibular exercises, as well as strate- therapy to treat people with TMD. gies to self-management and to reduce emotional components14. The scores found for AMIOFE after 23 therapy sessions reached The association between exercise treatments, occlusal splint, and the previously established normal values11. This indicates that the self-management instructions favored the new mouth opening speech therapy approach, combined with other dental and self- range to a functional threshold that does not cause the character- management modalities, proved to be effective for the orofacial istic noise of the eminence joint, and the expansion of the lateral myofunctional balance, and consequently for the reduction of mandibular movements with better symmetry. Although the TMJ musculoskeletal overload, for the patient’s perception and educa- and orofacial pain treatments are no longer totally centered on the tion regarding changes in myofunctional habits and behaviors occlusal aspects, the occlusal splint is still a good dental tool, either and therefore contributing to the treatment/management of due to the mechanisms of action or because of its cognitive effect TMD in the way recommended by the current literature. and improvement in the emotional aspects15. The number of speech therapy sessions was higher than that re- The identification of joint noises in the TMJ is based on the pa- ported in the literature, which is usually a total of 12 or 13 ses- tient’s report and on the palpation examination during the clini- sions18,19. In this case, the OMD presented important aspects cal evaluation protocol. The most frequent noises observed are related to TMD such as marked mandibular deviations during the click and crackle, but other types of noise can be identified, speech with exaggerated ceceo, swallowing with many cervical such as the eminence click. This type of click occurs at the end of and tongue compensations, mandibular rest without free func- the mouth opening and/or when the closing starts. It is detected tional space, that is, in a state of teeth clenching with the tongue when the condyle-disc complex translates beyond the joint emi- compressed most of the time; in some moments with the tongue nence, followed by a change in the position of the jaw. When interposed between the arches, causing strong marks on its sides. the mouth opening is limited, it is not possible to identify the The difficulty to install and automate myofunctional patterns eminence click since this type of noise is associated with the wide that favor the balance of the stomatognathic system led to a mouth opening movements16. Although frequently found, also higher number of therapeutic sessions, which was possible due in healthy patients, the eminence click is not a clinical diagnosis to the patient’s compliance with the proposed schedule. Experts criterion for TMD, and it is not registered in the most recent in the field of orofacial motricity claim that OMD may not be diagnosis protocol, the RDC/TMD16. However, this can bring the cause of TMD, but the more severe the OMD, more difficult great discomfort and impairment of the orofacial functions. its resolution without approaches that specifically target myo- The hyper excursion of the mandibular condyle can reflect a mis- functional orofacial re-education or rebalancing8. match of the mouth movements and muscle weakness that gen- The presence of comorbidities can be one complication or non- erates a range of motion higher than the functional need of the resolution factors of TMD after treatment, that is, another prob- individual. Speech therapy is capable of working on the learning lem that may occur in parallel with what is being treated, that has of a new neuromuscular position within the functional limits some relation and influence on its severity2,3,20,21. In this case, it that do not need maximum mandibular movements, preventing seems that the OMD was a TMD comorbidity since we cannot the occurrence of joint and eminence noises8. The main reason claim that it was the triggering factor, but its presence contrib- to refer a patient with TMD to an audiologist is the presence uted to the aggravation and maintenance of TMD. Rebalancing of musculoskeletal overload from OMD and parafunctional, or the altered orofacial myofunctional aspects, in association with deleterious oral habits. In this sense, the speech therapy proposed the other therapeutic modalities, contributed to the TMD reso- for this case was elaborated to reduce the overload on the trigem- lution, limiting the mandibular movements, reducing orofacial inal system related to the stomatognathic functions generated by pain, and remission of the pain referred on palpation, reducing improper muscle compensation acquired by different events over joint clicks and their intensity. time, and by the deleterious oral habits. These results also produced a lower and more balanced electro- Some speech therapy sessions, mindfulness practices in breathing myographic activity of the masseter and anterior temporal mus- and orofacial structures were well accepted by the patient with cles in the tests at rest, swallowing and maximum teeth clenching reports of improvement of the sensation of anxiety and increase (maximum voluntary contraction). Some studies have shown an of the global relaxation. The term mindfulness, refers to a state of increase in activity for evidence of high demand for muscle con- constant attention to some object, in order to observe, moment traction after treatment and a decrease for tests of low demand, after moment, the variations in that object over time. This object such as rest and swallowing8,11. In this case, lowering the electro- is called an anchor of attention, which can be the rhythm of myographic activity may have occurred due to excessive patient breathing, body or facial structures for example, where training care when clenching the teeth since it was a much-discussed as- its focus reduces states of anxiety17. This practice, however, was pect during the treatment. However, more important than in- introduced at this moment with the intention of contributing to creasing or decreasing the activity was to address the balance the conscious perception and execution of orofacial movements between the pairs of muscles and between the sides. This can and functions, which favors the education about functional cabe observed in the electromyographic examination during the pacities and limits. The primary objective was not to reduce the masticatory function of raisins, in which changes with a trend 85 Br J Pain. São Paulo, 2018 jan-mar;1(1):80-6 Melchior MO, Magri LV and Mazzetto MO to the balance between the work and balancing sides and the 8. de Felício CM, de Oliveira MM, da Silva MA. Effects of orofacial myofunctional therapy on temporomandibular disorders. Cranio. 2010;28(4):249-59. decrease of the activity of the anterior temporal muscles, quite 9. Ferreira CL, Machado BC, Borges CG, Rodrigues Da Silva MA, Sforza C, De Felício similar to the activity of the masseters. After the time spent to CM. Impaired orofacial motor functions on chronic temporomandibular disorders. J Electromyogr Kinesiol. 2014;24(4):565-71. achieve the myofunctional balance, we concluded that the elec- 10. Look JO, Schiffman EL,Truelove EL, Ahmad M. Reliability and validity of Axis I tromyographic results were satisfactory for this case, constituting of the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) 8 with proposed revisions. J Oral Rehabil. 2010;37(10):744-59. its individual limit . 11. de Felício CM, Medeiros AP, Melchior MO. Validity of the ’protocol of oro-facial myofunctional evaluation with scores’ for young and adult subjects. J Oral Rehabil. CONCLUSION 2012;39(10):744-53. 12. Melchior MO, Machado BC, Magri LV, Mazzetto MO. Effect of speech-language therapy after low-level laser therapy in patients with TMD: a descriptive study. Codas. Managing OMD together with dental and self-management 2016;28(6):818-22. 13. Slade GD, Fillingim RB, Sanders AE, Bair E, Greenspan JD, Ohrbach R, et al. therapies is essential not only for the improvement of pain but Summary of findings from the OPPERA prospective cohort study of incidence of also to modify the functional condition to achieve the balance of first-onset temporomandibular disorder: implications and future directions. J Pain. 2013;14(12 Suppl):T116-24. the stomatognathic system, specific to each clinical case of pain- 14. Michelotti A, Iodice G, Vollaro S, Steenks MH, Farella M. Evaluation of the short- ful TMD. In this sense, it is worth mentioning the importance of term effectiveness of education versus an occlusal splint for the treatment of myofascial pain of the jaw muscles. J Am Dent Assoc. 2012;143(1):47-53. dental and speech interventions in patients with orofacial myo- 15. Costa YM, Porporatti AL, Stuginski-Barbosa J, Bonjardim LR, Conti PC. Addi- functional disorders as possible comorbidity to painful temporo- tional effect of occlusal splints on the improvement of psychological aspects in tem- mandibular dysfunction. poromandibular disorder subjects: A randomized controlled trial. Arch Oral Biol. 2015;60(5):738-44. 16. Schiffman E,Ohrbach R, Truelove E, Look J, Anderson G, Goulet JP, et al. Interna- REFERENCES tional RDC/TMD Consortium Network, International Association for Dental Re- search; Orofacial Pain Special Interest Group, International Association for the Study of Pain. Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for Clini- 1. Slade GD, Ohrbach R, Greenspan JD, Fillingim RB, Bair E, Sanders AE, et al. Painful cal and Research Applications: recommendations of theInternational RDC/TMD temporomandibular disorder: decade of discovery from OPPERA studies. J Dent Res. Consortium Network* and Orofacial Pain Special Interest Group†. J Oral Facial Pain 2016;95(10):1084-92. Headache. 2014;28(1):6-27. 2. Ohrbach R, Dworkin SF. The evolution of TMD diagnosis: past, present, future. J 17. Kabat-Zinn J. An outpatient program in behavioral medicine for chronic pain pa- Dent Res. 2016;95(10):1093-101. tients based on the practice of mindfulness meditation: theoretical considerations and 3. Manfredini D, Winocur E, Ahlberg J, Guarda-Nardini L, Lobbezoo F. Psychosocial preliminary results. Gen Hosp Psychiatry. 1982;4(1):33-47. impairment in temporomandibular disorders patients. RDC/TMD axis II findings 18. de Felicio CM, Melchior Mde O, Da Silva MA. Clinical validity of the protocol for from a multicentre study. J Dent. 2010;38(10):765-72. multi-professional centers for the determination of signs and symptoms of temporo- 4. Scrivani SJ, Keith DA, Kaban LB. Temporomandibular disorders. N Engl J Med. mandibular disorders. Part II. Cranio. 2009;27(1):62-7. 2008;359(25):2693-705. 19. Machado BC, Mazzetto MO, Da Silva MA, de Felício CM. Effects of oral motor 5. Campi LB, Jordani PC, Tenan HL, Camparis CM, Gonçalves DA. Painful temporo- exercises and laser therapy on chronic temporomandibular disorders: a randomized mandibular disorders and central sensitization: implications for management-a pilot study with follow-up. Lasers Med Sci. 2016;31(5):945-54. study. Int J Oral Maxillofac Surg. 2017;46(1):104-10. 20. Visscher CM, Van Wesemael-Suijkerbuijk EA, Lobbezoo F. Is the experience of pain 6. Costa YM, Conti PC, de Faria FA, Bonjardim LR. Temporomandibular disorders in patients with temporomandibular disorder associated with the presence of comor- and painful comorbidities: clinical association and underlying mechanisms. Oral Surg bidity? Eur J Oral Sci. 2016;124(5):459-64. Oral Med Oral Pathol Oral Radiol. 2017;123(3):288-97. 21. Manfredini D, Ahlberg J, Winocur E, Guarda-Nardini L, Lobbezoo F. Correlation of 7. Pereira CC, De Felício CM. Os distúrbios miofuncionais orofaciais na literatura odon- RDC/TMD axis I diagnoses and axis II pain-related disability. A multicenter study. tológica: revisão crítica. Rev Dent Press Ortodon Ortop Facial. 2005;10(4):134-42. Clin Oral Investig. 2011;15(5):749-56.

86 Br J Pain. São Paulo, 2018 jan-mar;1(1):87-9 CASE REPORT

Pain treatment and recovery of functionality in a former athlete diagnosed with myofascial pain syndrome in the course of syringomyelia. Case report Tratamento da dor e recuperação da funcionalidade em ex-atleta diagnosticada com síndrome dolorosa miofascial no curso de siringomielia. Relato de caso

Renato Carvalho Vilella1

DOI 10.5935/2595-0118.20180018

ABSTRACT RESUMO

BACKGROUND AND OBJECTIVES: There are few studies JUSTIFICATIVA E OBJETIVOS: Existem poucos estudos que that address non-surgical treatment in cases of syringomyelia, abordam o tratamento não cirúrgico nos casos de siringomielia, which reduces the possibilities of treatment for the patient. The fato que diminui as possibilidades de tratamento para o paciente. objective of this study was to analyze the efficacy of the physio- O objetivo deste estudo foi analisar a eficácia do tratamento fi- therapeutic treatment for the symptoms of the pathology. sioterapêutico para os sintomas da doença. CASE REPORT: Idiopathic syringomyelia is a condition in RELATO DO CASO: A siringomielia idiopática é uma doença which a cystic-shaped cavity appears within the spinal cord. Af- na qual uma cavidade em forma de cisto aparece dentro da me- ter the diagnosis of syringomyelia in C3-C6, 3 years ago, the dula espinhal. Após o diagnóstico de siringomielia em C3-C6, patient, a former volleyball athlete, remained stable with no an- 3 anos atrás, a paciente, ex-atleta de voleibol, se manteve com esthetic dissociation, muscle atrophy or limb paresthesia. How- o quadro estável e sem dissociação anestésica, atrofia muscular ever, she began to have constant back and neck pain to the extent ou parestesia de membros, porém começou a ter dores lombares of limiting her functioning in jogging, volleyball, and difficulties e cervicais constantes a ponto de ter limitação da função em of movement in daily routine. The physiotherapeutic treatment corrida, voleibol e dificuldades de movimentação no dia a dia. in 6 sessions, worked in the muscle and fascial release with dry Durante o tratamento fisioterapêutico em 6 sessões foi abordada needling and manual myofascial release associated with specific a liberação muscular e fascial a partir do agulhamento à seco e vertebral adjustments with chiropractic techniques, and after the liberação miofascial manual associado a ajustes vertebrais espe- cessation of the pain, specific muscle strengthening exercises. cíficos com técnicas quiropráticas, e após cessamento das dores CONCLUSION: Physiotherapy showed to be an effective treat- fortalecimento muscular específico. ment for patient with syringomyelia that presented symptoms to CONCLUSÃO: A Fisioterapia demonstrou ser um tratamento myofascial pain syndrome. eficaz em uma paciente com siringomielia que apresentava sinto- Keywords: Low back pain, Neck pain, Pain, Physiotherapy, Sy- mas relacionados à síndrome dolorosa miofascial. ringomyelia. Descritores: Dor, Dor cervical, Dor lombar, Fisioterapia, Sirin- gomielia.

INTRODUCTION

Syringomyelia is an idiopathic degenerative and progressive chronic disease, characterized by a cavity in the spinal cord. The disease has an average of two to 13 people per 100,000 inhabitants, depending on the country and on the gender (2:1)1,2. Syringomyelia diagnosis is usually by MRI, and the image results can show localized or extensive cavities. The localized cavities are the ones that affect the space of up to three vertebrae, and the extensive cavities affect a space bigger than four vertebrae1,2.

1. Pesquisador autônomo. Belo Horizonte, MG, Brasil. The common symptoms of neurological alterations are a loss of sensation, weakness and limb paralysis, neuropathic pain and Submitted in October 12, 2017. general muscle pain, and it can evolve to loss of muscle mass and Accepted for publication in January 29, 2018. 3 Conflict of interests: none – Sponsoring sources: RV Palmilhas Funcionais. a picture of physical disability . Physiotherapy plays an important role in the treatment of pain, Correspondence to: Rua Bueno Brandão, 381 - Santa Tereza with techniques and management that can inhibit pain in pe- 31010-060 Belo Horizonte, MG, Brasil. ripheral and central levels. These techniques promote a com- E-mail: [email protected] petitive inhibition, removal of the mechanical and chemical © Sociedade Brasileira para o Estudo da Dor irritating components, release of endogenous opioids, cortical 87 Br J Pain. São Paulo, 2018 jan-mar;1(1):87-9 Vilella RC reorganization and homeostasis of the sympathetic and parasym- The differential physiotherapeutic diagnosis during the as- pathetic systems3. sessment included exacerbated muscle tension in the bilateral In individuals with neurological involvement, physiotherapy quadratus lumborum muscle, paravertebral in thoracolumbar improves the quality of life and functionality. The clinical in- and cervicothoracic regions, asymmetry in muscle activation struction for the physiotherapists is to perform the therapy between gluteus and oblique, and vertebral hypomobility spe- with a good theoretical background in order to increase the cific for L3-L4 flexion, rotation to the right in T12-L1 and movement strategies and create an environment where the pa- C2-C3. tient is able to achieve the highest independence level possible4. With no bone alterations presented in the examinations, The objective of this study was to analyze the efficacy of physio- physiotherapy started with dry needling (DN) to inhibit the therapy to treatment the symptoms of the disease. tension on the quadratus lumborum, bilateral, and paravertebral muscles, and also intratissue DN aiming at the systemi- CASE REPORT cally release of endogenous opioids for analgesia. After the muscle release, a chiropractic manipulation was Female patient, 32 years old, a former volleyball athlete, with a performed on L3-L4, T12-L1 and C2-C3 vertebrae that pre- history of low back and neck pain, diagnosed with syringomyelia sented hypomobility and restriction of the movement, thus at the same time. Curiously, the commonly known symptoms completely restoring mobility and movement. (limb paresthesia, sensation dissociation, and muscle atrophy) In the third session, the patient who was no longer in pain resulting from the disease were not present. After attempts to started a specific preventive muscle strengthening with stabi- treat with drug and complementary therapies, the symptoms lization of the cervical and lumbar spine, glutes and obliques persisted, and the patient started physiotherapy. Magnetic reso- strengthening exercises for body proprioception. nance imaging tests (Figure 1) between the day of the diagnosis In the sixth and last session, the patient was once again sub- and the beginning of physiotherapy showed that syringomyelia mitted to the VAS and to the Roland-Morris Questionnaire, did not evolve and the idiopathic cyst space remained stable. and the scores were zero in 10 and zero in 24, respectively, suggesting the absence of pain and physical disability5. Then, she was released to return the bodybuilding, jogging and volleyball activities with professional follow-up.

DISCUSSION

Muscle stress associated with trigger points (TP) cause pain, pseudo muscle weakness, and limitation of movement6. The stress and pain reported by the patient, possibly caused by syringomyelia, turned to a chronic picture similar the myofascial pain syndrome. The DN technique is relatively new and has been used in the cases of myofascial pain, with efficacy proven in the literature. In the technique, the needle is introduced directly in the point of tension previously assessed, causing an immediate recovery due to the mechanical rupture of the disorganized muscle fibers, releasing endogenous opioids and normalizing the local chemical environment7. The body performs biomechanical alterations for its own protection, and they lead to the hypomobility picture characterized as a pathological pattern. As the name says, hypomobility is the lack of movement or blockade to one or more directions and cause several biomechanical compensations that lead to painful situations. There are some techniques that promote the return of vertebral mobility. In this case, it was used chiropractic that involves the low-amplitude high-speed Figure 1. Magnetic Resonance Imaging manipulation of the spine, promoting the homeostasis of the movement and full recovery of the joint function8. The patient referred to pain as eight in 10 in the visual analog One of the biggest concerns of the physiotherapist is the pre- scale (VAS), diffuse in the lumbar and neck regions, causing lim- vention, to avoid the recurrence of the injury or symptoms. itation of movement, limitation of functionality in day-to-day Exercises of stabilization, strengthening and proprioception and also in sports functions. The Roland-Morris questionnaire to are widely used with this objective since they improve the assess physical disability was applied, with the initial score of 16 alignment of the spine, back pain and reduce the risk of ex- in 24, suggesting moderate to severe physical disability5. ternal influences to posture9. 88 Pain treatment and recovery of functionality in a former athlete diagnosed Br J Pain. São Paulo, 2018 jan-mar;1(1):87-9 with myofascial pain syndrome in the course of syringomyelia. Case report

CONCLUSION 3. Gosling AP. Mecanismos de ação e efeitos da fisioterapia no tratamento da dor. Rev Dor. 2012;13(1):65-70. 4. Umphred AD. Umphred’s Neurological Rehabilitation. 6th ed. Elsevier. 2013. 1262p. Physiotherapy proved to be an intervention with good results in 5. Falavigna A, Teles AR, Braga GL, Barazzetti DO, Lazzaretti L, Tregnago AC. In- struments of clinical and functional evaluation in spine surgery. Coluna/Columna. a patient with syringomyelia who had symptoms related to the 2011;10(1):62-72 myofascial pain syndrome. 6. Bennett R. Myofascial pain syndromes and their evaluation. Best Pract Res Clin Rheu- matol. 2007;21(3):427-45. 7. Dommerholt J, Moral MO, Gröbli C. Trigger point dry needling. J Man Manip Ther. REFERENCES 2006;14(4):70-87. 8. Souza MM. Manual de Quiropraxia, Quiroprática, Quiropatia: filosofia, ciência, arte e profissão de curar com as mãos. São Paulo: Ibraqui Livros; 2006. th 1. Rusbridge C, Flint G. Syringomyelia: a Disorder of CSF Circulation. 4 ed. Springer; 9. Toprak Çelenay S, Özer Kaya D. An 8-week thoracic spine stabilization exercise 2014. 359p. program improves postural back pain, spine alignment, postural sway, and core 2. Royo-Salvador BM. Syringomyelia, scoliosis and idiopathic Arnold-Chiari malforma- endurance in university students: a randomized controlled study. Turk J Med Sci. tions: a common etiology. Rev Neurol. 1996;24(132):937-59. 2017;47(2):504-13.

89 INSTRUCTIONS TO AUTHORS

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File name shall express illustration type numerical sequential order in superscript. Unpublished papers shall and number (Figure 1, Table 2, for example). Copies or reproductions of not be mentioned and preferably avoid mentioning abstracts pre- other publications shall be allowed only after attachment of express autho- sented in scientific events. References older than 5 years shall be rization of the Editing Company or of the Author of the original article. mentioned if fundamental for the article. Articles already accepted for publication may be mentioned with information that they are in Ethics: publication process. Up to six authors may be mentioned and, if When reporting experiments with human beings, please indicate wheth- there are more, include et al. after the names. Journal title shall be er procedures were in compliance with ethic standards of the Commit- abbreviated. tee in charge of the human experiment (institutional or regional), and with the Declaration of Helsinki from 1975, amended in 1983. The EXAMPLES OF REFERENCES number of the Research Ethics Committee approval shall be mentioned. Journal articles: - 1 author - Wall PD. The prevention of postoperative pain. Pain Registry of Clinical Trial: 1988;33(1):289-90. Br J Pain respects World Health Organization and International Commit- - 2 authors - Dahl JB, Kehlet H. The value of pre-emptive analgesia in tee of Medical Journal Editors – ICMJE policies for the registry of clinical the treatment of postoperative pain. Br J Anaesth 1993;70(1):434-9. trials, acknowledging the importance of such initiatives for international - More than 6 authors - Barreto RF, Gomes CZ, Silva RM, Signorelli disclosure of information about clinical research with open access. So, AA, Oliveira LF, Cavellani CL, et al. Pain and epidemiologic evalu- as from 2012, preference shall be given to the publication of articles or ation of patients seen by the first aid unit of a teaching hospital. Rev studies previously registered before a Platform of Clinical Trials Registry Dor. 2012;13(3):213-9. meeting the requirements of the World Health Organization and of the International Committee of Medical Journal Editors. The list of Platforms Article with published erratum: of Clinical Trials Registry may be found at http://www.who.int/ictrp/en, Sousa AM, Cutait MM, Ashmawi HA. Avaliação da adição do tra- from the International Clinical Trials Registry Platform (ICTRP). Among madol sobre o tempo de regressão do bloqueio motor induzido pela them there is the Brazilian Registry of Clinical Trials (ReBEC), which is lidocaína. Estudo experimental em ratos Avaliação da adição do tra- a virtual platform with free access for the registry of experimental and madol sobre o tempo de regressão do bloqueio motor induzido pela non-experimental studies carried out with human beings, in process or lidocaína. Estudo experimental em ratos. Rev Dor. 2013;14(2):130- closed, by Brazilian and foreign researchers, which may be accessed at 3. Erratum in: Rev Dor. 2013;14(3):234. http://www.ensaiosclinicos.gov.br. The registry number of the study shall be published at the end of the abstract. Supplement article: Walker LK. Use of extracorporeal membrane oxygenation for preop- Use of Abbreviations: erative stabilization of congenital diaphragmatic hernia. Crit Care Title, summary and abstract shall not contain abbreviations. When long Med. 1993;2(2Suppl1):S379-80. expressions are present in the text, they do not have to be repeated after INTRODUCTION. Book: (when strictly necessary) After their first mention in the text, which shall be followed by the Doyle AC, editor. Biological mysteries solved, 2nd ed. London: Sci- initials in brackets, it is recommended that their initials in capital letters ence Press; 1991. 477 80p. replace them. OS MELHORES PROFISSIONAIS RECONHECEM A IMPORTÂNCIA DAS MELHORES TERAPIAS PARA O TRATAMENTO DA DOR

TERAPIA POR ONDAS DE CHOQUE Alívio a longo prazo. Sem recidivas em 6 meses de acompanhamento

mais de 75% Dispersão do mediador da dor “Substância P” pacientes satisfeitos Estimulação de produção de colágeno Formação de novos vasos sanguíneos Reversão da inflamação crônica alívio a longo prazo Dissolução de fibroblastos calcificados não reincidência em 6 meses de acompanhamento Liberação de pontos gatilho

Em 95% a terapia por ondas de 85% dos pacientes choque diminui a síndrome dolorosa 85% retornam mais rápido “ ao esporte e melhora a função do joelho.”

Terapia por Ondas de Choque para osteoartrose de joelho Diminuição da dor N.I.Sheveleva, L.S. Minbaeva redução completa Главный Врач 4(10) Осень 2014 [artigo original em língua russa]

MAGNETOTERAPIA O efeito terapêutico constante para o paciente

Tecnologia de Campo Magnético FocalizadoTM: Efeito analgésico efeito anti-inflamatório Efeito trófico Efeito miorelaxante e anti-espasmos Efeito de vasodilatação Efeito antiedematoso

Tecnologia Standart: ...vantagem significativa “a favor da intervenção electromagnética aplicada.”

Magnetoterapia Em Osteoartrite na mão: Teste piloto Autor: Elvan Kanat, et al. Fonte: Terapias complementares em Medicina, 2013; 21: 603-608

BTL Industries Brasil btlnet.com.br btlondasdechoque.com.br

BTL_ADS_PageMagazine_SWTMagnetoterapia_A4_BR.indd 2 2/16/2018 4:08:07 PM Eficácia e Flexibilidade para o tratamento da Fibromialgia e A FAMÍLIA DE COMPLETA PREGABALINA DO BRASIL9 Dor Neuropática1-8, 11 50 mg | 75 mg | 100 mg | 150 mg

A DOR É DIFERENTE PARA CADA PACIENTE.10 O TRATAMENTO TAMBÉM PRECISA SER.10

PREBICTAL® (pregabalina). Cápsulas. Embalagem com 14 ou 28 cápsulas de 50mg, 75mg, 100mg ou 150mg. Uso Adulto. Uso Oral. Indicações: Tratamento da dor neuropática; terapia adjunta na epilepsia; transtorno de Ansiedade Generalizada (TAG); fibromialgia. Contraindicações: Hipersensibilidade à pregabalina ou componentes da fórmula. Advertências e Precauções: pacientes com intolerância a galactose, deficiência de lactase de Lapp ou má absorção de glicose-galactose não devem utilizar Prebictal®. Categoria de risco na gravidez: C. Este medicamento não deve ser utilizado por mulheres grávidas sem orientação médica. Pacientes não devem dirigir, operar máquinas complexas ou se engajar em atividades potencialmente perigosas pois Prebictal® pode produzir tontura e sonolência. Interações Medicamentosas: pregabalina pode potencializar efeitos do etanol e lorazepam. Prejuízo aditivo na função cognitiva e coordenação motora causado pela oxicodona. Redução da função do trato gastrintestinal inferior (obstrução intestinal, íleo paralítico, constipação) quando pregabalina coadministrada com medicamentos com potencial para produzir constipação (ex: analgésicos opioides). Reações Adversas: Tontura e sonolência (mais frequentes e principais motivos da descontinuação). Posologia: Dose inicial: 150mg/dia, em 2 ou 3 tomadas; pode ser aumentada para 300mg/dia (100mg três vezes ao dia ou 150 mg duas vezes ao dia) dentro de uma semana; dose máxima: 600mg/dia. Favor consultar a bula para lista completa de EA e detalhes sobre posologia. VENDA SOB PRESCRIÇÃO MÉDICA. SÓ PODE SER VENDIDO COM RETENÇÃO DA RECEITA. Reg. MS: 12214.0082 (75mg e 150mg), 1.2214.0096 (100mg) e 12214.0092 (50mg). SAC: 0800-166575. Informações adicionais disponíveis aos profissionais de saúde mediante solicitação a Zodiac Produtos Farmacêuticos S.A. Praça José Lannes, 40 – CEP 04571-100 – São Paulo, SP. CONTRAINDICAÇÃO: hipersensibilidade conhecida a qualquer componente da formulação. INTERAÇÃO MEDICAMENTOSA: Pode potencializar os efeitos de bebidas alcoólicas e de lorazepam. Prebictal® é um medicamento. Durante seu uso, não dirija veículos ou opere máquinas, pois sua agilidade e atenção podem estar prejudicadas. FA - 117- 16. SE PERSISTIREM OS SINTOMAS, O MÉDICO DEVERÁ SER CONSULTADO. Referências bibliográficas: 1. Jensen MP, Chodroff MJ, Dworkin RH. The impact of neurophatic pain on health-related quality of life: review and implications. Neurology. 2007 April 68(15):1178-82. 2. Baidya DK, Agarwal A, Khanna O, et al. Pregabalin in acute and chronic pain. J Anaesthesiol Clin Pharmacol. 2011 Jul;27(3):307-14. 3. Boomershine CS. Pregabalin for the management of fibromyalgia syndrome. J Pain Res. 2010 Jun 22;3:81-8. 4. Freynhagen R, Grond S, Schüpfer G, et al. Efficacy and safety of thiocolchicoside and pregabalin in the treatment of acute non-specific low back pain: an open label randomized prospective study. Int J Clin Pract. 2007 Dec;61(12):1989-96. Epub 2007 Sep 24. 5. Freynhagen R, Serpell M, Emir B, et al. A comprehensive drug safety evaluation of pregabalin in peripheral neuropathic pain. Pain Pract. 2015 January;15(1):47-57. 6. Freynhagen R1, Strojek K, Griesing T, et al. Efficacy of pregabalin in neuropathic pain evaluated in a 12-week, randomised, double-blind, multicentre, placebo-controlled trial of flexibleand fixed-dose regimens. 2005 Jun;115(3):254-63. 7. Bula Prebictal® 50 mg. 8. Bula Prebictal® 75 mg e 150 mg. 9. Revista Kairos, dez/2016. 10. Apkarian AV, Bushnell MC, Treede RD et al. Human Brain mechenisms of pain perception and regulation in health and disease. Eur I Pain 9(2005); 463-484. 11. Arnold LM, Russel IJ, Din EW, et al. A 14-week, randomized, double-blinded, placebo-controlled monotherapy trial of pregabalin in patients with fibromyalgia. J Pain. 2008 Sep;9(9):792-805.

CÓDIGO DO MATERIAL: FA-231-17. PRODUZIDO EM JANEIRO/2018. CODEIN É UM MEDICAMENTO. DURANTE SEU USO, NÃO DIRIJA VEÍCULOS OU OPERE MÁQUINAS, POIS SUA AGILIDADE E ATENÇÃO PODEM ESTAR PREJUDICADAS. CONTRAINDICAÇÃO: DEPRESSÃO RESPIRATÓRIA. INTERAÇÃO MEDICAMENTOSA: OS EFEITOS DEPRESSORES DA CODEÍNA SÃO POTENCIALIZADOS POR MEDICAMENTOS DEPRESSORES DO SNC. Referências bibliográficas: 1. CMED. Preços de Medicamentos (Preço Fábrica e Preço Máximo ao Consumidor). Brasília: ANVISA; 2017. [citado 04 jan 2018]. Disponível em: http://portal.anvisa.gov.br/documents/374947/2829072/ LISTA+CONFORMIDADE_2017-12-19.pdf/5c8ce4c2-ed4f-4406-935c-ab2b7dfde42e 2. Saha S, Beach MC, Cooper LA. Patient centeredness, cultural competence and healthcare quality. J Natl Med Assoc. 2008;100(11):1275-85.3. Bula Codein. Reg. MS nº 1.0298.0199.4. Walker DJ, Zacny JP. Subjective, psychomotor, and analgesic effects of oral codeine and morphine in healthy volunteers. Psychopharmacology (Berl). 1998;140(2):191-201. CODEIN fosfato de codeína - comprimidos30 mg ou 60 mg, USO ORAL. USO ADULTO - solução oral 3 mg/mL, USO ORAL. USO ADULTO E PEDIÁTRICO ACIMA DE 02 ANOS. INDICAÇÕES: alívio da dor moderada. CONTRAINDICAÇÕES: hipersensibilidade a codeína, outros opioides ou excipientes da fórmula; diarreia associada à colite pseudomembranosa causada por cefalosporina, lincomicina ou penicilina; diarreia causada por envenenamento; depressão respiratória, especialmente em presença de cianose e excessiva secreção brônquica; dependência a drogas, inclusive alcoolismo; instabilidade emocional ou tentativa de suicídio; condições onde há aumento da pressão intracraniana; arritmia cardíaca; convulsão; função hepática ou renal prejudicada; inflamação intestinal; hipertrofia ou obstrução prostática; hipotireoidismo; cirurgia recente do trato intestinal ou urinário; gravidez e lactação.Solução oral também é contraindicada em recém-nascido e bebês prematuros. ADVERTÊNCIAS E PRECAUÇÕES: pode suprimir os movimentos peristálticos no trato gastrintestinal; contraindicado em pacientes com obstrução gastrointestinal, especialmente íleo paralítico. Precaução em pacientes com doença pulmonar obstrutiva crônica, cor pulmonale ou com reserva respiratória diminuída. Possui potencial de causar abuso e dependência.Suspensão pode causar abstinência. Polimorfismo genético da enzima CYP2D6 resulta na incapacidade de converter codeína em morfina ou incrementa o metabolismo;recomenda-se indicar para estes pacientes outro tipo de analgésico para evitar risco de ineficácia ou de severa toxicidade. Uso odontológico:analgésico opioide diminui ou inibe a formação de saliva (desenvolvimento da cárie, doença periodontal, candidíase oral e certo desconforto). Gravidez, trabalho de parto e lactação: considerar risco-benefício, atravessa a placenta e é excretado no leite materno;uso de analgésicos opioidesna gravidez está associado com efeitos adversos no feto; uso durante o trabalho de parto pode resultar na depressão respiratória do recém-nascido; para algumas mães metabolizadoras ultrarrápidas da codeína, pode haver risco de morte para o lactente. Durante o tratamento, o paciente não deve dirigir veículos ou operar máquinas, pois sua habilidade e atenção podem estar prejudicadas. A codeína se transforma em morfina, que se presente na urina pode gerar resultado positivo e ser sugestivo dedoping .A solução oral contém açúcar. INTERAÇÕES MEDICAMENTOSAS: depressores do Sistema Nervoso Central (SNC); quinadina; anticolinérgicos. Para demais interações, vide bula do medicamento. POSOLOGIA: duração e forma de tratamento farmacológico da dor com a codeína dependem do tipo de dor, se é aguda ou crônica.Adultos: usualmente 30 mg (de 15 a 60 mg), a cada 4 ou 6 h; até 360 mg/dia.Crianças: solução oral - 0,5-1,0 mg/kg a cada4a6h,dose diária máxima de 60 mg. Contraindicada para controle da dor pós-operatória da adenoidectomia e amidalectomia. Utilizar apenas quando os potenciais benefícios ultrapassarem os riscos. Codein comprimidos não é adequado para uso pediátrico. Pacientes Idosos: mais susceptíveis a depressão respiratória. Baixas doses ou longo intervalo entre as doses. Geralmente se hipertrofia ou obstrução prostática e enfraquecimento da função renal, apresentam retenção urinária quando uso de analgésico opioide. Insuficiência Renal: começar na menor dose efetiva e titular com cautela; sugere-seredução das doses de manutenção ou aumento dos intervalos entre as doses. Recomenda-se reduzir a dose para 75% da dose normal se insuficiência renal moderada e para 50% se insuficiência renal grave. Insuficiência Hepática: iniciar com a menor dose eficaz e titular com cuidado. É provável que uma redução da dose seja necessária. REAÇÕES ADVERSAS:Muito Comuns (>10%): sudorese, obstipação, náuseas, vômitos, tontura e vertigem, sedação, sonolência e dispneia. SUPERDOSE: depressão respiratória com ou sem depressão do SNC, além de outros sintomas. Assegurar e manter as vias aéreas livres, ventilação. Naloxona. Lavagem gástrica. APRESENTAÇÕES: embalagem com 30 comprimidos de 30 ou 60 mg; solução oral de 3mg/mL em embalagem com 1 frasco de 120 mL e dosador. Para mais informações, vide bula do medicamento. CRISTÁLIA - Produtos Químicos Farmacêuticos Ltda. - Farm. Resp.: Dr. José Carlos Módolo - CRF-SP Nº 10.446 - Rod. Itapira-Lindóia, km14, Itapira-SP - CNPJ n° 44.734.671/0001-51 - Indústria Brasileira - SAC 0800-7011918 - nº do Lote, Data de Fabricação e Prazo de Validade: Vide Rótulo/Cartucho. CLASSIFICAÇÃO: VENDA SOB PRESCRIÇÃO MÉDICA – SÓ PODE SER VENDIDO COM RETENÇÃO DA RECEITA -

AN-UVF-CDN-1-2º-15-FEV/2018 - Material de distribuição exclusiva à classe médica Reg. MS Nº 1.0298.0199 - SE PERSISTIREM OS SINTOMAS, O MÉDICO DEVERÁ SER CONSULTADO.