Vol. 02 No 01 Jan/Feb/Mar. 2019

ISSN 2595-3192

BrJPBRAZILIAN JOURNAL OF PAIN Vol. 02 No 01 Jan/Feb/Mar. 2019

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

CONTENTS

Volumen 2 – nº 1 EDITORIAL January to March, 2019 Education in pain ______1 Trimestral Publication Manoel Jacobsen Teixeira, Lin Tchia Yeng

ORIGINAL ARTICLES SOCIEDADE BRASILEIRA PARA O Chronic pain in the elderly, associated factors and relation with the level and volume of ESTUDO DA DOR physical activity______3 DIRECTORY Fátima Ferretti, Marcia Regina da Silva, Fabiane Pegoraro, Jéssica Elis Baldo, Clodoaldo Biennium 2018-2019 Antonio De Sá

President Chronic pelvic pain portraits: perceptions and beliefs of 80 women ______8 Eduardo Grossmann João Elias de Godoi, Dário Rafael Macêdo dos Reis, Jakeline Resende Carvalho, José Miguel Vice-President de Deus Paulo Renato Barreiros da Fonseca Scientific Director Knowledge, attitude and practice regarding pharmacological methods of labor analgesia ______14 José Oswaldo de Oliveira Junior Bianca Ruschel Hillmann, Ana Maria Nunes de Faria Stamm Administrative Director Dirce Maria Navas Perissinotti Access of men with sickle cell disease and priapism in emergency services ______20 Treasurer Heros Aureliano Antunes da Silva Maia, Mateus Andrade Alvaia, Jayanne Moreira Carneiro, Juliana Barcellos de Souza Aline Silva Gomes Xavier, José de Bessa Júnior, Evanilda Souza de Santana Carvalho Secretary Janaina Vall Immediate analgesic effect of 2KHz interferential current in chronic low back pain: randomized clinical trial ______27 Av. Conselheiro Rodrigues Alves, 937 Nicole Almeida, Luis Henrique Paladini, Madeline Pivovarski, Fernanda Gaideski, Raciele Ivandra Guarda Korelo, Ana Carolina Brandt de Macedo Cj. 2 – Vila Mariana 04014-012 São Paulo, SP Health professionals’ barriers in the management, evaluation, and treatment of neonatal Phone: (55) 11 5904-2881/3959 pain ______34 www.dor.org.br Marialda Moreira Christoffel, Danielle Lemos Querido, Ana Luiza Dorneles da Silveira, Bruna E-mail: [email protected] Nunes Magesti, Ana Letícia Monteiro Gomes, Ana Claudia Coelho Santos da Silva

Quotations of Brazilian Journal of Pain Validation of an educational booklet for people with chronic pain: EducaDor ______39 shall be abbreviated to BrJP. Ana Shirley Maranhão Vieira, Kamyle Villa-Flor de Castro, Janine Ribeiro Canatti, Iasmyn Adélia Victor Fernandes de Oliveira, Silvia Damasceno Benevides, Katia Nunes Sá BrJP is not responsible whatosever by opinions. Incidence of chest pain as a symptom of acute myocardial infarction in an urgent care unit ___ 44 Andreia Valeria de Souza Miranda, Luís Fernando Rampellotti Advertisements published in this edition do no generate conflict of intestests. Palliative care: epidemiological profile with a biopsychosocial look on oncological patients ______49 Karoline Sampaio Castôr, Ed Carlos Rey Moura, Emanuel Cabral Pereira, Deborah Costa Alves, Thamires Sales Ribeiro, Plínio da Cunha Leal

Indexada na SciELO Indexada na LILACS Indexada na Latindex Relationship between the perceived social support and catastrophization in individuals with chronic knee pain______55 Publication edited and produced by Bruna Almeida, Adriana Capela, Joana Pinto, Vânia Santos, Cândida G. Silva, Marlene MWS Design – Phone: (055) 11 3399-3038 Cristina Neves Rosa Journalist In Charge Marcelo Sassine - Mtb 22.869 REVIEW ARTICLES Pain curricular guidelines for Psychologists in Brazil ______61 Art Editor Jamir João Sardá Junior, Dirce Maria Navas Perissinotti, Marco Aurélio da Ros, José Luiz Dias Anete Salviano Siqueira SCIENTIFIC EDITOR Difficulties faced by nurses to use pain as the fifth vital sign and the mechanisms/actions Durval Campos Kraychete Federal University of Bahia, Salvador, BA – Brazil. adopted: an integrative review ______67

CO-EDITORS Allana Fernandes Valério, Karina da Silva Fernandes, Grazielle Miranda, Fábio de Souza Terra Ângela Maria Sousa University of São Paulo, São Paulo, SP – Brazil. Dirce Maria Navas Perissinotti Non-pharmacological therapies for postpartum analgesia: a systematic review ______72 University of São Paulo, São Paulo, SP – Brazil. Eduardo Grossmann Larissa Ramalho Dantas Varella Dutra, Alane Macatrão Pires de Holanda Araújo, Maria Federal University of Rio Grande do Sul, Porto Alegre, RS – Brazil. Irimar de Paula Posso Thereza Albuquerque Barbosa Cabral Micussi University of São Paulo, São Paulo, SP – Brazil. Janaina Vall Federal University of Ceara, Fortaleza, CE – Brazil. Adherence to fibromyalgia treatment: challenges and impact on the quality of life_____81 José Aparecido da Silva University of São Paulo, Ribeirão Preto, SP - Brazil. José Oswaldo de Oliveira Júnior, Júlia Villegas Campos Ramos 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 Effects of hydrokinesiotherapy in pain, trophism and muscle strength in a child with Federal University of Mato Grosso, Cuiabá, MT, Brazil. Maria Belén Salazar Posso juvenile idiopathic arthritis. Case report______88 Christian University Foundation, Pindamonhangaba, SP – Brazil. Matheus Santos Gomes Jorge, Sabrina Casarin Vogelmann, Lia Mara Wibelinger Sandra Caires Serrano Pontifícia Universidade Católica de Campinas, São Paulo, SP – Brazil. Telma Regina Mariotto Zakka University of São Paulo, São Paulo, SP – Brazil. Learning pain neuroscience education from the WHOQOL-Bref instrument in the

EDITORIAL COUNCIL classroom. Case reports______93 Abrahão Fontes Baptista Kênia Fonseca Pires, Tatiana Andrade Cacho, Luiza Nolêto dos Santos Federal University of Pernambuco, Recife, PE – Brazil. Alexandre Annes Henriques General Hospital of Porto Alegre, Porto Alegre, RS – Brazil. Fábio Henrique de Gobbi Porto INSTRUCTIONS TO AUTHORS______97 University of Sao Paulo, São Paulo, SP - Brazil. Guilherme Antônio Moreira de Barros School of Medicine of Botucatu, Botucatu, SP – Brazil. Hazem Adel Ashmawi University of São Paulo, São Paulo, SP – Brazil. Ismar Lima Cavalcanti University Iguacu, Rio de Janeiro, RJ – Brazil. Jamir Sardá Junior University of Vale do Itajaí, Itajaí, SC – Brazil. João Batista Santos Garcia Federal University of Maranhão, São Luiz, MA – Brazil. José Geraldo Speciali University of São Paulo, Ribeirão Preto – Brazil. José Tadeu Tesseroli de Siqueira University of São Paulo, São Paulo, SP – Brazil. Josimari Melo de Santana Federal University of Sergipe, Aracaju, SE – Brazil. Juliane de Macedo Antunes National Institute of Traumatology and Orthopedics, Rio de Janeiro, RJ – Brazil. Karina Gramani Say Federal University of São Carlos, São Carlos, SP - Brazil. Kátia Nunes Sá Bahia School of Medicine and Public Health, Salvador, BA – Brazil. Manoel Jacobsen Teixeira University of Sao Paulo, São Paulo, SP - Brazil. Mauro Brito de Almeida Federal University of Pará, Belém, PA - Brazil. Miriam Seligman de Menezes Federal University of Santa Maria, Santa Maria, RS – Brazil. Mirlane Guimarães de Melo Cardoso Federal University of Amazonas, Manaus, AM – Brazil. Onofre Alves Neto Federal University of Goiás, Goiânia, GO – Brazil. Oscar Cesar Pires University of Taubaté, Taubaté, SP - Brazil. Paulo Cesar Rodrigues Conti School of Dentistry of Bauru, Bauru, SP – Brazil. Renato Leonardo de Freitas University of Sao Paulo, Ribeirão Preto, SP – Brazil. Rosana Maria Tristão Federal University of Brasilia, Brasilia, DF - Brazil. Silvia Regina Dowgan Tesseroli de Siqueira University of Sao Paulo, Sao Paulo, SP – Brazil. Vania Maria de Araújo Giaretta University of Taubaté, Taubaté - SP. Brazil. Walter Lisboa de Oliveira Federal University of Sergipe, Aracaju, SE – Brazil.

INTERNATIONAL 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/. BrJP. São Paulo, 2019 jan-mar;2(1):1-2 EDITORIAL

Education in pain Educação em dor

DOI 10.5935/2595-0118.20190001

The biomedical literature grows exponentially, and knowledge about molecular biology and immunology is expanding more rapidly1. Early diagnoses, the use of effective and safe therapies with favorable results are current requirements. This means that the advances in areas related to symptoms control and clinical decisions should be incorporated into the new modes of knowledge transmission and care of patients with pain2,3. The improvement of health education programs does not occur at the same speed in which knowledge multiplies. Many schools include descriptive themes in their curricula rather than analytical subjects and critical and logical thoughts4. However, since the publication of the model of medical graduation based on the Flexner report of 19125, the teaching of health sciences has incorporated biocentric and technocentric visions. We started to study the human body by parts. The diseases are now considered biological, cellular and molecular malfunctioning. Medical schools were organized to train students in diseases, to be specialists working in hospitals but not trained to care patients and, consequently, physicians were stimulated and trained to perform physical or chemical interventions to normalize the functioning of the body with an insufficient notion of the individual as a whole and in the society6. Some medical and paramedical concepts and practices are kept alive and widely disseminated and performed because they are truly useful, safe and effective. However, many are still used and will remain indefinitely, even without any evidence, substrates or grounds justifying their applicability because they sustain, adapt and surreptitiously propagate themselves based on poorly elaborated concepts about their realities7. This means that the awareness, dissemination and strategic use of good quality information can make a significant contribution so that, in future, the procedures that aim at the prevention and control of pain are used in a rational way and without the biases of traditions and interests other than the benefit of those who suffer from pain7,8. The meaning of medicine in the society and the relationship between health professionals, health policymakers and patients undergo constant change. The content and dissemination of medical curricula also evolve to ensure consistent delivery of high-quality medical services. Therefore, having the curriculum as an institutional educational proposal with the objective of informing, executing and evaluating educational programs with an ordered sequence of contents, and making appropriate use of the media to make public the scientific achievements and the rational application of health policies can contribute to revert this trend, both for the general population and for the professionals involved in the planning, prevention and treatment of pain9. We see progress in the areas of education, training, accreditation of professionals and care services in parallel with advances in pharmacology, rehabilitation, psychotherapy, and interventional pain procedures. Practitioners working in environments designated for primary care currently have the opportunity to receive good quality training on more common issues related to pain in undergraduate courses and symposiums organized by official and associative entities, without the influence of entities concerned only with profit. The creation of the Pain Leagues, the incorporation of the theme of pain in the undergraduate and graduate medical and paramedical curricula and in the university extension courses, the organization of internship programs in pain in the areas of medicine, dentistry, veterinary and psychology, fulfilled, in part, the needs of technical pain training with comprehensive information, provided that interventions are not the predominant or exclusive focus. Professionals dedicated to the treatment of pain working in clinics, isolated units, clinics or specialized centers should more significantly incorporate mental health, rehabilitation and education programs in the treatment, especially of chronic wild pain. For specialized professionals, simulation techniques have been developed to improve the skills to perform invasive or non-invasive procedures and, at the same time, better-founded guidelines have been developed for the application of prophylactic methods, drugs and invasive or non-invasive interventions in patients with pain6. There is an increasing number of studies on health education and controlled research with random samples on prevention, effectiveness of new drugs and therapeutic models, combinations of treatments with other interventions, the connection of therapeutic models with the mechanisms of pain responsible for different pain syndromes, identification of predictors of therapeutic responses, adequacy of treatments or characteristics of treatments to the individual characteristics of patients, and long-term maintenance of the positive responses to treatment of appropriately selected patients10,11.

Manoel Jacobsen Teixeira Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo, SP, Brasil. E-mail: [email protected] Lin Tchia Yeng Universidade de São Paulo, Faculdade de Medicina, Departamento de Fisiatria, Clínica de Funcionalidade e Dor, São Paulo, SP, Brasil. E-mail: [email protected]

1 BrJP. São Paulo, 2019 jan-mar;2(1):1-2 Teixeira MJ and Yeng LT

REFERENCES 6. Pimenta CA, Teixeira MJ, Simões P, Simões C, da Cruz Dde A, Okada M. [Lea- gue against pain: an experiment in extracurricular teaching]. Rev Esc Enferm USP. 1998;32(3):281-9. Portuguese. 1. Boulos M. Objetivos do ensino médico. Documentos CEDEM FMUSP; 1994. 45-54p. 7. Moritz E. Memetic science: I. General introduction. J Ideas. 1990;1:1-23. 2. O’Donnell JF, Baron JA. A strategy to teach medical decision making within a medical 8. Moritz E. Metasystems, memes and cybernetic immortality. In: Heylighen F, Joslyn C, school curriculum. J. Cancer Educ. 1991;6(3):123-8. Turchin V, eds. The quantum of evolution: toward a theory of metasystem transitions. 3. Saunders DC. The evolution of the hospices. In: The history of the management of New York: Gordon & Breach Science Publishers; 1995. 155-71p. pain: from early principles to present practice. [S.l.]: Carnforth, Lancs, Pathernnon P. 9. Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, et al. Health professionals Group, 1988. 167-78p. for a new century: transforming education to strengthen health systems in an interde- 4. Flexner A. Medical Education in the United States and Canada: A Report to the Car- pendent world. Lancet. 2010;376(9456):1923-58. negie Foundation for the Advancement of Teaching, Bulletin No 4, New York City: 10. Carr DB, Cousins MJ. Trends in pain management 1987-1996: an evidence-based The Carnegie Foundation for the Advancement of Teaching; 1910. survey. Curr Opin Anaesthesiol. 1997;10(5):xliii-xlvi. 5. Conferência Internacional dobre Cuidados Primários de Saúde Alma-Ata, URSS, 11. Worley SL. New directions in the treatment of chronic pain national pain strategy 6-12 de setembro de 1978. will guide prevention, management, and research. PT. 2016;41(2):107-14.

2 BrJP. São Paulo, 2019 jan-mar;2(1):3-7 ORIGINAL ARTICLE

Chronic pain in the elderly, associated factors and relation with the level and volume of physical activity Dor crônica em idosos, fatores associados e relação com o nível e volume de atividade física

Fátima Ferretti1, Marcia Regina da Silva2, Fabiane Pegoraro3, Jéssica Elis Baldo3, Clodoaldo Antonio De Sá1

DOI 10.5935/2595-0118.20190002

ABSTRACT RESUMO

BACKGROUND AND OBJECTIVES: Chronic pain is asso- JUSTIFICATIVA E OBJETIVOS: A dor crônica está associa- ciated with functional limitations in the elderly, negatively af- da a limitações funcionais em pessoas idosas, afetando negativa- fecting the health of this population. The activity and/or physi- mente a saúde dessa população. A atividade e/ou exercício físico cal exercise has been proposed as a non-drug intervention with tem sido proposto como uma intervenção não farmacológica positive effects in the treatment of chronic pain. Thus, this study com efeitos positivos no tratamento da dor crônica. Assim, este aimed to identify the prevalence of chronic pain in the elderly, estudo objetivou identificar a prevalência de dor crônica em ido- analyze the factors associated with pain and its relationship with sos, analisar os fatores associados à dor e sua relação com o nível the level and volume of physical activity practice. e volume de prática de atividades físicas. METHODS: Quantitative and cross-sectional research with 385 MÉTODOS: Pesquisa quantitativa e transversal com 385 idosos elderly (67.3% women and 32.7% men) who were evaluated re- (67,3% mulheres e 32,7% homens) que foram avaliados quanto garding the level and volume of physical activity practice, the pres- ao nível e volume de prática de atividades físicas, presença de ence of chronic diseases, presence and intensity of chronic pain. doenças crônicas, presença e intensidade de dor crônica. RESULTS: The prevalence of chronic pain in the sample was RESULTADOS: A prevalência de dor crônica na amostra estu- 58.2% and was associated with the gender and the presence of dada foi de 58,2% e foi associada com o sexo e com a presença chronic diseases (p<0.001). The median pain intensity was high- de doenças crônicas (p<0,001). A mediana da intensidade da dor er in sedentary women (p=0.005), as they presented a lower vol- foi mais alta em mulheres sedentárias (p=0,005), assim como ume of physical activity practices (p<0.001). elas apresentaram menor volume de prática de atividades físicas CONCLUSION: The prevalence of chronic pain among the (p<0,001). evaluated elderly is high and associated with the presence of CONCLUSÃO: A prevalência de dor crônica entre os idosos chronic diseases and to gender, being more prevalent among avaliados é alta e está associada à presença de doenças crônicas e women. Sedentary or insufficiently active elderly women report ao sexo, sendo mais prevalente entre as mulheres. Mulheres ido- higher pain intensity than active and very active women. There is sas sedentárias ou insuficientemente ativas relatam maior inten- poor correlation indicating that the level of physical activity de- sidade da dor do que as ativas e muito ativas. Há fraca correlação creases with increasing pain intensity and the number of chronic indicando que o nível de atividade física diminui com o aumento diseases. Elderly people with chronic pain have significantly low- da intensidade da dor e o número de doenças crônicas. Idosas er volumes of physical activity practice than those who do not. com dor crônica apresentam volumes de prática de atividade físi- Keywords: Chronic disease, Chronic pain, Elderly, Physical activity. ca significativamente menores do que as que não possuem. Descritores: Atividade física, Doença crônica, Dor crônica, Idoso.

Fátima Ferretti - https://orcid.org/0000-0002-0326-2984; INTRODUCTION Marcia Regina da Silva - https://orcid.org/0000-0002-9930-3102; Fabiane Pegoraro - https://orcid.org/0000-0003-4570-4880; Jéssica Elis Baldo - https://orcid.org/0000-0002-8171-8086; Brazil is experiencing a demographic transition characterized Clodoaldo Antonio De Sá - http://orcid.org/0000-0001-7409-8870. by the aging of its population. Data from the Brazilian Institute

1. Universidade Comunitária da Região de Chapecó, Programa de Pós-Graduação Stricto of Geography and Statistics (IBGE) indicate that the popula- Sensu em Ciências da Saúde, Chapecó, SC, Brasil. tion in the country is approximately 188 million inhabitants, 2. Universidade Comunitária da Região de Chapecó, Curso de Fisioterapia, Chapecó, SC, Brasil. 3. Universidade Comunitária da Região de Chapecó, Chapecó, SC, Brasil. of which 20 million are elderly and projections suggest that in 2030 the elderly will reach 41.5 million Brazilians. This picture Submitted in May 06, 2018. has reflected changes in the morbidity and mortality profile, Accepted for publication in September 04, 2018. Conflict of interests: none – Sponsoring sources: none with a higher occurrence of chronic diseases, with a higher prevalence among women1. Correspondence to: Servidão Anjo da Guarda, nº 295-D – Bairro Efapi Among chronic conditions, pain is one of the most common and 89809-900 Chapecó, SC, Brasil. is associated, in most cases, with musculoskeletal dysfunction E-mail: [email protected] and tissue injury, negatively interfering with the health of the © Sociedade Brasileira para o Estudo da Dor elderly2. Chronic pain is characterized as persistent events with 3 BrJP. São Paulo, 2019 jan-mar;2(1):3-7 Ferretti F, Silva MR, Pegoraro F, Baldo JE and De Sá CA a duration of at least three months, of a biopsychosocial nature, Each elderly in the home was informed about the purpose of which constitute an important public health problem, whose the research, its relevance, objectives, methods, expected ben- coping requires a multidisciplinary approach3. In general, associ- efits, potential risks associated with study participation, and ated with chronic pathological processes that last for months or how data would be collected and used later. All subjects who years, chronic pain has become the main complaint and cause agreed to participate in the study signed an Free and Informed of functional limitations in the elderly4, strongly affecting their Consent Form (FICT). independence in the accomplishment of daily tasks. All participants signed the FICT. Each participant was assessed On the one hand, sedentarism has been associated with an in- in relation to their cognitive ability through the MMSE. If the crease in chronic diseases5, the practice of mild, moderate or defined score for the inclusion criteria was reached, the partic- intense physical activity has been positively associated with the ipant moved to the next step that included the General Data positive perception of the health of the elderly6. In general, the questionnaire for the Elderly, adapted from Morais10, the pain elderly Brazilian population has been concerned with maintain- assessment using the visual numeric scale (VNS)11 and the ing a healthier, more active and independent life. The incentive Physical Activity Level (PAL) Assessment questionnaire, the to practice physical activities and/or exercises have been listed International Physical Activity Questionnaire (IPAQ) - short as an objective of different public policies and programs in the version12. health area7, with the potential to promote a healthy quality of The study followed all the recommendations of Resolution life, especially if they are performed in a systematic way8. This 466/2012/CONEP/CNS/MS and was approved by the Hu- study aimed to identify the prevalence of chronic pain in the man Research Ethics Committee of the institution under num- elderly, analyze the factors associated with pain and its relation ber CAAE n.613611160.0000.0116. with the level and volume of physical activity (PA) practice. Statistical analysis METHODS The data was organized and tabulated initially in the Micro- soft Excel spreadsheet. The descriptive statistics of the data This is a quantitative, analytical and cross-sectional research. were initially used. The statistical test of Shapiro-Wilk was The sample consisted of 385 elderly living in the urban area used to verify the normality of the data. The measures of fac- of the city of Chapecó/SC. The sample size was calculated tors associated with chronic pain were analyzed by the chi- based on a finite population of 13,606 elderly of both gen- square test. The Spearman correlation was used to check the ders1, considering a 95% confidence interval and a margin of correlation between the variables physical activity (PA) vol- error of 5%. ume with the number of chronic diseases and the intensity of The study included individuals of both genders over 60 pain by gender. The Mann-Whitney U-test was used for the years old, who had preserved cognitive ability, tested by the comparison of the median of the pain rating data by PAL of Mini-Mental State Examination (MMSE)9 (adopted as a crite- the elderly by gender, and the median of the volume of PA in rion score equal to or greater than 24, corrected for 17, when the elderly with and without chronic pain by gender. The data education was less than four years). were analyzed by the Statistical Package for Social Science for Elderly who were absent from the home on two visits by the Windows - SPSS version 20.0, and the significance level was researcher, or who were bedridden, or making use of ancillary set at p<0.05. devices for locomotion, such as wheelchairs were excluded from the sample. RESULTS The researchers who participated in the data collection were trained to use the instruments and conducted a pilot study that Table 1 presents the characterization data of the study sample involved the collection, extraction, and tabulation of the data. as age, gender, presence or absence of chronic pain and its in- The data collection was organized from the census map of the tensity. municipality, which includes 38 tracts. 11 census tracts were The presence of chronic pain in the studied sample was 58.2% randomly selected. The maps of these tracts were printed so and presented a statistically significant association (p<0.05) that researchers could plan the collection from the streets of with gender and the presence of chronic diseases (Table 2). each neighborhood. Every two houses, the first one was drawn Comparison of the median of the pain rating data by PAL and when the place was a building, all people over 60 years old among the elderly by gender shows significant results only for were interviewed. Lots and commercial establishments were women (Table 3). excluded and, when pulled, moved to the next home – and so There was a weak correlation between the PA volume and the on, in every street until reaching the sample. The visits were number of chronic diseases only for women (M-rs=-0.168 carried out from June to August of 2016 in all the residences p=0.007/H-rs=-045 p=0.615) and with pain intensity (M-rs=- of the tracts and streets drawn. Each researcher recorded the 0.230 p= 0.001/H-rs=-115 p=0.198). collection done at the elderly’s home on the map that was pre- The comparison of the medians of the PA volume in the elder- viously received. The research team met every Friday to assess ly with and without chronic pain by gender is shown in table the progress of collections, check the streets covered, enter the 4 and shows statistically significant results only for women data on the worksheet, and plan the following week. (p<0.05). 4 Chronic pain in the elderly, associated factors and relation BrJP. São Paulo, 2019 jan-mar;2(1):3-7 with the level and volume of physical activity

Table 1. Sample characteristics according to age group, gender, the DISCUSSION presence of chronic diseases, number of chronic diseases, chronic pain and its intensity, 2017 In this study, there was a predominance of the female gender, Variables Classification n= 385 (%) represented by 67.3% (n=259) and 60 to 69 years old in 45.5% Age (years old) 60-69 175 (45.5) (n=175), which is similar to the data presented by IBGE for this 70-79 154 (40.0) 1 ≥ 80 56 (14.5) region of Brazil . Literature already shows the feminization of old age, a factor associated with the greater care and awareness Gender Male 126 (32.7) Female 259 (67.3) that women have regarding their health, which leads them to 13,14 Chronic diseases Yes 331 (86.0) seek more health services and preventive programs . No 50 (13.0) One of the results of this study was the presence of chronic dis- Number of diseases None 50 (13.0) eases in 86% of the sample (n=331). These data are superior 15 Up to 3 304 (79.0) to that of the study by Silva and Catão carried out with 230 4 or more 31 (8.0) elderly in the state of Paraíba, where 69.5% of the population Chronic pain (VNS) None 161 (41.8) reported having a chronic disease. Another study with 1,062 Mild 40 (10.4) elderly showed that 74% reported the presence of chronic dis- Moderate 109 (28.3) eases16. These data show the high occurrence of these diseases in Severe 75 (19.5) the elderly. Healthy habits practice physical exercises and access VNS = visual numeric scale (0 = no pain; 1-3 = mild; 4-7 = moderate; 8-10 = severe). to health care can minimize the suffering that these diseases produce in the elderly’s life. In this sample 58.2% (n=221) presented chronic pain and in Table 2. Factors associated with the presence of chronic pain in the 28.3% (n=109) the intensity was moderate. A research conduct- 2 elderly, 2017 ed by Dellaroza and Pimenta with 451 elderly in the state of Variables Presence of chronic pain p-value Paraná, found a prevalence of pain in 51.4%, with 38.43% reporting moderate intensity, and a study by Landmark et al.17 con- Yes n (%) No n (%) ducted in Norway with 10,249 elderly identified that 35.13% Gender reported chronic pain of moderate intensity. It was observed in Male 57 (45.2) 69 (54.8) 0.001* these studies that chronic pain affected more than 50% of the Female 167 (64.5) 92 (35.5) population. The fact that the elderly live with painful conditions Age (years old) can cause suffering and different intercurrences in the health and 60 to 74 157 (59.5) 107 (40.5) 0.449 quality of life of this population. 75 or more 67 (55.4) 54 (44.6) In the two elderly groups, with pain and without chronic pain, there was a predominance of active and very active elderly, representing Physical activity level 50% (n=112) and 57.1% (n=92), respectively. Another important Sedentary or insuffi- 112 (69.9) 69 (38.1) 0.166 cient active finding in the study was the low sedentary classification in the elderly group with chronic pain, representing 10.7% (n=24) and without Active or very active 112 (54.9) 92 (45.1) chronic pain 3.7% (n=6). When considering the total sample, the Chronic disease percentage was less than 10% (7.8%), with 30 sedentary elderly. Presence 208 (62.1) 127 (37.9) 0.001* A research of 367 elderly women (60 years old or older) from the Absence 16 (32.0) 34 (68.0) cities of Presidente Prudente-SP and Uberaba-MG, who sought p = Pearson’s Chi-square statistic. * Significance level: p<0.05. to assess the PA level and the anthropometric variables of these

Table 3. Comparison of the medians of the pain scale of the elderly by the level of physical activity and gender, 2017 Group Male (n=126) p-value Female (n=259) p-value PAL ME (IQR) ME (IQR) Sedentary or insufficient active 0 (0-4) 0.132 5 (0-8) 0.005* Active or very active 2 (0-5.5) 2 (0-7) PAL = physical activity level; ME = median; IQR = interquartile range; p = Mann-Whitney U-statistic. * Significance level: p<0.05.

Table 4. Comparison of the medians of the physical activity volume of the elderly with and without chronic pain by gender, 2017 Variables Male (n=126) p-value Female (n=259) p-value PAVol (min/week) ME (IQR) ME (IQR) Presence of chronic pain 180 (77.5-242.5) 0.338 130 (75-240) 0.001* Absence of chronic pain 150 (100-300) 210 (132.5-297.5) PAVol (min/week) = physical activity volume in minutes per week. ME = median; IQR = interquartile range; p = Mann-Whitney U-statistic. * Significance level: p<0.05.

5 BrJP. São Paulo, 2019 jan-mar;2(1):3-7 Ferretti F, Silva MR, Pegoraro F, Baldo JE and De Sá CA women, found a similar result to that of this study (80.4 %) chronic conditions, including limitations of mobility, pain and were considered active and participated - on average, 1 year and emotional problems. 3 months - of PA programs18. Another study17 conducted in Norway with 10,249 elderly Other results diverge from the results of this study. A study by over 65 years old identified that increased frequency, duration, Lima et al.19 found an index of 66.9% of sedentary women in and intensity of recreational exercise was associated with lower 220 senior women. The results of the study by Macedo et al.20 chronic pain. Elderly who exercise at least two to three times a with 173 elderly showed that 33.72% (n=57) of the sample week have a 27% lower prevalence of chronic pain compared to were sedentary. The results found in the study show that the those who do not practice physical exercises, and the associations surveyed elderly are less sedentary than the elderly studied in were stronger among women than in men. Therefore, even with the cited studies. pain, physical exercise is effective, if planned according to the This divergent reality between the data of this research and specificities of each clinical picture. The increase of chronic dis- those found in the literature, regarding the percentage of ac- eases during aging is a factor that reduces the PA level among the tives and sedentary ones, can be explained by the fact that in elderly26. A study by Lopes et al.7 stated that the advancement the municipality where the research was carried out, the place of age might be accompanied by a higher number of chronic for specific PA practices for the elderly was implanted for more diseases, which has limited the PA practice. than a decade, called “City of the Elderly”. In this place, vis- The decrease in the PA practice in the elderly with limitations itors have access to medical consultation with a geriatrician, or chronic diseases may be associated with the fear that PA can supervised PA practice, such as bodybuilding, dance, Pilates, increase painful condition or increase the onset of other lesions. soil and water aerobics, as well as living space, games room, A study by Larsson et al.27 analyzed the influence of pain and cinema, among other benefits. The place is intended for all the kinesophobia characteristics (excessive fear of injury or re-inju- elderly in the municipality and activities are carried out fre- ry) as predictors of failure to perform PA in 1,141 elderly with quently twice a week. This public policy may have encouraged chronic self-reported pain. The study revealed that the PA level the elderly to remain more active. On the other hand, those was significantly lower among the elderly with chronic pain and with chronic pain of mild and moderate intensity, seek in phys- significantly associated with kinesophobia. ical exercise, the minimization of painful conditions, especially A study carried out in Brazil, by Silva, Abreu and Suassuna28 those resulting from postural alterations. with 30 elderly women with chronic pain, who sought to iden- On the other hand, when the intensity of chronic pain is high, tify the occurrence of kinesophobia, observed a presence of 80% it becomes one of the main factors limiting the performance of of them experiencing this condition. There was a moderate sig- PA in the elderly7. Leijon et al.21 when researching 1,358 patients nificant correlation between physical performance and kineso- enrolled in primary health care settings in Sweden, observed that phobia (r=541; p=0.002), revealing that the high incidence of pain was the most common reason for non-adherence to the kinesophobia in the elderly assessed compromised their physical practice of PA among older patients. performance. A study in Germany22 that analyzed the barriers to PA in 1,937 Encouraging a healthy lifestyle with regular PA practices reduces elderly with a mean age of 77 years old, observed that the three the risk of developing chronic diseases in this population29. The most cited barriers were poor health (57.7%), lack of compa- promotion of PA associated with better living conditions can ny (43.0%) and lack of interest (36.7%). Ensuring an active positively impact the quality of life of the general population. life, regardless of whether or not he/she has pain, can minimize Within this context, the health team must plan health actions painful conditions. Preventive programs that create mecha- not only with a view to treating the clinical conditions of this nisms of adhesion and stimulation to the PA practice need to phase of life, but also to carry out interventions aimed at pre- be strengthened23. venting, maintaining and promoting the health and functional The comparison of the PA level with the intensity of pain showed independence of the elderly to enjoy life with longevity. that sedentary or insufficiently active old women presented higher pain intensity than the active and very active ones. The results CONCLUSION of the correlation between the variables indicate that the PA volume decreases with the increased pain intensity and the number The presence of chronic pain is associated with a higher number of chronic diseases for women, although the correlation was con- of chronic diseases, by gender (women) and sedentary lifestyle. sidered weak (below -0.3)24. Sedentary or insufficiently active elderly women report greater Another fact observed in the study was related to the PA volume intensity of pain when compared to active and very active. There in the elderly with or without chronic pain. This aspect was ob- was also a weak negative, and statistically significant correlation served in women, where the PA volume is significantly lower in between the PA volume practiced with the intensity of pain and those with chronic pain. the number of chronic diseases in elderly women, and the PA A study by Sawatzky et al.25 examined PA as a mediator of the level decreased with increasing pain intensity and the number of impact of chronic conditions in the elderly in Canada. The au- chronic diseases. Regarding the PA practice volume, the study thors found that the elderly with chronic conditions are less like- identified that elderly women with chronic pain have significantly to engage in leisure PA of at least 1,000 Kcal per week. This ly lower volumes of PA practice than those who do not have association partially explained some negative consequences of chronic pain. 6 Chronic pain in the elderly, associated factors and relation BrJP. São Paulo, 2019 jan-mar;2(1):3-7 with the level and volume of physical activity

REFERENCES 14. Gomes KV, Zazá DC. Motivos de adesão à prática de atividade física em idosas. Revis- ta Brasileira de Atividade Física & Saúde. 2009;14(2):132-8. 15. Silva AD, Catão MH. Doenças sistêmicas em idosos não institucionalizados. HU Rev. 1. IBGE – Instituto Brasileiro de Geografia e Estatística. Distribuição da população por 2012;37(3):299-303. sexo, segundo os grupos de idade Brasil. Rio de Janeiro: IBGE; 2010. 16. Benedetti TR, Mazo GZ, Borges LJ. Condições de saúde e nível de atividade física em 2. Dellaroza MS, Pimenta CA. Impacto da dor crônica nas atividades de vida diária de idosos participantes e não participantes de grupos de convivência de Florianópolis. idosos da comunidade. Ciênc Cuid Saude. 2012;11(Suppl):235-42. Ciênc Saúde Coletiva. 2012;17(8):2087-93. 3. dos Santos FA, de Souza JB, Antes DL, d’Orsi E. Prevalence of chronic pain and its 17. Landmark T, Romundstad P, Borchgrevink PC, Kaasa S, Dale O. Associations be- Association with the sociodemographic situation and physical activity in leisure of tween recreational exercise and chronic pain in the general population: evidence from elderly in Florianópolis, Santa Catarina: population-based study. Rev Bras Epidemiol. the HUNT 3 study. Pain. 2011;152(10):2241-7. 2015;18(1):234-47. English, Portuguese. 18. Paulo TR, Gomes IC, Santos VR, Christofaro DG, Castellano SM, Freitas Júnior 4. Dellaroza MS, Pimenta CA, Duarte YA, Lebrão ML. [Chronic pain among elderly IF. Atividade física e estado nutricional: fator de proteção para doenças crônicas não residents in São Paulo, Brazil: prevalence, characteristics, and association with func- transmissíveis (DCNT) em idosas? Rev Bras Promoç Saúde. 2014;27(4):527-32. tional capacity and mobility (SABE Study)]. Cad. Saude Piblica.2013;29(2):325-34. 19. Lima AP, Lini EV, Tomicki C, Dellani MP, Portella MR, Doring M. Fatores associados Portuguese. à atividade física em idosos de Estação, Rio Grande do Sul: estudo de base populacio- 5. Lee IM, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT. Effect of physical nal. Rev Bras Ativ Fis Saúde. 2015;20(6):618-22. inactivity on major non-communicable diseases worldwide: an analysis of burden of 20. Macedo RM, Oliveira MR, Cilião MR, Prosdócimo AC, Macedo AC, França D, et disease and life expectancy. Lancet. 2012;380(9838):219-29. al. Nível de atividade física de idosos participantes de um programa de prevenção de 6. Cho SI, An DH. Effects of a fall prevention exercise program on muscle strength and doença cardiovascular. ASSOBRAFIR Ciência. 2015;6(3):11-20. balance of the old-old elderly. J Phys Ther Sci. 2014;26(11):1771-4. 21. Leijon ME, Faskunger J, Bendtsen P, Festin K, Nilsen P. Who is not adhering to phys- 7. Lopes MA, Krug RR, Bonetti A, Mazo GZ. Barreiras que influenciaram a não adoção ical activity referrals, and why? Scand J Prim Health Care. 2011;29(4):234-40. de atividade física por longevas. Rev Bras Ciênc Esporte. 2016;38(1):76-83. 22. Moschny A, Platen P, Klaassen-Mielke R, Trampisch U, Hinrichs T. Barriers to physi- 8. Binotto MA, Tassa KO. Atividade física em idosos: uma revisão sistemática baseada cal activity in older adults in Germany: a cross-sectional study. Int J Behav Nutr Phys no International Physical Activity Questionnaire (IPAQ). Estud Interdiscip Envelhec. Act. 2011;8(121):1-10. 2014;19(1):249-64. 23. Fernandes BL. Atividade Física no processo de envelhecimento. Rev Portal Divulg. 9. Crum RM, Anthony JC, Bassett SS, Folstein MF. Population-based norms 2014;4(40):43-8. for the Mini-Mental State Examination by age and educational level. JAMA. 24. Callegari-Jacques SM. Bioestatística: princípios e aplicações. Porto Alegre: Artmed; 1993;269(18):2386-91. 2003. 10. Morais EP. Envelhecimento no meio rural: condições de vida, saúde e apoio aos idosos 25. Sawatzky R, Liu-Ambrose T, Miller WC, Marra CA. Physical activity as a mediator of mais velhos de Encruzilhada do Sul-RS. (Tese) Ribeirão Preto: Universidade de São the impact of chronic conditions on quality of life in older adults. Health Qual Life Paulo, Escola de Enfermagem de Ribeirão Preto, Doutorado em Enfermagem; 2007. Outcomes. 2007;5(68):1-11. 11. Ciena AP, Gatto R, Pacini VC, Picanço VV, Magno IM, Loth EA. Influência da inten- 26. Coelho CF, Burini RB. Atividade física para prevenção e tratamento das doenças crôni- sidade da dor sobre as respostas nas escalas unidimensionais de mensuração da dor em cas não transmissíveis e da incapacidade funcional. Rev Nutr. 2009;22(6):937-46. uma população de idosos e de adultos jovens. Semina: Ciências Biológicas e da Saúde. 27. Larsson C, Ekval Hansson E, Sundquist K, Jakobsson U. Impact of pain character- 2008;29(2):201-12. istics and fear-avoidance beliefs on physical activity levels among older adults with 12. Matsudo SM, Araújo T, Matsudo V, Andrade D, Andrade E, Oliveira LC, et al. Ques- chronic pain: a population-based, longitudinal study. BMC Geriatr. 2016;16(1):2-8. tionário internacional de atividade física (IPAQ): estudo de validade e reprodutibili- 28. Silva NS, Abreu SS, Suassuna PD. Ocorrência de cinesiofobia e fatores associa- dade no Brasil. Revista Brasileira de Atividade Física & Saúde. 2001;6(2):5-18. dos em idosas com dor crônica musculoesquelética: um estudo piloto. Rev Dor. 13. Victor JF, Ximenes LB, Almeida PC, Vasconcelos FF. Perfil sociodemográfico e clíni- 2016;17(3):188-91. co de idosos atendidos em Unidade Básica de Saúde da Família. Acta Paul Enferm. 29. Valério MP, Ramos LR. Promoção de atividade física à população idosa: revisando 2009;22(1):49-54. possibilidades. Rev Didática Sistêmica. 2013;15(2):155-73.

7 BrJP. São Paulo, 2019 jan-mar;2(1):8-13 ORIGINAL ARTICLE

Chronic pelvic pain portraits: perceptions and beliefs of 80 women Retratos da dor pélvica crônica: percepções e crenças de 80 mulheres

João Elias de Godoi1, Dário Rafael Macêdo dos Reis1, Jakeline Resende Carvalho1, José Miguel de Deus2

DOI 10.5935/2595-0118.20190003

ABSTRACT RESUMO

BACKGROUND AND OBJECTIVES: Because of its expressive JUSTIFICATIVA E OBJETIVOS: Por sua expressiva prevalên- prevalence and difficult clinical management, chronic pelvic pain is cia e difícil manuseio clínico, a dor pélvica crônica é importante an important cause of morbidity, disability, and reduction of quality causa de morbidade, incapacidade e redução da qualidade de of life in women. Psychological factors influence the perception of vida em mulheres. Fatores psicológicos podem influenciar a per- pain and can interfere in the medical approach, justifying the appli- cepção da dor e interferir na abordagem médica, justificando a cation of projective tools, such as the pain portrait, previously not aplicação de recursos projetivos, como o retrato da dor, ante- applied in women with chronic pelvic pain. The objective of this riormente não aplicado em mulheres com dor pélvica crônica. study was to obtain a greater clarification about the psychological Objetivou-se trazer maior esclarecimento sobre a influência do component in the assessment of the chronic pelvic pain by applying componente psicológico na avaliação da dor pélvica crônica, por the pain portrait in women with chronic pelvic pain. meio da aplicação do retrato da dor em mulheres com dor pél- METHODS: This is an exploratory cross-sectional study con- vica crônica. ducted with 80 women with chronic pelvic pain. It was applied a MÉTODOS: Trata-se de um estudo de corte transversal ex- pre-structured interview to collect sociodemographic, behavioral ploratório realizado com 80 mulheres com dor pélvica crônica. and clinical data. The pain portrait was applied to investigate the Utilizou-se de entrevista pré-estruturada para coletar dados so- perceptions and beliefs about pain. The drawings were classified ciodemográficos, comportamentais e clínicos e, para investigar by content analysis and consensus among the authors. percepções e crenças sobre a dor, aplicou-se o retrato da dor. Os RESULTS: The average age of the participants was 39.40±9.21 desenhos foram avaliados e classificados por meio de análise de years, average pain intensity of 7.03±2.58 and average pain du- conteúdo e consenso entre os autores. ration of 8.84±7.65 years. The main portraits referred to negative RESULTADOS: As participantes tinham média de idade de feelings (37.50%), harmful instruments (33.75%) and geometric 39,40±9,21 anos, intensidade álgica média de 7,03±2,58 e du- forms (25%), with a predominance of cold colors (63.70%). More ração média de 8,84±7,65 anos. Os principais retratos reme- than 60% of the participants put hope only in medical procedures, tiam a sentimentos negativos (37,50%), instrumentos lesivos while 25% believed that there was no solution to their pain. (33,75%) e formas geométricas (25%), com predomínio de cores CONCLUSION: Women represented their chronic pelvic pain frias (63,70%). Mais de 60% das participantes depositavam es- in an affective way, with the use of few and cold colors. They perança apenas em procedimentos médicos, enquanto 25% delas considered themselves having a passive role in their treatment acreditavam não haver solução para sua dor. and related their pain to family losses. CONCLUSÃO: As mulheres retrataram sua dor pélvica crônica Keywords: Chronic pain, Pain assessment, Pelvic pain, Psycho- de modo afetivo, com uso de poucas cores e cores frias. Consid- social effects of the disease, Women. eraram-se em papel passivo no tratamento, além de relacionar a sua dor a perdas familiares. Descritores: Avaliação da dor, Dor crônica, Dor pélvica, Efeitos psicossociais da doença, Mulheres.

João Elias de Godoi: http://orcid.org/0000-0001-8754-5844; Dário Rafael Macêdo dos Reis - http://orcid.org/0000-0001-5412-0030; INTRODUCTION Jakeline Resende Carvalho - http://orcid.org/0000-0003-1361-4696; José Miguel de Deus - http://orcid.org/0000-0002-1841-7635. Chronic pelvic pain (CPP) is understood as a continuous or 1. Universidade Federal de Goiás, Faculdade de Medicina, Goiânia, GO, Brasil. intermittent non-menstrual pain, lasting for six months or 2. Universidade Federal de Goiás, Faculdade de Medicina, Hospital das Clínicas, Departa- mento de Ginecologia e Obstetrícia, Goiânia, GO, Brasil. more, located in the lower or pelvic abdominal region, interfering in daily activities and requiring clinical or surgical in- Submitted in September 27, 2018. tervention1,2. It is an important cause of morbidity, functional Accepted for publication in December 14, 2018. 3-6 Conflict of interests: none – Sponsoring sources: none disability and reduction of women’s quality of life (QoL) , involving 5.7 to 26.6% of women worldwide7. In Brazil, Sil- Correspondence to: 8 Primeira Avenida, s/nº, Bairro Setor Leste Universitário va et al. reported a CPP prevalence of 15.1% in women in 74605-020 Goiânia, GO, Brasil. childbearing age, while Coelho et al.9 reported a prevalence E-mail: [email protected] of 19% in women aged 14-60 years. In addition, it accounts © Sociedade Brasileira para o Estudo da Dor for about 10% of outpatient gynecological consultations, as 8 Chronic pelvic pain portraits: perceptions and beliefs of 80 women BrJP. São Paulo, 2019 jan-mar;2(1):8-13 well as 40 to 50% of gynecological laparoscopies and 12% of following questions were asked: Do you have any family con- hysterectomies10,11. flicts? Have you ever experienced physical or sexual violence? It has been demonstrated that in a significant share of women Regarding the behavioral variables, it was considered as a regular with CPP there are no changes in physical examination and physical activity the practice of exercises at least twice a week; ultrasonography, and in many cases, no organic diagnosis is alcohol consumption at least twice a week, and smoking at the found12,13. Furthermore, more than 70% of the patients related time of the interview. some remarkable or traumatic event to the onset of the symp- The pain intensity was obtained with the pain visual analog tom13. It is known that several psychological factors, which scale (VAS), where zero represents no pain and 10 the worst constitute the affective dimension of pain, have a potential in- imaginable pain. The PoP was used to study the perceptions fluence on pain perception and may interfere with diagnosis and beliefs15. and treatment14,15. The PoP was applied as proposed by Loduca and Samuelian15, A psychological domain can be represented and interpreted sub- and each patient was instructed to imagine that her pain had jectively through art. A great example of this is the artist Mag- a shape and to draw it on a sheet of paper. Color pencils (12 dalena Carmen Frieda Kahlo y Calderón, who portrayed in her colors), crayon (12 colors) and blue ballpoint pen were available paintings a personal and unique vision of chronic pain, compos- and used with no restrictions. Then, the patient wrote a succinct ing a visual narrative with diagnostic and therapeutic potential16. phrase to characterize the portrait, to facilitate the understand- In this context, Loduca and Samuelian15 reported the developing of the drawing. To expand the knowledge about the patient’s ment of the Portrait of Pain (PoP) in 1998, a projective resource pain and beliefs, a brief questionnaire was applied with the fol- in which the patient uses creativity to translate his/her pain in lowing questions: “Give a name to your pain”; “How old is it?”; the form of a drawing. This, coupled with a brief survey, seems “Can anyone help or can anything be done to lessen your pain?”; to be an interesting method to identify the patient’s perception “And can you do anything?”; “There ever has been a time in your of his/her pain and the associated suffering14,15. Also, Eliot and life that the pain was the same or worse than this?”15. Maier17 concluded that even the handling of colors has an im- Throughout the interview time, at least one of the researchers portant influence on affection, cognition, and behavior and can was available to clarify the patient’s questions about the ques- bring important information. tionnaire, without interfering in her responses and in the graph- The PoP analysis has not yet been specifically applied in wom- ical representation of pain. en with CPP, an entity that is clinically difficult to handle. The The drawings collected by the PoP were qualitatively evaluat- objective of this study was to clarify the influence of the psycho- ed and categorized in groups that were not mutually exclusive, logical component in the evaluation of the CPP by analyzing its due to their main characteristics and shared traces, through con- graphic expression in women with CPP and investigating their tent analysis18 and consensus among the authors. To form these perceptions and beliefs about pain. groups, the groups already described in the literature14,19 were taken into account and the others were formulated from the au- METHODS thors’ perception. The sample size was defined after observing the overlap of the An exploratory cross-sectional study was conducted with 80 PoP forms represented by the participants. After being catego- patients from the CPP Outpatient Clinic of the Gynecology rized, all groups reached at least six representations, which was Service of the Hospital das Clínicas da Universidade Federal de considered the saturation point. Goiás (HC-UFG/EBSERH) from March 2017 to January 2018. Then, the drawings were objectively evaluated for the predom- Patients diagnosed with CPP, aged 18 and above and who vol- inant use of warm colors (variants of the red-yellow spectrum) unteered to participate in the study were included. The exclusion and cool colors (variants of the green-blue spectrum including criteria were cancer patients, pregnant women, patients with neutral colors of the gray spectrum), adapted from the classifi- cognitive deficits and severe psychiatric disorders, or those who cation made by Johann Wolfgang von Goethe in his work “The- refused to participate. ory of Colors”17,20. Also, by agreement between the authors, the Through a pre-structured interview, sociodemographic data (age, drawings were classified as to the use of few or many colors, and ethnicity, formal schooling, paid labor activities, spouse, fam- the use of three or more colors is the criterion to be classified as ily conflicts, physical and sexual violence); behavioral (regular many colors. Finally, each name attributed to pain by the patient physical activity, alcohol consumption, smoking) and clinical was separated into groups. (intensity and duration of pain, worsening with the menstrual This study was approved by the Committee on Ethics in Re- cycle, drug relief, children, abortions, overweight and obesity, search of the HC-UFG/EBSERH, under the opinion No. hypertension, diabetes and previous surgeries) were collected. 1,957,243/2017, and all patients signed the Free and Informed The variables related to sociodemographic data and clinical data Consent Form (FICT). (children, abortions, hypertension, diabetes and previous surgeries) were obtained by self-report. Data related to weight and Descriptive analysis height were obtained by measurement in the interview and were The Epi Info™ 7.2.2.6 software was used for data tabulation and used to calculate the body mass index (BMI) for the overweight subsequent calculations of mean, standard deviations and abso- (BMI 25.0 <30.0) and obesity (BMI 30.0) classification. The lute and relative frequencies presented in this paper. ≥ ≥ 9 BrJP. São Paulo, 2019 jan-mar;2(1):8-13 Godoi JE, Reis DR, Carvalho JR and Deus JM

RESULTS (12.50%); vent (12.50%); religious background (11.25%); bad perceptions (11.25%); boring (8.75%) and swearing (6.25%). The mean age of the 80 participants was 39.40±9.21 years. So- Concerning the beliefs and perceptions regarding pain, 25% of ciodemographic, behavioral and clinical data collected are listed patients reported that nobody could help, or nothing could be in table 1. The mean pain intensity was 7.03±2.58 by VAS; mean done to reduce their pain; 32.50% of them could do nothing to duration of 8.84±7.65 years, and in 72.50% of cases, it worsened lessen their own pain. Most (62.50%) believed that only doctors with menstruation. About 85% were using drugs, with a mean of and medical procedures could mitigate their pain. In addition, pain relief of 59.60±33.70%. 81% answered that there was some moment in their lives that The analysis of the portraits resulted in the formation of eight they felt equal to or worse than that pain, with a large proportion main groups: negative feelings (37.50%); damaging instruments (48%) referring to the loss of a relative, such as father or mother. (33.75%); geometric shapes (25%); body parts (16.25%); scrib- Each of the eight groups formed by the PoP categorization was bles and/or amorphous (13.75%); people and scenes (10%); illustrated by the selection of a representative portrait, along with monsters (8.75%) and smiles (7.50%). The great majority of pa- a brief interpretative description and the characteristics of the tients (91.25%) used few colors; 63.70% used cool colors, and participants who created them. 36.30% used warm colors; 46.20% used blue, 32.50% used red 1. Negative feelings: Included 30 portraits. This was the most and 32.50% used black. prevalent category, represented by images of loneliness, hurt Eight groups were arranged by the analysis of the names de- heart, scream, darkness, people crying and tears, these being scribed by the participants for their pain: symptoms or char- the most frequent. Figure 1.A is the representation made by a acteristics of pain (20%); miscellaneous (17.50%); bad feeling 35-year-old patient, with VAS=8, lasting for eight years. One can note that few colors were used, and mostly cool ones. The Table 1. Sociodemographic, behavioral and clinical profile of 80 women with chronic pelvic pain attended between March/2017 and Ja- participant characterized her drawing as “Isolation and humor nuary/2018 * variation. Life is passing by and you are stuck”. Variables n % 2. Damaging instruments: Included 27 portraits, represented Ethnicity by knife, tear, burning, weight and/or lancets, these being the Brown 44 55.00 most prevalent. Figure 1.B shows the drawing of a 26-year-old woman, with VAS=10, lasting for three years. There are few col- White 24 30.00 ors and predominance of warm color (red). The drawing was Others 12 15.00 described “as if there was a knife cutting inside and out. And I Schooling (years) feel blood falling”. <8 22 27.50 3. Geometric shapes: 20 portraits represented by squares, tri- ≥8≤11 19 23.75 angles, spirals and circles, these being the most prevalent. Figure <11 35 43.75 1.C was made by a 32-year-old patient, with VAS=10, lasting Paid employment 42 52.50 for 20 years. She used a few colors and with a predominance of Had a spouse 65 81.25 warm color, red. During the investigation, the patient named her Had some family conflict 26 32.50 pain as “Infamous.” Suffered physical violence 28 35.00 4. Body parts: This category had 13 portraits with images of Suffered sexual violence 23 28.75 eyes, pelvis, bellies, uterus, legs, hearts and/or heads, these be- Behavioral data ing the most prevalent. Figure 1.D shows a uterus being in- jured with the use of a needle and a hammer, representing the Practiced regular physical activity 29 36.25 pain like a stab and weight, respectively. The 40-year-old par- Alcohol consumption 2 2.50 ticipant, with VAS=3, lasting for 8 years, said “this is how I feel Smoking 6 7.50 in my body.” She used many colors with a predominance of the Clinical data warm ones. Had children 67 83.75 5. People and scenes: Eight portraits represented by images of Had abortions 19 23.75 scenes and people, these being more prevalent. In Figure 1.E, Body mass index (kg/m2) for example, a 45-year-old woman with VAS=5, lasting for 17 Normal weight 36 45.00 years, represented her pain as “person on top of me” She used few Overweight (≥25.0 <30.0) 29 36.25 colors with a predominance of the cool ones, but she used warm Obesity (≥30.0) 15 18.75 colors in the painful points. Hypertension 19 24.00 6. Scribbles and/or amorphous: With 11 portraits, it main- Diabetes 5 6.20 ly shows scribbles images. Figure 2.A shows the representation of a 40-year-old patient, with VAS=10 with CPP for 27 years. Previous abdominal or pelvic surgeries 69 86.25 She used many colors with a predominance of the warm ones, Previous surgeries for disease investiga- 21 26.25 tion and/or treatment impulsively and strongly, evidenced by the breaking of the red *Chronic pelvic pain outpatient clinic at Hospital das Clínicas - Empresa Brasi- crayon. During the investigation, the patient named her pain as leira de Serviços Hospitalares/Universidade Federal de Goiás. “Decreasing.” 10 Chronic pelvic pain portraits: perceptions and beliefs of 80 women BrJP. São Paulo, 2019 jan-mar;2(1):8-13

A B

hammer needle

C D E

Figure 1. Free drawings representing the categories of the portrait of pain. Part I A = negative feelings; B = damaging instruments; C = geometric shapes; D = body parts; E = people and scenes.

A B C

Figure 2. Free drawings representing categories of the portrait of pain, part II A = scribbles and/or amorphous; B = monster; C = smiles.

7. Monsters: Seven portraits. Figure 2.B represents the pain of DISCUSSION a 40-year-old patient, VAS=10, lasting for 19 years. She used many colors with a predominance of the warm ones. During the The sociodemographic characteristics of the patients in this study investigation, the patient named her pain as “Witchcraft.” are similar to those of previous publication of the same service13. 8. Smiles: Six portraits. In Figure 2.C, for example, a 37-year-old par- However, the history of physical violence was more prevalent ticipant with VAS=5, lasting for six years, drew three smiling people. in this sample (35%) than in the mentioned article13 (15.80%). She used a few colors, with a predominance of the cool ones. During The same applied to the history of sexual violence (28.75 versus the investigation, the patient named her pain as “Day by day.” 11%, respectively). This can probably be explained by differenc- 11 BrJP. São Paulo, 2019 jan-mar;2(1):8-13 Godoi JE, Reis DR, Carvalho JR and Deus JM es in the data collection technique and number of interviewers, ing the pain of children with sickle cell anemia. Figure 2.C, for type of study or because this is a different sample. These results example, was interpreted as the phases in which the patient has have been associated with CPP in the literature21 and may have been experiencing CPP in the last years. an impact on the patient’s perceptions and beliefs. According to Goethe20, cool colors, originally described as “mi- When drawing figures that refer to negative feelings, patients used nus” colors, are directly related to negative feelings such as rest- their emotions as a tool to express their pain. The perception is that lessness, anxiety and cold, which corroborates the higher preva- in these patients, CPP is associated with emotional pictures with lence (63.7%) of this color spectrum in this study, especially in the externalization through bad feelings, hopelessness, catastrophization drawings of the “negative feelings” group. Thus, the drawings of and abandonment to their own fate as shown in figure 1.A. this group, of the “monsters” group and some of the “people and In the category of damaging instruments, the use of old experiences scenes” group showing pessimistic feelings, as well as the great use and bad sensations is perceived as comparative to the CPP. In these of cool colors may be related to a lower response to treatment and portraits, we see objects that can cause some injury or bad feeling worse prognosis. Such a phenomenon, found in the literature as that often have a direct relationship with the character of the CPP. pain catastrophizing, as well as its negative consequences for the Loduca et al.14 have described this type of PoP as objects that can ex- prognosis of CPP-patients, were reported by prospective cohort22, press physical discomfort. In figure 1.B, for example, the warm color and its relation with higher intensity of CPP and worse QoL were suggests intense suffering and heat in the blood-dripping drawing emphasized by Sewell et al.5. In different medical contexts, opti- and the written representation by the patient. mistic people have better QoL compared to people with low op- Geometric shapes were primarily used to represent pain behavior, timism levels or pessimistic people. Optimism may even provide such as expansion, irradiation and location. In addition, as report- less sensitivity to pain and better adaptation to chronic pain23. ed by Loduca et al.14, it can illustrate the idea of a vicious cycle In addition, Wiech24 confirms that the concept of pain as an actively (pain-stress-pain). In figure 1.C, concentric circles may externalize constructed experience is determined by expectations and beliefs. the behavior of their CPP as a pain that starts at a well-located The demonstration of negative beliefs and the lack of coping re- epicenter and spreads throbbing, protruding itself through or even sources by the participants of this study are evident in the drawings beyond the body. and questionnaires, since more than 60% of them put their hopes The act of drawing body parts was understood as the attempt only in medical procedures and 25% denied solutions to their pain. to justify, in a biological way, what the body has expressed. It is, Such facts suggest great passivity in coping with pain. Patients’ active therefore, the externalization of the CPP into two cores from two participation contributes to the treatment effectiveness, as highlight- parts, psychological and body. In addition, it should be noted ed by Brünahl et al.25,26 and by Alappattu and Bishop27, who have the association with damaging instruments and negative feelings demonstrated the presence of clinically relevant psychosocial and (tears). It is noted that the biological image portrayed in figure 1.C psychiatric factors among patients with CPP and encouraged the can indicate her facial and emotional image. This participant’s case investigation of psychopathologies among them. is a good illustration that the use of VAS alone does not reach the It is noteworthy that modern research on pain is still beginning real dimension of the patient’s suffering. to unravel the pathophysiological details of the affective domain In portraying people and scenes, patients expressed both the charac- of pain24. This fact, associated with the variability of the characteristics of pain and emotional states. In figure 1.E, it is noted that teristics of this domain from patient to patient5,15 and the lack of the patient’s pain is well-directed to the characteristic of her psycho- knowledge by clinicians of the few tools adapted for use in the Por- logical integrity, with the loss of autonomy, giving the idea of carry- tuguese language28 may contribute to the misdiagnosis of the CPP ing an extracorporal and relational weight, which would not be hers. psychological aspects among Brazilian women. The disconnection Loduca et al.14 also described scenes as significant PoP, illustrated by between VAS=3 and the drawing of figure 1.D in this study is a something external, negatively influencing the person’s autonomy. good illustration. This is a limiting factor of the physician’s action, Scribbles and/or amorphous can mean both subjectivity in inter- who needs to understand the nuances of the patients’ view of their preting one’s own pain and the strength and difficulty of living morbidity, recognizing their active role in their clinical improve- with something that influences one’s life. Figure 2.A, as well as ment, as well as promoting interdisciplinary treatment29. the impulsive form by which it was made, may suggest anger at This study, with the PoP, can favor the understanding of patients’ someone, angry with herself or with her fate for her intense and beliefs and perceptions about their pain, which can expand the enduring suffering. In addition, the term “Decreasing” is incon- possibilities of intervention. The research of these factors may of- sistent with the clinical picture and the PoP, which can mean a fer a therapeutic return to patients since other authors state that progressive reduction of her resilience. negative beliefs and expectations can be modified through learn- Portraits of monsters may represent pain as something unfamil- ing24,30. This makes room for interdisciplinary and multimodal iar, terrifying and inexplicable, reflecting the suffering and fear in approaches to promote coping strategies and reduce pain catastro- living daily with CPP. As an example, the portrait of figure 2.B phizing22,26,31,32. According to Neubern33, the therapist’s role is to associated with the name “Witchcraft” may symbolize evil, fear, deconstruct those beliefs considered inadequate and understand and loss of autonomy. pain as a subjective process linked to the subject and his/her social Smiles, on the other hand, suggest an effective way to face, hide world. The importance of this process is further reinforced by the and even reduce the intensity of pain, which can mean resilience. lack of benefit of the laparoscopic treatment over the clinical and These findings were also observed by Custódio et al.19 when study- psychotherapeutical, as reported by de Deus et al.13. Despite the 12 Chronic pelvic pain portraits: perceptions and beliefs of 80 women BrJP. São Paulo, 2019 jan-mar;2(1):8-13 paucity of controlled studies on the psychotherapy efficacy in CPP, pain catastrophizing, pelvic pain and quality of life. Scand J Pain. 2018;18(3):441-8. 6. Da Luz RA, de Deus JM, Conde DM. Quality of life and associated factors in Brazi- several authors reinforce their importance, especially due to their lian women with chronic pelvic pain. J Pain Res. 2018;11:1367-74. performance on psychosocial variables7,22,26,27,30,32, which increases 7. Ahangari A. Prevalence of chronic pelvic pain among women: an updated review. Pain Physician. 2014;17(2):E141-7. the relevance of the present study. 8. Silva GP, Nascimento AL, Michelazzo D, Alves Junior FF, Rocha MG, Silva JC, et al. Recent evidence has highlighted the assessment of pain in the High prevalence of chronic pelvic pain in women in Ribeirão Preto, Brazil and direct broad social context. Neuroscience research has observed the in- association with abdominal surgery. Clinics. 2011;66(8):1307-12. 9. Coelho LS, Brito LM, Chein MB, Mascarenhas TS, Costa JP, Nogueira AA, et al. 34 terconnection between physical and social experiences of pain . Prevalence and conditions associated with chronic pelvic pain in women from São Resilience and vulnerability were highlighted by Alschuler, Kratz Luís, Brazil. Braz J Med Biol Res. 2014;47(9):818-25. 35 10. Jarrell JF, Vilos GA, Allaire C, Burgess S, Fortin C, Gerwin R, et al. Consensus and Ehde as impacting factors in the perception of chronic pain, guidelines for the management of chronic pelvic pain. J Obstet Gynaecol Can. especially those more psychosocially focused. The resilience capac- 2005;27(9):869-910. 11. Yosef A, Allaire C, Williams C, Ahmed AG, Al-Hussaini T, Abdellah MS, et al. Mul- ity can be inferred by the PoP. More positive or negative emotional tifactorial contributors to the severity of chronic pelvic pain in women. Am J Obstet states were observed as well as the presence or absence of signifi- Gynecol. 2016;215(6):760.e1-760.e14. cant social and family ties. In addition, active interventions based 12. Howard FM. Chronic pelvic pain. Obstet Gynecol. 2003;101(3):594-611. 13. Deus JM, Santos AF, Bosquetti RB, Pofhal L, Alves Neto O. Analysis of 230 women on resilience and the patient-physician-patient relationship itself with chronic pelvic pain assisted at a public hospital. Rev Dor. 2014;15(3):191-7. focused on patient-centered care may be resources to increase the 14. Loduca A, Müller BM, Amaral R, Souza AC, Focosi AS, Samuelian C, et al. Chronic 36,37 pain portrait: pain perception through the eyes of sufferers. Rev Dor. 2014;15(1):30-5. resilience of women with CPP . 15. Loduca A, Samuelian C. Avaliação psicológica: do convívio com dores crônicas à ade- This article has intrinsic limitations to the method. Data collection são ao tratamento na clínica de dor. In: Alves Neto O. Dor, princípios e prática. 1ª ed. Porto Alegre: Artmed Editora; 2009. 382-97p. involved a subjective approach, and some patients showed difficul- 16. Courtney CA, O’Hearn MA, Franck CC. Frida Kahlo: portrait of chronic pain. Phys ty or resistance to represent their pain graphically. This may be a Ther. 2017;97(1):90-6. result of the more synthetic and objective approach provided by 17. Elliot AJ, Maier MA. Color psychology: effects of perceiving color on psychological functioning in humans. Annu Rev Psychol. 2014;65(1):95-120. other services and professionals, as well as the promotion of a more 18. Laurence B. Análise de conteúdo, 1ª ed. Lisboa: Edições 70 - Brasil; 2004. 20p. skeptical view of patients regarding the psychosocial component 19. Custódio LL, Leitão IM, Gomes IL, Mendes LC. Drawing pain for children with sickle cell anemia: the pain that hurts, really hurts. Rev Dor. 2017;18(4):321-6. of their pain. Also, it was a cross-sectional descriptive study, not 20. Goethe JW. Theory of Colours. 1st ed. London: John Murray; 1840. able to guarantee a causal relationship or results in generalization, 21. As-Sanie S, Clevenger LA, Geisser ME, Williams DA, Roth RS. History of abuse and its relationship to pain experience and depression in women with chronic pelvic pain. but it makes room for new prospective and analytical studies on Am J Obstet Gynecol. 2014;210(4):317.e1-317.e8. the subject. 22. Allaire C, Williams C, Bodmer-Roy S, Zhu S, Arion K, Ambacher K, et al. Chronic pelvic pain in an interdisciplinary setting: 1-year prospective cohort. Am J Obstet Gynecol. 2018;218(1):114.e1-114.e12. CONCLUSION 23. Kreis S, Molto A, Bailly F, Dadoun S, Fabre S, Rein C, et al. Relationship between optimism and quality of life in patients with two chronic rheumatic diseases: axial spondyloarthritis and chronic low back pain: a cross sectional study of 288 patients. Women with CPP have portrayed their pain drawing negative Health Qual Life Outcomes. 2015;13:78. feelings, damaging instruments, geometric shapes, body parts, 24. Wiech K. Deconstructing the sensation of pain: The influence of cognitive processes on pain perception. Science. 2016;354(6312):584-7. scribbles and/or amorphous, people and scenes, monsters and 25. Brünahl CA, Dybowski C, Albrecht R, Gregorzik S, Löwe B. Psychiatric comorbidity smiles. They used few and cold colors and named their pain with in patients with chronic pelvic pain syndrome (CPPS). J Psychosom Res. 2016;85:58. the emotional load. Besides, they considered themselves unable 26. Brünahl C, Dybowski C, Albrecht R, Riegel B, Höink J, Fisch M, et al. Mental disorders in patients with chronic pelvic pain syndrome (CPPS). J Psychosom Res. to contribute to the reduction of their pain and made an analogy 2017;98:19-26. between their pain and family losses. Such characteristics suggest 27. Alappattu MJ, Bishop MD. Psychological factors in chronic pelvic pain in women: relevance and application of the fear-avoidance model of pain. Phys Ther. the patients’ pain catastrophizing and their vulnerability, which 2011;91(10):1542-50. may compromise the prognosis. 28. Silva FU, Alcântara MA, Barroso OL. Crenças em relação às condições crônicas de saúde: uma revisão crítica de instrumentos adaptados para a língua portuguesa. Fisio- ter Mov. 2010;23(4):651-62. ACKNOWLEDGMENTS 29. Porto CC, Branco RFGR, Cantarelli GCF, Oliveira AM. Relação Médico-Paciente. In: Porto CC, Porto AL. Semiologia Médica. 7ª ed. Rio de Janeiro: Guanabara Koo- gan; 2014. 21-37p. To the women who have offered their time in moments of pain, 30. Dybowski C, Löwe B, Albrecht R, Brünahl CA. Pain perception and the anticipation to help in our education and to provide a better understanding of stigmatization due to mental illness – associations within a sample of patients with chronic pelvic pain syndrome (CPPS). J Psychosom Res. 2017;97:146-7. about those who suffer and about science. 31. Twiddy H, Bradshaw A, Chawla R, Johnson S, Lane N. Female chronic pelvic pain: the journey to diagnosis and beyond. Pain Manag. 2017;7(3):155-9. REFERENCES 32. Picard-Destelan M, Rigaud J, Riant T, Labat JJ. [What type of psychotherapy in the management of chronic pelvic and perineal pain?] Prog Urol. 2010;20(12):1111-5. French. 33. Neubern MS. Psicoterapia, dor & complexidade: construindo o contexto terapêutico. 1. ACOG Committee on Practice Bulletins Gynecology. ACOG Practice Bulletin No. Psicol Teor Pesq. 2010;26(3):515-23. 51. Chronic pelvic pain. Obstet Gynecol. 2004;103(3):589-605. 34. Sturgeon JA, Zautra AJ. Social pain and physical pain: shared paths to resilience. Pain 2. Howard FM. The role of laparoscopy in chronic pelvic pain: promise and pitfalls. Manag. 2016;6(1):63-74. Obstet Gynecol Surv. 1993;48(6):357-87. 35. Alschuler KN, Kratz AL, Ehde DM. Resilience and vulnerability in individuals with 3. Barcelos PR, Conde DM, Deus JM, Martinez EZ. [Quality of life of women with chronic pain and physical disability. Rehabil Psychol. 2016;61(1):7-18. chronic pelvic pain: a cross-sectional analytical study]. Rev Bras Ginecol Obst. 36. Hassett AL, Finan PH. The role of resilience in the clinical management of chronic 2010;32(5):247-53. Portuguese. pain. Curr Pain Headache Rep. 2016;20(39):1-9. 4. Luz RA, Rodrigues FM, Vila VS, Deus JM, Conde DM. Qualidade de vida de mulhe- 37. Náfrádi L, Kostova Z, Nakamoto K, Schulz PJ. The doctor-patient relationship and res com dor pélvica crônica. Rev Eletr Enf. 2015;17(3):1-7. patient resilience in chronic pain: a qualitative approach to patients’ perspectives. 5. Sewell M, Churilov L, Mooney S, Ma T, Maher P, Grover SR. Chronic pelvic pain - Chronic Illn. 2018:14(4)256-70.

13 BrJP. São Paulo, 2019 jan-mar;2(1):14-9 ORIGINAL ARTICLE

Knowledge, attitude and practice regarding pharmacological methods of labor analgesia Conhecimento, atitude e prática em relação aos métodos farmacológicos de analgesia de parto

Bianca Ruschel Hillmann1, Ana Maria Nunes de Faria Stamm2

DOI 10.5935/2595-0118.20190004

ABSTRACT having epidural available, and the ineffectiveness of non-opioid analgesics/ antispasmodics, and the practice of prescribing them. BACKGROUND AND OBJECTIVES: Labor pain is caused There was a minimal agreement between knowledge and practi- by several physiological changes and may cause psychological ce, and between attitude and practice on most of the other requi- damage to the parturient and her relatives and, therefore, must rements in each dimension. be relieved. The objective of this study was to evaluate the know- Keywords: Analgesia, Attitude and practice in health, Child- ledge, attitude, and practice of obstetricians concerning pharma- birth pain, Knowledge, Medical education, Obstetric analgesia, cological methods of labor analgesia. Pharmacological treatment. METHODS: Cross-sectional study (38 obstetricians working at public maternity hospitals). A structured questionnaire was RESUMO applied about knowledge, attitude and practice concerning systemic and regional pharmacological methods. The agreement JUSTIFICATIVA E OBJETIVOS: A dor do parto é causada magnitude was assessed by kappa coefficient. por diversas alterações fisiológicas e pode causar danos psicoló- RESULTS: We observed adequate knowledge about the indi- gicos à parturiente e seus familiares, portanto, deve ser aliviada. cations of all methods (31 to 86%), the contraindications of O objetivo deste estudo foi avaliar o conhecimento, atitude e opioids (92%) and the adverse effects of non-opioid analgesics prática de obstetras sobre métodos farmacológicos de analgesia /antispasmodics on the fetus (76%). Concerning attitude, they de parto. agree that non-opioid analgesics/antispasmodics do not minimi- MÉTODOS: Estudo transversal, com amostra de conveniência ze labor pain (98%) but should be available at the maternity (38 obstetras que atuam em maternidades públicas). Foi aplicado wards (89%) and that epidural analgesia is effective (100%) and um questionário estruturado sobre conhecimento, atitude e prá- should be available (94%). In practice, the indication of non-o- tica em relação a métodos farmacológicos sistêmicos e regionais. pioid analgesics/antispasmodic and epidural analgesia prevailed. Magnitude de concordância avaliada pelo coeficiente Kappa. In most of the requirements in each dimension (knowledge: K=- RESULTADOS: Observou-se conhecimento adequado nas 0.092 to 0.158; p=0.057 to 1.0 and attitude: K=-0.005 to 0.472; indicações de todos os métodos (31 a 86%), contraindicações p=0.004 to 1.0), there was minimal agreement with practice, dos opioides (92%) e efeitos adversos de analgésicos simples/an- except for the non-opioid analgesics/antispasmodics (K=0.421, tiespasmódicos no feto (76%). Na atitude, concordam que os p=0.009), and epidural analgesia (K=0.472, p=0.004), with a analgésicos simples/antiespasmódicos não funcionam no alívio moderate agreement. da dor do parto (98%), mas devem estar disponíveis nas ma- CONCLUSION: Knowledge was heterogeneous. The attitude ternidades (89%), e que a analgesia peridural é eficaz (100%) e was unanimous concerning the effectiveness and the need of deve estar disponível (94%). Na prática, prevaleceu a indicação de analgésicos simples/antiespasmódicos e da analgesia peridural. Na maioria dos quesitos, em cada dimensão (conhecimento: K=-0,092 a 0,158; p=0,057 a 1,0 e atitude: K=-0,005 a 0,472; p=0,004 a 1,0), houve concordância mínima com a prática, Bianca Ruschel Hillmann - https://orcid.org/0000-0003-0063-2385; excetuando analgésicos simples/antiespasmódicos (K=0,421;  Ana Maria Nunes de Faria Stamm - https://orcid.org/0000-0001-5186-1247. p=0,009) e analgesia peridural (K=0,472; p=0,004), com con- 1. Hospital Regional de São José, Departamento de Ginecologia, Florianópolis, SC, Brasil. cordância moderada. 2. Universidade Federal de Santa Catarina, Centro de Ciências da Saúde, Departamento de CONCLUSÃO Clínica Médica, Florianópolis, SC, Brasil. : O conhecimento foi heterogêneo. A atitude foi unânime quanto à eficácia e necessidade da analgesia peridural Submitted in October 12, 2018. estar disponível, e ineficácia dos analgésicos simples e antiespas- Accepted for publication in December 14, 2018. Conflict of interests: none – Sponsoring sources: none módicos, e a prática de prescrevê-los. Houve concordância míni- ma entre o conhecimento e a prática, e entre a atitude e a prática, Correspondence to: Rua Eng. Agronômico Andrei Cristian Ferreira, s/n – Trindade na maioria dos outros quesitos em cada uma das dimensões. 88040-900 Florianópolis, SC, Brasil. Descritores: Analgesia, Analgesia obstétrica, Atitudes e prática E-mail: [email protected] em saúde, Conhecimentos, Dor do parto, Educação médica, Tra- © Sociedade Brasileira para o Estudo da Dor tamento farmacológico. 14 Knowledge, attitude and practice regarding BrJP. São Paulo, 2019 jan-mar;2(1):14-9 pharmacological methods of labor analgesia

INTRODUCTION Friend Hospital], were invited to participate in the research. Of these, 38 professionals made up the convenience sample. Childbirth pain is caused by a number of physiological changes A structured questionnaire with open and closed questions and that occur in the body of the woman in labor, such as cervical di- space for comments at the end was prepared based on studies on latation, strain of the uterine fibers and the birth canal, traction KAP5-11; the theoretical basis on the subject12-20 and research21,22. of the ovaries and peritoneum, and compression of pelvic struc- The questionnaire was divided into three parts: tures and roots of the lumbar-sacral plexus1,2. This pain leads to 1. Characteristics of the study population, including questions anxiety and apprehension, with increased secretion of cortisol about prototypes of pharmacological methods of labor analgesia. and catecholamines, which may alter contractility and uterine 2. Dimension of knowledge, attitude and practice of obstetri- flow, affecting the course of labor and fetal well-being1. Pain can cians regarding these methods. Theoretical knowledge related to also cause psychological stress to the woman in labor and her the subtopics indications, contraindications and potential adver- relatives, making it difficult to interact with the newborn2 and, se effects on the woman in labor and the fetus, with open ques- therefore, requiring relief1. tions. Attitude, encompassing three subtopics - Does it work in The major challenges of analgesia during labor are adverse ef- relieving labor pain? Do the benefits outweigh the risks? Should fects on the fetus and the need to avoid excessive sedation of the it be available for use in the maternity ward? - with answers in patient so that she is cooperative, and the mother-baby bond Likert scale (5 options), and practice with one subtopic – Do you can be established after birth2,3. Considering these limitations, prescribe the method or not? several analgesic methods have been developed for pain control, 3. The level of satisfaction of these professionals with the phar- including systemic and regional non-pharmacological and pharmacological labor analgesia offered to the patients in these health macological methods1. institutions. Among the pharmacological methods, the systemic can be ad- The instrument was evaluated by two experts in this area, who ministered intravenously, intramuscularly or by inhalation1, and analyzed the form of presentation and the content, relating these the parenteral analgesia can be performed with non-opioid drugs elements to the tool’s ability to capture the phenomenon under (antihistamines, antispasmodics, non-opioid analgesics, and an- study. The suggested changes were accepted. ti-inflammatories) or opioids (such as morphine, dolantin, and The research was approved by the Human Research Ethics Commit- remifentanil). However, the regional methods - pudendal nerve tee of the university to which the researchers are affiliated - project block, spinal analgesia, and epidural analgesia - are often prefer- number 51673515.2.0000.0121 - and carried out after signing the red as they do not affect fetal well-being1. Free and Informed Consent Term (FICT), in accordance with the Considering the pharmacological systemic and regional me- resolution 196/96/MS of the Brazilian National Health Council. thods, their indications, contraindications and adverse effects, one can notice the decision-making complexity, as well as the Statistical analysis need to monitor the mother-baby binomial during their use. It was performed using IBM’s Statistical Package for Social Despite these potential difficulties, it is essential for the obstetri- Sciences (SPSS) software, version 23.0. cian to handle them since many women in labor do not present Responses regarding age and length of service were considered in a satisfactory degree of pain relief when submitted only to non- full years. As for the prototypes mentioned by the participants, -pharmacological methods. the order in which they were written was respected. Therefore, we propose a study to evaluate the knowledge, attitu- In the knowledge dimension, for each participant’s response to de, and practice (KAP) of obstetricians working in public mater- the subtopics, we assigned either the grade “appropriate” - when nity hospitals in southern Brazil, with regard to the main current there were at least 30% of correct answers and no incorrect ans- pharmacological methods of childbirth analgesia. We believe wer - and “inappropriate”, in the remaining cases. This evalua- that this type of research can capture what a group knows about tion was made using as reference a template developed from the a particular subject (knowledge), feelings and preconceived ideas literature review12-20. The level of knowledge of the study popula- in relation to the topic (attitude) and how they demonstrate this tion was considered excellent (when more than 75% of the par- knowledge and attitude in their actions (practice)4. ticipants showed adequate knowledge on that question), good The study also aims at describing the characteristics of the study (between 50 and 75%), moderate (between 25 and 50%) and population, the degree of agreement between these three dimen- low (less than 25%)6. sions, relating them to age and length of service in the delivery In the attitude dimension, the answers were dichotomized into room, and the satisfaction of these professionals with the labor “yes” and “no” and, in the practice dimension, into “prescribes” analgesia offered to their patients. and “does not prescribe”. The categorical variables were expressed in absolute numbers and METHODS proportions, while the continuous variables with normal distribution (measured by the Kolmogorov-Smirnov test) were expres- A cross-sectional, observational, descriptive and analytical study sed as mean and standard deviation (SD). conducted from July to November 2016. Fifty obstetricians wor- The magnitude of agreement between knowledge and practice, and king in three public maternity hospitals in southern Brazil, whi- between attitude and practice was evaluated by Cohen’s kappa coef- ch are part of the program Hospital Amigo da Criança [Children’s ficient, using the cut-off points proposed by Landis and Koch23. 15 BrJP. São Paulo, 2019 jan-mar;2(1):14-9 Hillmann BR and Stamm AM

The relationship between continuous variables (age and length of 33/38) and contraindications (92%, 35/38); as for nitrous oxide, service in the delivery room) and categorical variables (knowled- we observed a moderate degree of knowledge regarding indica- ge, attitude and practice) was assessed by the Student’s t-test. A tions (31%, 12/38) (Figure 1). p<0.05 was considered significant. As for regional methods of labor analgesia, the degree of knowledge was excellent regarding the indications of epidural anal- RESULTS gesia (84%, 32/38) and pudendal nerve block (79%, 30/38) (Figure 2). Of the 50 obstetricians who work at three public maternity hos- As for non-opioid analgesics and antispasmodics, approximately pitals in southern Brazil, 76% (38) participated in the study. half of the participants (47%, 18/38) believe that the benefits The mean age was 44±9 years and the mean length of time prac- outweigh the risks in most cases, and that they should be availa- ticing in the delivery room was 16±9 years. All of them have ble in maternity wards (89%, 34/38), knowing that they do not postgraduate degrees in gynecology and obstetrics residency, and relieve labor pain. As for opioids, even though the majority of one third (33%, 13/38) has a second specialization. the participants indicate that opioids should be available (92%, When asked to inform three pharmacological methods of chil- 35/38), 39% (15/38) believe that this method is effective. In the dbirth analgesia (prototypes)24, the most cited methods were case of nitrous oxide, 29% (11/38) indicate that it should be epidural analgesia (42%, 16/38), antispasmodic drugs (31%, available in maternity wards (Figure 3). 12/38), and parenteral opioids (15%, 6/38). With regard to epidural analgesia, the participants were unanimous The majority (68%; 26/38) expressed dissatisfaction with the about its effectiveness (100%) and the need to be available in ma- quality of labor analgesia offered to patients in the maternity ternity wards (94%), with 47% believing that the benefits outweigh ward where they work, with 26% (10/38) partially satisfied and the risks. As for pudendal nerve block, merely an attitude that it only 5% (2/38) satisfied. should be available in the maternity wards prevails (63%) (Figure 4). We observed a good knowledge of simple and antispasmodic The prescription of non-opioid analgesics and antispasmodics analgesics in terms of indications (73%, 28/38), and excellent in (50%, 19/38) was similar to that of epidural (47%, 18/38), fol- terms of adverse effects on the fetus (76%, 29/38). In the opioid lowed by pudendal nerve block (21%, 8/38) and opioids (21%; category, knowledge was excellent in terms of indications (86%, 8/38). There was no reference to the prescription of nitrous oxide.

100 100 90 90 80 80 70 70 60 60 50 50 40 40 30 30 positive answers appropriate knowledge 20

Percentage of participants with Percentage 20 of participants with Percentage 10 10 0 Non-opioid analgesics Opioids Nitrous oxide 0 and antispasmodics Non-opioid analgesics Opioids Nitrous oxide and antispasmodics Does it relieve labor pain? Do benefits outweigh risks in most cases? Should they be available in maternity wards? Indications Contraindications Adverse effects woman in labor Adverse effects on fetus

Figure 1. Obstetricians’ knowledge degree regarding pharmacologi- Figure 3. Obstetricians’ attitude regarding systemic pharmacological cal systemic methods of labor analgesia methods of labor analgesia

90 120

80 100 70 80 60

50 60 40 40 30 positive answers appropriate knowledge

20 of participants with Percentage 20 Percentage of participants with Percentage 10 0 0 Epidural analgesia Pudendal nerve block Epidural analgesia Pudendal nerve block Does it relieve labor pain? Do benefits outweigh risks in most cases? Indications Contraindications Adverse effects woman in labor Adverse effects on fetus Should they be available in maternity wards?

Figure 2. Obstetricians’ knowledge degree regarding regional phar- Figure 4. Obstetricians’ attitude regarding regional pharmacological macological methods of labor analgesia methods of labor analgesia

16 Knowledge, attitude and practice regarding BrJP. São Paulo, 2019 jan-mar;2(1):14-9 pharmacological methods of labor analgesia

Analytical statistics DISCUSSION The Kappa analysis showed reasonable agreement for opioids (k=0.281, p=0.043) and moderate agreement for non-opioid It is important that the patient in labor is offered pain relief me- analgesics and antispasmodics (k=0.421, p=0.009) and epidural thods to avoid trauma and increase the degree of satisfaction in (k=0.472, p=0.004), between ATTITUDE - question “Do be- order to facilitate the interaction of the baby with the family. In nefits outweigh risks in most cases?” and medical PRACTICE. two studies conducted on the African continent, it was obser- Reasonable agreement (k=0.211; p=0.034) was also observed for ved that most professionals believe that pain relief is necessary non-opioid analgesics and antispasmodics between ATTITU- during childbirth25,26, but approximately half of them did not DE - question “Should they be available in maternity wards?” administer any analgesic method (48%), and of these, more than and PRACTICE. In most other questions, in each dimension half (54%) did not mention reasons for this25, while some still (knowledge: k=-.092 to 0.158; p=0.057 to 1.0; and attitude: k=- believe that analgesia is not necessary because childbirth pain is 0.005 to 0.472; p=0.004 to 1.0), there was minimum degree of a natural process26. agreement with practice. In this scenario, we can still consider that the patient may have When assessing opioids and relating knowledge, attitude and different needs throughout labor – and may use more than one practice to the age of the participants, there was a statistically method of analgesia – which highlights the importance of the significant difference between the mean ages in the ATTITUDE obstetricians to have knowledge, attitude and confidence in the dimension – question “Do you believe they should be available use the pharmacological methods available at their workplace, in maternity wards?”, with a mean of 45 and 34 years for positive choosing the best method in each situation. This is evidenced and negative responses, respectively (mean difference=11 years, in the comments of the participants, because hospitals from the Student’s t = 2.068; 95% CI=0.215 – 22.128, p=0.046). In the Brazilian public healthcare system (SUS) do not always have pro- PRACTICE dimension, the mean age was 38 and 45 years for fessionals to perform epidural analgesia. positive and negative responses, respectively (difference=7 years, The literature has shown that non-opioid analgesics and antispas- Student’s t=-2.064; 95% CI=-14.690 – 0.120; p=0.047). modics cannot be considered methods of labor analgesia because There was also a significant difference in ATTITUDE related they are not effective12,13. Although 98% of participants believe to pudendal nerve block – question: “Do you believe it relieves in their ineffectiveness, this method is one of the prototypes of labor pain?” – with the mean age being 52 years and 43 years for labor analgesia in the minds of these obstetricians and one of the positive and negative responses, respectively (difference = 9 years; most prescribed methods. This ambivalence among knowledge, Student’s t = 3.002; 95% CI=1.918 – 14.582; p=0.017). attitude and practice may be because these drugs show a low The relation between the average length of time working in risk to the fetus and low interference on the course of labor and, the delivery room and knowledge, attitude and practice, sho- although they do not relieve pain, they increase the satisfaction wed a statistically significant difference regarding opioids in the with the care provided and with the delivery when compared to dimension KNOWLEDGE - question “adverse effects on the placebo14,15. fetus” - with an average of 7 years in the “adequate” responses Adequate knowledge about the indications and contraindica- and 17 years in the “inadequate” response (difference=10 years; tions of opioids was observed, but only 40% of the participants Student’s t=-2.040; 95% CI=-20.295 – 0.058; p=0.049). In the believe in their effectiveness, regardless of what research on this dimension ATTITUDE - question “Do you believe it should topic shows3,14,16. Most assure that the risks do not outweigh the be available in maternity wards?” – there was an average of 17 benefits, an attitude that is corroborated by practice, by not pres- years in those with a positive response and 5 years in those with a cribing them (4/5 of the participants), which is in agreement negative response (difference=12 years; Student’s t = 2.062; 95% with the guidelines of the Brazilian Department of Health that CI=0.193 – 23.198; p=0.046). they should not be used routinely17. There was also a statistically significant difference in relation to The mean age of participants who prescribe opioids is lower than the length of time working in the delivery room regarding pu- that of non-prescribers, which may be due to an accumulation of dendal nerve block, in the dimension ATTITUDE - “Do you negative experiences with the use of these drugs over time. believe it relieves labor pain?”, with an average of 23 years in par- Nitrous oxide, which has been used in labor analgesia in many ticipants with a positive response, and 15 years with a negative countries for decades, for its effectiveness and low risks14,18, is a response (difference=8 years; Student’s t=3.330; 95% CI=3.002 method unknown to participants, who also consider that its risks – 14.069; p=0.005). do not outweigh the benefits and do not prescribe it. This may reflect the Brazilian reality because, although this gas is com- Comments monly available for use in general anesthesia, few hospitals use it Among the 13 participants (34.2%, 13/38) who made com- during childbirth. ments, 6 mentioned it was difficult to have access to pharma- The degree of knowledge about the indications for epidural cological methods in general, 6 mentioned epidural analgesia analgesia was adequate, with a positive attitude regarding its ef- was unavailable due to the absence of an anesthesiologist in the fectiveness (100% of respondents), benefits that outweigh risks obstetric center or their refusal to provide it, and 2 participants (45%), and availability in maternity wards (95%), besides being cited the professionals’ and patients’ lack of knowledge about one of the most prescribed methods and the most cited pro- analgesia methods. totype. There was also a tendency for the attitude of believing 17 BrJP. São Paulo, 2019 jan-mar;2(1):14-9 Hillmann BR and Stamm AM that benefits outweigh risks leading to the practice of prescribing dic analgesics, while it was low in the other subtopics of this it. Currently, this is the most effective method of analgesia1,14 dimension. and, therefore, it should be available in all maternity wards19,20. In general, participants have a positive attitude regarding epidu- Of the pharmacological methods, it is the only one that is admi- ral and non-opioid analgesics and antispasmodics, and a negative nistered by anesthesiologists, and not by obstetricians,14 but it is attitude regarding the remaining methods. crucial that the knowledge of whoever indicates it is extended to The most prescribed methods by obstetricians are non-opioid its contraindications and adverse effects, to avoid the bias of pa- analgesics/ antispasmodics and epidural, with less expressive tient selection and inadequate monitoring of its adverse effects. numbers or absence of other methods. Regarding pudendal nerve block, we observed that the physicians also had adequate knowledge about its indications and, REFERENCES although most believe that it should be available, the attitude of believing in its ineffectiveness prevails, and that its benefits do 1. Anjos KF, Santos VC, Souzas R. Parto, aborto e puerpério: assistência humanizada à mulher. Rev Bras Ginecol Obstet. 2010;13(1):44-55. not outweigh the risks. In practice, those who do not prescribe it 2. Camano LSE. Assistência ao Parto e Tocurgia. 2002. 1-324 p. prevail (4/5 of the participants). 3. Anderson D. A review of systemic opioids commonly used for labor pain relief. J Midwifery Womens Health. 2011;56(3):222-39. Erratum in: J Midwifery Womens It was also observed that obstetricians with a higher mean age Health. 2011;56(4):411-8. and longer time working in the delivery room tend to believe in 4. Kaliyaperumal K. Guideline for conducting a knowledge, attitude and practice (KAP) study. Community Ophthalmol. 2004;4(1):7-9. the effectiveness of pudendal nerve block more frequently than 5. Wang Y, Zhu R, Huang N, Li W, Yang L, Zhang S, et al. Knowledge, attitudes, and younger obstetricians with less time working in this area. This re- practices survey of drug allergy among healthcare practitioners in central China: a lationship may reflect a decrease in the indication for episiotomy multicenter study. Asia Pac Allergy. 2016;6(2):105-11. 6. Magalhães VC, Oliveira DL, Prado FO. Knowledge, risk perception and attitu- and an increase in the use of the vacuum extraction over forceps des of Dentistry students with regard to HIV/AIDS. RGO, Rev Gaúch Odontol. in recent years, having an impact on its indication as a method 2015;63(3):291-300. 27-29 7. Silveira NS, Vasconcelos CT, Nicolau AI, Oriá MO, Pinheiro PN, Pinheiro AK. Kno- of labor analgesia . wledge, attitude and practice of the smear test and its relation with female age. Rev Lat The convenience sample of this study highlights the qualification Am Enfermagem. 2016;24. English, Portuguese, Spanish. 8. Colak D, Oguz A, Yazilitas D, Imanaglu IG, Altinbas M. Morphine: patient kno- of professionals working in public maternity wards and hospitals, wledge and attitudes in the central anatolia part of Turkey. Asian Pac J Cancer Prev. who in order to get a position in these healthcare institutions had 2014;15(12):4983-8. to be approved in a selection process and demonstrate experien- 9. Lopes FS, Duarte AC, Gusman PB, Silva D, Ganem EM, Barros GA. Evaluation of the knowledge of postoperative pain among participants of a virtual scientific journey ce in the delivery room. This allows us to infer the competence in Anesthesiology. Rev Dor. 2016;17(2):111-6. of these obstetricians in their respective fields of work. Never- 10. Ke LS, Chiu TY, Lo SS, Hu WY. Knowledge, attitudes, and behavioral intentions of nurses toward providing artificial nutrition and hydration for terminal cancer patients theless, it is clear that among the available methods, knowledge in Taiwan. Cancer Nurs. 2008;31(1):67-76. does not always cover the range of questions and, in practice, the 11. Dias IM, Almeida SM, Dias JM, Leite IC. ‘Specialists’ perception and opinion about most prescribed methods are simple analgesics, antispasmodics self-medication of patients with temporomandibular disorders and orofacial pain. Rev Dor. 2017;18(1):32-7 and epidural analgesia. 12. Novikova N, Cluver C. Local anaesthetic nerve block for pain management in labour. We observed a minimum degree of agreement between know- Cochrane Database Syst Rev. 2012;(4):CD009200. 13. Uptodate. Scopolamine systemic drug information. 2017 [cited 2017 Jul 20]. Available ledge and practice, and between attitude and practice in most of from: https://www.uptodate.com/contents/scopolamine-systemic-drug-information. the subtopics of each dimension, and reasonable to moderate in 14. Jones L, Othman M, Dowswell T, et al. Pain management for women in labour: an overview of systematic reviews. Cochrane Database Syst Rev. 2013;(6):CD009234. the others, this fact being common to other studies that take this 15. Othman M, Jones L, Neilson JP. Non-opioid drugs for pain management in labour. methodology into account5-7. Cochrane Database Syst Rev. 2012;(7):CD009223. The lack or absence of public policies in the regulation of la- 16. Tveit TO, Halvorsen A, Seiler S, Rosland JH. Effectiveness and adverse effects of intravenous remifentanil patient-controlled analgesia used in a stepwise approach for bor analgesia methods, combined with what the Department of labour: an observational study. Int J Obstet Anesth. 2013;22(1):19-25. Education and Culture advocates as a proposal for a medical re- 17. Ministério da Saúde. Diretrizes Nacionais de Assistência ao Parto Normal. 2017. 53p. 18. Klomp T, van Poppel M, Jones L, Lazet J, Di Nisio M, Lagro-Janssen AL. Inha- sidency program, in which this topic is neither emphasized nor led analgesia for pain management in labour. Cochrane Database Syst Rev. addressed30, and the possibility of memory bias when sampling 2012;(9):CD009351. 24 19. Gilbert J Grant M. Pharmacologic management of pain during labor and delivery. the data , are potential limitations to be considered. Uptodate; 2017 [cited 2017 Jul 20]. Available from: https://www.uptodate.com/con- Considering that most of the participants are not satisfied with tents/pharmacologic-management-of-pain-during-labor-and-delivery?source=sear- the childbirth analgesia provided to patients, which may reflect ch_result&search=analgesia+de+parto&selectedTitle=1~37. 20. Anim-Somuah M, Smyth RM Jones L. Epidural versus non-epidural or no analgesia the difficulties encountered for performing epidural analgesia, in labour. Cochrane Database Syst Rev. 2011;(12):CD000331. we suggest studies on the perception of women in labor concer- 21. Gil AC. Como elaborar projetos de pesquisa. São Paulo. Atlas S.A; 2002. 175p. 22. Pereira JCR. Análise de dados qualitativos: Estratégias Metodológicas para as Ciências ning the analgesia received. da Saúde, Humanas e Sociais. 3ª ed.1.reimpr. São Paulo: Editora da Universidade de São Paulo; 2004. CONCLUSION 23. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33(1):159-74. 24. Kim YY, Park JH, Kang HJ, Lee EJ, Ha S, Shin SA. Level of agreement and factors Regarding knowledge, attitude and practice of obstetricians wor- associated with discrepancies between nationwide medical history questionnaires and hospital claims data. J Prev Med Public Health 2017;50(5):294-302. king at three public maternity hospitals in southern Brazil, we 25. Ogboli-Nwasor E, Adaji S, Bature S, Shittu O. Pain relief in labor: a survey of awa- concluded that good to excellent knowledge prevailed in relation reness, attitude, and practice of health care providers in Zaria, Nigeria. J Pain Res. 2011;4:227-32. to the indication of regional pharmacological methods, opioid 26. McCauley M, Stewart C, Kebede B. A survey of healthcare providers knowledge and contraindications, and adverse effects of simple and antispasmo- attitudes regarding pain relief in labor for women in Ethiopia. MC Pregnancy Child- 18 Knowledge, attitude and practice regarding BrJP. São Paulo, 2019 jan-mar;2(1):14-9 pharmacological methods of labor analgesia

birth. 2017;17(1):56. 29. Hehir MP, Reidy FR, Wilkinson MN, Mahony R. Increasing rates of operative vaginal 27. Escuriet R, Pueyo ML, Perez-Botella M, et al. Cross-sectional study comparing public delivery across two decades: accompanying outcomes and instrument preferences. Eur and private hospitals in Catalonia: is the practice of routine episiotomy changing? J Obstet Gynecol Reprod Biol. 2013;171(1):40-3. BMC Health Serv Res. 2015;11;15:95. 30. Ministério de educação e cultura. proposição de conteúdo dos programas de resi- 28. Chehab M, Courjon M, Eckman-Lacroix A, Ramanah R, Maillet R, Riethmuller D. dência médica. 2006. Available from: http://portal.mec.gov.br/ index.php?option=- [Impact of a major decrease in the use of episiotomy on perineal tears in a level III com_docman&view=download&alias=6511-ginecologia-obstetricia-sesu-rm&Ite- maternity ward]. [Article in French] J Gynecol Obstet Biol Reprod. 2014;43(6):463-9. mid=30192.

19 BrJP. São Paulo, 2019 jan-mar;2(1):20-6 ORIGINAL ARTICLE

Access of men with sickle cell disease and priapism in emergency services Acesso de homens com doença falciforme e priapismo nos serviços de emergência

Heros Aureliano Antunes da Silva Maia1, Mateus Andrade Alvaia1, Jayanne Moreira Carneiro2, Aline Silva Gomes Xavier2, José de Bessa Júnior2, Evanilda Souza de Santana Carvalho2

DOI 10.5935/2595-0118.20190005

ABSTRACT and the need for healthcare professionals to educate young boys and men with sickle cell disease and their caregivers about priapism in BACKGROUND AND OBJECTIVES: Priapism is one of the advance to allow adequate self-care and prevent complications. complications of sickle cell disease characterized by a persistent Keywords: Erectile dysfunction, Priapism, Sickle cell disease. and painful erection, which can lead to erectile dysfunction and sexual impotence. The objective of this study was to understand RESUMO how men with sickle cell disease and priapism access emergency care. JUSTIFICATIVA E OBJETIVOS: O priapismo é uma das METHODS: A qualitative study conducted in a reference complicações da doença falciforme caracterizada por ereção per- healthcare unit to people with sickle cell disease in the second sistente e dolorosa, podendo levar à disfunção erétil e impotên- largest city in Bahia. Seven adult men with sickle cell disease cia sexual. O objetivo deste estudo foi compreender como os who had experienced priapism participated in the study. The homens com doença falciforme e priapismo acessam os cuidados data were collected by semi-structured interview and thematic nos serviços de emergência. story designs and submitted to content analysis. MÉTODOS: Estudo qualitativo realizado em unidade de saúde RESULTS: Priapism is seen as a lack of genital health. Partic- referência para pessoas com doença falciforme no segundo maior ipants use strategies to manage it at home to avoid embarrass- município baiano. Participaram do estudo 7 homens adultos ment, which ends up in cocooning. Access to emergency services com doença falciforme que já vivenciaram priapismo. Utilizou-se is motivated by persistent and relentless pain; and limited by entrevista semiestruturada e desenhos-história com o tema, anal- the fear of priapism being mistaken for sexual deviance, lack of isados por análise de conteúdo. knowledge about the complication as a urologic emergency and RESULTADOS: O priapismo é visto como uma falta de saúde financial shortfall, which confers a worse prognosis about erectile genital. Os participantes usam estratégias para seu manuseio em function. Men are embarrassed and discriminated by healthcare domicílio para evitar constrangimentos, o que acaba isolando-os and support professionals, which discourages them from access- socialmente. O acesso aos serviços de emergência é motivado ing these services in the future. pela dor persistente e irredutível; e limitado pelo temor do pria- CONCLUSION: This study emphasizes the importance of early pismo ser confundido como resultado de desvio sexual, descon- diagnosis of sickle cell disease, the orientation of family members hecimento da complicação como emergência urológica e carên- cia financeira, o que confere pior prognóstico sobre a função erétil. Os homens sofrem constrangimento e discriminação pelos profissionais de saúde e de apoio das unidades, o que os desmo- Heros Aureliano Antunes da Silva Maia - https://orcid.org/0000-0003-4751-5987; tiva a acessar esses serviços no futuro. Mateus Andrade Alvaia - https://orcid.org/0000-0003-0075-4753; Jayanne Moreira Carneiro - https://orcid.org/0000-0003-3961-7959; CONCLUSÃO: Este estudo ressalta a importância do diagnósti- Aline Silva Gomes Xavier - https://orcid.org/0000-0002-3012-6849; co precoce da doença falciforme, da orientação de familiares e da José de Bessa Júnior - https://orcid.org/0000-0003-4833-4889; Evanilda Souza de Santana Carvalho3 - https://orcid.org/0000-0003-4564-0768. necessidade de os profissionais de saúde educarem os meninos/ homens jovens com doença falciforme e seus cuidadores sobre o 1. Universidade Estadual de Feira de Santana, Departamento de Saúde, Curso de Medicina, Feira de Santana, BA, Brasil. priapismo de forma prévia, para permitir o adequado autocuida- 2. Universidade Estadual de Feira de Santana, Departamento de Saúde, Programa de Pós- do futuro e prevenção de complicações. Graduação em Saúde Coletiva, Feira de Santana, BA, Brasil. Descritores: Disfunção erétil, Doença falciforme, Priapismo. Submitted in July 20, 2018. Accepted for publication in September 17, 2018. INTRODUCTION Conflict of interests: none – Sponsoring sources: Fundação de Amparo à Pesquisa do Estado da Bahia (FAPESB). Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq). Priapism is the total or partial continuous erection of the penis Correspondence to: Avenida Transnordestina, s/n - Novo Horizonte for more than four hours accompanied or not by sexual stimula- 44036-900 Feira de Santana, BA, Brasil. tion and orgasm1. It is considered a urologic emergency requir- E-mail: [email protected] ing urgent care or even surgical procedure to avoid complica- © Sociedade Brasileira para o Estudo da Dor tions such as irreversible erectile dysfunction2. 20 Access of men with sickle cell disease and priapism in emergency services BrJP. São Paulo, 2019 jan-mar;2(1):20-6

Sickle cell disease (SCD) is one of the causes of priapism. SCD This study was guided by the following question: how do men is more common among Afrodescendants, affecting about 3,500 with SCD and priapism access care in emergency services? The births per year in Brazil. The incidence is related to the percent- overall objective is to understand how men with SCD and pria- age of Afrodescendants in each region. The state of Bahia has the pism access care in emergency services. highest incidence of the disease: it affects 1: 655 live births and 1:17 live births carries the trace3. METHODS SCD interferes in man’s life, delays sexual maturation, compromises physical development and causes limitations in several A qualitative, descriptive, exploratory study conducted in a He- levels due to the clinical variability of this disease4. Priapism is moglobinopathies Specialized Center (HSC) in the city of Feira among the SCD complications and retrospective data points out de Santana, Bahia, Brazil. This study is linked to the master proj- that it affects approximately 30% of men with SCD5. ect “Representations about the body and SCD: repercussions on SCD causes ischemic priapism, with time-dependent hypoxia, daily life, care, and sexuality”. hypercapnia, and acidosis. It is a condition analogous to the The present study and its master project met the ethical prin- compartment syndrome, which occurs due to the stagnation of ciples for research with human beings. The recommendations blood in the sinusoids of the corpus cavernosum during physio- of the National Research Council, according to Resolution logical erections, obstructing venous drainage. In 12h histolog- 466/2012 of the National Health Council, were adopted. ical changes occur - interstitial edema, progressive endothelium Seven men participated in this study with a confirmed diag- destruction, basement membrane exposure - and thrombocyte nosis of SCD, asymptomatic, in an outpatient setting, aged adhesion in 24h. Within 48 hours, there are thrombi in the si- over 18 years, having already experienced priapism at some nusoidal space, muscle necrosis and fibroblast transformation, point in their lives and are frequent visitors of the HSC. The culminating in erectile dysfunction1. participants were informed about the study’s objectives, the Priapism compromises the quality of life of a man with SCD, voluntary and anonymous character of their participation, causing financial, affective, social and sexual impacts. Men with and that their acceptance to participate had no relation to SCD say that priapism brings feelings like shame, humiliation, their visits to the HSC. Then, they signed the Free and In- and fear. The fear of becoming sexually impotent hurts the prin- formed Consent Form (FICT). ciple of virility and deconstructs man’s masculinity with pria- The number of participants was established by the data satura- pism. Such a scenario develops a refusal of intimacy and difficul- tion criterion. As “priapism” refers to the Greek god of fertility, ties in affective relationships4. Priapus11, to ensure anonymity and secrecy, names of Greek dei- The access to healthcare is impaired in men with priapism and ties were drawn and attributed to portray the participants. SCD due to the barriers in the access to primary care. People The projective technique of story-theme drawing was used to with SCD are encouraged to seek secondary care directly6, es- produce the data. First, the intention and purpose of this tech- pecially the emergency services. However, in these services, the nique were explained. Then, the participants received a sheet of body may be in a homeostatic imbalance, imposing obstacles paper in blank and pencil, and they were asked to create a draw- that limit life goals, triggering feelings of fear, insecurity, anxi- ing on the topic “man with SCD and priapism in the urgent ety, and the expectation of quick and effective assistance by the care unit”. They were also asked to tell a story about the drawing healthcare team7. and give it a title. Subsequently, a semistructured interview was People with SCD seek services more frequently than the general conducted with closed sociodemographic questions and open population, and about 29% of these visits result in hospitaliza- questions about the priapism experience in the context of emer- tion8. In the U.S., people with SCD reported dissatisfaction with gency services. the quality of care provided in urgent care units in addition to The data was collected between November 2016 and February the excessive waiting time in comparison with other groups of 2017 by a qualified male interviewer, in a closed and private patients, even when they presented higher levels of pain and were environment (consulting rooms) of the HSC where the partici- screened as higher priority9. In Brazil, the access to emergency pants felt comfortable to share their experiences. The interviews services is hampered due to overcrowding, inadequate physical were recorded and transcribed in full immediately after their structure, the distance between the patient’s residence and the completion. The average duration of the interviews was 40 min- unit, and lack of financial resources for commuting10. utes, and they were closed when reached the content saturation. This study is justified by the importance of SCD as a public health The story-theme drawing has two stages: the creation of the issue in Brazil, with neglected history and high impact in the af- drawing and the production of a story from the drawing cre- fected populations and the territories they live due to the lack of ated, which allows a subjective and discursive interpretation of knowledge about the implications of the disease. In addition to the material produced, in which the two stages complete one exploring the health events in patients with SCD, giving more another. The model proposed by Coutinho12 was used to analyze visibility to the subject. Likewise, it favors health professionals’ re- this material. It consists of systematic observation and superficial flection about the structure of the emergency services that assist reading of the drawings and stories to know the data; select the men with SCD complications, such as priapism, allowing for eval- material by graphic similarity or proximity of themes. Then, fol- uation and redirection of healthcare actions to better care practices lowed the other steps, a more in-depth and targeted reading; the reducing the damages to the sexual health of these men. analysis and interpretation of the thematic contents grouped by 21 BrJP. São Paulo, 2019 jan-mar;2(1):20-6 Maia HA, Alvaia MA, Carneiro JM, Xavier AS, Bessa Júnior J and Carvalho ES categories and subcategories, and finally, the graphic interpreta- priapism came from SCD [...]. In a man’s head, what does it mean tion of the drawings12. when you’re erect? What do you want? – Zeus. The content analysis method proposed by Bardin’s13 was used When it is the first time, he thinks he has a problem, that his health to treat the data, which aims to obtain indicators that allowed is precarious, and the concern is: what to do? It is bad because he the inference of knowledge regarding the conditions of produc- keeps on thinking he will not be able to get laid normally with his tion/reception of these messages. There are three analysis phases: wife or girlfriend, he is afraid of failing ...– Hercules. pre-analysis, with the purpose to organize the material, select The experience is also permeated by shame and embarrass- the documents to be analyzed, formulate hypotheses or guiding ment. These situations occur unexpectedly, whether at work, questions, elaborate indicators that support the final interpreta- in places with friends and with the family. In general, people tion. Then the exploitation of the material, where the decisions around the man with SCD do not know about the priapism made in the pre-analysis phase are systematically applied. And complication and its relation to the disease, acting in a prej- then the treatment of the results, where inferences are made and udiced way and exposing the man with SCD to embarrassing the gross results are transformed into meaningful and valid re- situations. sults, proposing interpretations about the expected objectives or For those who go through this problem every day, (priapism), it is other unexpected discoveries. complicated; it is shame, shyness, prejudice, shameful, you are embarrassed, you cannot explain to someone if you do not have someone RESULTS close to you to talk, explain your problem – Theseus. Thus, men with SCD are secluded at home and use strategies Seven men with ages between 27 and 48 years participated in to revert the prolonged erection and pain with the use of teas, this study. Three were black, three were brown, and one yellow. cold water bath with medicinal plants on the penis, distraction, Four were married; 4 retired; 4 catholic; 5 with limited formal walking (Figure 1), try to urinate, to masturbate, or seek dis- schooling (did not reach high school) and 5 with low income (≤1 creet partners for intercourse in an attempt not to be mistaken minimum wage). or judged as sexual abusers. Among their clinical characteristics, 5 had type HbSS, and 2 When I was not oriented, I took showers, got wet, put ice; I was told had type HbSC. The SCD diagnosis was late in 4 men. The first to bathe my penis with aroeira (a plant), they said that it was good episode of priapism varied from 15 to 27 years old. The average ... I drank sugarcane tea; I stayed under the shower for long periods duration of the episodes for 5 men was ≤4h, usually occurring until that feeling of numbness passed, it seemed that he was numb. at night. Three men had no episodes of priapism in the last 6 It did not pass, it relieved. It passed with time; we also kept it out of months, while one man reported daily occurrence. mind – Hercules. All participants reported pain crises as the reason to seek the It is not telling anyone, to prevent from inventing a story, a gossip, emergency (ER). Two men have never sought the ER for pria- chitchat, so that the people do not create a trap, an invention of pism. They go from home to the ER by bus, bicycle, taxi or the something worse, like rape or something, prejudice, you have to talk neighbors give them a ride, and sometimes they walk. to someone close to you, who will support you – Theseus. The experiences of men with priapism were organized into three You wake up at dawn, like that (with priapism), you get up, go to categories which will be presented below: the bathroom, urinate, it continues, what comes to your mind? Oh, I have to get a woman [...] those who don’t understand, will throw Interpretation of priapism and strategies to handle it at home water, stay under the shower, watch porn, try to masturbate [...] in Men with SCD interpret priapism as an injury to health, a dis- the man’s head, what comes up is to watch a porn movie, masturbate ability, or a lack of genital/sexual health. They see it as an invol- until it diminishes – Zeus. untary painful erection experience, unpredictable, more frequent at night, that makes urination difficult. The strategies for handling priapism are modified based on the It’s complicated to have a long-lasting erection, and moreover, it guidelines given by health professionals when the man with SCD hurts. What is more difficult in priapism is not the erection, but the is able to share his experience with them. pain – Zeus. It is usually at night, at dawn. I’m sleeping and then I wake up with Factors that motivate and limit the access to emergency the erection and already feeling pain – Hades. services In its first occurrences, due to the lack of knowledge of this com- Among the motivating factors to access emergency services, is plication and its connection with SCD, prolonged involuntary the failure of home treatment strategies combined with pain be- erection is attributed to sexual desire and/or greater virility. The coming unbearable. This fact demonstrates that emergencies, in worry, fear, and lack of knowledge about how to handle the sit- general, are seen as the last resource to solve priapism. Another uation bring thoughts of insecurity and fear of future sexual per- factor that helps a man to access these services is that he has a formance. reliable person who offers him support and transportation to the I felt like a lucky guy because having an erection for two, three hours service. ... who can get it? Almost nobody. I did not know that priapism was I usually did not go to anyone. Because I was afraid. The last time generated by SCD. I thought it was just me. Only after I had the I had (priapism), I was with my wife, she took me to the ER, but first crises, I started to read about what SCD was; I could see that before that, I’ve never asked for help to anyone – Hermes. 22 Access of men with sickle cell disease and priapism in emergency services BrJP. São Paulo, 2019 jan-mar;2(1):20-6

Figure 1. Johnny and his cock Story: “Once upon a time there was this guy, Johnny, who woke up at night after a wonderful dream that he was having sex. When he woke up, his penis was erect; nothing could get his penis down. What did he do? He walked, and walked, and walked in his house... The penis went down slowly, after half an hour, then he laid down again and went to sleep” – Ares.

It was not working (the strategies), the pain was constant and what rienced priapism, which highlights the difficulty of discussing I was doing was not working [...] depends on the pain, the situation sexuality issues during medical visits. at the moment, if it’s light, we wait, if it’s not possible to go immedi- We need to learn. We do not learn this in our daily routine. I have ately (the ER) not to have complications – Hades. SCD since I was seven, and I learned about it (priapism) only when Shame presents itself in multiple ways among the factors that I was almost 20 [...]. Since it (priapism) is part of SCD, we should limit/impair the access: omit to tell the parents about the epi- know about recurrence, symptoms [...] we had to have this conver- sodes of priapism in adolescence, predict that he will be attended sation with the doctor in charge of the case, the specialist, but in our by a female health professional or predict embarrassing/negative entire lives we have not had this conversation, nobody ever told me situations because they have already heard negative reports of that it could happen – Hermes. other men with SCD and priapism. Such aspects affect the image Another factor that makes it difficult to access emergency ser- of man as an invulnerable person. vices is the transportation to arrive at these services. This depends The man has to take care of himself, but it’s a shame. He feels on the financial resources of the individuals, usually scarce, and ashamed to get there in this embarrassing situation. Getting there with the need to hide the erection (Figure 2) in the priapism running the risk of being attended by a woman, it is more difficult crisis during commuting. to talk about the subject, priapism, I’ve heard from a patient who I went walking (to the ER), which is not so far, and as I walked went and felt abashed – Poseidon. from home until there ... about 15 minutes, as I was walking the Since the penis is in an advanced erection, there is an embarrassment blood was circulating better, and when I arrived, there was no more because people notice it, it is visible, and usually, the person takes the (in priapism) – Hades. hand to the place because of the pain – Hermes. She (the mother) scolded me, asking why I did not say anything, Experiences of men with sickle cell disease and priapism in why did I hide, I shouldn’t, I should have told her, and she would emergency services have taken me straight to the hospital – Zeus. In the emergency services, there are embarrassing experiences The lack of early diagnosis of SCD, the lack of knowledge of caused by health professionals and other members of the support priapism as a complication of SCD and its urologic emergency staff, such as receptionists and stretcher-bearer. Such experiences character (when over 2 hours of duration), and its intermittent are based on prejudice due to the lack of knowledge about SCD occurrence - recurrent episodes of short duration also contribute and priapism, professional ignorance of genital cases and to keep the delay in seeking care. the privacy of the person. The association of priapism with sexual The lack of knowledge about the relationship with SCD is me- psychological disorders, masturbation practice, and also the con- diated by health professionals who, even when assisting the man nection of the image of a man with erection in public situations with SCD since childhood, do not inform the child and its care- to the stereotype of sexual abuser are extremelly embarassing. givers (usually women) about the possibility of future occurrence [...] When I was leaving the operating room, the boy carrying the and how to handle the event. Young and adult men also feel stretcher joked; he said: “you had a lot of hand job, haven’t you?” ashamed in telling the health professional that they have expe- (Masturbation), I was quiet: “No, that was not it” – Zeus. 23 BrJP. São Paulo, 2019 jan-mar;2(1):20-6 Maia HA, Alvaia MA, Carneiro JM, Xavier AS, Bessa Júnior J and Carvalho ES

Figure 2. The painful walking Story: “... he called his mother, and his mother called him to go to the bus stop to go to the hospital ... to ask the doctor what was that: the penis was hard, and nothing could soften it. The mother was a little angry because she wanted him to take the bus, but he didn’t want to get on the bus because he was ashamed and soon it started to rain. She insisted so much that he got on the bus and went to the hospital under the rain” – Theseus.

He was a health professional, he was joking, relaxing, but we were tense After establishing the relationship between priapism and SCD, ... For other people, it was an offense, and because of this, the person did there is a greater level of clarification due to the information of not want to go to the doctor anymore, because he was ashamed, unable the health professionals about SCD, priapism, how to handle it, to talk, “Your penis is numb? What have you done, boy?” – Hercules. and its complications. Some professionals calm the person and The lack of knowledge of the diagnosis of SCD by the man who provide a humanized care, encourage the man with priapism to experiences the first priapism events, added to the ignorance of seek discretion and when possible, isolate him as a way to keep health professionals, contribute to a possible unwillingness to be his privacy. Care is also given through analgesia, hydration and attended by these professionals, which causes even more embar- in severe cases, with the aspiration of the content of the penis rassment in men and delayed care. (Figure 3). Previously, when we did not know it was SCD, “we were ping- The professionals tried to calm me down, the doctor saying it was ponged from one to another (professionals)”, but today when you normal, the urologist, he knew what was happening, so he tried to say that you have SCD, it’s better, it’s not perfect, but it improved a calm me down, that it was not a voluntary but an involuntary issue. lot. They did this to me, they transferred me back and forth, “it is not He told me to relax and wait for the procedure. After the procedure with this one, refer to another, Dr. John Doe, ah, but he is not here, (aspiration of the penis), I began to understand a little more what he is coming, “they played this ping-pong game- Hercules. was happening – Hermes.

Figure 3. Priapism of the desert Story: “When I got to the emergency, I realized that what I thought was good for me was actually bad - I ended up going to surgery, with my penis full of needles, painful sensation - not to mention shame. That’s why I drew the cactus, that was how I felt stuck by needles, like thorns, that marked me. Priapism, after the pain crisis, is the worst thing one can have” – Zeus.

24 Access of men with sickle cell disease and priapism in emergency services BrJP. São Paulo, 2019 jan-mar;2(1):20-6

discomfort in men and a sense of expropriation of their body, The expectation of the aspiration of the penis content procedure which makes them relinquish their innermost, physical and psy- together with the knowledge of the possibility of complications chological sphere20. from priapism, such as erectile dysfunction, evoke feelings of fear Resistance to public transportation and financial restrictions and concern. In our country, there is still a shortage of profes- leads to the use of their own car, or friends/family car, or even sionals able to perform the procedure of aspiration of the penis, walking as a means of protection and privacy. In a study car- which exposes men with SCD and priapism to a higher risk of ried out in the United States8, 79% of the patients with SCD complications due to delay in treatment. and pain crisis admitted to the emergency arrived went there The risk of erectile dysfunction increases as seeking help and walking. treatment is delayed. This complication scares the man with Health professionals and support staff in emergency services SCD, reflecting his vulnerability to depression and the possibil- generate situations of discrimination and embarrassment to men ity of committing suicide. Although most of them fear sexual with SCD in priapism. The body language and the eyes commu- impotence, one of the participants reported that it is possible to nicate feelings that denounce the act of caring. It is important to live with erectile dysfunction provided there is a re-significance be careful with the posture and facial expression to avoid embar- of sexual relation, so that pleasure for a man is not only linked rassment to the patient21. to penetration. The emergency environment in this study was configured as a It was a very difficult and painful procedure. I ended up with a se- space to obtain the first information of priapism as a complica- quel (erectile dysfunction), sex is not just penetration. So I learned tion. Health education in the hospital setting may include the to deal with it, make do with what you have, at first it was compli- spouse or the parents of the hospitalized person, discuss the im- cated, I will not lie, because the erection is an asset to man that you pact of the disease on the family life, and encourage the adoption can’t take away, you take whatever you want from a man, but do his of healthy behaviors22. erection, he gets mad, even suicidal – Zeus. Men with SCD and priapism expressed feelings of fear regarding the surgery to emptying the penis, which converges with the DISCUSSION results of a study23 in which the surgical procedure was related to a kind of abandonment, yet temporary. This interferes with The sociodemographic and clinical profile of the participants in the feeling of life continuity, it appears as something unexpected this study is consistent with the literature, that is low schooling, and unwanted and can be related as the last chance to keep the unemployment, low family income14 and age range of the first erectile and sexual function. episodes of priapism15. The higher frequency of late diagnosis of Erectile dysfunction is predictable in 90% of the ischemic pri- SCD in this study can be explained by the fact that mandatory apism cases lasting more than 24 hours1, and the duration in- early diagnosis is still recent in Brazil (National Neonatal Screen- terferes with the preservation of the function11. Waiting for a ing Program - 2001)16. spontaneous resolution of priapism and the delay in seeking pro- The duration of priapism episodes of less than 4h characteriz- fessional help in emergency units were common in the reports, es intermittent priapism, usually nocturnal and handled suc- indicating the need for investment in education to understand cessfully with home-based strategies and allows normal erectile the disease, its complications and the self-care of these men since function between episodes17. However, there is an association their childhood, when the first episodes of priapism occur, in between the increase in frequency and duration of the episodes addition to informing their families to provide support. of intermittent priapism preceding major acute attacks (>4h) of In the present study, reports of men with SCD and erectile dys- greater severity1. function after priapism stated that they try to keep their sexual The use of strategies to handle priapism at home is an attempt to life active with their partners, varying positions during inter- avoid long waits and attendance by female health professionals course, without any specific strategy. Some of the participants do in emergencies - services seen as a last option. However, in more not have partners, and they did not report any practice of seeking severe cases of priapism, the ineffectiveness of home strategies individual pleasure, probably for fear of stimulating new crises. leads to the idea that priapism is an insoluble problem18. A study18emphasized that participants mentioned the impact on Themes that involve the patients’ sexuality, such as priapism, sexual life as the most distressing aspect of priapism; saying that face silence from health professionals. Education for parents/ they had nothing to offer their partners in the affective-sexual caregivers on priapism is necessary since the childhood of boys perspective and felt unable to attract or keep partners, generating with SCD, just as it is routine to approach the warning signs, loneliness, loss of self-esteem and hope. teaching spleen palpation to recognize splenic sequestration, use of special drugs and vaccines, and other recommendations CONCLUSION by health professionals6. Care is not seen as a male, but female practice, which leads men The experiences of men with SCD and priapism are permeated to subdue their health needs. Health services are often perceived by feelings of shame and embarrassment, whether at home, in as feminine and fragile spaces, attended and composed by wom- social situations or healthcare service units, undermining access en, generating in men a sense of not belonging to that space19. to care. Priapism is a complication that occurs in the adolescence In addition, the exposure to nudity in emergency services creates and early adulthood of man, a period in which many still live 25 BrJP. São Paulo, 2019 jan-mar;2(1):20-6 Maia HA, Alvaia MA, Carneiro JM, Xavier AS, Bessa Júnior J and Carvalho ES with their parents and hide the occurrence of the episodes, mak- SCD and their caregivers about priapism to allow adequate self- ing it difficult to seek help. care in the future and avoid complications. The attribution of different meanings to priapism by men with SCD is influenced by the access to the early diagnosis ACKNOWLEDGMENTS of SCD, so that not knowing the etiological relation of priapism to the disease, men can understand it as a demonstra- To all collaborating authors and those who had direct or indirect tion of virility and sexual potency. Even attributing positive participation in this study. To the National Council for Scientific meanings, the man with priapism adopts measures at home to and Technological Development\CNPq. To the Foundation for induce the relief of pain and the detumescence of the organ. Research Support of the State of Bahia (FAPESB). To the State The persistence of pain, associated with the failure of these University of Feira de Santana measures, motivates the man with SCD and priapism to seek emergency services late and in general, supported by people REFERENCES whom he trusts. 1. Broderick GA. Priapism and sickle-cell anemia: diagnosis and nonsurgical therapy. J Access to care in emergency services is hampered by the embar- Sex Med. 2012;9(1):88-103. rassment imposed by priapism and by the financial situation of 2. Roghmann F, Becker A, Sammon JD, Ouerghi M, Sun M, Sukumar S, Djahangirian men with SCD. The embarrassment is present in every moment O, et al. Incidence of priapism in emergency departments in the United States. J Urol. 2013;190(4):1275-80. of the journey to access specialized care. It is present at the mo- 3. Cordeiro RC, Ferreira SL, Santos AC. Experiências do adoecimento de pessoas com ment of asking for help, when using a means of transportation anemia falciforme e estratégias de autocuidado. Acta Paul Enferm. 2014;27(6):499-504. 4. Rios TAO, Xavier ASG, Carvalho ESS, Passos SSS, Araújo EM, Ferreira SL. Significados to go to the emergency unit (reason why some prefer to walk) do priapismo para pessoas com doença falciforme. In: Carvalho ESS, Xavier ASG, orga- and is also anticipated when the man with SCD assumes that nizadores. Olhares sobre o adoecimento crônico: representações e práticas de cuidado às pessoas com doença falciforme. Feira de Santana: UEFS Editora; 2017. 253-62p. he will be attended by female health professionals, which hurts 5. Serjeant G, Hambleton I. Priapism in homozygous sickle cell disease: a 40-year study his masculinity. And, finally, it is materialized when attended by of the natural history. West Indian Med J. 2015;64(3):175-80. unskilled professionals. 6. Gomes LM, Pereira IA, Torres HC, Caldeira AP, Viana MB. Acesso e assistência à pessoa com anemia falciforme na Atenção Primária. Acta Paul Enferm. 2014;27(4):348-55. The lack of knowledge of priapism as a urological emergency, its 7. Carvalho EMMS. A pessoa com doença falciforme em uma unidade de emergência: consequences and the recurrent character of shorter duration of limites e possibilidades para o cuidar da equipe de enfermagem [Dissertação]. Niterói (RJ): Universidade Federal Fluminense; 2014. intermittent priapism also discourage the search for emergency 8. Yusuf HR, Atrash HK, Grosse SD, Parker CS, Grant AM. Emergency department care help by men with SCD. visits made by patients with sickle cell disease: a descriptive study, 1999-2007. Am J Prev Med. 2010;38(4 Suppl):S536-41. In the emergency care units, the man with SCD and priapism 9. Haywood C, Tanabe P, Naik R, Beach MC, Lanzkron S. The impact of race and disea- still faces embarrassing situations when interacting with health se on sickle cell patient wait times in the emergency department. Am J Emerg Med. 2013;31(4):651-6. professionals and support staff (reception, stretcher bearers, 10. Dubeux LS, Freese E, Felisberto E. Acesso a hospitais regionais de urgência e emergên- janitors, among others). This is based on the lack of knowledge cia: abordagem aos usuários para avaliação do itinerário e dos obstáculos aos serviços about the disease and its complications, not to mention the as- de saúde. Physis. 2013;23(2):345-69. 11. Pal D, Biswal D, Ghosh B. Outcome and erectile function following treatment of sociation of the man in a situation of erection in public with the priapism: An institutional experience. Urol Ann. 2016;8(1):46-50. stereotype of sexual abuser and of people with sexual deviations. 12. Coutinho MC. Sentidos do trabalho contemporâneo: as trajetórias identitárias como estratégia de investigação. Cad Psicol Soc Trab. 2009;12(2):189-202. In spite of these limitations, in these emergency care units, the 13. Bardin L. Análise de Conteúdo. São Paulo: Editora 70; 2011. man with priapism obtains professional information about the 14. Felix AA, Souza HM, Ribeiro SB. Aspectos epidemiológicos e sociais da doença falciforme. Rev Bras Hematol Hemoter. 2010;32(3):203-8. SCD and the care measures required in new occurrences of pria- 15. Furtado PS, Costa MP, Ribeiro do Prado Valladares F, Oliveira da Silva L, Lordêlo M, pism, and its consequences. Lyra I, et al. The prevalence of priapism in children and adolescents with sickle cell Because of the delay in seeking help and being treated at the disease in Brazil. Int J Hematol. 2012;95(6):648-51. 16. Braga JA. Medidas gerais no tratamento das doenças falciformes. Rev Bras Hematol emergency care units, it is often necessary to have more invasive Hemoter. 2007;29(3):233-8. and complex procedures such as penis emptying surgeries, which 17. Dupervil B, Grosse S, Burnett A, Parker C. Emergency department visits and inpa- tient admissions associated with Priapism among males with sickle cell disease in the generates feelings of fear and uncertainty for the man with pri- United States, 2006-2010. PLoS One. 2016;11(4):2006-10. apism over his future sexual performance due to the possibility 18. Addis G, Spector R, Shaw E, Musumadi L, Dhanda C. The physical, social and psychological impact of priapism on adult males with sickle cell disorder. Chronic of erectile dysfunction. In this sense, this study indicates that it Illn. 2007;3(2):145-54. is necessary to review the existing protocols to define the waiting 19. Gomes R, Nascimento EF, Araújo FC. [Why do men use health services less than time to treatment, taking into account the particularities of each women? Explanations by men with low versus higher education]. Cad Saude Publica. 2007;23(3):565-74. Portuguese. country; such as the mobility conditions of the means of trans- 20. Pupulim JS, Sawada NO. Physical privacy regarding body exposure and manipula- portation and the quality and efficiency in being promptly cared tion: perception of hospitalized patients. Texto Contexto Enferm. 2010;19(1):36-44. 21. dos Santos RM, Viana IR, da Silva JR, Trezza MC, Leite JL. [The nurse and patient’s at the emergency care units in each location. nudity]. Rev Bras Enferm. 2010;63(6):877-86. Portuguese. This study emphasizes the importance of early diagnosis of the 22. Silva MA, Pinheiro AK, Souza AM, Moreira AC. Promoção da saúde em ambientes hospitalares. Rev Bras Enferm. 2011;64(3):596-9. sickle cell disease, the education of family members and the need 23. Fighera J, Viero EV. Vivências do paciente com relação ao procedimento cirúrgico: of health professionals to early educate boys and young men with fantasias e sentimentos mais presentes. Rev SBPH. 2005;8(2):51-63.

26 BrJP. São Paulo, 2019 jan-mar;2(1):27-33 ORIGINAL ARTICLE

Immediate analgesic effect of 2KHz interferential current in chronic low back pain: randomized clinical trial Efeito analgésico imediato da corrente interferencial de 2KHz na dor lombar crônica: ensaio clínico randomizado

Nicole Almeida1, Luis Henrique Paladini1, Madeline Pivovarski1, Fernanda Gaideski1, Raciele Ivandra Guarda Korelo1, Ana Carolina Brandt de Macedo1

DOI 10.5935/2595-0118.20190006

ABSTRACT RESUMO

BACKGROUND AND OBJECTIVES: Interferential current JUSTIFICATIVA E OBJETIVOS: A corrente interferencial é is widely used in clinical practice for the treatment of low back amplamente utilizada na prática clínica para o tratamento da dor pain, but there is no literature consensus regarding its parame- lombar, porém não há consenso na literatura sobre seus parâmet- ters. The objective of this study was to analyze the immediate ef- ros. O objetivo deste estudo foi analisar o efeito imediato da cor- fect of the 2KHz interferential current in chronic low back pain. rente interferencial de 2KHz na dor lombar crônica. METHODS: This randomized controlled clinical trial was previ- MÉTODOS: Ensaio clínico, controlado randomizado, foi pre- ously approved by the Research Ethics Committee of the Federal viamente aprovado pelo Comitê de Ética em Pesquisa da Uni- University of Paraná, with the participation of 105 individuals with versidade Federal do Paraná. Participaram 105 indivíduos com chronic low back pain (>12 weeks) of both genders. Participants dor lombar crônica (>12 semanas), de ambos os sexos. Os par- were randomized in 3 groups: placebo group (PG, n=35), electrical ticipantes foram randomizados em 3 grupos: grupo placebo stimulus off; interferential current1 (IG1, n=35), carrier frequency (GP, n=35), estímulo elétrico desligado, grupo interferencial1 2KHz, AMF of 2Hz, motor intensity level and IG2, n=35, carrier (GI1, n=35), frequência portadora de 2KHz, AMF de 2Hz, frequency 2KHz, AMF of 100Hz, sensory intensity level. All groups intensidade a nível motor e grupo interferencial2 (GI2, n=35), were subjected to a single application for 30 minutes with 4 elec- frequência portadora de 2KHz, AMF de 100Hz, intensidade a trodes in a crossed-shape position in the lumbar region. nível sensorial. Todos os grupos foram submetidos a uma única RESULTS: The visual analog scale, McGill pain scale, Oswestry aplicação durante 30 minutos, com 4 eletrodos posicionados de Low Back disability questionnaire, Roland Morris disability maneira cruzada na região lombar. questionnaire and Algometria of pressure were used for evalua- RESULTS: Para avaliação e reavaliação, foi utilizada a escala tion and revaluation. analógica visual, escala da dor de McGill, Questionário de dor CONCLUSION: It may be noticed that by the visual analog lombar de Oswestry, Questionário de Incapacidade de Ro- scale and questionnaires, the interferential current provided an land-Morris e Algometria de Pressão. immediate analgesic effect in chronic lumbar pain regardless of CONCLUSÃO: Pode-se perceber que, pela escala analógica vi- the mode of stimulation. sual e pelos questionários, a corrente interferencial proporcionou Keywords: Analgesia, Chronic pain, Electric stimulation thera- efeito analgésico imediato na dor lombar crônica independente- py, Low back pain. mente do modo de estimulação. Descritores: Analgesia, Dor crônica, Dor lombar, Terapia por estimulação elétrica. Nicole Almeida - https://orcid.org/0000-0001-5128-5585; Luis Henrique Paladini - https://orcid.org/0000-0002-7376-7830; INTRODUCTION Madeline Pivovarski - https://orcid.org/0000-0002-3853-6957; Fernanda Gaideski - https://orcid.org/0000-0002-3798-7641; Raciele Ivandra Guarda Korelo - https://orcid.org/0000-0002-6754-098X; Lower back pain (LBP) is a multifactorial clinical condition,  Ana Carolina Brandt de Macedo - https://orcid.org/0000-0002-1514-7887. related to biopsychosocial, sociodemographic and economic 1. Universidade Federal do Paraná, Departamento de Prevenção e Reabilitação em Fisiote- factors1-3, affecting approximately 84% of the world popula- rapia, Curitiba, PR, Brasil. tion. Around 30 to 33% of the population presenting acute Submitted in September 28, 2018. episodes of LBP end up developing chronic lower back pain Accepted for publication in December 10, 2018. (CLBP)4, i.e., persistent pain for more than 12 weeks3. Most Conflict of interests: none – Sponsoring sources: none of CLBP causes are non-specific and may be associated with Correspondence to: increased central sensitization5 and inefficiency in the con- Ana Carolina Brandt de Macedo 6 Rua Aristides Pereira da Cruz, 21 casa 57 – Portão trol of pain endogenous . Prolonged pain may increase the 80330-290 Curitiba, PR, Brasil. excitability of afferent neurons (hypersensitivity) which may E-mail: [email protected] lead to changes in their plasticity, resulting in an exaggerated © Sociedade Brasileira para o Estudo da Dor response to pain7. 27 BrJP. São Paulo, 2019 jan-mar;2(1):27-33 Almeida N, Paladini LH, Pivovarski M, Gaideski F, Korelo RI and Macedo AC

Identifying effective non-invasive and non-pharmacological and Informed Consent Form (FICT) (Resolution 466/2012 treatments for CLBP can lead to significant gains and substan- of National Health Council). tial results in morbidity and costs related to this population8. Exclusion criteria were: disc herniation or another disc dis- Treatments for CLBP primarily aim to reduce pain and disabili- ease, no lower back pain on the evaluation day, use of drugs ty9. The analgesic approaches used in CLBP raise a lot of discus- within 24 hours before the instrument application and surgi- sions and sometimes are controversial. However, it is known that cal procedure in the abdominal and lumbar regions. physiotherapy is an excellent support in its treatment through The data was collected at the Physiotherapy laboratory of the therapeutic exercises, health education and also by means of elec- Federal University of Paraná and Prevention and Functional trotherapy2,10. Rehabilitation Service of the Hospital de Clínicas in Curitiba Electrotherapy uses electrical currents for therapeutic purposes, from March 2017 to March 2018. such as analgesia11. Interferential current (IC) is an electric current of medium frequency, modulated at low-frequency, capable Intervention of penetrating deeper in tissues compared to other low-frequency Participants were randomized in 3 groups, into blocks of 5: currents. low-frequency interferential group (IG1), high-frequency in- The guidelines on CLBP treatment mention IC as a non-phar- terferential group (IG2) and placebo group (PG). macological treatment for pain reduction3, and may be advan- For IC application, the participant was positioned in the tageous in relation to other types of procedures, such as sur- prone position. Four silicone electrodes (9x5cm) with con- gery10,12. However, they highlight the low evidence level in the ductor gel were arranged crosswise, fixed by adhesive tape, studies, suggesting the need for more research related to the 3cm away from the L3 and L5 spinous processes, to the right topic1,3,10,11,13,14. Fuentes et al.15 found in their systematic review and the left. that despite the musculoskeletal pain reduction observed after CF of IC used was of 2KHz and frequency variation (ΔF) IC, these results are inconclusive due to the reduced number of of 0Hz. In IG1, the chosen amplitude modulation frequency studies and the methodological heterogeneity. (AMF) was 2Hz and motor level intensity. In IG2, the AMF IC equipment allows the adjustment of the medium frequen- was 100Hz and sensory level intensity. AMF selection was cy (carrier frequency) according to the therapeutic objective. based on the frequencies used in Transcutaneous Electrical The literature indicates that carrier frequencies (CF) of 2KHz Neural Stimulation (TENS). According to Robertson et al.21 are more appropriate for muscle contraction and 4KHz for high-frequency and low-intensity electrical pulses produce an analgesia16,17. However, these data are only found in books analgesic effect through the theory of pain gates while those and are not evidenced in scientific studies10. There is still a lot of low frequency and high intensity stimulate the endorphin of controversies in the literature regarding adequate IC pa- release. PG was subjected to the equipment application but in rameters for both CF and frequency modulation to promote the off mode. All groups received a single application lasting analgesia18,19. 30 minutes. Only two studies evaluated the immediate IC effects on pain. Fuentes et al.20 studied the IC acute effect associated or not to Evaluation the therapist interaction in CLBP. They observed greater analge- Participants were assessed through a specific record containing sia in the IC-treated groups but did not indicate the CF used, data of identification, anamnesis, pain evaluation (VAS and only the 0Hz frequency modulation and the treatment time (30 McGill Pain Questionnaire), pressure algometry and Oswestry min). Corrêa et al.12 measured the CF analgesic effect between 1 Low Back Pain Questionnaire (OLBPQ) and Roland Morris and 4KHz of IC in individuals with CLBP after the first session, Disability Questionnaire (RMDQ), validated in Portuguese. after 12 sessions and after 4 months, and saw that IC provided VAS consists of a horizontal line with 10cm in length, num- an immediate analgesic effect after the first session, regardless bered from zero to 10, with zero indicating no pain and 10 of CF. These two studies show that the 2KHz CF was not used, maximum pain. Participants indicated the point representing despite the more satisfactory analgesic results with lower carrier the intensity of their pain at the time of evaluation22. frequencies showed in the literature10,12. The McGill Pain Questionnaire (MPQ) validated in Portu- So, this study aimed at analyzing the immediate analgesic effect guese23 evaluates several aspects of pain through words (de- of 2KHz IC in CLBP through the subjective and objective per- scriptors) chosen by the participant to express his/her pain. ception of pain, as well as evaluating the functional capacity of The 78 descriptors (words qualifying pain) are divided into these individuals. four categories: sensory-discriminative, affective-motivational, evaluative-cognitive and mixed, and also in 20 subcate- METHODS gories each containing 4 to 6 words. The individual should choose none or a word from each subcategory. The numeri- A randomized, controlled clinical trial in which were selected cal index of the descriptors was calculated by the number of male and female participants older than 18 years with CLBP words chosen by the participants to characterize their pain, (longer than 12 weeks)3, of non-specific origin and with vi- being 20 the maximum value23. sual analog scale (VAS) pain greater than 1. After oral in- The pressure algometer (EMG System do Brasil) is a me- vitation, those who accepted to participate signed the Free chanical device to apply point-pressure to cause pain, with 28 Immediate analgesic effect of 2KHz interferential current BrJP. São Paulo, 2019 jan-mar;2(1):27-33 in chronic low back pain: randomized clinical trial an indication of the force exerted (known pressure exerted, Statistical analysis constant area). It has a display showing mean value and max- For statistical analysis, the results were expressed as mean ± imum peak, V/Kgf/cm2 calibration report with signal condi- standard deviation and submitted to the normality analysis and tioning, power supply, analog output via BNC connector al- variances homogeneity using the Shapiro Wilk and Levene tests, lowing the external synchronism with other signal acquisition respectively. For parametric variables, paired t Student test was systems and with a system of integrated signal acquisition. It performed in the pre- and post-comparison, and Tukey’s post was applied before and immediately after the IC application hoc ANOVA in the comparison between the groups. The study to compare the intensity of pain in kilograms/force (KgF) by adopted p<0.05 value for statistical significance. the same previously trained examiner (ICC=0.95). For the evaluation, 2 points were marked for control in the anterior RESULTS tibial, one in the right and the other in the left, 4 points in the lumbar region: 5cm away from the third and fifth lumbar One hundred and five patients were evaluated, divided into 3 vertebra, both on the right and the left side. The algometer tip groups: IG1 (n=35), IG2 (n=35) and PG (n=35) (Figure 1). (1cm in diameter) was pressed at each point perpendicularly There was no sample loss. The recruitment period comprised to the participant’s skin, which was instructed to warn when between March and November 2017. he/she could no longer withstand the pressure. The development rate was 0.3kgf/s12. Three collections were performed at each point with a 1-minute interval. Then, the arithmetic mean was taken to define the pressure pain threshold (PPT). Individuals with lower back pain (n=105) OLBPQ is the most recommended instrument to measure the functional impact of LBP and has been translated and validat- Assessment ed into Portuguese24. It consists of 10 sessions referring to daily activities that can be interrupted or impaired due to LBP. Each of them contains six statements, which progressively describe a greater degree of difficulty in activity than the pre- PG (n=35) IG1 (n=35) IG2 (n=35) ceding statement. The statements are scored from zero to five, resulting in a maximum score of 50. The dysfunction degree IC IC CF: 2KHz, CF: 2KHz, given by OLBPQ was classified as no dysfunction (0%), min- IC desligada AMF: 100 HZ, AMF: 2HZ, imal dysfunction (1 to 20%), moderate dysfunction (21 to T: 30 min I: sensory level I: motor level 40%), severe dysfunction (41 to 60%) and disability (above T: 30 min T: 30 min 60%)23. For results comparison, the total questionnaire score and the dysfunction degree were used. 25 The Brazilian RMDQ , which is widely used to evaluate the Reassessment functional performance associated with LBP, is composed of 24 questions related to activities of daily living, pain, and function. For each affirmative question, 1 point was assigned. Figure 1. Study Design The score is the sum of the values, being possible to get a IC = interferential current; CF = carrier frequency; AMF = amplitude modu- minimum score of “0” and a maximum score of “24”. The lation frequency. individuals assessed with a score equal to or greater than “14” were classified as functionally disabled25. The reassessment be- Table 1 shows the clinical and sociodemographic characteris- gan shortly after the application. tics of the studied population. The sample calculation was defined taking a difference of two Pain intensity decreased significantly in the three groups, and points in the pain intensity through VAS, using the Gpower in IG1 and IG2 there was a decrease of more than 3 points on 3.0 program. The statistical power of 0.95 was considered; the scale (zero to 10). In intergroup comparison, a difference alpha of 0.05 and effect of 0.4; totaling 102 participants, be- was found between IG1 and IG2 with PG, but with no differ- ing 34 per group. This study selected 105 participants, being ence between IG1 and IG2 (Table 2). above the desired sample size. Regarding the algometry result in the lumbar region, significance The randomization was performed in blocks22. Nine blocks was only found in L3R and L3L in the IG2 intragroup (Table 3). were established with 15 participants in each, that is, in the Table 4 refers to the results found through the questionnaires draw envelope, there were 5 pieces of paper with IG1 written applied. Regarding MPQ, the pain index was reduced in the on them, 5 with IG2 and 5 with PG. The draw was blind to three groups during the analysis of intragroup data. In OLB- the participant. PQ and RMDQ, there was a significant reduction in the three The Ethics and Research Committee in Human Beings of groups when compared to the initial evaluation. However, the Health Sciences Department of the Federal University of when the groups were compared, no difference was found be- Paraná approved this study under number 1145540 and regis- tween IG1 and IG2 and placebo. tered in the clinical trial records with number RBR 59YGR8. Table 5 presents the results of the intergroup differences. 29 BrJP. São Paulo, 2019 jan-mar;2(1):27-33 Almeida N, Paladini LH, Pivovarski M, Gaideski F, Korelo RI and Macedo AC

Table 1. Clinical and sociodemographic characteristics Variables IG1 IG2 PG (n=35) (n=35) (n=35) Age (mean±SD) (years) 43.3 ± 15.3 42.2 ± 14.3 32.9 ± 15.6 Gender (n, %) Female 23 (65.7) 23 (65.7) 21 (60) Male 12 (34.3) 12 (34.3) 14 (40) Education (n, %) Incomplete elementary school 1 (2.9) 0 (0) 1 (2.9) Complete elementary school 0 (0) 2 (5.7) 1 (2.9) Incomplete secondary school 7 (20) 6 (17.1) 3 (8.6) Complete secondary school 9 (25.7) 7 (20) 3 (8.6) Incomplete higher education 11 (31.4) 10 (28.6) 20 (57.1) Complete higher education 7 (20) 10 (28.6) 7 (20) Lifestyle habits Smoker (n, %) 2 (5.7) 4 (11.4) 2 (5.7) Alcohol consumption (n, %) 7 (20) 1 (2.9) 4 (11.4) Sedentary (n, %) 17 (48.6) 14 (40) 17 (48.6) Time of pain (years) (mean, min, max, median) 5.81; 3; 34; 3 6.54; 3; 31; 3 4.46; 3; 17; 3 Location of pain (n, %) Centralized 12 (34.3) 8 (22.9) 10 (28.6) On the right 7 (20) 9 (25.7) 5 (14.3) On the left 1 (2.9) 1 (2.9) 4 (11.4) Bilateral 15 (42.9) 17 (48.6) 16 (45.7) Period of the day when pain worsens (n, %) Morning 14 (40) 12 (34.3) 8 (22.9) Afternoon 6 (17.1) 7 (10) 7 (10) Night 15 (42.9) 16 (45.7) 20 (57.1) Activities that exacerbate pain (n, %) Walking 9 (25.7) 14 (40) 12 (34.3) Sitting 13 (37.1) 17 (48.6) 11 (31.4) Getting down 9 (25.7) 19 (54.3) 15 (42.9) Standing up 8 (22.9) 11 (31.4) 10 (28.6) Climbing stairs 5 (14.3) 12 (34.3) 11 (31.4) Effort/lifting object 31 (88.6) 28 (80) 31 (88.6) IG1 = low-frequency interferential group; IG2 = high-frequency interferential group; PG = placebo group.

Table 2. Evaluation of pain by visual analog scale IG1 IG2 PG (n=35) (n=35) (n=35) VAS Before After Before After Before After (mean ± SD) 5.3 ± 2.1 2.0 ± 1.9*# 4.7 ± 1.8 1.0 ± 1.4*# 4.9 ± 2.3 3.0 ± 2.0* IG1 = low-frequency interferential group; IG2 = high-frequency interferential group; PG = placebo group; VAS = visual analog scale. *p<0.05 - intragroup (paired t test). # p<0.05 comparing with PG.

Table 3. Results of pressure pain threshold PPT IG1 IG2 PG (mean ± SD) (n=35) (n=35) (n=35) Before After Before After Before After ATL 4.6 ± 2.7 4.5 ± 2.6 5.5 ± 1.8 5.3 ± 1.6 5.6 ± 1.9 5.1 ± 2.1 ATR 4.7 ± 2.4 4.5 ± 2.4 5.9 ± 1.8 5.6 ± 1.6 4.4 ± 1.7 5.3 ± 1.9 L3L 4.6 ± 2.8 4.9 ± 2.9 4.8 ± 1.4 5.3 ± 1.7* 4.4 ± 1.7 4.5 ± 1.8 L3R 4.8 ± 2.9 4.8 ± 2.9 4.6 ± 1.4 5.1 ± 1.4* 4.4 ± 1.8 4.7 ± 1.8 L5L 4.6 ± 2.6 4.9 ± 3.0 4.7 ± 1.5 5.1 ± 1.6 4.5 ± 1.8 4.6 ± 1.8 L5R 4.7 ± 2.9 5.1 ± 2.7 4.7 ± 1.8 5.1 ± 1.4 4.9 ± 2.4 4.9 ± 2.3 PPT = pressure pain threshold; IG1 = low-frequency interferential group; IG2 = high-frequency interferential group; PG = placebo group; AT = anterior tibial; L3 = 3rd lumbar vertebra; L5 = 5th lumbar vertebra; L = left; R = right. *p<0.05.

30 Immediate analgesic effect of 2KHz interferential current BrJP. São Paulo, 2019 jan-mar;2(1):27-33 in chronic low back pain: randomized clinical trial

Table 4. Results from the McGill, Oswestry pain questionnaires for lower back pain assessment and Roland Morris Disability Questionnaire IG1 IG2 PG (n=35) (n=35) (n=35) Before After Before After Before After MPQ (mean±SD) Sensory 7.7 ± 2.6 4.0 ± 3.3* 8.5 ± 2.2 4.0 ± 3.3* 8.3 ± 3.3 5.4 ± 2.7* Affective 3.0 ± 1.8 0.7 ± 1.3* 3.8 ± 1.7 0.9 ± 2.1* 3.5 ± 1.9 1.8 ± 1.5 Evaluative 1.4 ± 0.7 0.4 ± 0.7 1.1 ± 0.3 0.4 ± 0.6* 1.2 ± 1.3 0.9 ± 1.4 Miscellaneous 3.0 ± 1.7 1.4 ± 1.3* 3.5 ± 1.6 1.1 ± 1.5* 3.2 ± 1.1 2.0 ± 1.4* Total 15.2 ± 4.9 6.6 ± 6.0* 17 ± 4.7 6.4 ± 6.8* 16.2 ± 6.1 10.2 ± 4.9* OLBPQ Before After Before After Before After Total 11.4 ± 4.4 5.2 ± 3.9*# 13.7 ± 6.0 5.6 ± 5.7*# 11.1 ± 5.7 7.0 ± 4.5* Dysfunction level n (%) No dysfunction 0 (0) 3 (8.6) 0 (0) 5 (14.3) 0 (0) 2 (5.7) Minimal dysfunction 17 (48.6) 28 (80) 12 (34.3) 24 (68.6) 17 (48.6) 28 (80) Moderate dysfunction 17 (48.6) 4 (11.4) 17 (48.6) 4 (11.4) 16 (45.7) 4 (11.4) Severe dysfunction 1 (2.9) 0 (0) 6 (17.1) 2 (5.7) 2 (5.7) 1 (2.9) RMDQ Before After Before After Before After Total 9 ± 4.2 5.1 ± 3*# 11.2 ± 5.3 4.6 ± 4.4*# 9.9 ± 6.0 6.9 ± 5.1* FD (n, %) Yes 4 (11.4) 0 (0) 9 (25.7) 1 (2.9) 10 (28.6) 3 (8.6) IG1 = low-frequency interferential group; IG2 = high-frequency interferential group; PG = placebo group; MPQ = McGill Pain Questionnaire; OLBPQ = Oswestry Low Back Pain Questionnaire; RMDQ = Roland Morris Disability Questionnaire; FD = functional disability. *p<0.05 - intragroup (paired t test). # p<0.05 - comparing with PG.

Table 5. Intergroup difference (IG1, IG2 and PG) of the analyzed variables after the interferential current application Outcomes Differences between interventions with a 95% confidence interval IG1 versus PG p-value IG2 versus PG p-value IG1 versus IG2 p-value VAS (0-10) 1.4 (0.5 to 2.3) 0.02* 1.7 (0.8 to 2.6) 0.00* -0.3 (-1.2 to 0.5) 0.40 MPQ Sensory (0-10) -1.0 (-2.1 to 0.1) 0.56 -0.6 (-1.7 to 0.5) 0.56 -0.4 (-1.5 to 0.7) 0.56 Affective (0-5) -0.7 (-1.5 to -0.0) 0.04* -0.3 (-1.0 to 0.4) 0.44 -0.4 (-1.2 to 0.2) 0.20 Evaluative (0-1) -0.1 (-0.4 to 0.1) 0.27 -0.3 (-0.6 to -0.0) 0.01 0.2 (-0.0 to 0.4) 0.15 Miscellaneous (0-4) -0.4 (-1.0 to 0.2) 0.17 -0.3 (-0.9 to 0.3) 0.32 -0.1 (-0.72 to 0.5) 0.32 Total (0-20) -2.3 (-4.6 to 0.0) 0.05 -1.5 (-3.8 to 0.8) 0.20 -0.8 (-3.1 to 1.5) 0.50 OLBPQ (0-50) -2.1 (0.2 to 4.0) 0.03* 4.0 (2.2 to 5.9) 0.00* 1.9 (-0.0 to 3.83) 0.06 RMDQ (-24) 2.9 (1.0 to 4.8) 0.02* 3.4 (1.5 to 5.3) 0.00* 0.5 (-1.3 to 2.3) 0.59 Algometry ATR 0.86 (-0.5 to 0.6) 0.77 0.6 (-0.5 to 0.6) 0.82 0.0 (-0.5 to 0.6) 0.94 ATL 0.8 (-0.5 to 0.6) 0.77 0.1 (-0.4 to 0.7) 0.70 -0.0 (-6.6 to 0.5) 0.92 L3R -0.3 (-0.8 to 0.2) 0.29 -0.2 (-0.7 to 0.3) 0.40 -0.5 (-1.0 to 0.0) 0.06 L3L 0.2 (-0.3 to 0.7) 0.45 0.3 (-0.1 to 0.9) 0.17 -0.1 (-0.7 to 0.3) 0.54 L5R -0.1 (-0.7 to 0.5) 0.74 -0.04 (-0.7 to 0.6) 0.88 -0.7 (-0.7 to 0.5) 0.82 L5L 0.1 (-0.4 to 0.7) 0.61 0.14 (-0.4 to 0.7) 0.61 -0.0 (-0.6 to 0.5) 0.99 IG1 = low-frequency interferential group; IG2 = high-frequency interferential group; PG = placebo group; AT = anterior tibial; L3 = 3rd lumbar vertebra; L5 = 5th lumbar vertebra; L = left; R = right. *Significant difference (p<0.05). MPQ = McGill Pain Questionnaire; OLBPQ = Oswestry Low Back Pain Questionnaire; RMDQ = Roland Morris Disability Questionnaire.

31 BrJP. São Paulo, 2019 jan-mar;2(1):27-33 Almeida N, Paladini LH, Pivovarski M, Gaideski F, Korelo RI and Macedo AC

DISCUSSION performance of their participants after applying the 1KHz and 4KHz IC and did not find satisfactory results. Albornoz-Cabello This study showed that the IC caused a decrease in the subjective et al.28, on the other hand, used 4000Hz IC, 65Hz frequency perception of pain and also an improvement in the functionality modulation, 95Hz frequency variation, and 1/1 slope during ten in relation to PG. sessions and saw improvement in the functional capacity of the Assessing the short-term (immediate) analgesic effect, not only individuals with CLBP. long-term after IC application, is essential for clinical practice. Venancio et al.10 emphasized that lower frequency carrier cur- Often CLBP-patients are unable to perform kinesiotherapy be- rents, such as 1 and 2KHz, are more uncomfortable, but have cause of the high pain or, in some cases, kinesiotherapy may lead higher analgesic effects than higher CF, such as 8 and 10kHz. to the exacerbation of this condition. So, IC can be used to min- This study corroborated these data since there were significant imize or suppress pain before or after exercise. improvements after IC application with 2KHz CF. Despite this Few studies have evaluated the immediate analgesic effects af- assertion, most studies used the 4KHz frequency12,15,27,29. ter IC application in CLBP12,15,20. Most studies evaluated the It should be emphasized that the study has some limitations, long-term effects of this equipment on healthy individuals10,27, such as failure to perform it double-blinded and the lack of func- CLBP-individuals12,27; or associated with other therapies and tional tests in the evaluation instruments. currents29,30. This study is the first one to evaluate the frequen- However, it should be noted that the study was carried out with cy of 2KHz in CLBP-individuals with two different AMF, one a large number of participants, in a blinded way and with all the of high frequency (AMF=100Hz) and one of low frequency evaluation instruments validated and culturally adapted for the (2KHz). Brazilian population. Moreover, pressure algometry is considered The results found in the subjective measurement of pain pre- the gold standard for measuring pain sensitivity by pressure33. sented strong effects of 2KHz IC treatment, regardless the AMF chosen. This result is reinforced by Corrêa et al.12, who found CONCLUSION more significant effects on the immediate reduction of pain after IC application with lower frequencies (1KHz), and also by It was found that the IC provided an immediate analgesic effect Fuentes et al.20 who found satisfactory results of IC in relation in CLBP. However, further studies should be performed with to placebo, but did not indicate the CF used, only the frequency other protocols to define the best parameter of this current for modulation of 0Hz. Only the study by Pereira et al.31 evaluated CLBP treatment. the IC immediate effects in the frequency of 2KHz and found no significant results in changing the pain threshold for cold REFERENCES and heat. However, this study evaluated healthy individuals and not CLBP ones. It was emphasized that there was no difference 1. Chou R, Huffman LH. Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical between the groups that applied IC, i.e., there was no interfer- practice guideline. Ann Intern Med. 2007;147(7):505-14. ence of the chosen AMF. Johnson and Tabasam32 and Claro et 2. Chou R, Huffman LH. Nonpharmacologic therapies for acute and chronic low back 27 pain: a review of the evidence for an American Pain Society/American College of al. also found no difference in the groups treated with different Physicians clinical practice guideline. Ann Intern Med. 2007;147(7):492-504. AMFs in healthy subjects. 3. Delitto A, George SZ, Van Dillen LR, Whitman JM, Sowa G, Shekelle P, et al. Low back pain. J Orthop Sports Phys Ther. 2012;42(4):A1-57. It was observed that in the objective pain evaluation, through 4. Ladeira CE. Evidence based practice guidelines for management of low back pain: algometry, no immediate analgesic results were found (only physical therapy implications. Rev Bras Fisioter. 2011;15(3):190-9. in L3R and L3L of IG2), unlike the study by Corrêa et al.12 5. Nijs J, Apeldoorn A, Hallegraeff H, Clark J, Smeets R, Malfliet A, et al. Low back pain: guidelines for the clinical classification of predominant neuropathic, nocicepti- 10 and Venancio et al. , who observed PPT increase immediate- ve, or central sensitization pain. Pain Physician. 2015;18(3):E333-46. ly after the intervention, but at the frequency of 1KHz. It was 6. Mlekusch S, Schliessbach J, Cámara RJ, Arendt-Nielsen L, Jüni P, Curatolo M. Do central hypersensitivity and altered pain modulation predict the course of chronic low expected that, along with the significant decrease in VAS, the back and neck pain? Clin J Pain. 2013;29(8):673-80. PPT increase occurred, but this did not happen. Perhaps this 7. Kuner R, Flor H. Structural plasticity and reorganisation in chronic pain. Nat Rev Neurosci. 2016;18(1):20-30. Erratum in: Nat Rev Neurosci. 2017;18(2):113. was due to the IC electrical stimulus that have momentari- 8. Thiese MS, Hughes M, Biggs J. Electrical stimulation for chronic non-specific low ly blocked the mechanoreceptors stimulus through the Abo back pain in a working-age population: a 12-week double blinded randomized con- fibers excitability which may have decreased the PPT, or by trolled trial. BMC Musculoskeletal Disord. 2013;14:117. 9. Searle A, Spink M, Ho A, Chuter V. Exercise interventions for the treatment of chro- the interference of the individual himself who may not want nic low back pain: a systematic review and meta-analysis of randomised controlled to feel the strong pressure (as much as he/she could) of the trials. Clin Rehabil. 2015;29(12):1155-67. 10. Venancio RC, Pelegrini S, Gomes DQ, Nakano EY, Liebano RE. Effects of carrier algometer after having his/her lumbar region pain diminished frequency of interferential current on pressure pain threshold and sensory comfort in by the treatment. humans. Arch Phys Med Rehabil. 2013;94(1):95-102. Although no therapeutic exercises have been performed in this 11. Corrêa JB, Costa LO, de Oliveira NT, Sluka KA, Liebano RE. Effects of the carrier frequency of interferential current on pain modulation in patients with chronic nons- protocol, significant improvement in the functional perfor- pecific low back pain: a protocol of a randomised controlled trial. BMC Musculoskelet mance of the individuals could be observed through OLBPQ Disord. 2013;14(1):195. 12. Corrêa JB, Costa LO, Oliveira NT, Lima WP, Sluka KA, Liebano RE. Effects of the and RMDQ with a substantial treatment effect in IG2 and mod- carrier frequency of interferential current on pain modulation and central hypersen- erate in IG1. These data are reinforced by Facci et al.29, who used sitivity in people with chronic nonspecific low back pain: a randomized placebo-controlled trial. Eur J Pain. 2016;20(10):1653-66. IC as an intervention form, but with CF of 4KHz. However, 13. Qaseem A, Wilt TJ, McLean RM, Forciea MA. Noninvasive treatments for acute, Corrêa et al.12 also used the RMDQ to evaluate the functional subacute, and chronic low back pain: a clinical practice guideline from the American 32 Immediate analgesic effect of 2KHz interferential current BrJP. São Paulo, 2019 jan-mar;2(1):27-33 in chronic low back pain: randomized clinical trial

College of Physicians. Ann Intern Med. 2017;166(7):514-30. validity. Spine. 2007;32(4):481-6. 14. Wong JJ, Côté P, Sutton DA, Randhawa K, Yu H, Varatharajan S, et al. Clinical prac- 25. Nusbaum L, Natour J, Ferraz MB, Goldenberg J. Translation, adaptation and valida- tice guidelines for the noninvasive management of low back pain: A systematic review tion of the Roland Morris questionnaire- Brazil Roland-Morris. Braz J Med Biol Res. by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. 2001;34(2):203-10. Eur J Pain. 2017;21(2): 201-16. 26. Ferreira JC, Patino CM. Randomization: beyond tossing a coin. J Bras Pneumol. 15. Fuentes JP, Armijo Olivo S, Magee DJ, Gross DP. Effectiveness of interferential cur- 2016;42(5):310. English, Portuguese. rent therapy in the management of musculoskeletal pain: a systematic review and 27. Claro AD, Kanezawa BA, Camargo MD, Paes VM, Portolez JL, Bertolini GR. Pres- meta-analysis. Phys Ther. 2010;90(9):1219-38. sure and cold pain threshold in healthy subjects undergoing interferential current at 16. Goats GC. Interferential current therapy. Br J Sports Med. 1990;24:87-92. different amplitude modulated frequencies. Rev Dor. 2014;15(3):178-81. 17. Prentice WE. Therapeutic modalities in rehabilitation. McGraw Hill Professional; 28. Albornoz-Cabello M, Maya-Martín J, Domínguez-Maldonado G, Espejo-Antúnez L, 2017. Heredia-Rizo AM. Effect of interferential current therapy on pain perception and 18. Ward AR, Robertson VJ, Makowski RJ. Optimal frequencies for electric stimu- disability level in subjects with chronic low back pain: a randomized controlled trial. lation using medium-frequency alternating current. Arch Phys Med Rehabil. Clin Rehabil. 2017;31(2):242-9. 2002;83(7):1024-7. 29. Facci LM, Nowotny JP, Tormem F, Trevisani VF. Effects of transcutaneous elec- 19. Ward AR. Electrical stimulation using kilohertz-frequency alternating current. Phys trical nerve stimulation (TENS) and interferential currents (IFC) in patients with Ther. 2009;89(2):181-90. nonspecific chronic low back pain: randomized clinical trial. São Paulo Med J. 20. Fuentes J, Armijo-Olivo S, Funabashi M, Miciak M, Dick B, Warren S, et al. Enhan- 2011;129(4):206-16. ced therapeutic alliance modulates pain intensity and muscle pain sensitivity in 30. Shanahan C, Ward AR, Robertson VJ. Comparison of the analgesic efficacy of in- patients with chronic low back pain: an experimental controlled study. Phys Ther. terferential therapy and transcutaneous electrical nerve stimulation. Physioter. 2014;94(4):477-89. 2006;92(4):247-53. 21. Robertson V, Ward A, Low J, Reed A. Eletroterapia explicada: princípios e prática. 4ª 31. Pereira GD, Cassolato KM, Lazarin PH, Canto TO, Portolez JL, Bertolini GR. Efeito ed. Rio de Janeiro: Elsevier; 2009. da corrente interferencial, 2000Hz, no limiar de dor induzida. Rev Bras Med Esporte. 22. Ludington E, Dexter F. Statistical analysis of total labor pain using the visual analog 2011;17(4):257-60. scale and application to studies of analgesic effectiveness during childbirth. Anesth 32. Johnson MI, Tabasam G. An investigation into the analgesic effects of different fre- Analg. 1998;87(3):723-7. quencies of the amplitude modulated wave of interferential current therapy on cold- 23. Pimenta CA, Teixeira MJ. Questionário de dor McGill: proposta de adaptação para a -induced pain in normal subjects. Arch Phys Med Rehabil. 2003;84(9):1387-94. língua portuguesa. Rev Esc Enferm USP. 1996;30(3):473-83. 33. Dagtekin O, König E, Gerbershagen HJ, Marcus H, Sabatowski R, Petzke F. [Mea- 24. Vigatto R, Alexandre NM, Correa Filho HR. Development of a Brazilian Portuguese suring pressure pain thresholds. Comparison of an electromechanically controlled version of the Oswestry Disability Index: cross-cultural adaptation, reliability, and algometer with established methods]. Schmerz. 2007;21(5):439-44. German.

33 BrJP. São Paulo, 2019 jan-mar;2(1):34-8 ORIGINAL ARTICLE

Health professionals’ barriers in the management, evaluation, and treatment of neonatal pain Barreiras dos profissionais de saúde no manuseio, avaliação e tratamento da dor neonatal

Marialda Moreira Christoffel1, Danielle Lemos Querido1, Ana Luiza Dorneles da Silveira2, Bruna Nunes Magesti1, Ana Letícia Monteiro Gomes1, Ana Claudia Coelho Santos da Silva1

DOI 10.5935/2595-0118.20190007

ABSTRACT RESUMO

BACKGROUND AND OBJECTIVES: Despite the solid results JUSTIFICATIVA E OBJETIVOS: Apesar de resultados solid- on pain management strategies in neonatology, it is necessary to ificados sobre as estratégias de gestão da dor em neonatologia, identify and explore the barriers that may hamper the attention faz-se necessário identificar e explorar as barreiras que dificul- to pain and the implementation of the scientific evidence widely tam a atenção à dor e a implementação na prática assistencial disseminated in the literature in the care practice. The objective of das evidências científicas amplamente difundidas na literatura. this study was to describe the barriers encountered by the health- O objetivo deste estudo foi descrever as barreiras encontradas care professionals of a neonatal intensive care unit regarding the pelos profissionais de saúde de uma unidade de terapia intensiva management, evaluation, and treatment of newborn pain. neonatal em relação ao manuseio, avaliação e tratamento da dor METHODS: Descriptive, exploratory, quantitative study car- de recém-nascidos. ried out in a maternity hospital in the city of Rio de Janeiro. MÉTODOS: Estudo descritivo exploratório, quantitativo, real- Forty-two nursing technicians, 22 nurses, 20 physicians, and 2 izado em uma maternidade do município do Rio de Janeiro. Par- physiotherapists participated in the study. The data was collected ticiparam 42 técnicos de enfermagem, 22 enfermeiros, 20 médi- in an interview using a form and the data was analyzed by de- cos e 2 fisioterapeutas. Foi realizada uma entrevista utilizando-se scriptive statistics. um formulário para coleta de dados e estes foram analisados com RESULTS: Among the barriers found it stands out the lack of train- uso de estatística descritiva. ing on neonatal pain, no use of scales, the absence of routine and RESULTADOS: Entre as barreiras encontradas destacam-se a protocols for the treatment of pain, and the need for greater safety ausência de treinamento sobre dor neonatal, a não utilização de for the evaluation and treatment of pain. It was also observed that escalas, ausência de rotina e protocolos para o tratamento da dor there is a gap between knowledge and care practice in the unit. e a necessidade de maior segurança para a avaliação e o tratamen- CONCLUSION: The identification of these barriers is essential to da dor. Observou-se, também, que existe uma lacuna entre o to establish strategies based on knowledge-transfer to overcome conhecimento e a prática assistencial na unidade. the obstacles and improve the care given to newborns in the neo- CONCLUSÃO: A identificação dessas barreiras torna-se essen- natal intensive care unit. cial para que se busquem estratégias fundamentadas na trans- Keywords: Neonatal intensive care units, Newborn, Pain. ferência de conhecimento para vencer os obstáculos e melhorar a assistência prestada aos recém-nascidos na unidade de terapia intensiva neonatal. Marialda Moreira Christoffel - https://orcid.org/0000-0002-4037-8759; Descritores: Dor, Recém-nascido, Unidades de terapia intensiva Danielle Lemos Querido - https://orcid.org/0000-0003-4895-296X; neonatal. Ana Luiza Dorneles da Silveira - https://orcid.org/0000-0003-4126-7919; Bruna Nunes Magesti - https://orcid.org/0000-0001-9901-6659; Ana Leticia Monteiro Gomes - https://orcid.org/0000-0001-6220-5261; INTRODUCTION Ana Claudia Coelho Santos da Silva - https://orcid.org/0000-0001-5693-7378.

1. Universidade Federal do Rio de Janeiro, Escola de Enfermagem Anna Nery, Rio de Ja- Currently, health professionals responsible for the treatment neiro, RJ, Brasil. 2. Universidade Federal Fluminense, Escola de Enfermagem Aurora de Afonso Costa, Ni- and diagnosis of newborns (NB) admitted in the neonatal terói, RJ, Brasil. intensive care unit (NICU) recognize pain as a result of the procedures performed. However, there are barriers related to Submitted in June 13, 2018. Accepted for publication in December 10, 2018. the knowledge of the pain management process, including the Conflict of interests: none – Sponsoring sources: Conselho Nacional de Desenvolvim- identification of the signs, evaluation, and treatment, that pre- ento Científico e Tecnológico\CNPq. Bolsa de Pós-Doutorado Sênior (Processo número 1,2 158257/2011-1). vent its practice . International3,4 and national1 studies about the knowledge, Correspondence to: Rua Afonso Cavalcanti, 275 - Cidade Nova attitudes and practices of health and nursing professionals on 20211-110 Rio de Janeiro, RJ, Brasil. the management of neonatal pain show important gaps in the E-mail: [email protected] understanding of fundamental neurobiological mechanisms © Sociedade Brasileira para o Estudo da Dor that rule the development of the somatosensory system and its 34 Health professionals’ barriers in the management, BrJP. São Paulo, 2019 jan-mar;2(1):34-8 evaluation, and treatment of neonatal pain response to potentially painful stimuli, pain assessment, and The participants had three days to return the questionnaire, non-pharmacological and pharmacological interventions to re- with the envelope sealed and put in a box identified with the lieve the pain during ongoing NB care. name of one of the researchers, who remained in the sector NB’s in NICU’s that require longer hospitalization undergo during the collection period. several daily painful procedures5. There is strong evidence for The variables extracted from the questionnaire referred to the pro- the use of non-pharmacological interventions (skin-to-skin file of the health professionals, including gender, age, educational contact, breastfeeding, and non-nutritive sucking) as well as background, professional qualification, functional link with the analgesic methods that are available but are not yet incorporat- unit, work regime and number of employment relationships, job ed into the NICU care practice1.2. satisfaction, qualification/orientation in neonatal pain and knowl- Untreated pain can have negative effects on the newborn, edge, practices and attitude in pain management. The last question especially on premature infants who are exposed to pain and was the description of five barriers related to the pain management stress during a phase that is undergoing rapid brain devel- process of the NB in the NICU, in order of priority. opment with the nerve pathways in the process of devel- The study was approved by the Research Ethics Committee of opment. In addition, it has long-term consequences such the Maternity School of the Federal University of Rio de Ja- as slower postnatal growth and neurological development, neiro, opinion number 186.719 of 01/18/2013, following all high cortical activation and changes in brain development, the ethical principles determined in Resolution 466/12 of the the temperament of negative affectivity, cognitive and mo- National Health Council. tor deficit6. The health professional must act as an advocate of the NB’s Statistical analysis rights not to feel pain when there are means to avoid it7. There- The data were organized in Microsoft Excel spreadsheet soft- fore, it is critical that the evidence available on the use of effec- ware, version 2010 and double typing with the correction of tive measures to manage pain be used to improve the quality of divergences and inconsistencies was used as the reliability crite- care provided to the NB2. rion. The analysis was done by descriptive statistics. Pain prevention should be the goal of the team that assists the NB, not only because it is legal and ethical care, but also to RESULTS avoid the exposure of these babies to repeated procedures that negatively impact their neurodevelopment8. Of the 86 professionals interviewed, the majority were female Despite the solid results on pain management strategies in neo- (89.5%). Of the male professionals, six (7.0%) were nursing natology, it is necessary to identify and explore the barriers that technicians and three (3.5%) doctors. The average age of the undermine the attention to pain and the implementation of participants was 34.1 years, with a standard deviation of 7.4. the scientific evidence widely disseminated in the literature in Regarding the educational background, among nursing tech- the care practice9,10. nicians, three (3.5%) had an academic degree, one (1.2%) had The objective of this study was to describe the barriers encoun- neonatal nursing specialization, and four (4.7%) were attend- tered by health professionals of a NICU regarding manage- ing the undergraduate course. The majority (81.8%) of nurses, ment, assessment, and treatment of pain in newborns. all the physicians, and all the physiotherapists had a lato sensu postgraduate degree or were attending stricto sensu postgraduate METHODS course. Regarding the functional link in the study unit, 25 (29.1%) were This is a descriptive, cross-sectional study with a quantitative civil servants, and 54 (62.8%) had a cooperative link/were hired. approach, carried out at the NICU of a teaching maternity Regarding the work regime, the majority (92.8%) of the nurs- ward in the city of Rio de Janeiro, which provides multi-pro- ing technicians and 63.7% of the nurses worked on a 24-hour fessional assistance offering specific care to pregnant women duty by 120-hour rest format, being possible to run extra shifts. and high-risk newborns. Regarding the other professionals, it was observed that 35% of The health professionals of the unit who provide direct assis- the physicians had a 20h-weekly work journey and 100% of the tance to the NB were included, and the others were excluded. physiotherapists a 24h-weekly work journey. The study population comprised 96 health professionals work- Most of the professionals (76.7%) had more than one job. Nine ing in the institution. After the invitation to participate, the (21.4%) technicians, 8 (36.4%) nurses, 10 (50%) physicians, non-probabilistic sample was of 86 interviewees, among them and one (50%) physiotherapist did not work in the neonatal unit 42 nursing assistants/technicians, 22 nurses, 20 physicians, and in their other job. When evaluating the working conditions in two physiotherapists. the unit surveyed, 33 (78.6%) nursing technicians, 18 (31.8%) Data collection was from February to April 2013. Each partic- nurses, seven (35%) physicians, and one (50%) physiotherapist ipant received a copy of the semistructured questionnaire with said they were satisfied with those conditions. open and closed questions after signing the Free and Informed Although the majority of the health professionals (66.3%) hav- Consent Term (FICT). Each questionnaire was in a sequen- ing said that they obtained information about neonatal pain tially numbered brown envelope, ensuring the participant’s during their vocational, undergraduate or lato sensu graduate anonymity. training, the most cited source of information was the man- 35 BrJP. São Paulo, 2019 jan-mar;2(1):34-8 Christoffel MM, Querido DL, Silveira AL, Magesti BN, Gomes AL and Silva AC agement directions and/or guidance from other healthcare pro- The barriers related to the complexity of NB care highlighted fessionals. the hostile, noisy and overly bright environment of the NICU, Concerning the knowledge of care routine related to pain man- the need for different care procedures and consequent excessive agement, 10 (23.8%) technicians, seven (31.8%) nurses and one manipulation, the clinical state of the NB, the use of drugs such (5%) physician reported that there is a pain protocol that includ- as sedatives and opioids and the valorization of heavy over light ed neonatal pain scales. technology (Table 2). Regarding the barriers pointed out by the health professionals Finally, the barriers related to the institutional system that out- related to the process of pain management, such as assessment stood were the lack of routine and protocol to assess and treat and treatment, we identified the individual and teamwork con- neonatal pain, followed by overcrowding (Table 3). nection with the complexity of the care of the newborn and with the institutional system. DISCUSSION The barriers related to the individual and teamwork that most stood out were the need for training on the subject of pain, followed by The barriers pointed out by health professionals in the pain lack of communication among health professionals (Table 1). management process that mostly stood out touched individual

Table 1. Distribution of barriers identified by health professionals from the perspectives of the individual and teamwork Barriers identified TEC NR MD PT n (%) n (%) n (%) n (%) Need for training on the subject of pain 39 (24.0) 11 (15.0) 07 (10.0) 02 (25.0) Need for training to use pain assessment scales 02 (1.3) 05 (7.0) 05 (7.0) - Lack of professional knowledge about pain assessment and treatment - 07 (10.0) 04 (6.0) 01 (12.5) Professional’s uncertainty regarding pain assessment and treatment 08 (4.9) 03 (4.0) 03 (4.0) -- Insufficient notes and remarks in medical records - - 01 (1.0) - Professional demotivation 03 (1.8) 01 (1.0) - - I don’t see barriers 01 (0.6) - - - Lack of communication among health professionals 21 (13.0) 08 (11.0) 05 (7.0) 01 (12.5) Relationship among professionals 05 (3.0) - - - Beliefs and attitudes of health professionals 04 (2.0) 04 (6.0) 03 (4.0) - TEC = nursing technician; NR = nurse; MD = physician; PT = physiotherapist.

Table 2. Distribution of barriers identified by health professionals based on the complexity of the newborn care Barriers identified TEC NR MD PT n (%) n (%) n (%) n (%) Neonatal intensive care unit environment (noise, brightness) 07 (4.3) 01 (1.0) 04 (6.0) - Procedures (intubation, CPAP, bath, drug administration) 12 (7.3) 02 (3.0) 01 (1.0) - Minimal handling/excessive handling 08 (4.9) 04 (4.0) 03 (3.0) - Clinical status of the newborn (extreme premature, neuropathies) 08 (4.9) 02 (3.0) 03 (4.0) 02 (25.0) Newborn in humidified incubator 01 (0.6) - 01 (1.0) - Newborn using drugs (sedatives, opioids) 02 (1.3) 04 (6.0) 03 (4.0) - Valorization of heavy technology over light technology - 02 (3.0) - - CPAP = continuous positive airway pressure; TEC = nursing technician; NR = nurse; MD = physician; PT = physiotherapist.

Table 3. Distribution of barriers identified by health professionals regarding the institutional system Barriers identified TEC NR MD PT n (%) n (%) n (%) n (%) Lack of routine and protocol to assess and treat neonatal pain 20 (12.0) 07 (10.0) 13 (19.0) 02 (25.0) Overcrowding 13 (8.0) 04 (6.0) 07 (10.0) - Human Resources 08 (4.9) 01 (1.0) 05 (7.0) - Working hours - 01 (1.0) - - Absence of parents 01 (0.6) - - - Institutional culture 01 (0.6) 04 (6.0) 01 (1.0) - TEC = nursing technician; NR = nurse; MD = physician; PT = physiotherapist.

36 Health professionals’ barriers in the management, BrJP. São Paulo, 2019 jan-mar;2(1):34-8 evaluation, and treatment of neonatal pain issues, teamwork, the complexity of the NB care and institu- surrounded by technologies that aim to reduce the morbid- tional issues. ity and mortality of the NBs, seeking their survival with The pain management process goes from the identification quality of life19. of the signs of pain manifested by the NB, the assessment In this sense, it is up to the professionals who work in the unit using scales, action plan, and treatment. When referring to to develop mechanisms to overcome these barriers, elaborating pain management, health professionals emphasized the need strategies to minimize the impact of this environment on the for training on the subject of pain due to the lack of knowl- NB recovery. Some suggestions such as the need to identify these edge regarding pain assessment and treatment, showing its difficulties and the implementation of a team or committee re- impracticability. sponsible for neonatal pain issues were pointed out9,20. Gaps in the knowledge of the team regarding the assessment, Regarding the barriers of the institutional and organizational sys- treatment, and management of neonatal pain have already tem, the lack of routines and protocols to assess and treat neona- been identified as obstacles in the effective management of tal pain were pointed out. pain10,11. Professional educational and training strategies It is recognized that the healthcare based on protocols, espe- translate to theoretical knowledge that is transferred to the cially those built with the participation of healthcare profes- practice of care, driving changes in this practice, and provid- sionals, is likely to have a positive impact on the quality of ing tools for these professionals. The presence of continuous pain assessment and its treatment. Structured guidelines and education based on scientific evidence helps professionals to protocols provide a systematization for the treatment of neona- adopt effective and safe measures to control pain12. tal pain and boost the outcomes, being useful instruments for Insufficient notes and remarks in the medical records also ap- the multifaceted management of pain, contributing to profes- peared as a barrier in this study. The professional should feel sional qualification and decision-making, as well as facilitating motivated and value his/her work by always registering it. the incorporation of new technologies and the dissemination However, it is worth mentioning that due to the lack of knowl- of knowledge12,21. edge regarding the subject, the record is frail since the manage- Issues regarding the working hours of the professionals and the ment of pain has not been translated as recognized care. optimal number of human resources also appeared as difficulties. This record is part of the health information system, enables Since there are professionals with more than one job, it is possi- the ethical and legal support of the assistance, works as audit- ble that the working hours have also appeared as a difficulty for ing and development instrument of the teaching and research the management of pain, as this fact is reflected in an excessive in the nursing area13. The scientific deficiency in relation to workload. pain makes the professional insecure and demotivated which In this sense, although there are tools to calculate the adequate can be leading factors to other problems. number of professionals to the needs of the service, there is still The team that works in NICU can suffer from stress and lose shortness of professionals in health institutions, and it is recom- motivation to work14, which is pointed out as a factor that mended the elaboration of studies that correlate the sizing of makes difficult the assessment, treatment, and management personnel to the workload and the development of quality indi- of neonatal pain in the present study. cators associated with this issue22. From terms of teamwork, the lack of communication among This observation by the participants can be an opportunity to health professionals is pointed out as a barrier to the imple- review the amount of personnel that despite being in accordance mentation of evidence in practice, as well as the group’s be- with the current resolutions, need to carry out multifaceted care liefs and attitudes. This gap is present both among managers tasks. Thus, due to the complexity and the relevant nature of care and care workers and among health workers on a shift gener- in an entire and humanized way to the seriously or potentially ating lack of interprofessional collaboration and difficulty in seriously ill newborn, it becomes necessary a larger number of sharing information15. professionals to perform this work. To humanize the care, it is necessary to establish adequate The absence of the parents was identified only by one of the pro- communication among the members of a team, resulting in fessionals as a difficulty to assess, treat and manage pain. It was greater proximity of the workgroup with consequent stan- noticed that the lack of parents’ involvement during the painful dardization of tasks. Failure in communication among differ- experience of hospitalized NB undermines the partnership be- ent categories can lead to professional stress14. tween the professionals and the parents9. Regarding the beliefs and attitudes that the group uses in re- Therefore, it is recommended to involve the parents in the man- lation to neonatal pain, it can be noted that some behaviors agement of the infant’s pain, contributing to a more humanized may be linked to the obsolete myths that due to the immatu- care. However, the work culture and the organizational charac- rity of the NB systems, especially premature NB, the percep- teristics of a NICU make this process very difficult9. tion of pain in this population would be negligible16. It is up to the health professional to brief the parents about The newborns in NICUs are exposed to innumerable in- the signs of pain, especially the mothers who most often expe- vasive procedures and a stressful environment that brings a rience the hospitalization of their children. Besides the brief- series of negative consequences to their neurodevelopment, ing, these mothers should be invited to participate in care to making them susceptible to pain and stress14,17,18. In fact, the be able to call the team at the first sign of discomfort or stress care of NBs admitted in the NICU involves complex care, of their NB23. 37 BrJP. São Paulo, 2019 jan-mar;2(1):34-8 Christoffel MM, Querido DL, Silveira AL, Magesti BN, Gomes AL and Silva AC

One limitation of the study was the non-participation of the unit 4. Lago P, Frigo AC, Baraldi E, Pozzato R, Courtois E, Rambaud J, et al. Sedation and analgesia practices at Italian neonatal intensive care units: results from the EU- service managers in the presentation of a good practice policy ROPAIN study. Ital J Pediatr. 2017;43(1):26. in pain management, bringing current evidence for changes in 5. Courtois E, Droutman S, Magny JF, Merchaoui Z, Durrmeyer X, Roussel C, et al. Epidemiology and neonatal pain management of heelsticks in intensive care units: the clinical practice, consistently and systematically, in the con- EPIPPAIN 2, a prospective observational study. Int J Nurs Stud. 2016;59:79-88. tinuous care of the newborn. Also, there is a need to discuss the 6. Valeri BO, Holsti L, Linhares MB. Neonatal pain and developmental outcomes in competencies of each healthcare professional regarding the use children born preterm: a systematic review. Clin J Pain. 2015;31(4):355-62. 7. Conselho Nacional dos Direitos da Criança e do Adolescente. Direitos da Criança e of more complex pain scales and non-pharmacological and phar- do Adolescente Hospitalizados. Resolução n° 41 de outubro de 1995. Diário Oficial macological measures in the relief of neonatal pain. da União. Brasília, DF, 17 out. 1995. 8. Prevention and management of procedural pains in the neonate. APP American Acad- The identification of the barriers in this study led to the exe- emy of Pediatrics. Committee on Fetus and Newborn. Section on Anesthesiology and cution of a training course to build collective knowledge, the Pain Medicine. Pediatrics. 2016;137(2):e20154271. 9. Marfurt-Russenberger K, Axelin A, Kesselring A, Franck LS, Cignacco E. The expe- disclosure of the institutional material and incorporation of the riences of professionals regarding involvement of parent s in neonatal pain manage- practice in NB care. Thus, institutional actions were implement- ment. J Obstet Gynecol Neonatal Nurs. 2016;45(5):671-83. ed crowned with the protocol for the non-pharmacological man- 10. Abdel Razeq NM. Barriers that impede the provision of pain care to neonates by nurses in Jordan. J Obstet Gynecol Neonatal Nurs. 2016;45(3):371-7. agement of neonatal pain, currently available online and printed 11. Cong X, Delaney C, Vazquez V. Neonatal nurses’ perceptions of pain assessment and in a separate folder in the unit. management in NICUs: a national survey. Adv Neonatal Care. 2013;13(5):353-60. 12. Christoffel MM, Castral TC, Dare MF, Montanholi LL, Scochi CG. Knowledge of healthcare professionals on the evaluation and treatment of neonatal pain. Rev Bras CONCLUSION Enferm. 2016;69(3):516-22. 13. Carneiro SM, Dutra HS, Costa FM, Mendes SE, Sena CA. Uso de abreviaturas nos registros de enfermagem em um hospital de ensino. Rev Rene. 2016;17(2):208-16. The present study showed that there are barriers and that neo- 14. Ministério da Saúde. Secretaria da Atenção à Saúde. Departamento de Ações Pro- natal services need to have educational programs to improve the gramáticas Estratégicas. Atenção humanizada ao recém-nascido de baixo peso: Méto- do canguru: manual técnico. Brasília: Ministério da Saúde; 2013. clinical practice in the relief of neonatal pain. 15. Puchalski Ritchie LM, Khan S, Moore JE, Timming C, van Lettow M, Vogel JP, et al. Low- and middle-income countries face many common barriers to implementation of ACKNOWLEDGMENTS maternal health evidence products. J Clin Epidemiol. 2016;76:229-37. 16. Prestes AC, Balda RC, Santos GM, Rugolo LM, Bentlin MR, Magalhães M, et al. Painful procedures and analgesia in the NICU: what has changed in the medical per- To the National Council for Scientific and Technological Devel- ception and practice in a ten-year period? J Pediatr. 2016;92(1):88-95. 17. Mörelius E, He HG, Shorey S. Salivary cortisol reactivity in preterm infants in opment\CNPq. Brasília-DF, Brasil, for the support to conduct neonatal intensive care: an integrative review. Int J Environ Res Public Health. the study with the Postdoctoral Senior Fellowship (Process num- 2016;13(3):pii:E337. 18. Martins SW, Dias FS, Enumo SR, Paula KM. Pain assessment and control by nurses ber 158257\2011-1). of a neonatal intensive care unit. Rev Dor. 2013;14(1):21-6. 19. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Pro- REFERENCES gramáticas e Estratégicas. Atenção à saúde do recém-nascido: guia para os profissionais de saúde, v.4. Brasília: Ministério da Saúde; 2014. 20. Purteimur S, Nouri M. The barriers to pain management in the neonatal intensive 1. Soares AC, Caminha MF, Coutinho AC, Ventura CM. Pain in the neonatal unit: the care unit. Pediatric Crit Care Med. 2014;15(Suppl 4):214. knowledge, attitude and practice of the nursing team. Cogitare Enferm. 2016;21(2):1-10. 21. Lim Y, Godambe S. Prevention and management of procedural pain in the neonate: 2. Sposito NP, Rossato LM, Bueno M, Kimura AF, Costa T, Guedes DM. Assessment an update, American Academy of Pediatrics 2016. Arch Dis Child Educ Pract Ed. and management of pain in newborns hospitalized in a Neonatal Intensive Care Unit: 2017;102(5):254-6. a cross-sectional study. Rev Lat Am Enfermagem. 2017;25:e2931. English, Portu- 22. Menegueti MG, Nicolussi AC, Scarparo AF, Campos LF, Chaves LD, Laus AM. Nurs- guese, Spanish. ing personnel staffing in hospital services: an integrative literature review. Rev Eletr 3. Anand KJ, Eriksson M, Boyle EM, Avila-Alvarez A, Andersen RD, Sarafidis K, et Enferm. 2013;15(2): 551-63. al. Assessment of continuous pain in newborns admitted to NICUs in 18 European 23. Santos MC, Gomes MF, Capellini VK, Carvalho VC. Maternal assessment of pain in countries. Acta Paediatr. 2017;106(8):1248-59. premature infants. Rev Rene. 2015;16(6):842-7.

38 BrJP. São Paulo, 2019 jan-mar;2(1):39-43 ORIGINAL ARTICLE

Validation of an educational booklet for people with chronic pain: EducaDor Validação de uma cartilha educativa para pessoas com dor crônica: EducaDor

Ana Shirley Maranhão Vieira1, Kamyle Villa-Flor de Castro2, Janine Ribeiro Canatti2, Iasmyn Adélia Victor Fernandes de Oliveira2, Silvia Damasceno Benevides2, Katia Nunes Sá1

DOI 10.5935/2595-0118.20190008

ABSTRACT RESUMO

BACKGROUND AND OBJECTIVES: Socio-educational JUSTIFICATIVA E OBJETIVOS: Ferramentas socioeducativas tools aimed at the population with chronic pain can help in the voltadas para a população com dor crônica podem auxiliar no knowledge about trigger mechanisms, beliefs, and attitudes to- conhecimento sobre mecanismos desencadeantes, crenças e ati- wards pain that may be useful in their control. In addition to tudes frente à dor, que podem ser úteis no seu controle. Além developing them, it is necessary to evaluate whether these tools de desenvolvê-las, se faz necessário avaliar se essas ferramentas are valid for therapeutic use. The objective of this study was to são válidas para o uso terapêutico. O objetivo deste estudo foi describe the validation process of an educational booklet for peo- descrever o processo de validação de uma cartilha educativa para ple with chronic pain. pessoas com dor crônica. METHODS: This study was developed in three stages: question- MÉTODOS: Este estudo foi desenvolvido em três etapas: con- naires for the evaluation of the booklet by patients and profes- strução de questionários para avaliação da cartilha por pacientes sionals, interview, and content validation. The sample consisted e profissionais, entrevista e validação de conteúdo. A amostra of 60 patients with chronic pain and six professionals specialized consistiu de 60 pacientes com dor crônica e seis profissionais in your treatment. For validation, the Content Validity Index per especializados no seu tratamento. Para validação, foi utilizado items was used considering a score greater than or equal to 80%. o Índice de Validade de Conteúdo por itens considerando um RESULTS: All six domains evaluated in the booklet obtained a escore maior ou igual a 80%. Content Validity Index per items score greater than 80%. The RESULTADOS: Todos os seis domínios avaliados na cartilha Content Validity Index per items overall rate of the domains obtiveram escore do Índice de Validade de Conteúdo por itens evaluated by the patients was 88% while for the health profes- maior que 80%. A taxa global do Índice de Validade de Conteú- sionals it was 92%. do por itens dos domínios avaliados pelos pacientes foi de 88% CONCLUSION: The EducaDor booklet showed to be valid for enquanto que para os profissionais de saúde foi de 92%. use in the education of patients with chronic pain. CONCLUSÃO: A cartilha EducaDor mostrou-se válida para o Keywords: Chronic pain, Health education, Validation study. uso na educação de pacientes com dor crônica. Descritores: Dor crônica, Educação em saúde, Estudo de validação.

INTRODUCTION

Chronic pain (CP) is defined as “a stressful experience associated with an actual or potential tissue injury with sensory, emotional, cognitive and social components”1 that lasts for more than six

Ana Shirley Maranhão Vieira - https://orcid.org/0000-0002-7170-4203; months, with daily or almost daily frequency. In Brazil, CP is Kamyle Villa-Flor de Castro - https://orcid.org/0000-0001-8496-4576; considered a public health problem with a high incidence and Janine Ribeiro Canatti - https://orcid.org/0000-0002-5726-8388; prevalence2. CP impacts more than 40% of the Brazilian pop- Iasmyn Adélia Victor Fernandes de Oliveira - https://orcid.org/0000-0003-0180-5997; 3,4 Silvia Damasceno Benevides - https://orcid.org/0000-0002-4877-0835; ulation . Katia Nunes Sá - https://orcid.org/0000-0002-0255-4379. The multifactorial nature of CP calls the need for new preven- 1. Escola Bahiana de Medicina e Saúde Pública, Salvador, BA, Brasil. tive and therapeutic modalities for its control. Thus, the use 2. Universidade Federal da Bahia, Instituto de Ciências da Saúde, Salvador, BA, Brasil. of multidimensional approaches involving biological, psycho-

Submitted in September 10, 2018. logical, and social aspects, as well as health education activ- Accepted for publication in December 10, 2018. ities that address these biopsychosocial aspects may result in Conflict of interests: none – Sponsoring sources: none immediate and late benefits. This effect was superior to those Correspondence to: obtained with conventional interventions, such as drugs and Katia Nunes Sá physiotherapy5,6. Av. D. João VI, 275 – Brotas 40290-000, Salvador, BA, Brasil. Making people aware of the meaning of pain, how it behaves, E-mail: [email protected] its common causes, risk factors, and how to prevent or treat it E-mail: [email protected] effectively may contribute to control the symptoms and optimize © Sociedade Brasileira para o Estudo da Dor the use of health services6-8. 39 BrJP. São Paulo, 2019 jan-mar;2(1):39-43 Vieira AS, Castro KV, Canatti JR, Oliveira IA, Benevides SD and Sá KN

Different methods have been adopted to carry out educational sent Form (FICT) and received a copy of the booklet to read. The processes in the health area, including the distribution of booklets, reading occurred in a waiting room and the time available to do it personal construction studies, videos, group activities, and lec- was according to the individual need of each judge. The evaluation tures6,9-11. However, the literature is scarce on approaches that use questionnaire was applied immediately after. The evaluators guar- written educational materials, such as booklets involving guide- anteed the confidentiality of the answers by not identifying the lines for the treatment of patients with CP. Through booklets, judges, and the answers were filed for later analysis. patients, family and caregivers can get the knowledge about the situations that trigger pain and what to do to help minimize it12,13. Content validation Thinking about this, Mendez et al.14 developed a booklet for ed- The Content Validity Index (CVI) was used to validate the edu- ucation in CP, called EducaDor, which goes beyond the purely cational pain booklet by items17,18 considering a cut-off point for biomedical model of their approach. The booklet explains pain approval of equal or above 78% when there are seven or more from its concept to its processing, simply and objectively, and judges and 86% for six judges19. The CVI evaluates the propor- proposing coping strategies. Aiming at the use of the booklet in tion of evaluators who judged certain aspects of the booklet as an extended way in clinical practice, the objective of this study satisfactory, which were assessed through the structured ques- was to validate a socio-educative booklet on CP by patients and tionnaire. The items of the questionnaires that had a score of 1 health professionals. and 2 were classified as unsatisfactory answers, and those with a score of 3 or 4 were classified as satisfactory. The final score was METHODS calculated from the number of evaluators who judged each item as satisfactory, divided by the number of evaluators: This is a study to validate a light technology in health, conducted number of answers 3 or 4 at the Pain Outpatient Clinic of the University Hospital Profes- CVI = sor Edgar Santos (HUPES) of the Federal University of Bahia total number of evaluators (UFBA), from June 2015 to November 2016. Semi-structured questionnaires were elaborated and applied in This study was approved by the Research Ethics Committee of a voluntary sample of patients with CP and health professionals the Institute of Health Sciences of UFBA of 2015 with number with experience in assisting this profile of patients to validate the 44318415.7.0000.5662. All the recommendations of Resolu- booklet. Among the professional team of the outpatient clinic, tion 466/12 of the National Health Council that comply with six professional who met the eligibility criteria were selected as the Declaration of Helsinki have been expressly complied with. judges, as suggested by Joventino et al.15. The validation by the RESULTS target audience was done with 10 patients per health professional, totaling 60 patients. Patients enrolled in the HUPES/UFBA Pain Outpatient Clinic For the validation process of the booklet, 60 patients with CP were included, with a diagnosis of CP, literate, aged between 18 and six health professionals with experience in the care of this and 60 years. Those who did not understand the evaluation instru- population were interviewed. Table 1 shows the level of educa- ment were excluded. We included healthcare professionals with a tion and gender of the judges interviewed. Most of the inter- minimum of 5 years of experience in the care of patients with CP. viewed patients were female (83.3%) with complete elementary This work consisted of three steps: elaboration of the question- school (38.3%) and secondary school (38.3%). As for the health naires for validation of the booklet by the judges, interview, and professionals, 83.3% had complete higher education (Table 1), validation of the content. while only 6 (10.0%) patients had this level of education. Table 1. Educational level of the judges expressed in absolute and Elaboration of the questionnaires relative frequency The questionnaires were elaborated based on the evaluation crite- Variables Patients Health professionals ria to validate educational material, the Suitability Assessment of (n and %) (n and %) 16 Materials (SAM) . This method consists of evaluating the written Education content in terms of understanding, described as the relative diffi- Incomplete elementary school 4 (6.6) - culty in understanding the meaning. For this, the questions ap- Complete elementary school 23 (38.3) - plied had as answer option the degree of understanding, and these answers were graded in the Likert scale from “1” to “4”, corre- Incomplete secondary school 4 (6.6) - sponding to “no,” “little,” “considerable” and “totally, respectively. Complete secondary school 23 (38.3) - Complete higher education 6 (6.10) 5 (83.3) Interview Complete vocational course - 1 (16.6) Four members of the research group conducted the interview. Ini- Gender tially, the purpose of the study and a brief introduction about the Male 10 (16.6) 2 (33.3) content of the booklet was presented to the volunteers by agreeing Female 50 (83.3) 4 (66.6) to participate and being in compliance with the inclusion and ex- Total 60 (100) 6 (100) clusion criteria, the volunteer signed the Free and Informed Con- 40 Validation of an educational booklet for people with chronic pain: EducaDor BrJP. São Paulo, 2019 jan-mar;2(1):39-43

Structured questionnaires were prepared for the validation of the educational booklet by the judges. One questionnaire was direct- The final score of the questionnaires was based on CVI. The total ed to patients and one to health professionals. number of answers that categorized the items of the booklet as The questionnaire for patients (Figure 1A) had five domains: satisfactory were recorded. The analysis was performed for each content, presentation of the literature, illustration, readabil- domain of the questionnaire, and at the end, the value of the ity, printing, and overall evaluation. The questionnaire for total CVI was calculated, obtaining the value of 88 and 92% for health professionals (Figure 1B) had six domains, the ones patients and health professionals, respectively (Table 2). already cited plus scientific accuracy. The questionnaires for Table 2. Values of the Content Validity Index by item by domain patients and health professionals had 22 and 24 questions, respectively. After the questions of each domain, there was Domains Patients Health (%) professionals (%) some space available for comments and suggestions for ad- justments by the judges. 1. Scientific accuracy NA 100 2. Contents 87 92

Questionnaire for validation of the chronic pain booklet 3. Presentation of the literature 86 90 EducaDor - Questionnaire for Patients 4. Illustration 84 88 Educational Level: ( ) Elementary school ( ) Secondary school 5. Readability and printing 94 94 ( ) Higher education 1 - No 2 - Little 3 - Considerable 4 - Totally 6. Overall evaluation 88 100 No: not at all; denial Total CVI 88 92 Little: not much; insufficient NA = not applicable. Considerable: in sufficient quantity; a lot Totally: completely Contents DISCUSSION 1. Is the purpose of this booklet clear to you? 1 2 3 4 This study aimed to validate a socio-educational material on CP 2. Did you like the advice presented in the booklet? in the format of a booklet that have been developed in a previ- 1 2 3 4 14 3. Did you like the order in which the texts are presented? ous study , to check if it could be applied as a health educa- 1 2 3 4 tion resource, from the perspective of patients and specialized 4. Do you think there is any information missing? professionals. The final scores of the evaluation reached a level 1 2 3 4 of excellence in the agreement of the judges and indicated that 5. Are all the information presented necessary? 1 2 3 4 the EducaDor booklet is valid and can be used as a therapeutic Space for comments / suggestions resource. Several factors have been pointed out as predictors of CP, among Figure 1A. Questionnaire for patients them, be female and have a low level of schooling20,21. Differ- ences in pain perception between genders are well evidenced Questionnaire for validation of the chronic pain booklet in the literature22-25. Experimental studies with animals26,27 and EducaDor - Questionnaire for Health Professionals humans28, support the hypothesis that women have higher pain Educational Level: ( ) Elementary school ( ) Secondary school ( ) Higher education perception because they are more exposed to specific situations 1 - No 2 - Little 3 - Considerable 4 - Totally such as dysmenorrhea and childbirth. The education level low- Legend: er than 11 years has been pointed out as the major risk factor No: not at all; denial for this condition29. The sociodemographic characteristics of the Little: not much; insufficient Considerable: in sufficient quantity; a lot sample of patients interviewed were compatible with the profile Totally: completely cited in these previous studies. Precisely because of this profile, Scientific Accuracy the use of socio-educational materials may be fundamental for 1. Is the content of the booklet in accordance with current know- health literacy, which may have an impact on pain relief30. ledge? The professionals interviewed attributed 100% scientific accu- 1 2 3 4 2. Are the recommendations presented in the booklet correctly ad- racy to the material evaluated. This score gives confidence for dressed? the immediate adoption of the material by other professionals 1 2 3 4 in clinical practice. Careful professionals have uncertainties in Space for comments / suggestions reinforcing erroneous beliefs commonly found in websites and Content instruction materials not based on science. Due to the multi- 1. Is the purpose of the booklet clear? 1 2 3 4 factorial characteristic of the CP and the information available 2. Are the recommendations presented satisfactory? on the internet, coping with the problem has been a challenge 1 2 3 4 for health professionals9. The knowledge about pain with a sci- 3. Does the content of the booklet follow a logical line of reasoning? entific basis comes as a supporting strategy for the treatment of 1 2 3 4 people with CP. Pain education programs use approaches that Figure 1B. Questionnaire for health professionals allow providing information on pain etiology, nosology and 41 BrJP. São Paulo, 2019 jan-mar;2(1):39-43 Vieira AS, Castro KV, Canatti JR, Oliveira IA, Benevides SD and Sá KN pain pathophysiology. This type of approach makes it possible is suggested that the EducaDor booklet is validated in other pain to equip patients for greater awareness of the different causal and centers in other Brazilian regions and its effect on the intensity aggravating factors. The knowledge acts in the social representa- and other phenomena related to CP be tested in a randomized tions and the experiences of the disease, facilitating its recovery31. clinical trial. Ease of reading and printing were the best-evaluated items, both by professionals and patients. This result shows the importance of CONCLUSION careful preparation of the printed material so that it has sufficient durability to be consulted several times and fulfill its purpose8. A Patients suffering from chronic pain and health professionals systematic review32 pointed out that socio-educational programs specialized in its treatment validated the content, the adopted have an influence on the improvement of pain and movement, language, the topics covered and the illustrations of the Educa- and in minimizing disabilities and reducing the utilization of Dor booklet. health services. The recognition of the quality of the “EducaDor” booklet may indicate that this tool can be an aid in the treatment REFERENCES of CP in Brazil, due to the biopsychosocial aspects involved14. The elaboration of printed educational material is a means of 1. Williams AC, Craig KD. Updating the definition of pain. Pain. 2016;157(11):2420-3. 2. Teixeira M, Teixeira W, Santos F, Andrade D, Bezerra S, Figueiró J, et al. Epidemiolo- communication between the health professional and the patient gia clínica da dor músculo-esquelética. Rev Med. 2001;80(spe1):1-21. that not only requires a clear identification of the target audience 3. Sá K, Baptista AF, Matos MA, Lessa I. Chronic pain and gender in Salvador population, Brazil. Pain. 2008;139(3):498-506. but a direct and intuitive way to convey the content addressed. 4. Ferreira Kdos S, Oliver GZ, Thomaz DC, Teixeira CT, Foss MP. Cognitive deficits in To raise and keep the interest of the reader, one must consider the chronic pain patients, in a brief screening test, are independent of comorbidities and medication use. Arq Neuropsiquiatr. 2016;74(5):361-6. language, layout, and illustration. However, it is the illustration 5. McGillion MH, Watt-Watson J, Stevens B, Lefort SM, Coyte P, Graham A. Randomi- that will, by far, ensure the readability and the comprehension of zed controlled trial of a psychoeducation program for the self-management of chronic a text33. In the “content” domain of the questionnaire, patients cardiac pain. J Pain Symptom Manage. 2008;36(2):126-40. 6. Haugli L, Steen E, Laerum E, Nygard R, Finset A. Learning to have less pain - is it and professionals were asked about the clarity of the purpose of possible? A one-year follow-up study of the effects of a personal construct group lear- the booklet, the comprehension of the text, the order of the texts ning programme on patients with chronic musculoskeletal pain. Patient Educ Couns. 2001;45(2):111-8. and the need for information. Approximately 87% of the patients 7. Moseley L. Combined physiotherapy and education is efficacious for chronic low back and 92% of the professionals judged the content to be satisfactory. pain. Aust J Physiother. 2002;48(4):297-302. 8. Moseley GL, Nicholas MK, Hodges PW. A randomized controlled trial of intensive However, the illustration had the lowest score in the patients’ view neurophysiology education in chronic low back pain. Clin J Pain. 2004;20(5):324-30. (84%). Although it is a satisfactory level, future editions should 9. Louw A, Zimney K, O’Hotto C, Hilton S. The clinical application of teaching people consider the possibility of improving the illustrations. Limit the about pain. Physiother Theory Pract. 2016;32(5):385-95. 10. Meeus M, Nijs J, Oosterwijck J, Van Alsenoy V, Truijen S. Pain physiology education number of illustrations, make them simpler and more representa- improves pain beliefs in patients with chronic fatigue syndrome compared with pacing tive, emphasizing important points in the text description, listing and self-management education: a double-blind randomized controlled trial. Arch Phys Med Rehabil. 2010;91(8):1153-9. real-life events are strategies that facilitate the communication of 11. Ryan RM, Weinstein N, Bernstein J, Brown KW, Mistretta L, Gagné M. Vitalizing content to the reader. Thus, people with low schooling can benefit effects of being outdoors and in nature. J Environ Psychol. 2010;30(2):159-68. 33 12. Gallagher L, McAuley J, Moseley GL. A randomized-controlled trial of using a book from these materials and types of language . of metaphors to reconceptualize pain and decrease catastrophizing in people with “EducaDor” tried to explain the concept of pain in a clear and chronic pain. Clin J Pain. 2013;29(1):20-5. detailed way, addressing acute and chronic pain, their charac- 13. van Ittersum MW, van Wilgen CP, van der Schans CP, Lambrecht L, Groothoff JW, Nijs J. Written pain neuroscience education in fibromyalgia: a multicenter randomi- teristics and differences, processing, coping approaches and zed controlled trial. Pain Pract. 2014;14(8):689-700. misbeliefs that patients and caregivers have concerning pain. So 14. Mendez SP, Sá KN, Araújo PC, Oliveira IA, Gosling AP, Baptista AF. Desen- volvimento de uma cartilha educativa para pessoas com dor crônica. Rev Dor. far, there are no validated educational booklets for patients with 2017;18(3):199-211. CP in Brazil. However, several educational materials are avail- 15. Joventino ES, Oriá MO, Sawada NO, Ximenes LB. Apparent and content validation of maternal self-efficiency scale for prevention of childhood diarrhea. Rev Lat Am able on websites for this population. In addition to addressing Enfermagem. 2013;21(1):371-9. concepts, these materials also discuss sleep quality, anxiety, and 16. Doak CC, Doak LG, Root JH. Learner Verification and Revision of Materials. In: nd pharmacological and non-pharmacological treatments. Increas- Doak, CC, Doak LG, Root JH. Teaching Patients with Low Literacy Skills. 1996. 2 ed. Philadelphia: Lippincott Company; 1996. 167-88p. ing evidence shows that knowing the neurophysiology of pain 17. Alexandre NM, Coluci MZ. Validade de conteúdo nos processos de construção e helps to reduce the incapacity and catastrophization of patients adaptação de instrumentos de medidas. Ciênc Saúde Coletiva. 2011;16(7):3061-8. 18. Polit, DE, Beck CT. Essentials of Nursing Research. 6th Ed. Philadelphia: Lippincott with CP, improving physical movements and compliance with Williams & Wilkins; 2006. several therapies34. Although the “EducaDor” does not address 19. Coluci MZ, Alexandre NM, Milani D. Construção de instrumentos de medida na área da saúde. Ciênc Saúde Coletiva. 2015; 20(3):925-36. the treatments for CP, the themes are explained from the stories, 20. Sá K, Baptista AF, Matos MA, Lessa I. Prevalence of chronic pain and associated questions, and fears reported by this population. The text pres- factors in the population of Salvador, Bahia. Rev Saude Publica. 2009;43(4):622-30. ents reports of experiences of people who live with pain, allowing English, Portuguese. 21. Malta DC, Oliveira MM, Andrade SS, Caiaffa WT, Souza MF, Bernal RT. Factors as- the reader to identify himself with the content exposed. sociated with chronic back pain in adults in Brazil. Rev Saude Publica. 2017;51(Suppl As a limitation, we can mention that this booklet is validated 1):9s. English, Portuguese. 22. Palmeira CC, Ashmawi HA, Posso IP. Sexo e percepção da dor e analgesia. Rev Bras for only one reference pain center, located in Salvador, Bahia, Anestesiol. 2011;61(6):820-8. that has specific sociocultural characteristics. Moreover, the small 23. Greenspan JD, Craft RM, LeResche L, Arendt-Nielsen L, Berkley KJ, Fillingim RB, et al. Studying sex and gender differences in pain and analgesia: a consensus report. Pain. number of health professionals interviewed may not express 2007;132(Suppl 1):S26-45. what the experts from other regions would consider relevant. It 24. Unruh AM. Gender variations in clinical pain experience. Pain. 1996;65(2-3):123-67. 42 Validation of an educational booklet for people with chronic pain: EducaDor BrJP. São Paulo, 2019 jan-mar;2(1):39-43

25. Riley J 3rd, Robinson ME, Wise EA, Myers CD, Fillingim RB. Sex differences in the 2012;13(2):111-8. perception of noxious experimental stimuli: a meta-analysis. Pain. 1998;74(2-3):181-7. 30. Santos ML, Paixão RL, Osorio-de-Castro CG. Avaliação da alfabetização em saúde do 26. Fillingim RB, Gear RW. Sex differences in opioid analgesia: clinical and experimental sujeito de pesquisa. Rev Redbioética/UNESCO. 2013;1(7):84-95. findings. Eur J Pain. 2004;8(5):413-25. 31. Gazzinelli MF, Gazzinelli A, Reis DC, Penna CM. [Health education: knowledge, 27. Thompson AD, Angelotti T, Nag S, Mokha SS. Sex-specific modulation of spinal social representation, and illness]. Cad Saude Publica. 2005;21(1):200-6. Portuguese. nociception by alpha2-adrenoceptors: differential regulation by estrogen and testoste- 32. Vieira A, Braga RM, Bartz PT, Candotti CT. Efetividade da escola postural em porta- rone. Neuroscience. 2008;153(4):1268-77. dores de dor lombar crônica inespecífica. Acta Fisiatr. 2012;19(3):184-91. 28. Lira MO, Carvalho MF. Dor aguda e relação de gênero: diferentes percepções em 33. Moreira MF, Nóbrega MM, Silva MI. Comunicação escrita: contribuição para a ela- homens e mulheres. Rev Rene. 2013;14(1):71-81. boração de material educativo em saúde. Rev Bras Enferm. 2003;56(2):184-8. 29. Sardá Jr JJ, Nicholas MK, Pimenta CA, Asghari Ali. Preditores biopsicossociais de 34. Louw A, Puentedura EL. Therapeutic neuroscience education, pain, physiotherapy dor, incapacidade e depressão em pacientes brasileiros com dor crônica. Rev Dor. and the pain neuromatrix. Int J Health Sci. 2014;2(3):33-45.

43 BrJP. São Paulo, 2019 jan-mar;2(1):44-8 ORIGINAL ARTICLE

Incidence of chest pain as a symptom of acute myocardial infarction in an urgent care unit Incidência da queixa de dor torácica como sintoma de infarto agudo do miocárdio em uma unidade de pronto-atendimento

Andreia Valeria de Souza Miranda1, Luís Fernando Rampellotti2

DOI 10.5935/2595-0118.20190009

ABSTRACT RESUMO

BACKGROUND AND OBJECTIVES: Chest pain is one of JUSTIFICATIVA E OBJETIVOS: A dor no peito é um dos the main reasons why individuals seek urgent and emergency principais motivos que levam os indivíduos a buscarem serviços services. It is a symptom that may suggest several pathologies, de urgência e emergência. Trata-se de um sintoma que pode su- among which the acute coronary syndrome, which makes differ- gerir diversas doenças, dentre as quais a síndrome coronariana ential diagnosis difficult. The objective of this study was to iden- aguda, o que dificulta o diagnóstico diferencial. O objetivo prin- tify the incidence of chest pain confirmed as acute myocardial cipal deste estudo foi identificar a incidência de dor torácica con- infarction in an urgent care unit in the city of Joinville; and spe- firmada como infarto agudo do miocárdio em uma unidade de cifically to describe the epidemiological profile of patients with pronto-atendimento do município de Joinville; e os específicos chest pain due to acute myocardial infarction, regarding gender, foram: traçar o perfil epidemiológico dos pacientes com dor to- age, type of acute myocardial infarction and cardiac enzyme al- rácica por infarto agudo do miocárdio quanto ao sexo, faixa etá- terations; identify how individuals described the symptom; to ria, tipo de infarto agudo do miocárdio e alterações de enzimas recognize other factors causing chest pain and to know the inci- cardíacas; identificar o modo como os indivíduos descreveram o dence of chest pain related to non-cardiac causes. sintoma; reconhecer outros fatores causadores de dor torácica e METHODS: Documentary study, descriptive and quantitative conhecer a incidência de dor torácica relacionada a causas não approach. cardíacas. RESULTS: The incidence of chest pain as a symptom of acute MÉTODOS: Estudo documental, descritivo e de abordagem myocardial infarction corresponded to 1% of the sample, affect- quantitativa. ing males. Several other causes were pointed out stemmed from RESULTADOS: A incidência de dor torácica como sintoma de the international code of diseases to seek care for this complaint. infarto agudo do miocárdio correspondeu a 1% da amostra, aco- CONCLUSION: The study evidenced the relevance of this metendo indivíduos do sexo masculino. Diversas outras causas complaint in emergency and urgent care units and the need to foram apontadas, a partir do código internacional de doenças, recognize the clinical manifestations and acute myocardial in- para a procura de atendimentos por essa queixa. farction screening for differential diagnosis. CONCLUSÃO: O estudo evidenciou a relevância dessa quei- Keywords: Angina, Chest pain, Infarction. xa nas unidades de urgência e emergência e a necessidade do reconhecimento das manifestações clínicas e triagem do infarto agudo do miocárdio para o diagnóstico diferencial. Descritores: Angina, Dor no peito, Infarto.

INTRODUCTION

Andreia Valeria de Souza Miranda - https://orcid.org/0000-0002-1730-4225; Chest pain is one of the most frequent causes of the search Luís Fernando Rampellotti - https://orcid.org/0000-0002-0346-8747. for medical care in urgent and emergency units. However, such a symptom referred to in many different ways is not 1. Faculdade São Fidélis, Centro Sul Brasileiro de Pesquisa, Extensão e Pós-Graduação, De- partamento de Enfermagem, Joinville, SC, Brasil. always related to the manifestation of the acute coronary 2. Faculdade São Fidélis, Centro Sul Brasileiro de Pesquisa, Extensão e Pós-Graduação, Jo- syndrome (ACS)1,2. inville, SC, Brasil. The relevance and magnitude of the subject have been ex- Submitted in March 12, 2018. pressed in world statistics. In the United States, for example, Accepted for publication in December 03, 2018. Conflict of interests: none – Sponsoring sources: none chest pain was the complaint of 5.8 million individuals, out of the 113 million admitted in urgent care units (UCU). Correspondence to: According to the world scenario, there are 4 million cases of Av. Juscelino Kubitscheck, 627 - Centro 3,4 89201-001 Joinville, SC, Brasil. patients assisted with chest pain complaints per year . E-mail: [email protected] Cardiovascular diseases (CVD) represent a group of diseas- © Sociedade Brasileira para o Estudo da Dor es that can cause chest pain symptom, which incidence has

44 Incidence of chest pain as a symptom of acute BrJP. São Paulo, 2019 jan-mar;2(1):44-8 myocardial infarction in an urgent care unit increased in the last decades. In 2011 alone, there were ap- METHODS proximately 20 million people affected by CVD worldwide, out of which 12 million died. In Brazil, CVD is the leading This study was carried based on the graduate thesis of the cause of mortality, and in 2009 there were 1 million hospi- Nursing course in Urgent Care Unit the School of São Fidélis talizations, costing 1.9 billion reais to the Unified Health (CENSUPEG). To develop this study, we used descriptive, System (SUS)3-5. documentary research, with a quantitative approach6. The re- Regarding the complaint, it may or may not be suggestive search was carried out in an urgent care unit (UCU) in the of ischemic coronary disease, in which segment angina and city of Joinville, SC. acute myocardial infarction (AMI) are included. Therefore, The city of Joinville was founded on March 9, 1851. Today, chest discomfort may lead to a cardiological approach or it has more than 500 thousand inhabitants and one of the point to other causes. Needless to say that the suspicion of highest per capita income of Brazil, besides being a big indus- ACS will require a specific clinical approach1,2. trial hub. Regarding the ACS characteristics, it is worth mentioning The city offers urgent and emergency care at two first-aid units that angina indicates the involvement of the heart muscle by (FA) and one UCU, in addition to two public hospital emer- ischemia. Therefore, there are two main forms of manifesta- gency rooms, one pediatric, one obstetric and two privates. tion, unstable and stable angina. While in the first the pain The study was carried at the East UCU, located at Rua Mafalda intensity is progressive and does not relieve at rest, the latter Laurindo, in the Aventureiro district. The unit is part of the city presents constant intensity, being perceived under efforts, network of urgent care and is subordinated to the city depart- and relieved by rest. Due to diabetic neuropathy, subjects ment of health and maintained with municipal and federal re- with diabetes mellitus may have an AMI without mentioning sources. The Aventureiro district is the most populous of the city pain, and the sweating may be interpreted as hypoglycemia2. of Joinville, home to about 40 thousand inhabitants working in AMI occurs when the blood supply to the myocardium the industry, retail and services. through the coronary arteries is inefficient to its demands, The UCU performs about 500 medical care every 12h, 24h a leading to ischemia and tissue necrosis. In the United States, day, 7 days a week. It provides medical care in internal medicine, AMI affects 1 million people per year and is accounts for general surgery, pediatrics, and dentistry to citizens in a situa- 466,000 deaths1,3. tion of illness or health problem that characterizes urgency and Regarding clinical screening for the diagnosis of AMI, chang- emergency. The Institution adopts the Manchester Classification es in myocardial necrosis markers, especially an increase in model. troponin combined or not with changes in the electrocardio- The study was conducted based on the urgent care records graphic pattern of the ST-segment or pathological Q wave, (UCR), filed at the unit and the registry of patient classification define the diagnosis and characterize the disease as ACS with in the of Microsoft Excel Spreadsheet - 2000, in which all patients, or without ST-segment elevation, which occurrence or not, their complaints and the flowchart were inserted. are indicators of the extent of myocardial injury1. The medical records of the users who visited the unit from March Together with the ACS as a cause of chest pain, there are 1 to 31, 2017, reporting chest pain were selected, and they were others of musculoskeletal, gastrointestinal, psychiatric and classified according to the flowchart number 25 - chest pain. All pulmonary origin, and they are, in general, benign. On the UCR records from individuals over 18 years of age were selected, other hand, there are specific diseases such as acute aortic dis- with no age limit. The records with incomplete medical care data section, pulmonary thromboembolism, hypertensive pneu- were excluded. mothorax, cardiac tamponade, and esophageal rupture and It was a retrospective study with the purpose of analyzing all perforation, which cause higher mortality than the first4. UCR records that met the inclusion criteria described. Thus, the Therefore, given the diversity of diseases and clinical condi- initial sample consisted of 310 records. tions that are manifested by chest pain, the differential diag- The data was collected on a spreadsheet (Microsoft Excel 2016), nosis is difficult and, at the same time, essential to establish in which the data has been inserted. The variables were: identi- the proper approach for the ACS treatment. Consequently, fication (initials), gender (M - male and F - female), age (Arabic professionals working in urgent care units need to know numerals) in years, complaint (by numbers representing three and recognize the causes, incidence, epidemiological aspects major categories of the chest pain complaint [complaint = 1) and characteristics of the clinical manifestations of the main chest pain, 2) chest pain and left upper limb (LUL) and right causes of chest pain that leads to seeking of medical care3. upper limb (RUL); 3) chest pain and other symptoms], Interna- Thus, the overall objective of the study was to identify the tional Classification of Diseases (ICD - 10), electrocardiogram incidence of chest pain confirmed as AMI in a UCU. The (A - alteration, S - no alteration, R - performed, NR - not per- specifics were to trace the epidemiological profile of patients formed) and troponin ([+] altered;] [- ] unaltered, R- performed with AMI-related chest pain regarding gender, age, type of and NR - not performed). AMI and cardiac enzyme alterations; identify how subjects The data were analyzed by simple statistical analysis, arithme- described the symptom; recognize other factors that cause tic mean, median, percentage, and mode that gave origin to the chest pain, and to know its incidence related to non-cardiac tables. The incidence of the chest pain complaint was obtained causes. from the total universe of patients who sought the service during

45 BrJP. São Paulo, 2019 jan-mar;2(1):44-8 Miranda AV and Rampellotti LF the study month. The calculations were performed using the Mi- As for the symptoms, none of them had chest pain radiating to crosoft Excel (2016) software, and the data were organized in the LUL. Two had only chest pain, and one had chest pain as- descriptive charts7. sociated with other symptoms. Regarding gender, the three cases One year was established for the storage of the forms used in data were male. On the other hand, there was age dispersion in the collection, under the responsibility of the researchers. After this selected categories. Therefore it was not possible to relate this period the forms were shredded to make the information unus- data to the findings of other authors. Table 2 shows the data on able. Any form of scientific disclosure was carried out without the diagnosis of AMI. the identification of participants. This research followed the legal requirements. This project was Table 2. Epidemiological profile of patients diagnosed with acute my- submitted to the Development and Structure Program of the ocardial infarction in March 2017 in the urgent care East unit Unified Health System - ProgeSUS, - of the City Secretary of Gender Age Complaint Electrocardiogram Troponin Health of Joinville, to request admission to the study site, hav- (years) ing been approved (Official Letter 118/2017 / SMS/GAB/GGE/ Male 41 1* SST NR NARAS). Male 22 1** SST NR Male 65 3** Normal Altered RESULTS *chest pain; ** chest pain and other symptoms; SST = ST-segment elevation; NR = not performed. Source: authors (2018). The study analyzed 300 UCR that met the proposed inclusion criteria in March. Ten records were excluded due to ICD-10 The study also identified other causes for chest pain complaints, non-observance. grouped according to ICD-10, described by the organic systems Regarding the epidemiological characteristics of patients who affected by these diseases in the following order of incidence: sought care for chest pain in a UCU, the majority were women (58.66%). Regarding age, there was an expressive demand from respiratory/pulmonary, musculoskeletal, nervous and gastroin- young adults between 18 and 30 years with this complaint, ac- testinal, shown in table 3. counting for 83 (27.66%) of the total visits. Table 3. Main causes of chest pain grouped by organic systemic The age group between 31 and 50 years and above 51 accounted groups according to ICD-10 of patients with chest pain attended in for 112 (37.33%) and 105 (35%) respectively, with a mean age March 2017 in the urgent care East unit of 43 years (Table 1). Organic systems Frequency (n and %) Concerning the description of the complaint among the three Respiratory/pulmonary 54 / 18 categories in which chest pain was grouped, according to the Musculoskeletal 39 / 13 description of the classifier in the UCR record, complaint 1, chest pain, had a frequency of 139, while complaint 2, chest Nervous 33 / 11 pain and RUL or LUL had a frequency of 32, and complaint Cardiac 14 / 4.7 3, chest pain and other symptoms appeared 129 times. It was Gastrointestinal 10 / 3.3 observed that only 32 individuals presented typical chest pain, Cases described as symptoms and not 150 / 50 while 129 (43%) patients had, besides chest pain, associated as diagnosis symptoms such as dizziness, palpitation, sweating, nausea, vom- Source: authors (2018). iting, among others. As for the management of the complaint during the clinical care, The cases described by the ICD-10 corresponding to symptoms 135 electrocardiogram tests were requested, and the cause of 165 and/or did not have the cause defined accounted for half of the (55%) chest pain cases was determined without the need of ad- sample and may be related to the ICD-10 non-observance of the ditional diagnostic exams. In addition, cardiac enzyme collection diagnostic conclusion or the diagnostic vagueness of this com- was requested for 74 (24.66%) individuals. plaint at the moment of care. Among the medical assistance, there were three cases of AMI, corresponding to 1% of the sample. Still on the findings, among DISCUSSION the AMI, two were diagnosed by the alteration in the electrocardiographic tracing, namely ST-segment elevation and one case The predominance of female subjects who seek the urgent care by elevated troponin level. units because of chest pain complaint found in the study cor-

Table 1. Epidemiological characterization of patients with complaints of chest pain assisted in the East urgent care unit in March 2017 Gender Age group (years) Electrocardiogram Enzymes Male Female Average Mode Median R NR A R NR A 124 176 43.30 21 43 135 165 2 74 225 1 R = performed; NR = not performed; A = altered. Source: authors (2018).

46 Incidence of chest pain as a symptom of acute BrJP. São Paulo, 2019 jan-mar;2(1):44-8 myocardial infarction in an urgent care unit roborates the study by Araújo and Marques,2 in which chest About 50% of the AMI cases showed a change in the ECG pain was also predominantly female, accounting for 70% of tracing with ST-segment elevation. In this study, of the three the sample. confirmed cases, two had altered electrocardiograms, that is, Regarding chest pain as an AMI symptom, Mussi, Ferreira and 66.7%, similar to the study by Mansur et al.10. The same au- de Menezes8 pointed out that the AMI treatment in women usu- thors10 stated that there was a 91% specificity of the diagno- ally starts later than in men, since they relativize the symptoms sis by this method, which may justify why no tissue necrosis from resistance to pain and because professionals, in general, at- markers test, also called cardiac enzymes, was performed in tribute to a psychological factor. In the present study, there were the UCU. no women affected by AMI, although this was the largest group The study showed that the cardiac causes are not the first cause with this pain complaint. of chest pain, and among the cardiac causes AMI is one of the As for age, the expressive demand for young adults was also diseases, but there are others, as also identified in a study by Bar- observed in the study by Missaglia, Nerins and Silva3 in which bosa et al.4. this frequency reached 50%. Similar studies, such as Araújo and From the perspective of the diversity of etiologies for this com- Marques2, Missaglia, Neris and Silva3 showed frequencies of plaint, the performance and attention of the healthcare profes- 40% for individuals aged between 50 and 59 years and 49% for sional as the patient arrives at the emergency service are determi- individuals between 41 and 50 years, respectively. These authors nant for the proper clinical approach. The knowledge about the also noted that the age above 60 years is the age group with the ACS symptoms and the patient’s history by the risk classification highest incidence, a fact that in this study is statistically close to nurse to identify the predisposing factors determine the priori- the described studies, although the largest number was not in tization of the care, the approach, and early intervention when this age group. necessary11. Reggi and Stefanini1 suggest that associated symptoms like diz- Therefore, although the great majority of the chest pain com- ziness, palpitation, sweating, nausea, vomiting, among others, plaints are not confirmed as AMI, the morbidity and mortality are more frequent than chest pain radiating to the LUL, a fact associated with chest pain attributed to cardiac etiologies drive pointed out as useful for the differential diagnosis, as well as a the care in the clinical screening of this symptom. sentinel for old or diabetic patients who may have an AMI and On the other hand, in the study by Missaglia, Neris and Silva3, not present the typical symptoms. cardiac causes accounted for a significant part of the sample. It is Similar studies by Missaglia, Neris and Silva3 and Araújo and worth mentioning that that study was performed in a reference Marques2 have shown that about 10% of chest pain complaints cardiologic emergency room, which may justify the dissonance are confirmed as AMI. Thus, in this unit, this mean was lower with this and other similar studies in which the so-called “un- than in other studies since it indicated an incidence of 1% in the specified” or “unknown” causes were also more frequent than sample. Although 74 individuals (24.7%) have been submitted coronary causes, although there was no agreement for the inci- to cardiac enzyme test, only 3 (1%) were confirmed as AMI, out dence of various diseases4,12,13. of which only one individual required laboratory tests to confirm the diagnosis, and all the other 73 patients had this non-related CONCLUSION ACS complaint. A study by Barbosa et al.4 states that many patients are submitted Chest pain is a frequent complaint in the UCU with prevalence to the ACS protocol due to diagnosis limitations, some of which in female subjects. could be overcome by more detailed and accurate clinical screen- The complaint of chest pain as an AMI symptom represented ing and the patient’s history. a small portion of the sample, below the incidence in similar The higher incidence of AMI in males, corresponding to the studies. three cases confirmed in this study, corroborate the studies de- There was a significant vagueness of the cause of the chest pain scribed. complaint. This may be related to the non-observance of the Besides the male predominance, Dessotte, Dantas and Schmidt9 ICD-10 with the diagnostic conclusion or diagnostic vagueness showed an average age of 55.8 years of patients diagnosed with of this complaint at the time of care. AMI, the youngest being 25.4 years old and the oldest 79.4 years. This data is very similar to those obtained in this study, REFERENCES an average of 42.6, and ages of 22 years for the youngest and 65 1. Reggi S, Stefanini E. Diagnóstico das síndromes coronarianas agudas e modelo siste- for the oldest. These authors identified that most of the patients matizado de atendimento em unidades de dor torácica. Rev Soc Cardiol Estado de São with AMI also had risk factors for coronary artery disease, such Paulo. 2016;26(2):78-85. as hypertension, smoking, obesity, and dyslipidemia, which were 2. Araújo RD, Marques IR. Compreendendo o significado da dor torácica isquêmica de pacientes admitidos na sala de emergência. Rev Bras Enferm. 2007;60(6):676-80. not analyzed in this study. Parte inferior do formulário. Regarding clinical manifestation, none of the patients diagnosed 3. Missaglia MT, Neris ES, Silva ML. Uso de protocolo de dor torácica em pronto atendimento de hospital referência em cardiologia. Rev Bras Cardiol. 2013;26(5):374-81. with AMI reported typical pain. In the study, there were two cas- 4. Barbosa AC, Silva AS, Cordeiro AA, Ribeiro BN, Pedra FR, Borges IN, et al. Diag- es of patients who reported only chest pain and one case (33.3%) nóstico diferencial da dor torácica: ênfase em causas não coronarianas. Rev Med Minas Gerais. 2010;20(2Suppl 1):S24-9. of atypical complaint frequency, which is similar to the frequen- 5. Huguenin FM, Pinheiro RS, Almeida RM, Infantosi AF. [Characterization of the cy reported by Reggi and Stefanini1. variation of health care taking into account the costs of hospital admissions for acute 47 BrJP. São Paulo, 2019 jan-mar;2(1):44-8 Miranda AV and Rampellotti LF

myocardial infarction a in Brazilian Unified Health System]. Rev Bras Epidemiol. 10. Mansur PH, Cury LK, Destro-Filho JB, Resende ES, Destro JP, de Oliveira LM, et al. 2016;19(2):229-42. English, Portuguese. [Analysis of electrocardiographic recordings associated with acute myocardial infarc- 6. Severino AJ. Metodologia do Trabalho Científico. 24ª ed. São Paulo: Cortez Editora; tion]. Arq Bras Cardiol. 2006;87(2):106-14. Portuguese. 2016. 11. Caveião C, Santos RB, Montezeli JH, Visentin A, Brey C, Oliveira VB. Dor torácica: 7. Batistti ID, Batistti G. Métodos Estatísticos. Ijuí (RS): Coleção Educação a Distância. atuação do enfermeiro em um pronto atendimento de um hospital escola. Rev Enferm Série Livro-texto. Editora Unijuí. 2008. 80p. Disponível em: http://bibliodigital.uni- Cent O Min. 2014;4(1):921-8. jui.edu.br:8080/xmlui/bitstream/handle/123456789/277/Métodos estatísticos.pdf. 12. Domingues GR, Moraes-Filho JP. Dor torácica não-cardiogênica. Arq Gastroenterol. 8. Mussi FC, Ferreira SL, de Menezes AA. [Experience of women in face of pain from 2009;46(3):233-40. acute myocardial infarction]. Rev Esc Enferm USP. 2006;40(2):170-8. Portuguese. 13. Gal PL, Teixeira MJ, Bergel RH, Jacobsen WG, Dor torácica. Rev Med. 2001;80(ed. 9. Dessotte CA, Dantas RA, Schmidt A. [Patients symptoms before a first hospitalization due esp. pt.2):341-50. Disponível em: http://www.revistas.usp.br/revistadc/article/ to acute coronary syndrome]. Rev Esc Enferm USP. 2011;45(5):1097-104. Portuguese. view/69990.

48 BrJP. São Paulo, 2019 jan-mar;2(1):49-54 ORIGINAL ARTICLE

Palliative care: epidemiological profile with a biopsychosocial look on oncological patients Cuidados paliativos: perfil com olhar biopsicossocial dentre pacientes oncológicos

Karoline Sampaio Castôr1, Ed Carlos Rey Moura2, Emanuel Cabral Pereira3, Deborah Costa Alves3, Thamires Sales Ribeiro3, Plínio da Cunha Leal2

DOI 10.5935/2595-0118.20190010

ABSTRACT CONCLUSION: Knowing the profile of patients is key to identify the obstacles to the effective implementation of palliative BACKGROUND AND OBJECTIVES: Palliative care is a set of care, making it possible to implement targeted measures. practices that encompasses patients with life-threatening diseases Keywords: Epidemiological profile, Oncology, Palliative care. which approach is no longer curative, but comforting, including care for the family. The objective of this study was to verify the RESUMO epidemiological profile of cancer patients in palliative care. METHODS: We interviewed 100 cancer patients in palliative JUSTIFICATIVA E OBJETIVOS: Os cuidados paliativos são care, as well as the sociodemographic and biopsychosocial vari- um conjunto de práticas que abrangem pacientes portadores de ables, using the Karnofsky index, Palliative Performance Scale doenças ameaçadoras da vida e cuja abordagem deixa de ser cu- and Edmonton Symptom Assessment Scale. rativa e passa a ser baseada em conforto, incluindo cuidados com RESULTS: The prevalent age group was between 51-60 years a família. O objetivo deste estudo foi verificar o perfil epidemi- (34%), more than half female (77%), incomplete elementary ológico de pacientes oncológicos em cuidados paliativos. school (40%) and resident in the interior of Maranhão (73%). MÉTODOS: Foram entrevistados 100 pacientes oncológicos em Concerning the use of pain drugs, 52% reported not forgetting to cuidados paliativos quanto às variáveis sociodemográficas e biopsi- take their pain drug, while 56% took drug on their own. As to the cossociais, utilizando-se o índice de Karnofsky, a Escala de Perfor- diagnosis, only 13% of the interviewees were aware of a palliative mance Paliativa e a Escala de Avaliação de Sintomas de Edmonton. diagnosis, and more than half of them were aware of primary or RESULTADOS: Observou-se faixa etária mais prevalente entre oncological diagnosis (65%). Regarding the evaluation of func- 51 e 60 anos (34%), mais da metade do sexo feminino (77%), tional capacity, 52% had the Karnofskys index between 70 and nível escolar fundamental incompleto (40%) e residente no in- 90%; Palliative Performance Scale, 62% between 80 and 90%, terior do Maranhão (73%). Quanto ao uso de analgésicos, 52% and Edmonton Symptom Assessment Scale the following most relataram não esquecer de tomar o fármaco para dor; enquanto significant variables in tiredness, (60%); sadness, (84%); anxiety, 56% tomam fármaco por conta própria. Quanto ao diagnóstico, (73%); lack of appetite, (51%) and absence of well-being (79%). apenas 13% dos entrevistados conhecem o diagnóstico paliativo, e mais da metade conhece o diagnóstico primário ou oncológico (65%). Quanto à avaliação da capacidade funcional, 52% tem índice de Karnofsky avaliado entre 70 e 90%; Escala de Perfor- mance Paliativa, 62% estão entre 80 e 90% e Escala de Avaliação Karoline Sampaio Castôr - https://orcid.org/0000-0001-7635-8752; de Sintomas de Edmonton as seguintes variáveis mais signifi- Ed Carlos Rey Moura - https://orcid.org/0000-0002-7752-0683; cantes em cansaço, (60%); tristeza, (84%); ansiedade, (73%); Emanuel Cabral Pereira - https://orcid.org/0000-0003-4227-1944; Deborah Costa Alves - https://orcid.org/0000-0001-9063-854X; falta de apetite, (51%) e ausência de bem-estar (79%). Thamires Sales Ribeiro - https://orcid.org/0000-0002-7063-7539; CONCLUSÃO: Conhecer o perfil de pacientes é relevante para Plínio da Cunha Leal - https://orcid.org/0000-0003-1336-8528. a identificação pontual de obstáculos na implementação efetiva 1. Universidade Ceuma, Faculdade de Medicina, Departamento de Ciências da Saúde, São dos cuidados paliativos. Possibilitando assim, a implementação Luís, MA, Brasil. 2. Universidade Federal do Maranhão, Hospital São Domingos, Departamentos de Me- de medidas direcionadas. dicina I e Anestesiologia, São Luís, MA, Brasil. Descritores: Cuidados paliativos, Oncologia, Perfil epidemiológico. 3. Universidade Federal do Maranhão, Faculdade de Medicina, Centro de Ciências Biológi- cas e da Saúde, São Luís, MA, Brasil. INTRODUCTION Submitted in July 19, 2018. Accepted for publication in December 10, 2018. Conflict of interests: none – Sponsoring sources: none According to the Brazilian National Academy of Palliative Care (ANCP), in its manual of 20121, palliative care has historically been Correspondence to: R. Seroa da Mota, 23 – Apeadouro associated with the term Hospice. This word comes from the start of 65031-630 São Luís, MA, Brasil. the Christian age when these institutions played a role in the spread of E-mail: [email protected] Christianity through Europe. The original Hospices were shelters (like © Sociedade Brasileira para o Estudo da Dor hostels) which would welcome and take care of pilgrims and travelers, 49 BrJP. São Paulo, 2019 jan-mar;2(1):49-54 Castôr KS, Moura EC, Pereira EC, Alves DC, Ribeiro TS and Leal PC and the first report on these dated from the th5 Century when Fabiola, say goodbye and have control over other time issues; and be able to a disciple of St Jerome, would care for travelers coming from Asia, Af- leave at the right time, not having life prolonged uselessly6,7. rica, and other Eastern countries, at the Hospice of the Port of Rome. The purpose of this study was to check the epidemiological profile of Etymologically, the word ‘palliative’ comes from the verb palliare, cancer patients in PC, attended to by a cancer hospital in the Brazilian which means cloak or mantle (protection); hence the verb ‘paliar’ has state of Maranhão. By constructing the profiles of the patients, it is acquired many meanings, such as: to make something less hard, to possible to develop new implementation strategies and patient care. remedy, to soothe or relieve. The concept of palliative care (PC) is based on this notion, as palliative treatment is a kind of treatment that METHODS “gives a momentary remedy for the solution of a problem yet does not solve the problem permanently”2. This is a longitudinal, prospective, observational and quantitative According to the definition of the World Health Organization study. One hundred patients under PC were interviewed at the ‘Alde- (WHO), reviewed in 20023, Palliative Care is an approach which nora Bello’ cancer hospital in the city of São Luís, capital of the state implements and promotes quality of life (QoL) of patients and their of Maranhão, Brazil. The sample was found by free demand in the families, when the patients have illnesses that threaten the continuity outpatient pain unit of this hospital, or during hospitalization, and of their lives, through prevention and relief of suffering. This approach was chosen at random up to n=100. The calculation of the sample requires early identification, evaluation, and treatment of pain and within a population of 156 people, with a confidence rate of 90%, any other problems of physical, psychosocial and spiritual nature”. with an error margin of 5%. The formula for the calculation of the PC is based on principles, rather than protocols. Nowadays, no one size of the sample for a reliable estimate of the mean for the population talks about terminality, but rather of illness that threatens life. Care right (µ) is given by: from the moment of diagnosis is also recommended, expanding this Z ⋅σ 2 field of action. Similarly, no mention shall be made of the impossibil- n = α/2 ity of cure; instead, one shall mention the possibility of treatment to ( E ) modify the illness, thereby removing the concept that “nothing else can In this formula, n is the number of individuals in the sample, Z is be done”. For the first time ever, an approach includes spirituality as α/2 one of the dimensions of the human being. The family is also remem- the critical value which corresponds to the degree of confidence as re- σ bered, and therefore provided with assistance, even after the death of quested, and is the standard deviation (SD) of the variable studied. the patient, during the period of mourning1. E is the margin of error or the maximum error for estimation. This Ideologues and palliativist professionals believe that those who work identifies the maximum difference between the sample mean (X) and exclusively towards a cure end up not realizing the true limits of their the true mean of the whole population. practical activities, as also the limits applicable when dealing with The criteria for exclusion were patients undergoing curative treatment; the patient, his or her feelings, and his or her reactions. The main patients from the private hospital network; patients who were cogni- criticisms show that this excess of medical power produces what has tively unable to answer the questions; patients who did not agree to been defined as “therapeutic imprisonment,” perceived by those who participate in the research or who decided not to participate in the believe in the idea of PC as an invasion of the sick body. The propos- research later on. The main criteria of inclusion were cancer patients al of PC is therefore regarded as a move to break this paradigm and in PC in the public health sector of the hospital here identified, from thus construct a new style of medicine, with the exercise of medical March 2017 until the required number of patients (n) for the sample power being expanded and made more sophisticated, in a mediating was obtained. There were no cases of people who decided not to par- way and together with the interdisciplinary team. The palliativists also ticipate or refused to be interviewed. All the patients who took part work with the acceptance of the inevitable worsening of the disease in this study signed the Free and Informed Consent Form (FICT). and try to minimize pain, so that the patient may live through this The material used for data collection was a closed questionnaire with process with QoL4. socio-demographic questions including age, gender, ethnicity, educa- The new Brazilian Code of Medical Ethics5, approved by Resolution tional level, and origin; and also, objective questions about awareness 1.931/09 of the Federal Medical Council (CFM), has helped towards of the patient’s diagnosis and prognosis, and validated scales of func- greater dissemination of the philosophy of Palliative Care and advises tional and psycho-affective evaluation. The instruments or scales used the doctor to avoid therapeutic obstinacy for terminally ill patients. in the said questionnaire were the Karnofsky score, the Palliative Per- “Good death” should respect the 12 aspects identified by a British formance Score (PPS) and the Edmonton Symptom Assessment (ESAS), group studying the health of the elderly. For a “good death”, the pa- all these having been validated. tients need to know that death is nigh and understand what can be The Karnofsky score describes the growing levels of activity and in- expected, be able to maintain control over what is happening; be giv- dependence, with values ranging from zero to 100, where zero cor- en due privacy and dignity; have control over pain relief and other responds to death, and 100 represents a normal level of physical per- symptoms; be able to choose where death occurs (whether at home formance and aptitude to carry out normal activities, especially those or in some other location); have access to any kind of information or involving self-care. In adaptation, the lowest index is 10, meaning that knowledge; have access to spiritual and emotional support; have access the patient is about to die, and in a process where death is rapidly pro- to PC anywhere, and not just in hospital; have control over who is gressing. This is the instrument most commonly used in the prognosis present, and who the end shall be shared with; be able to issue advance of cancer therapy, as this is a measure of performance for the classifica- guidance so that the patient’s wishes may be respected; have time to tion of a person’s skills to carry out activities, by evaluating the progress 50 Palliative care: epidemiological profile with a BrJP. São Paulo, 2019 jan-mar;2(1):49-54 biopsychosocial look on oncological patients of the patient after therapeutic procedures or establishing the patient’s Regarding the use of medication for pain relief, we observed that 52% capacity of receiving therapy8. of the subjects mentioned that they never forget to take their med- PPS is an instrument that has been validated and is widely used within icines for pain relief; 57% mentioned that they do not stop taking PC to follow and monitor the evolutive curve of the illness, thereby medicine for pain relief when they feel better; 56% reported self-med- establishing grounds for decision-making, expectations of prognosis, ication, and 78% said they never set their alarm clocks to remind and definition of terminality. Among other factors, the PPS evalu- them about medication times (Table 1). We also observed that 13% ates the severity of the disease, and the patient’s capacity to take care of the people interviewed knew about palliative diagnosis, while 87% of himself. An accurate estimate of the prognosis helps to plan the did not (Table 2). medical action, and also establishes the best moment to prioritize PC Concerning primary diagnosis, we noticed that 65% are aware of rather than curative measures, also identifying when this first type of the diagnosis of cancer, while 35% are not. Regarding the advanced treatment becomes exclusive9. ESAS is a scale for evaluation and mon- healthcare directive, 100% of the sample was unaware. Another fact itoring of physical and psychological symptoms that use of the fol- observed is the fact that 92% of subjects did not have any physical lowing variables: pain, fatigue, nausea, depression, anxiety, drowsiness, exercise activity. appetite, well-being, shortage of breath, and some blank space so that the patient may add any other symptoms experienced. ESAS was de- Table 1. Distribution of patients under palliative care evaluated according to their regular use of drugs. São Luís, 2018 veloped by Bruera et al.10, at the Unit for Cancer Patients in Palliative Variables Sample Care at the General Hospital at Edmonton, Canada. It comprises 10 n=100 items, each being linked to a visual numeric scale (VNS) ranging from Yes No zero to 10, where zero represents the absence of the symptom and 10 means that the symptom shows its most extreme manifestation. The Forget to take medication for pain relief 48 52 authors later added one of the items (shortage of breath), and there Stop taking medication when feeling better 43 57 was also a shift from the visual analog scale (VAS) to VNS, as it is Take medicines through self-medication 56 44 currently known. Set the alarm clock to ring at medicine times 22 78 ESAS is a scale that is valid for control and handling of symptoms, as it is easy, simple, and quick to use11. Table 2. Distribution of patients under palliative care evaluated according This whole research project was based on Resolution No. 466/12 of to the knowledge of palliative diagnosis and primary diagnosis. São Luís, 2018 the National Health Council (CNS), which establishes guidelines and standards to regulate research involving human subjects. The Research Variables Sample n=100 Ethics Committee approved the study under opinion No.1,939,689, Yes No of 2017. Aware of primary or oncological diagnosis 65 35 Statistical analysis Aware of palliative diagnosis 13 87 All the data collected were tabulated and then statistically analyzed using Microsoft Excel 2013. The results were shown in the descriptive Considering the evaluation of functional capacity, we saw that 52% and tabular form. Initially, the analysis using descriptive statistics was of the patients had a Karnofsky score between 70% and 90%; a total made through frequency tables for the variables as analyzed, we esti- of 9% of these correspond to a Karnofsky score of 70%: there is no mated the mean, standard deviation, and maximum and minimum of need for assistance for personal care, but the person is unable to car- the numerical variables. The level of significance to reject the hypoth- ry out normal activities such as household chores and active tasks. A esis of nullity was 5%, which means that any p-value less than 0.05 further 12% had a Karnofsky score of 80%, which means that these (p<0.05) was considered statistically significant. people can carry out normal tasks, albeit with effort. These people also showed some signs and symptoms of the illness, but incapacity is only RESULTS present for activities requiring a lot of effort. Finally, 31% of the sample shows a Karnofsky score of 90%, meaning a capacity to carry out The evaluation was carried out on 100 patients under PC at a special- normal tasks; signs and symptoms of the disease are minimal among ized cancer hospital in the capital of the state of Maranhão, through these people (Table 3). the application of a quantitative questionnaire, considering social and Table 3. Distribution of patients under palliative care evaluated based on demographic data. We observed that in the population prevailed the their functional capacity, according to the Karnofsky scale. São Luís, 2018 age group from 51 to 60 years (34%), females (77%), brown (51%), Variables Sample (n=100) black (28%) and white (21%). Regarding marital status, 67% reported having a fixed partner. Sixty-two percent of the sample population Functional capacity of 80% 12% were Evangelical Christians. Forty percent did not finish their primary Functional capacity of 90% 31% education; 73% lived in the interior of the state of Maranhão, and Functional capacity of 70-90% 52% 92% did not work. Out of the patients in the sample, 54% were unaware of the legal rights of patients with cancer; 94% had a caregiver, Turning now to PPS, we saw that 62% of the subjects had PPS scores whether a family member or not; 82% did not know how to use the between 80 and 90%; of these, 34% have a PPS of 80%: total ambula- Internet to learn more about their diagnosis. tion, activities with effort, some evidence of the disease, carries out full 51 BrJP. São Paulo, 2019 jan-mar;2(1):49-54 Castôr KS, Moura EC, Pereira EC, Alves DC, Ribeiro TS and Leal PC self-care, normal ingestion, and level of consciousness preserved. Twen- this perspective, in most cases, men tend to suffer more from severe ty-eight percent have a PPS of 90%, which entails full ambulation, nor- and chronic health conditions than women do and also die earlier mal activities, some evidence of the disease, execution of full self-care, than they do15. normal ingestion, and level of consciousness preserved (see Table 4). Over half the population studied reported a fixed partner and a specific caregiver. The literature shows that support from the spouse or Table 4. Distribution of patients under palliative care evaluated by functio- other family members is, indeed, very important for people with a nal capacity according to PPS. São Luís, 2018. life-threatening disease. It is also evident that a person with cancer Variables Sample (n=100) tends to adapt better to situations of life-threatening diseases and the PPS 80% 34% stress that this condition brings when there is a high level of social and PPS 90% 28% family support16. PPS 80-90% 62% On the other hand, the burden overload on the caregiver is often linked to episodes of depression, anxiety, physical and mental fatigue, Moving on to ESAS, we saw that the following variables showed: pain stress, and worse QoL for the patient, which could even generate risks 17 (53% between 2 and 5); fatigue (60% between 6 and 9); nausea (58% for the patient’s physical and psychological health . The family mem- between 1 and 4); sadness (84% between 6 and 9); anxiety (73% be- bers and caregivers, whether these are part of the family or not, should tween 6 and 9); drowsiness (55% between 4 and 7); lack of appetite be part of the medical and multiprofessional assistance involved in 1 (51% between 6 and 9); lack of well-being (79% between 6 and 9), palliative care . The human being is not isolated but leads a life that and shortage of breath (61% between 1 and 4). Others not reported is inserted in a biological, psychological and social context. Therefore, (Table 5). looking in one direction is not just a flaw in care for the patient-family axis, but is also a flaw in the formation of the medical and professional Table 5. Distribution of patients under palliative care, evaluated by their concepts behind health issues, which propose the defense of life. functional capacity, using ESAS. São Luís, 2018 The State of Maranhão has publicly owned Oncology Centers in the Variables ESAS Sample n=100 regions around the cities of Caxias and Imperatriz, in a move to reduce Point score from zero to 10 the flow of patients at Cancer Hospitals in the state capital. However, most of the people surveyed (73%) live in the countryside of the State Pain, score between 2 and 5 53% of Maranhão, which could lead to an overload of the health system Fatigue, between 6 and 9 60% under study, and maybe the most seriously ill patients may not even Nausea, between 1 and 4 58% be able to get to the hospital. Another relevant fact is that nearly all Sadness, between 6 and 9 84% the patients interviewed do not have paid work, and most of them do Anxiety, between 6 and 9 73% not even know the rights of the cancer patient, such as retirement on Drowsiness, between 4 and 7 55% the grounds of invalidity, and a financial bonus for illness (sick pay). Loss of appetite, between 6 and 9 51% The continuous travel involved generates costs, inconvenience, and Lack of well-being, between 6 and 9 79% emotional problems involving the treatment of the patient, including the family, leading to absences at outpatient appointments or cases Shortage of breath, between 1 and 4 61% where only a representative appears. According to Carvalho and Par- Others 0% sons1, the goals of CP include the provision of comfort to the patient; reduction of emotional stress; better QoL, and lower quantity (or DISCUSSION complete absence) of invasive intervention. This means that the physical distance between the care team and the patient is also a relevant The demographic transition in Brazil started with the decline in mortal- factor for the implementation of a PC in an efficient manner. ity rates and then, after some time, with a decrease in birth rates, thereby Most of the population under study has not completed primary ed- bringing about significant changes in the age structure of the Brazilian ucation. According to some studies related to the diagnosis of cancer, population12. According to Carneiro et al.13, with the recent aging pro- a low educational level, linked to low income, is a factor that affects cess among the population, which predicts an exponential growth in access to health services, thereby leading to a delay in seeking health the number of elderly people, it is also possible to predict that there care, and to a reduction in the number of preventive examinations shall be a sharp increase in the prevalence of cancer and other chronic such as mammograms and pap smears and prostate tests18-20. degenerative diseases such as hypertension, diabetes mellitus, and diseases The low educational level is also linked to the late diagnosis of can- of the bones and joints. The values corresponding to the age, gender and cer and, hence, to higher mortality, not to mention the association to educational level in this study correspond to what was expected when worse standards of health care21. Indeed, the higher the educational we compared with the findings of specialized literature. level, the greater shall be the patient’s understanding of QoL, basic The higher occurrence among females is also the expected profile for sanitation, and health criteria. Therefore, people with more elaborate emerging countries14, where the number of cases of cancer among concepts of health shall have a better perception of painful situations, women is higher than among men14. Here it is also worth pointing while people with less knowledge about what an ideal state of health out that the female population is also the segment of the population is shall have greater “tolerance” to pain. They can be less demanding that goes to the doctor earlier and more often, which could be one in this appraisal of their own state of health, thereby delaying the act reason why cancer appears to be more common among women. In of seeking a health service and possibly also delaying the diagnosis. 52 Palliative care: epidemiological profile with a BrJP. São Paulo, 2019 jan-mar;2(1):49-54 biopsychosocial look on oncological patients

This fact is a major cause for concern, as the patient and/or the caregiv- of anxiety and depression among patients living with cancer is higher er should understand as much as possible, to correctly implement the than that in the general population29. Other authors comment on the guidance related to health and specific treatment. This data can be even fact that a diagnosis of cancer brings many doubts and lack of security more alarming if we consider the quality of education, a factor that can and could even lead to psychiatric disorders. These disorders are usually underestimate the true social and cultural level of this population. The considered as belonging to one of two basic groups, namely anxiety, understanding is directly related to greater participation in treatment and depression. Depression is one of the psychiatric disorders that is and to the involvement of the person as an active participant in deci- hardest to diagnose in cancer patients, due to the similarity of symptoms sion-making with regard to self and proposed interventions. According between cancer and the adverse effects of their treatment, which often to Carvalho e Parsons1, autonomy is one of the pillars of PC, making prevail over the symptoms of this disorder30. the subject become more participant in making decisions, thereby es- Chronic inflammation is also shown as a pro-tumoral factor, leading tablishing a better relationship between doctor and patient22,23. to a tumor’s aggressive growth and spread. Many inflammatory factors In this study, we saw a very fine line drawn between those patients that trigger tumor growth are also responsible for syndromes such as who made adequate use of drugs for pain and those who did not. It anorexia and cachexia, pain, and shortened lifespan31. was also observed that a substantial part of the sample said that they Pedroso, Araújo and Stevanato28 said that this chronic inflammation do not forget to take the drugs for pain relief, and neither do they stop is related to the increased mass of body fat, with the adipose tissue taking the medication when they feel better. More than half said that being an important source of circulatory pro-inflammatory cytokines. they make use of self-medication, and similarly, the overwhelming In this way, the loss of weight would reduce the production of pro-in- majority do not have the habit of setting their alarm clock to go off flammatory cytokines (IL-6, TNF) and increase the production of at medication times, mentioning that they take their medication at anti-inflammatory agents (IL-10, IL-1ra). For this, the reduction in times close to those recommended by the doctor. calorie intake and an increase in physical exercise would work as effec- The main disadvantage in not treating oncological pain, or in treating tive strategies for the general reduction of inflammation. this pain incorrectly, is that the prognosis is then poor, and there could In the sample, we saw that a minority of people interviewed (13%) be a rise in complications arising from the disease, which in turn raises were aware of the palliative diagnosis, while the majority of the sub- the occurrence of deterioration of the general clinical health of the jects (87%) we not aware of. When the issue turns to the primary patient. Treatment of pain brings a significant relief of the associated diagnosis, we saw that over half the subjects were aware of the diagno- symptoms24,25. It is well known that untreated pain leads to anxiety sis of cancer, and 35% did not know about it. Several factors could and depression, thereby worsening such losses and harming cognitive play a part in the non-encoding of the message on the doctor-patient functions, daily activities, social activities and sleep patterns26. axis32,33. The doctor must pay attention throughout his or her dis- We also see that over half the population studied in this research had course to behaviors such as the use of technical jargon and constant a Karnofsky score between 70 and 90% and PPS between 80 and interruptions while the patient is speaking. Technical terms should 90%. Percentages corresponding to the ability for self-care, the perfor- only be used when absolutely necessary, together with a clarification as mance of daily activities in an autonomous way and with the level of to why they are used. And interruptions should be discouraged, using consciousness preserved, gives the idea that PC is not a synonym of another method, which is that of guiding the conversation to what is terminality of the disease, imminent death, or end of life. Another da- most relevant. tum within this context that called our attention is the fact that nearly Simpson et al.34, identified problems with the language used by medi- all the interviewees did not practice physical exercises, even though cal professionals, generally related to lack of clarity, excessive use of jar- they are statistically capable of doing so. Physical activity is proven gon, and restricted sharing of meanings of expressions used, between to be associated with modulation of pain, improvement of stress and the doctor and patient. In the opinion of Beckman and Frankel35, the general mood, and is also linked to the reduction of depression. A continuous interruption of the patient’s talk causes some inhibition review carried out by Courneya et al.27 in more than 40 studies inves- and retraction when the patient has something else to say. tigating the practice of physical activities and QoL in cancer patients Communication between doctor and patient should offer conditions showed that physical activity, during chemotherapy and radiotherapy so that there may be the promotion of health, making the user/ care- during post-treatment, showed good benefits in QoL, with the im- giver autonomous to negotiate with regard to treatment and to condi- provement of general physical skills, body composition, and reduction tions that favor self-care36. When caring for cancer patients, we often of fatigue. Physical exercise, indeed, seems to influence the defense of come across communication of bad news (BN) which can involve not the host against cancer. Pedroso, Araújo and Stevanato28 mentioned only the unveiling of the actual diagnosis but also the worsening of the that physical exercise during the period of treatment could help to ac- disease and the need to be sent for PC and home care. Most doctors tivate biological mechanisms, increasing the presence of enzymes that agree that the best way to give BN is through a patient-centered ap- act upon free radicals and Natural Killer cells, meaning that tumors proach, in which the information is given gradually and steadily, while are less likely to form. also, at the same time, encouraging them to talk about their feelings On the ESAS scale, we found variables with intensity levels greater than and concerns, both now and in the future. This kind of communica- 5, on a scale ranging from zero to 10. The following variables were ob- tion needs professional preparation and training37. served over the median: fatigue (60% with scores of 6 to 9); sadness Another justification for the data found in this study is when patient (84% between 6 and 9); anxiety (73% between 6 and 9); loss of appetite and family have different ideas about the treatment to be given, or about (51% between 6 and 9) and lack of well-being (79% between 6 and 9). life-end issues, making communication ineffective. The family meets These values agree with the findings of the literature that the prevalence challenges, and not only the requirements of the caring role but also the 53 BrJP. São Paulo, 2019 jan-mar;2(1):49-54 Castôr KS, Moura EC, Pereira EC, Alves DC, Ribeiro TS and Leal PC pain caused by the possibility of the death of the family member. As an scores during disease trajectory predicts survival. Palliat Med. 2012;27(4):367-74. 10. Bruera E, Kuehn N, Miller MJ, Selmser P, Macmillan K. The Edmonton Symptom important element in the last days of the patient’s life, sometimes in a Assessment System (ESAS): a simple method for the assessment of palliative care pa- move to protect the patient from additional suffering, they ask the doc- tients. J Palliat Care. 1991:7(2):6-9. 11. Monteiro DR, Kruse MH, Almeida MA. Avaliação do instrumento Edmonton Symp- tor not to give all the information about diagnosis and prognosis, thus tom Assessment System em cuidados paliativos: revisão integrativa. Rev Gaúcha Enferm. establishing the “conspiracy of silence” or the “pact of silence.” 2010;31(4):785-93. The pact or conspiracy of silence is described38,39 as an implicit or ex- 12. Alves JED. A transição demográfica e a janela de oportunidade. São Paulo: Instituto Fernand Braudel de Economia Mundial; 2008. plicit agreement between family members, friends, and professionals, 13. Carneiro LAF, Campino ACC, Leite F, Rodrigues CG, Santos GMM, Silva ARA. En- to change the information that is passed on to the patient, to hide the velhecimento populacional e os desafios para o sistema de saúde brasileiro. São Paulo: 40 Instituto de Estudos de Saúde Suplementar; 2013. diagnosis or the severity of the situation . 14. Ministério do Planejamento Orçamento e Gestão. Sinopse do censo demográfico On the other hand, in some countries, the reality of advance health- 2010. Brasília: Instituto Brasileiro de Geografia e Estatística. [acesso em 10 out 2016]. 41 Disponível em: http://www.censo2010.ibge.gov.br/ care directives is already present and has been so for some time . In 15. Carvalho FP, Silva SK, Oliveira LC, Fernandes AC, Solano LC, Barreto EL. Conheci- Brazil, there is no specific legislation on this matter, but this is made mento acerca da política nacional de atenção integral à saúde do homem na estratégia known within the medical environment, through a Resolution passed de saúde da família. Rev APS. 2016;16(4):386-92. 16. Yildirim Y, Kocabiyik S. The relationship between social support and loneliness in by the Federal Medicine Council (CFM). Turkish patients with cancer. J Clin Nurs. 2010;19(5-6):832-9. It was observed that the whole sample (100%) is not aware of ad- 17. Prade CF, Casellato G, Silva AL. Cuidados Paliativos e comportamento perante a morte. In: Knobel E (ed.). Psicologia e humanização: assistência aos pacientes grave. vance healthcare directives. To address this issue with the patient, it is São Paulo: Atheneu; 2008. 149-158p. necessary that the doctor should first address issues that are so often 18. Paiva EP, Motta MC, Griep RH. Conhecimentos, atitudes e práticas acerca da de- tecção do câncer de próstata. Acta Paul. Enferm. 2010;23(1):88-93. procrastinated, such as prognosis, death and PC, facing social issues 19. Höfelmann DA, Anjos JC, Ayala AR. Sobrevida em dez anos e fatores prognósticos such as low educational level, and cultural issues, which often help to em mulheres com câncer de mama em Joinville, Santa Catarina, Brasil. Ciênc Saúde make communication more difficult. However, these factors should Coletiva. 2014:19(6);1813-24. 20. Thuler LCS, Bergmann A, Casado L. Perfil das pacientes com câncer do colo do útero not prevent communication and knowledge from the patients. no Brasil, 2000-2009: estudo de base secundária. Rev Bras Cancerol. 2012;58(3):351-7. Another relevant item of data is the fact that over half the sample 21. Albano JD, Ward E, Jemal A, Anderson R, Cokkinides VE, Murray T, et al. Can- cer mortality in the United States by education level and race. Natl Cancer Inst. (82%) does not use the Internet to find out more about their diagno- 2007;99(18):1384-94. sis. The Internet is a significant tool for information and communica- 22. Hossne WS. Relação médico-paciente: competência do médico. In: Segre M, Cohen C (org.). Bioética. 3ª ed. São Paulo: Edusp; 2002. 106-18p. tion and has become more and more readily available to the general 23. Mourão CM, Albuquerque MA, Silva AP, Oliveira MS, Fernandes AF. Comunicação population. Information about advance healthcare directives, diagno- em enfermagem: uma revisão bibliográfica. Rev Rene. 2009;10(3):139-45. ses, and medical conduct can easily be found on the e-world. 24. Brasil, Ministério da Saúde. Instituto Nacional de Câncer. Cuidados Paliativos On- cológicos: controle da dor. Rio de Janeiro: INCA; 2001. 25. Costa AI, Chaves MD. Dor em paciente oncológico sob tratamento quimioterápico. CONCLUSION Rev Dor. 2012;13(1):45-9. 26. Miceli AV. Dor crônica e subjetividade em oncologia. Rev Bras Cancerol. 2002;48(3):363-73. The present study showed a significant lack of awareness that still af- 27. Courneya KS, Friedenreich CM, Sela RA, Quinney HA, Rhodes RE. Correlates of adherence and contamination in a randomized controlled trial of exercise in cancer fects patients in PC. Information such as diagnosis and treatment are survivors: an application of the theory of planned behavior and the five factor model not yet clear. Factors such as educational level, origin, improper use of of personality. Ann Behav Med. 2002;24(4):257-68 drugs for pain relief: these are just some of the factors that have a direct 28. Pedroso W, Araújo MB, Stevanato E. Atividade física na prevenção e na reabilitação do câncer. Motriz. 2005;11(3):155-60. influence on the implementation of PC. Habits such as lack of phys- 29. Lucchese R, Sousa K, Bonfin SP, Vera I, Santana FR. Prevalência de transtorno mental ical exercises could make the illness worse, or limit the prognosis of comum na atenção primária. Acta Paul Enferm. 2014;27(3):200-7. 30. Stark DP, House A. Anxiety in cancer patients. Br J Cancer. 2000;83(10):1261-7. the client within his or her biological, psychological or social context. 31. Caperuto E, Navarro F. Lipídios, patologias associadas e exercício: câncer/caquexia. In: Lima WP. (org.). Lipídios e exercício: aspectos fisiológicos e do treinamento. São REFERENCES Paulo: Phorte; 2009. 119-30p. 32. Nassar P. Tudo é comunicação. São Paulo: Lazuli; 2003. 118-120p. 33. Lévy P. Árvores de Saúde. Interface. 1999;3(4):143-56. 1. Carvalho RT, Parsons HA (org.). Manual de Cuidados Paliativos ANCP. 2a ed. São 34. Simpson M, Buckman R, Stewart M, Maguire P, Lipkin M, Novack D, et al. Doctor-pa- Paulo: ANCP; 2012. 40-42p. tient communication: the Toronto consensus statement. BMJ. 1991;303(6814):1385-7. 2. Magalhães JC. Cuidar em fim de vida: experiências durante a formação inicial de 35. Beckman HB, Frankel RM. The effect of physician behavior on the collection of data. enfermagem. Lisboa: Coisas de Ler; 2009. 109p. Ann Intern Med. 1984;101(5):692-6. 3. Davies E, Higginson IJ. Better palliative care for older people. Copenhagen: WHO; 2004. 36. Fiedler RC. A teoria da ação comunicativa de Habermas e uma nova proposta de 4. Menezes RA, Ventura M. Ortotanásia, sofrimento e dignidade: entre valores morais, desenvolvimento e emancipação do humano. Rev Educ. 2006;I(1):93-100. medicina e direito. Rev Bras Ciênc Soc. 2013;28(81):213-29 37. Hancock K, Clayton JM, Parker SM, Walder S, Butow PN, Carrick S, et al. Discrep- 5. Conselho Federal de Medicina (Brasil). Resolução nº 1.931, de 17 de setembro de ant perceptions about endof-life communication: a systematic review. J Pain Symptom 2009. Código de Ética Médica. Diário Oficial da União 24 set 200; Seção I. Manage. 2007;34(2):190-200. 6. Smith R. A good death. BMJ. 2000;320:129-30. 38. Chaturvedi SK, Loiselle CG, Chandra PS. Communication with relatives and collusion 7. Conselho Federal de Medicina (Brasil). Resolução nº 1.995, de 09 de agosto de 2012. in palliative care: A cross-cultural perspective. Indian J Palliat Care. 2009;15(1):2-9. Dispõe sobre as diretivas antecipadas de vontade dos pacientes. Diário Oficial da 39. Bermejo J, Villacieros M, Carabias R, Sánchez E, Díaz-Albo B. Conspiración del silencio União 31 ago 2012; Seção I. en familiares y pacientes al final de la vida ingresados en una unidad de cuidados paliati- 8. Rustøen T, Cooper BA, Miaskowski C. The importance of hope as a mediator of vos: nivel de información y actitudes observadas. MEDIPAL. 2013;20(2):49-59. psychological distress and life satisfaction in a community sample of cancer patients. 40. Takieldin MA. Impacto social y familiar ante la enfermedad incurable. MEDPAL, Cancer Nurs. 2010;33(4):258-67. Interdisciplina y Domicilio. 2010;2(3):13-15. 9. Chan EY, Wu HY, Chan YH. Revisiting the palliative performance scale: change in 41. Dadalto L. Testamento Vital. 2ª ed. Rio de Janeiro: Lumen Juris; 2013. 95-156p.

54 BrJP. São Paulo, 2019 jan-mar;2(1):55-60 ORIGINAL ARTICLE

Relationship between the perceived social support and catastrophization in individuals with chronic knee pain Relação entre suporte social percebido e catastrofização em indivíduos com dor crônica do joelho

Bruna Almeida1, Adriana Capela1, Joana Pinto1, Vânia Santos1, Cândida G. Silva1,2, Marlene Cristina Neves Rosa3

DOI 10.5935/2595-0118.20190011

ABSTRACT poor/low evidencing the need to consider other factors in the catastrophization study. BACKGROUND AND OBJECTIVES: Catastrophization and Keywords: Catastrophization, Chronic pain, Perceived social social support influence health outcomes in people with chron- support. ic pain. However, there is still no consensus regarding the relationship between these factors, and the information available RESUMO in what relates to chronic pain in the knee joint is even scarcer. The objective of this study was to describe and understand the JUSTIFICATIVA E OBJETIVOS: Tanto a catastrofização como relationship between the perceived social support and pain cata- o suporte social influenciam os resultados na saúde de indivíduos strophization in adults with chronic knee pain. com dor crônica. Porém, não há consenso sobre a relação entre METHODS: Sociodemographic data were collected, and the esses fatores, sendo escassa a informação direcionada à articulação West Haven-Yale Multidimensional Pain Inventory and Pain do joelho. O objetivo deste estudo foi descrever e compreender a Catastrophizing Scale were completed by the participants. The relação entre o suporte social percebido e a catastrofização da dor sample included 28 participants attending daycare institutions em idosos com dor crônica do joelho. in Aveiro, Braga and Leiria districts (Portugal). MÉTODOS: Foi feita a coleta de dados sociodemográficos, em RESULTS: Seventy-five percent of the participants presented conjunto com o preenchimento dos instrumentos West Hav- clinically significant catastrophization, and 64.3% reported high en-Yale Multidimensional Pain Inventory e Pain Catastrophizing perceived social support. There is a direct relationship between Scale pelos participantes. A amostra foi constituída por 28 par- high catastrophization and frequent solicitations and distraction ticipantes, institucionalizados em regime de centro de dia dos responses. Conversely, an inverse association between high cat- distritos de Aveiro, Braga e Leiria (Portugal). astrophization levels and infrequent negative responses was ob- RESULTADOS: Setenta e cinco por cento dos participantes served in the collected sample. apresentaram catastrofização clinicamente significativa e 64,3% CONCLUSION: Useful social support contributes to a mal- referiram alto suporte social percebido. Verificou-se uma relação adaptive response to pain by increasing catastrophization levels, diretamente proporcional entre a elevada catastrofização e as res- and the catastrophic response may be a way to ask for support. postas solícitas e de distração frequentes. Contrariamente, existe There is a direct association between the perceived social sup- uma associação inversamente proporcional entre o elevado nível port and the catastrophization of chronic knee pain in the par- de catastrofização e as respostas negativas pouco frequentes na ticipants. However, the association between these variables was amostra recolhida. CONCLUSÃO: O suporte social útil contribui para uma resposta desadaptativa à dor, pelo aumento dos níveis de catastro- fização, podendo a resposta catastrófica constituir um meio para Bruna Almeida - https://orcid.org/0000-0002-6501-7263; solicitar apoio. Denota-se uma associação diretamente propor- Adriana Capela - https://orcid.org/0000-0001-7725-5675; cional entre o suporte social percebido e a catastrofização da dor Joana Pinto - https://orcid.org/0000-0001-6234-8326; Vânia Santos - https://orcid.org/0000-0002-8497-3234; crônica do joelho nos participantes. Contudo, a relação demon- Cândida G. Silva - https://orcid.org/0000-0002-7092-1169; strou ser pobre/baixa, evidenciando a necessidade de considerar  Marlene Cristina Neves Rosa - https://orcid.org/0000-0001-8276-655X. outros fatores no estudo da catastrofização. 1. Instituto Politécnico de Leiria, Escola Superior de Saúde, Leiria, Portugal. Descritores: Catastrofização, Dor crônica, Suporte social per- 2. Universidade de Coimbra, Centro de Química de Coimbra, Coimbra, Portugal. 3. Instituto Politécnico de Leiria, Escola Superior de Saúde, CiTechCare, Leiria, Portugal. cebido.

Submitted in August 06, 2018. INTRODUCTION Accepted for publication in December 14, 2018. Conflict of interests: none – Sponsoring sources: none Chronic pain (CP) is a world public health problem1,2. Current- Correspondence to: Rua General Norton de Matos, Apartado 4133 ly, CP is defined by lasting longer than three months, not con- 2411-901 Leiria, Portugal. sidering other aspects2. In Portugal, 37% of the adult population E-mail: [email protected] suffers from CP, resulting in a strong personal and social im- © Sociedade Brasileira para o Estudo da Dor pact1,2. Chronic pain in the knee in adults is common around the 55 BrJP. São Paulo, 2019 jan-mar;2(1):55-60 Almeida B, Capela A, Pinto J, Santos V, Silva CG and Rosa MC world, with the highest percentage attributed to osteoarthritis, a tion. After selecting the 28 individuals that fulfilled the criteria, chronic, progressive condition strongly correlated with aging3-5. the sociodemographic questionnaire for characterization of the Considering the several physiological mechanisms that contrib- sample and pain, previously constructed by the researchers, was ute to musculoskeletal CP, the current conceptual pain models applied. Of the pain-characterizing criteria, only the values for include a biopsychosocial approach that involves reciprocal in- pain intensity were not obtained from the sociodemographic teractions between biological, psychological and social factors6-8. questionnaire, based on item 1 of part A of the West Haven-Yale In the context of psychological factors, catastrophization is de- Multidimensional Pain Inventory (WHY-MPI), validated to the fined as an overly negative and unreal mental state that arises Portuguese population9. during the CP experience or its anticipation. Catastrophization The evaluation of social support was also based on the WHY- encompasses three dimensions: rumination or obsession related MPI, an instrument composed of 52 items, with scores from to pain; magnification or exaggeration in valuing the threat it zero to six, distributed in three distinct parts. Items 5, 10 and 15 represents; and devaluation of the capacity/resources to control of part A were used to obtain the data on the evaluation of the and manage the painful experience9,10. support received by the participant. In addition, part B, which is Regarding the relevant social factors in the conceptual models subdivided into negative responses (items 1, 4, 7, 14), solicitous of pain, social support is of crucial importance11. Social support responses (items 2, 3, 5, 8, 11 and 13) and distractive responses is characterized as a multifactorial concept, defined as the provi- (items 6, 9, 12 and 14), allowed to obtain data related to the per- sion of resources between provider and receiver, to promote the ceived social support. In the case of the predominance of nega- welfare of the latter. Perceived social support is defined as the tive responses, the perceived social support is said to be punitive, support that the individual perceives as available in case of need, and when the frequency of solicitous and distractive responses is while the social support received describes the support that was greater, the perceived social support is useful9. The introductory effectively provided12,13. part of this scale provided data on the significant person and the Two contradictory perspectives explain the relationship between cohabitation of the participant and this person9. social support and catastrophization in individuals with CP. To evaluate pain catastrophization, the Portuguese version of the According to the Communal Coping Model, catastrophization Pain Catastrophizing Scale (PCS)9 was used. This instrument con- arises as a way of the individual to request assistance and em- sists of 13 items, with scores from zero to 4, with a total scoring pathic responses from people of their social environment. These between zero and 52. Higher scores determine higher levels of cat- responses, especially when given by the spouse, can maintain or astrophic thoughts. The level of catastrophization was considered reinforce the expression of pain. On the other hand, other stud- clinically relevant when the total PCS score was greater than or equal ies have shown that, when provided by individuals who do not to 30. The 13 items of the PCS are grouped in the following dimen- belong to the marital relationship, higher levels of social support sions: rumination (items 8, 9, 10 and 11), magnification (items 6, 7 result in lower frequency and intensity of pain11,14,15. and 13), and helplessness (items 1, 2, 3, 4, 5 and 12)9,16,17. Thus, it is fundamental to develop and contribute to new stud- Study with ethical approval (document approval of the three in- ies in this area in order to clarify the contradictory relationship stitutions: 108.03 February 2018; 3454.032018; 054.27 Janu- among these factors that influence the health outcomes of indi- ary 2018). Clinical Trial Identifier: NCT02746835. viduals with CP. This study aimed to answer the question “What is the relation- Statistical analysis ship between perceived social support and catastrophizing in in- A descriptive analysis was performed of the data obtained from dividuals with CP in the knee”? the sociodemographic questionnaire, WHY-MPI and PCS through the distribution of absolute and relative simple frequen- METHODS cies, central trend measures, such as the arithmetic mean, and dispersion measures as the standard deviation. A cross-sectional, descriptive study conducted with the participation Table 1 shows the variables used for the analysis of the results re- of old people living in a daycare center of 3 institutions of the dis- garding the perceived social support. For the variables perceived tricts of Aveiro, Braga, and Leiria (Portugal). The inclusion criteria social support, negative responses, solicitous responses, distrac- to participate in this study was age over 65 years and CP in the knee. tive responses, rumination, magnification and helplessness, two The subjects were included in the sample after the explanation of the levels of values were defined, based on the midpoint of the am- study procedure and completing the Free and Informed Consent plitude of values of the total score in each variable. For example, Form (FICT), according to the Declaration of Helsinki. The cog- below and above the midpoint are considered, respectively, few nitive impairment that prevented the coherent completion of the and many negative, solicitous, or distractive responses. Regard- instruments was the exclusion criterion. The process of data collec- ing the pain catastrophizing data, the total PCS score was ana- tion included the authorization request to the institutions to collect lyzed, as well as the catastrophization level defined based on the the data and to the subsequent direct contact with the participants. cut-off value of the scale. Considering the probabilistic and statistical inference rules that The relationship between social support and pain catastrophi- ensure the trend to normality in samples that include 25 to 30 zation was assessed using the Pearson correlation coefficient be- individuals, 30 individuals were recruited, but only 28 had sta- tween the total PCS score and the various dimensions of the part ble health conditions during the direct contact of data collec- B of the WHY-MPI scale (negative, solicitous and distractive 56 Relationship between the perceived social support and BrJP. São Paulo, 2019 jan-mar;2(1):55-60 catastrophization in individuals with chronic knee pain

Table 1. Variables analyzed to study the relationship between the perceived social support and chronic pain catastrophization Instruments Variables Values Sociodemographic questionnaire Marital status Married; not married WHY-MPI Pain intensity zero to 6 (Part A - Item 1) (zero - No pain; 6 - Very intense pain) Perceived social support Total score (Part A - Items 5, 10 and 15) zero to 18 Level of perceived social support Low (zero to 9) High (10 to 18) Negative responses Total score (Part B - Items 1, 4, 7 and 14) 0 to 24 Level of negative responses Few (zero to 9) Many (13 to 24) Solicitous responses Total score (Part B - Items 2, 3, 5, 8, 11 and 13) zero to 36 Level of solicitous responses Few (zero to 9) Many (19 to 36) Distractive responses Total score (Part B - Items 6, 9, 12 and 14) zero to 24 Level of distractive responses Few (zero to 9) Many (13 to 24) Significant person Father/mother, child, another relative; spouse; neighbor, friend, partner/companion; house colleague; others PCS Total score zero to 52 Catastrophization level Clinically not significant (zero to 29) Clinically significant (30 to 52) Rumination Total score Items 8, 9, 10 and 11 zero to 16 Rumination level Little (0 to 8) A lot (9 to 16) Magnification Total score Items 6, 7 and 13 zero to 12 Magnification level: Little (zero to 6) A lot (7 to 12) Helplessness Total score Items 1, 2, 3, 4, 5 and 12 zero to 24 Helplessness level: Little (zero to 12) A lot (13 to 24) WHY-MPI = West Haven-Yale Multidimensional Pain Inventory; PCS = Pain Catastrophizing Scale. responses). Additionally, the correlation between pain intensity not significant), to understand if the catastrophization of pain is and the total PCS score, with the various dimensions of part B of superior among married individuals11. the WHY-MPI scale, was analyzed by calculating the Spearman All statistical procedures were performed with the IBM® SPSS® correlation coefficient (r). To interpret the values obtained, the Statistics software, version 23. following standard intervals were considered: poor correlation (r<0.30), weak (r: 0.30-0.50), moderate (r: 0.50-0.70), strong (r: RESULTS 0.70-0.90) and very strong (r>0.90)18. Based on the Communal Coping Mode, a cross-tabulation was The sample consisted of 78.6% females and 21.4% males, with constructed between the variables marital status (married, un- an average age of 79.25 years. Of the 28 individuals, 39.3% are married) and catastrophization level (clinically significant and widowers, and the percentage of married individuals (25%) was 57 BrJP. São Paulo, 2019 jan-mar;2(1):55-60 Almeida B, Capela A, Pinto J, Santos V, Silva CG and Rosa MC also significant. Also, 64.3% of the respondents had only the first nated, being more frequent in the right knee or bilateral (35.7%). schooling cycle (4 years). Concerning pain intensity, 39.3% of the participants had signifi- In relation to the characterization of pain, the localized pain cant pain, evaluated in 4 on a scale from zero to 6. (71.4%), anterior (60.7%) and continuous (60.7%) predomi- More than half of the participants (57.14%) identified their father, mother, child or another relative as their significant person, Table 2. Perceived social support and the percentage of the sample who mentioned the spouse Classes Frequency % (25%) is still considerable. About 75% of the participants live WHY-MPI - Part A (items 5, 10 and 15) with the significant person. Level of social support received Regarding the evaluation of the social support received by the Few 10 35.7 participant, 64.3% said they have a lot of support (Table 2). Re- Much 18 64.3 garding the responses by the significant person, the majority said WHY-MPI - Part B that they had few negative responses (89.3%), many solicitous Negative responses responses (67.9%) and few distractive responses (60.7%). Few 25 89.3 The total PCS score showed an average of 35.14, a value that is Many 3 10.7 a predictor of a clinically significant level of catastrophization Solicitous responses Few 9 32.1 (Table 3). It is worth mentioning that 75% of the participants Many 19 67.9 presented a clinically significant catastrophization. Distractive responses Concerning the different dimensions of the PCS scale (Table Few 17 60.7 4), the majority of the participants indicated much rumination Many 11 39.3 (67.9%), much magnification (71.4%) and much helplessness WHY-MPI = West Haven-Yale Multidimensional Pain Inventory. (78.6%), with no specific trend to any of the dimensions. The data of the present study showed a poor correlation Table 3. Pain catastrophization (r=0.219) between: (i) pain intensity and total PCS score; (ii) Catastrophization n=28 pain intensity and negative (r=0.001), solicitous (r=0.191) and Total PCS (mean±SD) 35.14±10.28 distractive (r=0.120) responses of the significant person. There Catastrophization level - frequency was also a positive correlation between the total PCS score and Clinically significant (≥30) 21 (75%) Clinically not significant (<30) 7 (25%) the solicitous and distractive responses, poor (r=0.209) and weak PCS = Pain Catastrophizing Scale. (r=0.342), respectively, with higher values for the distractive responses. The correlation between the total PCS score and the Table 4. Catastrophization dimensions negative responses was poor and negative (r=-0.162). Concern- ing the relation between the various dimensions of part B of Frequency (n=28) % the WHY-MPI scale, there was a moderate positive correlation Rumination Few 9 32.1 (r=0.624) between the solicitous and distractive responses and a Much 19 67.9 moderate negative correlation (r=-0.591) between the solicitous Magnification and negative responses (Table 5). Few 8 28.6 In order to understand the data trend regarding catastrophiza- Much 20 71.4 tion among married individuals, and knowing that they identi- Helplessness fied the spouse as the significant person, the marital status and Few 6 21.4 the level of catastrophization were cross-checked showing an evi- Much 22 78.6 dent trend between the analyzed variables (Table 6).

Table 5. Correlation between pain intensity and the total score of the Pain Catastrophizing Scale and the dimensions of the social support and the correlation between the total score and the dimensions of the perceived social support Spearman correlation Total PCS Negative responses Solicitous responses Distractive responses (n=28) Pain intensity 0.219 0.001 0.191 0.120 Coefficient of correlation Pearson correlation (n=28) Total PCS Negative responses Solicitous responses Distractive responses Total PCS -0.162 0.209 0.342 Coefficient of correlation Negative responses -0.591** -0.427* Coefficient of correlation Solicitous responses 0.624** Coefficient of correlation Distractive responses Coefficient of correlation PCS = Pain Catastrophizing Scale; * The correlation is significant at the 0.05 level (bilateral); ** The correlation is significant at the 0.01 level (bilateral).

58 Relationship between the perceived social support and BrJP. São Paulo, 2019 jan-mar;2(1):55-60 catastrophization in individuals with chronic knee pain

Table 6. Cross-check between the cutoff value of the Pain Catastro- non-adaptive response to pain due to the increase in catastrophiza- phizing Scale and married status tion levels. Taking into account the characteristics of the sample of Cross-tabulation Marital status: this study, where more than 80% of the participants identified the married (n=7) significant person as a relative, the data obtained seem to reinforce Catastrophization level that the care provided by a family member reinforces the expression Clinically significant 4 Clinically non-significant 3 of pain, answering the original question of this study. If the health professional is aware of this reality and some coping strategies and caregiver education, he/she can play a relevant role in the manage- DISCUSSION ment of pain catastrophization. This study had some limitations. On the one hand, since it was Most of the studies in this area state that the perceived social a cross-sectional study, it did not allow to state the directionality support has been identified as influential in the management of of the relations. On the other hand, the size of the sample and pain in chronic situations and that catastrophization negatively the concentration of ages in a high and narrow age group can affects the health outcomes of people with pain11,14,15. However, also be a limitation to the study, not allowing to generalize the the relationship between the perception of social support and conclusions obtained for the remaining population. Also, the the catastrophizing levels in individuals with chronic knee pain disparity between the number of married individuals and indi- is not consensual in the literature. viduals of other marital status did not allow conclusions to be From the results obtained in this study, it was possible to ob- compared with the Communal Coping Model. In addition, with serve that the majority of the sample presented clinically signif- only self-reported data from participants about social support, icant catastrophization (Table 3), with a greater impact on the it was not possible to know if the catastrophization of pain was helplessness dimension. These results are consistent with a study associated with the perceived support responses or its actual pro- that investigated the associations among the catastrophizing vision by the significant person. Therefore, in a clinical context, dimensions, concluding that helplessness plays a predominant it should be considered not only the patient’s perspective but role in catastrophization in individuals with CP19. Regarding the also of the significant person to understand the quality of the perceived social support, it can still be observed that most of relationship between them and the level of support effectively the participants had a greater frequency of solicitous and dis- provided in the real context of the individual’s life. tractive responses in comparison with the frequency of negative responses (Table 2). The same was seen in a study conducted by CONCLUSION Gauthier al.20 that showed a greater frequency of solicitous and distractive responses. In addition, more than half of the sample In this study, the association between the perceived social sup- of this study referred to the social support received as frequent. port and the catastrophization of knee CP was directly propor- According to the literature, catastrophization is associated with the tional but low. activation of the brain areas involved in response to pain, being a non-adaptive behavior aiming at the attainment of social support, REFERENCES capable of increasing the intensity of pain. However, the literature points out that the higher the intensity of pain, the greater the 1. IASP. How Prevalent Its Chronic Pain? Pain Clin Update. 2003;XI(2):1-4. 2. Azevedo LF, Costa-Pereira A, Mendonça L, Dias C, Castro-Lopes JM. Epidemiology inhibition of the activated brain areas. Accordingly, the results of of chronic pain: a population-based nationwide study on its prevalence, characteristics this study showed a positive but poor relationship between cata- and associated disability in Portugal. J Pain. 2012;13(8):773-83. 3. Ilori T, Ladipo MM, Ogunbode AM, Obimakinde AM. Knee osteoarthritis and per- strophization and pain intensity, which can be explained by the ceived social support amongst patients in a family medicine clinic. S Afr Fam Pract. significant level of pain intensity10,21,22. Thus, one can conclude 2016;1(1):1-5. 4. McDougall JJ. Arthritis and pain. Neurogenic origin of joint pain. Arthritis Res Ther. that the reading and interpretation of catastrophization by health 2006;8(6):220. professionals should be performed considering two axes: the level 5. Quicke JG, Foster NE, Thomas MJ, Holden MA. Is long-term physical activity of social support and the quantification of the perceived pain, the safe for older adults with knee pain? A systematic review. Osteoarthritis Cartilage. 2015;23(9):1445-56. latter using the analog scales frequently used in the clinical context. 6. Adams LM, Turk DC. Psychosocial factors and central sensitivity syndromes. Curr In the present study, the results showed a directly proportional rela- Rheumatol Rev. 2015;11(2):96-108. 7. Edwards RR, Cahalan C, Mensing G, Smith M, Haythornthwaite JA. Pain, ca- tionship between high catastrophization and frequent solicitous and tastrophizing, and depression in the rheumatic diseases. Nat Rev Rheumatol. distractive responses as well as an inversely proportional association 2011;7(4):216-24. 8. Gatchel RJ. The biopsychosocial model of chronic pain. In: Clinical Insights, editor. between a high catastrophizing level and less frequent punitive re- The biopsychosocial model of chronic pain. 2013. 5-17p. sponses. Individuals with more frequent solicitous and distractive 9. Azevedo LF, Pereira AC, Dias C, Agualusa L, Lemos L, Romão J, et al. Questionários responses had more catastrophization and individuals with more fre- sobre dor crónica. tradução, adaptação cultural e estudo multicêntrico de validação de instrumentos para rastreio e avaliação do impacto da dor crónica. Dor. 2007;15:6-37. quent negative responses had less catastrophization. Previous studies 10. Leung L. Pain catastrophizing: an updated review. Indian J Psychol Med. in this area have found a similar data trend explaining that in the 2012;34(3):204-17. 11. López-Martínez AE, Esteve-Zarazaga R, Ramírez-Maestre C. Perceived social support context of CP, solicitous and distractive responses to pain behav- and coping responses are independent variables explaining pain adjustment among iors and absence of negative responses may reinforce catastrophiza- chronic pain patients. J Pain. 2008;9(4):373-9. 11,20 12. Bogossian FE. Social support: proposing a conceptual model for application to mid- tion . Thus, in the cases analyzed, useful social support, in which wifery practice. Women Birth. 2007;20(4):169-73. solicitous and distractive responses predominate, predisposes to a 13. Cramer D, Henderson S, Scott R. Mental health and adequacy of social support: a 59 BrJP. São Paulo, 2019 jan-mar;2(1):55-60 Almeida B, Capela A, Pinto J, Santos V, Silva CG and Rosa MC

four-wave panel study. Br J Soc Psychol. 1997;35(Pt 2):285-95. 19. Adachi T, Nakae A, Maruo T, Shi K, Maeda L, Saitoh Y, et al. The relationships be- 14. Che X, Cash R, Fitzgerald P, Fitzgibbon BM. The social regulation of pain: auto- tween pain catastrophizing subcomponents and multiple pain-related outcomes in nomic and neurophysiological changes associated with perceived threat. J Pain. Japanese outpatients with chronic pain: a cross-sectional study. Pain Pract. 2018;17 2018;19(5):496-505. [Epub ahead of print]. 15. Sullivan MJ, Thorn B, Haythornthwaite JA, Keefe F, Martin M, Bradley LA, et al. 20. Gauthier LR, Rodin G, Zimmermann C, Warr D, Librach SL, Moore M, et al. The Theoretical perspectives on the relation between catastrophizing and pain. Clin J Pain. communal coping model and cancer pain: the roles of catastrophizing and attachment 2001;17(1):52-64. style. J Pain. 2012;13(12):1258-68. 16. Sullivan MJ, Adams H, Sullivan ME. Communicative dimensions of pain catastroph- 21. Krahé C, Springer A, Weinman JA, Fotopoulou A. The social modulation of pain: izing: social cueing effects on pain behaviour and coping. Pain. 2004;107(3):220-6. others as predictive signals of salience – a systematic review. Fornt Hum Neurosci. 17. Sullivan MJ. The Pain Catastrophizing Scale. User Manual. 2009. 3-22p. 2013;7:386. 18. Broekmans T, Gijbels D, Eijnde BO, Alders G, Lamers I, Roelants M, et al. The 22. Suso-Ribera C, García-Palacios A, Botella C, Ribera-Canudas MV. Pain catastroph- relationship between upper leg muscle strength and walking capacity in persons with izing and its relationship with health outcomes: does pain intensity matter? Pain Res multiple sclerosis. Mult Scler. 2013;19(1):112-9. Manag. 2017;2017:9762864.

60 BrJP. São Paulo, 2019 jan-mar;2(1):61-6 REVIEW ARTICLE

Pain curricular guidelines for Psychologists in Brazil Diretrizes para o currículo em dor para Psicólogos no Brasil

Jamir João Sardá Junior1, Dirce Maria Navas Perissinotti2, Marco Aurélio da Ros3, José Luiz Dias Siqueira4

DOI 10.5935/2595-0118.20190012

ABSTRACT RESUMO

BACKGROUND AND OBJECTIVES: It is widely recognized JUSTIFICATIVA E OBJETIVOS: É amplamente reconhecido that pain is undertreated, largely determined by the minimal que há subtratamento da dor, em grande medida determinado academic training on the subject. This article aims to propose pela reduzida formação acadêmica e profissional sobre o tema. O and present curricular guidelines in pain for undergraduate and presente artigo visou propor e apresentar diretrizes curriculares graduate psychologists in Brazil. em dor para psicólogos em nível de graduação e pós-graduação CONTENTS: From an extensive literature review about educa- no Brasil. tion and pain, and based on national and international guide- CONTEÚDO: A partir de extensa revisão de literatura sobre lines, curricular guidelines that contemplate the psychologist’s o tema educação e dor, e baseados em diretrizes nacionais e in- education have been developed. The skills and competencies ad- ternacionais, foram desenvolvidas diretrizes curriculares que dressed in the training of the psychologist should contemplate contemplam a formação do psicólogo. As habilidades e compe- their multifactorial nature, the importance of multidimensional tências abordadas na formação do psicólogo devem contemplar evaluation, theoretical and technical models for interventions a sua natureza multifatorial, importância da avaliação multidi- and management of the painful condition and aspects related to mensional, modelos teóricos e técnicas para as intervenções e research and ethical aspects. manejo da condição dolorosa e os aspectos referentes à pesquisa CONCLUSION: The contents proposed in the pain curriculum e aspectos éticos. for psychologists can and should be integrated considering the CONCLUSÃO: Os conteúdos propostos no currículo de dor regional characteristics and demands of the educational institu- para psicólogos podem e devem ser integrados considerando-se tions and the availability of qualified professionals to teach and as características e demandas regionais, das instituições de ensino can be applied both to undergraduate and graduate courses. It e a disponibilidade de profissionais habilitados para ministrá-lo, is believed that having curricular guidelines to teach this sub- podendo ser aplicado tanto aos cursos de graduação quanto os ject not only broadens the psychologist’s understanding of the de pós-graduação. Entende-se que o ensino desse tema a partir health-disease process, but also increases their professional possi- dessas diretrizes curriculares, não só amplia a compreensão do bilities to perform their roles in multi, inter and transdisciplinary psicólogo sobre o processo de saúde-doença, como aumenta suas healthcare levels. possiblidades de atuação profissional em diversos níveis de aten- Keywords: Curricular guidelines, Curriculum, Education, Pain, ção à saúde de forma multi, inter e transdisciplinar. Psychology. Descritores: Currículo, Diretrizes curriculares, Dor, Educação, Psicologia.

INTRODUCTION

Jamir João Sardá Junior - https://orcid.org/0000-0001-9580-8288; Dirce Maria Navas Perissinotti - https://orcid.org/0000-0002-0165-8328; Psychology as a science and profession, besides having several areas Marco Aurélio da Ros - https://orcid.org/0000-0003-4370-3120; of activity, presents different theoretical models about certain phe- José Luiz Dias Siqueira - https://orcid.org/0000-0001-6885-1686. nomena, including those that are opposed. 1. Universidade do Vale do Itajaí, Clínica Espaço da Articulação Temporomandibular, Flo- It is important to recognize that in psychology the dominant the- rianópolis, SC, Brasil. oretical models of health until the mid-1980s were strongly based 2. Universidade de São Paulo, Faculdade de Medicina, Divisão de Anestesiologia, Diretora Administrativa da Sociedade Brasileira para o Estudo da Dor, São Paulo, SP, Brasil. on mentalist psychology, influenced by the Cartesian assumptions 3. Universidade do Vale do Itajaí, Faculdade de Medicina, Residência Multidisciplinar em that contemplate in their pillars the body/soul dichotomy (res cog- Medicina da Família e Comunidade, Florianópolis, SC, Brasil. 1,2 4. Clínica Singular, Campinas, SP, Brasil. itans - res extensa) . These models propose the understanding of the body in a way analogous to the machine, in which the func- Submitted in April 12, 2018. tioning of the components or organs determines the final product. Accepted for publication in December 10, 2018. Conflict of interests: none – Sponsoring sources: none Alterations of external origin in a given structure or organ (e.g., bacteria, viruses, accidents) or due to abnormalities of the organ Correspondence to: Av. Campeche 1157, C-1, 403 – Campeche determine shifts in its function. The treatments based on the per- 88063-300 Florianópolis, SC, Brasil. spective in question consist in identifying the cause of the dysfunc- E-mail: [email protected] tion and correcting it, eliminating the pathogenic agent, and/or © Sociedade Brasileira para o Estudo da Dor alleviating its symptoms. It is a dualistic and reductionist model, 61 BrJP. São Paulo, 2019 jan-mar;2(1):61-6 Sardá Junior JJ, Perissinotti DM, Ros MA and Siqueira JL the body/mind split is total, and the subject understood as the orientation began to be challenged and lost their hegemony. patient is nothing more than the host of the pathology or disorder. Another important theoretical moment of the conceptual health However, the evolution of the biomedical model of Cartesian na- models is marked by the development of the biopsychosocial ture when compared with previous explanatory models, such as model proposed by Engel6 that emphasized the dynamic relation- the magical representations of primitive peoples up to the 2nd cen- ship between biological, psychological and social factors in the tury, where health and disease were mediated by supernatural forc- understanding of the health-disease binomial. Among the main es, is evidenced. For Sevalho3 and Scliar4, the history of represen- critiques of Engel5,6 and other authors1,7 to the biomedical mod- tations of health and disease was always based on the relationship el, it can be highlighted the criticism of the understanding of the between the bodies of men and the environment that surrounds disease based on the causality model. The fact that the presence them in their various dimensions. Under the present perspective, of a biological disorder does not always clarify the meaning of the the environment must be understood in its social and historical symptoms presented by the patient. The little importance attribut- context, which is determinant in the construction of overlapping ed to the psychological variables considered by the authors as or beliefs, values, and health-disease representations that contributed more important than biological variables in determining the sus- to the development of health practices. ceptibility, severity, and course of a disease. The fact that according The biomedical model seems to result in part from the evolution to the biomedical model, the role assumed by the patient is little of paradigms proposed by Galen (2nd century), the contributions or nothing related to the pathological agent or biological disorder of Greco-Roman medicine and Arabic medicine, which transmit- “causer” of the disease; the existence of evidence that treatment ted some of these concepts to the Middle Ages3. On the other success is influenced by psychosocial aspects (e.g., placebo effect) hand, the biomedical model in force since the 16th century gained and that the doctor-patient relationship affects clinical outcomes strength after the Industrial Revolution. Its assumptions were (e.g., adherence). The critics and assumptions of the biopsychoso- drawn from several conceptions, but the most important was the cial model opposed the objectivity and exemption of the observer one that opposed the earlier coming from the conception of the in the understanding of the phenomenon, the mind-body reduc- movement of social medicine of the 19th century, which stated that tionism, and dualism, dogmas proposed by the biomedical model. the health-disease process was determined by the social organiza- Concomitantly with the movement of conceptual paradigm shifts tion of production. For this, the biomedical model rescued old in health started in the mid1970s, Health Psychology begins to discoveries as the microscope, for example, and proposed to mod- develop its identity as an area of activity. In the late 1970s, the ify the dissociation between the biological and the social. There American Psychological Association created the Health Psycholo- was until that time the hyper valuation of the biological, and now gy Division, which initially had four objectives: to study the caus- unicausality logic of the health-disease process has been created. es and origins of certain diseases scientifically, to promote health, On the other hand, the biomedical model undeniably left behind to prevent and treat diseases, promote public policies7. Moreover, a legacy of positive heritages, such as technological and therapeutic since the last two decades of the twentieth century, there has been advances (e.g. microscope, isolation of bacilli and viruses, isola- a greater insertion of psychologists in the health area, particularly tion of chemical substances) and allowed the treatment of several in hospital institutions8. Thus, the 1980s can be characterized as epidemics and development of public health measures (e.g. basic the frame of the insertion of the psychologist in the area of health. sanitation measures and treatment of specific diseases)2,3. Therefore, it would be natural that over the years a redefinition Although the biomedical model has been effective for the under- of the theoretical models, an object of study, objectives, practices, standing and treatment of several acute diseases, some central fea- and places of attention. tures may be challenged as a scientific paradigm. It presents a du- Health psychology can be defined as the application of psycholog- alistic conception, with a materialist and reductionist orientation, ical knowledge and techniques to health, diseases and health care9. as well as a lack of satisfactory explanation for the etiology or de- Matarazzo10 defines health psychology as “... the set of scientific, velopment of several diseases by denying the social determination educational and professional contributions that the different psy- involved in the health-disease process, especially the chronic ones, chological disciplines make to the promotion and maintenance a central problem in the health sphere from the mid-20th century2. of health, to the prevention and treatment of the disease, to the In addition, excessive technicality and biomedical-oriented clinical identification of etiological correlates and health diagnoses, disease practice have contributed to the development of the impersonal and related dysfunctions, improvement of the health system and character of the therapeutic relationship and disqualification or the formation of a health policy”. inattention to the subjective experience of the patient1,5, aspects Regarding the objectives, health psychology practices aim to con- that significantly interfere with the patient’s painful experience tribute to the improvement of psychological well-being and qual- and have important implications. ity of life, as well as contribute to the reduction of hospital admis- On the other hand, in the mentalist model, the concept of sions, optimize the use of drugs and the adequacy of the search for conversion and the contributions of the psychosomatics may services, care and health resources by users11. mark a moment of psychology in the understanding of the In addition to the aspects already described, some authors empha- psychic etiology of diseases. In the imaginary of most psy- size the importance of distinguishing the object of study of health chologists, there are still remnants of this semiological mod- psychology. For Teixeira12, the object of study of health psychol- el that seeks the psychic etiology of organic diseases. From ogy is the understanding of how biological, behavioral and social the mid-1980s these theoretical models of eminently clinical factors influence health and disease. Other authors point out the 62 Pain curricular guidelines for Psychologists in Brazil BrJP. São Paulo, 2019 jan-mar;2(1):61-6 construction of knowledge and practices directed to the social pro- a shortage in the training of psychologists about the problem and duction of health as the object of the study and intervention13-15. that there is a need to propose curricular guidelines that can guide Starting from the idea described, it is necessary to initially contex- their practice; there is sufficient reason for institutions such as the tualize the area of action in pain, as a subspecialty of the psycholo- Brazilian Association of Psychology Education (ABEP), the Coun- gist’s performance, inserted in the field of health psychology. cil system - Federal Council and Regional Councils of Psychology, It should also be pointed out that neurosciences have also contrib- Educational Institutions, coordinators of psychology undergrad- uted greatly to the production of evidence that has broadened the uate courses, teachers and students, and others involved with the understanding of the interactions between physiological, behavioral, topic of this article understand the relevance of the minimum cognitive, emotional and illness aspects. These advances include the training in pain that seems to be of extreme interest both for the discovery that the brain has an active role in the development of category of psychologists and for the other professional categories the painful condition, be it acute or chronic, filtering, selecting and of health in the national panorama of the pain problem. modulating the determinant inputs16. Such advances and discoveries This article does not pretend to speak deeply about the different have led to other relevant advances, among them the consideration theoretical models of health in psychology or health concepts, but of the affective-motivational and cognitive-evaluative dimensions to highlight some theoretical and historical assumptions aimed at as fundamental aspects of the pain experience, as important as the establishing curricular guidelines for the formation of the psychol- sensory-discriminative aspect17. Finally, the notion that the pain ex- ogist in the area of pain. perience is formed from the complex interaction of different brain The intention to propose the curriculum in pain for psychologists areas related to factors such as sensations, emotions, memories, and was to stimulate the approach of the topic in the undergraduate thoughts, among some aspects of the psychological sphere18. and graduate degrees, providing subsidies for the integration of the Having said it, it is possible to delimit common theoretical frame- topic into curriculum frameworks, as well as to stimulate reflec- works of Health Psychology shared by the Psychology of Pain that tions on the psychologist’s training and praxis in the area. in terms of theoretical models has quite solid bases. And, as far as the understanding of the participation of psychological aspects in CONTENTS the health-disease process is concerned, the production of knowledge is also very consistent. In terms of evidence of the efficacy With the purpose of proposing the curriculum in pain for psy- of psychological interventions, there are also significant results16,17 chologists, a committee was formed composed of members of the published in scientific circles of excellence. Brazilian Society for the Study of Pain (SBED), members of the However, the applicability of this knowledge is not contemplated Pain and Mental Health Education Committees, Board Members in the training of the psychologist during his or her graduation, as and specialists of remarkable knowledge in the area. The commis- has also been occurring in other areas of practice18. sion consulted the specialized literature through database research, Jensen and Turk17 argue that the topic of pain should be part of the identifying several relevant articles on the topic18-21. Some IASP curriculum in the training of the psychology professional, not only guidelines also served as a guiding medium22 for the achievement because of the seminal contributions made by psychologists to the of the task, as well as aspects described congruent with the Core current understanding of this important public health problem, Curriculum for Professional Education in Pain19 and with the but also because of the importance of identifying the instances IASP Core Curriculum in Pain for Psychologists23. of primary care that could benefit the users of the health system Since pain is a stressful experience associated with possible tissue through preventive interventions that have already demonstrated damage with sensory, emotional, cognitive and social compo- effectiveness in reducing or alleviating it, as well as its impact on nents24 and despite the conceptual evolution of this phenome- psychological and physical functioning. Based on these assump- non, scientific development and the expansion of clinical pain tions, the cited authors establish some guidelines and propose sug- care, there are still enormous challenges for the adequate treat- gestions for future developments in research and clinical practice, ment of pain. since they credit the relevant role of psychology in improving and To describe the advances made in the area succinctly, Sessle20 understanding the pain condition and its treatment. The authors described some central aspects to be addressed: further provide a model of how psychologists exert significant in- • Recognition of the multidimensionality of pain and the importance fluence in different fields of action because different theoretical of biopsychosocial factors in the expression and behavior of pain; models and approaches have been developed and put into practice • Identification of peripheral and central nociceptive processes; for the understanding and treatment of pain that are useful for • Discovery of various endogenous neurochemical and intrinsic psychologists working in other areas of action. Thus, the authors pathways in the brain and their nociceptor influences, transmis- think that chronic pain is an important area of study that offers sion and behavior; information on translational research for “all” psychologists. • Development of concepts and insights about the neuroplastici- Considering the high global prevalence of pain and that there is ty of pain processing that can lead to chronification; currently a wealth of solid knowledge about psychology on the top- • Advances in the field of brain imaging and molecular biology ic; that there is solid evidence on the participation of psychological and their applicability relevant to the field of study; factors in both their chronification and the resulting incapacity • Improvements in surgical, pharmacological, and behavioral and suffering interfering in the outcome of medical interventions; procedures in pain management, where such improvements in- that there is a lack of multidisciplinary interventions; that there is clude developing drug delivery systems, offering a broader range 63 BrJP. São Paulo, 2019 jan-mar;2(1):61-6 Sardá Junior JJ, Perissinotti DM, Ros MA and Siqueira JL of analgesics and other drugs for patient management, use of CURRICULAR CONTENTS interventional procedures, physical rehabilitation and cognitive-behavioral therapy, among some. In proposing the contents to be addressed in a curriculum in These aspects would depend to a great extent on the reorgani- pain for psychologists faces the challenge of contemplating the zation of the Unified Health System (SUS) to treat pain more various biopsychosocial aspects of pain and its feasibility. In this adequately since, in private clinics in some services, this occurs sense, in a way, instead of an ideal and extensive curriculum, the more frequently when compared to public services, especially purpose was to delineate minimum curricular guidelines, which when considered the primary and medium complexity levels of do not fully satisfy the dense training that a specialist psycholo- health care. gist should guide in the context of the complexity of pain. The synthesis of the mentioned aspects allows glimpsing the evo- To better understand these issues, or to have a glimpse in their lution of the available resources and the great variety of proce- breadth, curriculum in pain for psychologists proposed by the dures or resources developed in the last 30 years for the under- IASP23 will be presented first, citing only its axes and topics and standing and treatment of pain. some subtopics. Subsequently, the curriculum guidelines in However, in two other major areas still need further develop- pain for Brazilian psychologists that seem more appropriate at ment: pain education for professionals working with patients the moment will be presented. with pain such as education in pain for patients themselves. The Multidimensional Nature of Pain axis should contemplate The area dedicated to the development of public policies that five topics: A. Introduction and conceptual aspects of pain, B. includes adequate budgets for research subsidies and regulates Neurophysiology and mechanisms of pain; C. Theories and the practices of health promotion and appropriate treatment di- models of pain (considering its implications for treatment); D. rected to pain relief18,20,23,25 still needs to be further developed due Ethical aspects; E. Assessment of interventions and research. to the lack of information on the cost-effectiveness of adopting The Pain Assessment and Measurement axis should contemplate psychological interventions31. the following aspects: A. Experimental pain; B. Clinical assess- Pain education for health professionals at all levels has been re- ment of pain; C. Assessment of dimensions associated with pain; peatedly identified as an important step towards shifting ineffec- D. Epidemiological assessment; E. Psychological and behavioral tive pain management practice. assessment of the individual with chronic pain or pain associated Given this context, this curriculum in pain for psychologists with cancer; F. Assessment of other psychological aspects and based on the core curriculum of IASP23 was aimed at: mental disorders; G. Assessment of treatment results. 1. Provide students and psychology professionals with an over- The pain management axis should address: A. Motivational as- view of the multidimensional nature of pain based on clinical pects; B. Early intervention; C. Operant treatment; D. Cogni- aspects and basic sciences; tive-behavioral treatment; E. Relaxation and Biofeedback; F. Hyp- 2. Introduce strategies for the assessment and measurement of the nosis; G. Psychological treatment of childhood pain; H. Family various dimensions of pain for use in clinical practice and research; therapy for chronic pain; I. Interdisciplinary interventions. 3. Provide support for understanding the contribution of psy- The axis relating to clinical conditions should contemplate as- chosocial aspects to pain, physical incapacity, functional capaci- pects such as A. Classification according to the criteria of the Sta- ty, and psychic suffering; tistical Manual of Mental Disorders (DSM), International Clas- 4. Understand the role of evidence-based therapies and psycho- sification of Diseases (ICD) and IASP; and B. Comorbidities. logical treatments; All the contents described in the IASP23 Core Curriculum have 5. Contribute to the development of multidisciplinary, interdis- been briefly described, considering only the central topics with- ciplinary or transdisciplinary interventions in the treatment of out describing the subtopics addressed. patients with pain. Based on these assumptions and contents outlined by the IASP23 These objectives were drawn from the principle that pain treat- and other previously mentioned topics, including national pro- ment requires an integrated biological, psychological, behavioral ductions in this area27-32, the proposal of a minimum curriculum and social approach, based on the understanding of the partici- on pain for Brazilian psychologists proposes a discipline on bio- pation of psychological and social factors, as well as the central psychosocial aspects of pain, with a minimum workload of 30 and peripheral nervous system in mediating and modulating the hours, in order to prepare the psychology students and profes- pain experience23. sionals for a better understanding of the painful phenomenon in To achieve the objectives, students and professionals should fa- their biopsychosocial aspects and to act effectively in a multidis- miliarize themselves with theoretical and intervention models ciplinary team or individually in interface with the other health based on empirical evidence, considering their epistemologi- areas considering the human subjectivity. cal aspects and social determinants, so that the provisional and The proposed curriculum should be supported by a consistent fleeting nature of the concept of pain can be considered, bearing basis of scientific literature that addresses the following thematic in mind that knowledge is constantly being built. Teachers and axes and contents: opinion makers in the area should be encouraged to adopt a crit- I. Multidimensional nature of pain; ical assessment perspective for decision-making in reviewing the II. Multidimensional pain assessment; scientific evidence, available resources, benefits and limitations III. Pain management and interventions; of interventions26. IV. Research and ethical aspects. 64 Pain curricular guidelines for Psychologists in Brazil BrJP. São Paulo, 2019 jan-mar;2(1):61-6

Multidimensional nature of pain tution that houses consistent knowledge to do so. The contents The unit should contemplate the contents minimally: described in the curriculum should also be inserted in the Pain a. Definition and classification of pain; Leagues. The participation of psychologists in their professional b. Epidemiology of pain; body, stimulating the involvement of Psychology students and c. Nociceptive and neuropathic mechanisms of pain; professionals in their organization, and according to the IASP, d. Theories and models of pain; pain clinic offers effective care. The teams should be composed e. The biopsychosocial perspective of pain. of at least 4 professionals specialized in pain treatment: a doctor, a nurse, a physical therapist and a mental health professional, or Multidimensional pain assessment psychologist or psychiatrist, provided they have adequate train- The aspects addressed in this unit should address the following topics: ing in non-pharmacological and psychotherapeutic treatments. a. Assessment of the sensorial dimension of pain; The contents addressed in the curriculum in pain for psycholo- b. Assessment of cognitive and neuropsychological aspects of pain; gists, as well as for other professionals, should take into account c. Assessment of emotions; the following five principles23: 1) Every health professional has d. Assessment of mental disorders; an obligation to be empathic, accessible and work with patients e. Assessment of coping strategies; and family members in pain management; 2) Professional learn- f. Assessment of quality of life and related measures; ing opportunities provide students with the understanding and g. Assessment of family and occupational aspects; appreciation of the experience of other professionals besides their h. Elaboration of psychological documents. own; 3) Comprehensive assessment and management of pain are multidimensional (i.e., sensory, emotional, cognitive, develop- Pain management and interventions mental, behavioral, spiritual, cultural) and requires the collabo- The contents addressed in this axis should contemplate: ration of various health professionals; 4) Effective results in the a. Clinical approaches: contributions of the various evi- pain management occur when health professionals work with dence-based psychological approaches in the treatment of pain; patients, relatives, community and health care providers (such as b. Interdisciplinary interventions and adherence; insurers and medical covenants); 5) Interprofessional education c. Education of the patient with pain, relaxation techniques, in pain is more successful when it reflects real-world practices meditation; and is integrated at the beginning of the educational experience. d. Palliative care; Once there are qualified professionals, broader educational ac- e. Health promotion; tions can be structured, expanding the range of training reper- f. Spirituality. toires and not restricted to professional training, but also active in other sectors, subsidizing partners and users of health systems. Research and ethical aspects These actions may include addressing the following aspects23: The ethical aspects should be part of this thematic axis: • Inform the public, government/policymakers, the media, com- a. Rights of patients with pain; municate with the intent to leverage knowledge about the issue b. Racial, ethnic and sociodemographic disparities; by disseminating possibilities for treatments aimed at preventing c. Legal issues; chronification; d. Ethical principles of research; • Synthesize new information related to pain for the general pub- e. Research design. lic, as well as health professionals and other public and private The curriculum design based on these guidelines should include spheres of action; evidence-based topics and sub-topics, regional needs and the • Develop educational materials on pain for patients, health pro- availability of resources and well-trained professionals. fessionals, governments/policymakers aiming at opinion-making about pain prevention and intervention; DISCUSSION • Collaborate and subsidize public and private entities interested in initiatives that foster the development and dissemination of It was decided to elaborate a shorter version of the curriculum in scientific psychological information; pain for psychologists, considering that the curriculum proposal • Inform and support the mobilization of patient advocacy for IASP psychologists is quite extensive and would require a groups as well as support initiatives of organized patient groups great deal of time, a large number of professionals, to approach for support. the proposed content, being little feasible before the Brazilian reality. CONCLUSION The proposal to build a minimum curriculum for psychologists aims to stimulate the teaching of pain and delineate its parame- The curricular proposal for pain training of the psychology pro- ters in undergraduate and graduate courses. It is understood that fessional and student can provide the development of skills and the contents of the curriculum will be adapted according to the competencies to perform diagnoses that contemplate the various human resources available in the region in which it is applied dimensions of the painful experience, allowing the planning and and whose workload for the topic can and should be dissemi- the accomplishment of interdisciplinary psychological interven- nated through various means, preferably supported by an insti- tions whenever possible. 65 BrJP. São Paulo, 2019 jan-mar;2(1):61-6 Sardá Junior JJ, Perissinotti DM, Ros MA and Siqueira JL

ACKNOWLEDGMENTS Psicol Estud. 2001;6(2):57-63. 14. Camargo-Borges C, Cardoso CL. A psicologia e a estratégia saúde da família: com- pondo saberes e fazeres. Psicol Soc. 2005;17(2):26-32. To Psychologist Dr. Cristiani Kobayashi, Professor at the Paulista 15. Spink MJP. Psicologia social e saúde. Práticas, saberes e sentidos. Coleção Psicologia Social, Guaresci PA, Jovchelovitch S (editores). Petrópolis: Editora Vozes; 2003. (UNIP) and Psychologist Dr. José Aparecido da Silva, Professor 16. Flor H, Turk D, eds. Chronic Pain: an integrated biobehavioral approach. Seattle: of Psychology department at the University of São Paulo (USP) IASP Press; 2011. Ribeirão Preto for the important and valuable contributions 17. Jensen MP, Turk DC. Contributions of psychology to the understanding and treatment of people with chronic pain: why it matters to ALL psychologists. Am Psychol. made during the elaboration of the Guidelines for the Curricu- 2014;69(2):105-18. lum in Pain for Psychologists in Brazil. 18. Loeser JD. Five crises in pain management. Pain Clinical Updates. 2012;20(1):1-4. 19. Charlton JE, (editor). Core Curriculum for Professional Education in Pain. Seattle: IASP; 2005. REFERENCES 20. Sessle B. Unrelieved pain: a crisis. Pain Res Manag. 2011;16(6):416-20. 21. Cousins MJ, Brennan F, Carr DB. Pain relief: a universal human right. Pain. 1. Borrel-Carrió F, Suchman AL, Epstein RM. The biopsychosocial model 25 years later: 2004;112(1-2):1-4. principles, practice and scientific inquiry. Ann Fam Med. 2004;2(6):576-82. 22. International Association for the Study of Pain, Declaration of Montreal, IASP, Editor. 2. Correia E. Uma visão fenomenológica-existencial em psicologia da saúde?! Análise 2010. 2p. Psicológica. 2006;3(XXIV):337-41. 23. McGrath PA, Flor H, Turner T, Vlaeyen J, Williams AC. Curriculum outline on pain 3. Sevalho G. Uma abordagem histórica das representações sociais de saúde e doença. for Psychology. IASP. 2012. Cad Saúde Pública. 1993;9(3):349-63. 24. Williams AC, Craig KD. Updating the definition of pain. Pain. 2016;157(11):2420-3. st 4. Scliar M. História do Conceito de Saúde. Rev Saúde Coletiva. 2007;17(1):29-41. 25. Seers K, Watt-Watson J, Bucknall T. Challenges of pain management for the 21 cen- 5. Engel GL. The clinical application of the biopsychosocial model. Am J Psychiatry. tury. J Adv Nurs. 2006;55(1):4-6. 1980;137(5):535-44. 26. DeSantana JM, Souza JB, Reis FJ, Gosling AP, Paranhos E, Barbosa HF, et al. Currí- 6. Engel GL. The need for a new medical model: a challenge for biomedicine. Science. culo em dor para graduação em Fisioterapia no Brasil. Rev Dor. 2017;18(1):72-8. 1977;196(4286):129-36. 27. Perissinotti DM, Portnoi AG. Psychobehavioral and psychosocial aspects of neuropa- 7. Straub RO. Psicologia da saúde. Porto Alegre: Artmed; 2005. thic pain patients. Rev Dor. 2016;17(Suppl 1):S79-84. 8. Traverso-Yépez M. A interface psicologia social e saúde: perspectivas e desafios. Psicol 28. Loduca A, Müllher BM, Amaral R, Souza AC, Focosi AS, Samuelian C, et al. Re- Estud. 2001;6(2):49-56. trato de dores crônicas: percepção da dor através do olhar dos sofredores. Rev Dor. 9. Evans B, Marks DF. Health Psychology. Theory, research and practice. 3rd ed. London: 2014;15(1):30-5. Sage Publications; 2011. 29. Portnoi A. A Psicologia da Dor. São Paulo: Roca; 2014. 10. Matarazzo JD. Behavioral health and behavioral medicine: frontiers for a new health 30. Siqueira JL, Morete MC. Avaliação psicológica de pacientes com dor crônica: quando, psychology. Am Psychol. 1980;35(9):807-17. como e por que encaminhar? Rev Dor, 2014;15(1):51-4. 11. American Psychological Association, what does a health psychology does and how 31. Sardá Júnior JJ, Nicholas MK, Pimenta CA, Asghari A. Preditores biopsicossociais to become one, in Health psychology. AP. Association, Editor. New York: American de dor, incapacidade e depressão em pacientes brasileiros com dor crônica. Rev Dor, Psychological Association; 2004. 2012;13(2):111-8. 12. Teixeira JAC. Psicologia da saúde. Análise Psicológica, 2004;3(XXII):441-8. 32. Silva JA, Ribeiro-Filho NP. A dor como um problema psicofísico. Rev Dor. 13. Dimenstein M. O psicólogo e o compromisso social no contexto da saúde coletiva. 2011;12(2):138-51.

66 BrJP. São Paulo, 2019 jan-mar;2(1):67-71 REVIEW ARTICLE

Difficulties faced by nurses to use pain as the fifth vital sign and the mechanisms/actions adopted: an integrative review Dificuldades enfrentadas pela enfermagem na aplicabilidade da dor como quinto sinal vital e os mecanismos/ações adotados: revisão integrativa

Allana Fernandes Valério1, Karina da Silva Fernandes1, Grazielle Miranda2, Fábio de Souza Terra1

DOI 10.5935/2595-0118.20190013

ABSTRACT RESUMO

BACKGROUND AND OBJECTIVES: Pain was recognized JUSTIFICATIVA E OBJETIVOS: A dor foi reconhecida como as the fifth vital sign in 1996, and many nurses have difficulty quinto sinal vital em 1996 e muitos enfermeiros têm dificuldades in evaluating it. Since it is necessary to know the difficulties to em avaliá-la. Mediante a necessidade de conhecer as dificuldades use pain as a fifth vital sign, this study aims at acquiring a bet- na aplicabilidade da dor como quinto sinal vital, justifica-se este ter knowledge about pain, assessment methods and strategies/ estudo com o intuito de conhecer a dor, os métodos para avalia- actions to guarantee its control. The objective of this study was to ção e as estratégias/ações para garantir seu controle. O objetivo identify and analyze, in the Brazilian and international literature, deste estudo foi identificar e analisar, na literatura brasileira e the difficulties faced by nurses to use pain as the fifth vital sign internacional, as dificuldades enfrentadas pela enfermagem na and the mechanisms/actions adopted. aplicabilidade da dor como quinto sinal vital e os mecanismos/ CONTENTS: It is an integrative review in which the search for ações adotados. scientific articles was carried out in LILACS, BDENF, Scielo, CONTEÚDO: Trata-se de uma revisão integrativa em que a Pubmed, Scopus and Web of Science databases, using the de- busca de artigos científicos foi realizada nas bases e bancos de da- scriptors nursing, pain, and pain and vital signs management in dos: LILACS, BDENF, Scielo, Pubmed, Scopus e Web of Scien- Portuguese, English, and Spanish. The selection criteria were the ce. Utilizou-se os descritores enfermagem, dor, manuseio da dor period from 1995 to 2017 in the three languages mentioned. e sinais vitais nos idiomas português, inglês e espanhol. Definiu- After searching and reading the articles, nine studies were in- -se como critérios de seleção o período de 1995 a 2017 e os três cluded. Two categories were listed after reading the articles: 1) idiomas citados; e após a busca e a leitura dos artigos foram in- difficulties faced by nurses to use pain as a fifth vital sign and 2) cluídos nove estudos. Com a leitura dos artigos foram elencadas mechanisms/actions adopted to minimize the difficulties faced duas categorias: 1) dificuldades enfrentadas pela enfermagem na by nurses to use pain as a fifth vital sign. aplicabilidade da dor como quinto sinal vital e 2) mecanismos/ CONCLUSION: It was evidenced that it is important that nurs- ações adotados para amenizar as dificuldades enfrentadas pela es consider/assess pain as the fifth vital sign, therefore aiming enfermagem na aplicabilidade da dor como quinto sinal vital. at better care, which, consequently, will influence the quality of CONCLUSÃO: Evidenciou-se que é necessário que os profis- care provided, improving patient’s health and quality of life. sionais enfermeiros atentem para a importância de considerar/ Keywords: Nursing, Pain, Pain management, Vital signs. avaliar a dor como quinto sinal vital, visando um melhor atendimento que, consequentemente, influenciará na qualidade da assistência prestada, melhorando a saúde e a qualidade de vida do paciente. Descritores: Dor, Enfermagem, Manuseio da dor, Sinais vitais.

Allana Fernandes Valério - https://orcid.org/0000-0002-6748-1385; Karina da Silva Fernandes - https://orcid.org/0000-0002-8298-6082; INTRODUCTION Grazielle Miranda - https://orcid.org/0000-0001-6206-7452;  Fábio de Souza Terra - https://orcid.org/0000-0001-8322-3039. Pain was first recognized and cited as the fifth vital sign in 1996 1. Universidade Federal de Alfenas, Escola de Enfermagem, Alfenas, MG, Brasil. by James Campbell (President of the American Pain Society)1. 2. Universidade Federal de Alfenas, Escola de Enfermagem, Mestranda pelo Programa de Pós-Graduação em Enfermagem, Alfenas, MG, Brasil. One of Campbell’s goals was to raise health professionals’ awareness about the beneficial effects of proper pain assessment and Submitted in July 10, 2018. early management2. Accepted for publication in December 13, 2018. Conflict of interests: none – Sponsoring sources: none Since the nursing team is close to the patients, as well as other health professionals, such as physicians, it is crucial that Correspondence to: Rua Gabriel Monteiro da Silva, 700 – Centro the nursing leadership recognizes their responsibility with the 37130-001 Alfenas, MG, Brasil. individual with pain, so that the nurse can systematize the E-mail: [email protected] nursing care and identify the appropriate interventions for © Sociedade Brasileira para o Estudo da Dor pain relief. This may minimize its effects, contribute for better 67 BrJP. São Paulo, 2019 jan-mar;2(1):67-71 Valério AF, Fernandes KS, Miranda G and Terra FS evolution of the patient and, consequently, provide an effec- excluded post-duplication and reading in full. Thus, in the crit- tive treatment to pain3. ical and analytical reading, nine articles were selected, five from Once the professional is able to evaluate and record the per- LILACS, one from Pubmed, and three from Scopus (Figure 1). son’s complaint, he/she can improve the care of the patient Table 1 shows the synthesis of the results obtained from the with pain4. But in the professional practice, the nursing team selected articles regarding the variables of the title of the arti- may face some difficulties in using pain as the fifth vital sign4.5. cle, periodical, authors, year and country of publication and Given the above, the present study is justified by the need to language know the difficulties encountered by these professionals in the Of the articles selected, only one has been published in the assessment of pain as the fifth vital sign. Also, to present the last five years; five articles in the last 10 years and three arti- mechanisms and actions adopted in the attempt to solve or cles published more than 10 years ago. Most were published reduce these difficulties to improve the management, the con- in Brazil (five articles), the Portuguese language predominat- trol, assessment, and care for patients who complain of pain. ed (five articles), and four were described in English (Table 1). Thus, pain assessment is of great relevance to nurses as well Regarding the type of study, the predominance was quanti- as to other health professionals, and it is important that they tative research (five articles), but it is worth mentioning the have the knowledge and implement it in health institutions. development of qualitative, mixed, and theoretical reflection The objective of this study was to identify and analyze, by an studies. Of the subjects evaluated in the selected studies, the integrative review in the Brazilian and international litera- nurses prevailed, but there was also the participation of nurs- ture, the difficulties faced by the nursing team to use pain as ing technicians/assistants and patients. Regarding the level of the fifth vital sign and the mechanisms and actions adopted. evidence of the investigations analyzed in this review, eight studies are classified as evidence level VI and one with no CONTENTS level, indicating studies with low evidence levels. Two categories were listed after analyzing the results and con- It is an integrative review of the literature, and the method- clusions of the articles selected: 1) difficulties faced by the ological reference was adopted to conduct this review6. This nursing team to use pain as the fifth vital sign; and 2) mech- framework addresses six phases to be followed: elaboration anisms and actions adopted to minimize the difficulties faced of the guiding question, search or sampling in the literature, by nursing in using pain as the fifth vital sign. data collection, analysis of the studies included, discussion of the results and submission of the integrative review. Difficulties faced by nursing to use pain as the fifth vital sign The guiding question of this survey was: what are the diffi- The most reported difficulty in the articles included in this culties faced by the nursing team to use pain as the fifth vital review was the lack of knowledge of the nursing team profes- sign? The search for scientific articles was carried out in the sionals. Some authors have mentioned that nurses have little following databases: LILACS, BDENF (Nursing Database), knowledge of acute pain. Many said that they had a super- Scielo, Pubmed, Scopus and Web of Science. ficial knowledge in school and others report that they have 15 The Health Sciences Descriptors (DeCS) were used to locate never had access to this information, being something new . the articles that composed the sample: nursing, pain, pain management, and vital signs in Portuguese, Spanish and En- glish; and the MESH Database descriptors: nursing, pain, Articles found in the pain management, and vital signs. The Boolean operator rep- databases (n=65203) resented by the connector term AND was used, and associa- LILACS: 4089 Scielo: 4559 tions between all the selected descriptors. BDENF: 2419 As the selection criteria, the cut-off period from 1995 to 2017 Pubmed: 41389 was defined. Articles in Portuguese, Spanish, and English in Scopus: 6650 the searched databases that answered the proposed question Web of Science: 6097 were selected. Publications in duplicate in the databases were Articles excluded after excluded. reading titles and An integrative review data collection instrument was used abstracts (n=65117) Articles elegible in the that included variables such as study identification data (ar- databases (n=86) Articles excluded ticle title, periodical, authors, year, country of publication because they are and language) and study characterization (objectives, type of in duplicate in the study, subjects of the study, results, and conclusions)7. databases (n=48) and Articles included (n=09) after reading in full (n=29) The database search found 65,203 articles. There were 21 eli- LILACS: 05 gible articles in LILACS, 15 in Scielo, 13 in BDENF, seven in Pubmed: 01 Pubmed, 14 in Scopus and 16 in Web of Science, totaling 86 Scopus: 03 eligible articles. Nine articles were in duplicate in LILACS, 15 in Scielo, 13 in BDENF, three in Scopus and eight in Web of Figure 1. Flowchart of articles identification and selection Science, totaling 48 duplicate articles. Of these, 29 articles were Source: Prepared by the authors. 68 Difficulties faced by nurses to use pain as the fifth vital sign BrJP. São Paulo, 2019 jan-mar;2(1):67-71 and the mechanisms/actions adopted: an integrative review

Table 1. Characteristics of the articles included Authors Title of the article Periodical Year Country of publication Language Niekerk and The impact of the nurse-physician relationship on bar- Pain Management 2003 Australia English Martin8 riers encountered by nurses during pain management Nursing Vallerand, Templin Barriers to pain management by home care nurses Home Health Care 2004 United States English and Hasenau9 Nurse Pedroso and Pain: fifth vital sign, a challenge for the care in nu- Texto & Contexto 2006 Brazil Portuguese Celich10 rsing Enfermagem Blondal and The challenge of caring for patients in pain: from the Journal of Clinical 2009 United States English Halldorsdottir11 nurse’s perspective Nursing Saça et al.3 Pain as 5th vital sign: role of the nursing staff in the Journal of the 2010 Brazil Portuguese private hospital with management of Basic Health Health Sciences Unit Institute Bottega and Pain as the fifth vital sign: use of the assessment sca- Texto & Contexto 2010 Brazil Portuguese Fontana12 le by nurses in general hospital Enfermagem Wang and Tsai13 Nurses’ knowledge and barriers regarding pain ma- Journal of Clinical 2010 United States English nagement in intensive care units Nursing Nascimento and Assessment of pain as the fifth vital sign: opinion of Acta Paulista de 2011 Brazil Portuguese Kreling5 nurses Enfermagem Araujo and Pain: evaluation of the fifth vital sign. A theoretical Brazilian Journal 2015 Brazil Portuguese Romero14 reflection of Pain Source: Prepared by the authors.

Another difficulty mentioned in the articles was commu- al believes that the patients overestimate their pain and have nication among professionals. In this respect, it should be difficulty to express it. Professionals also find it difficult to use noted that in some situations, the preference of health pro- evaluation scales, either due to lack of knowledge or difficulty fessionals for an autonomous practice may lead to a lack of in interpreting the pain measurement instruments5,23,24. It was communication with nurses, thus disregarding their opin- also noted that many patients are reluctant to talk about pain ions or decisions16,17. because they fear being classified as frail and grouch25. Communication, many times complex and ineffective be- In the context about the use of instruments to assess pain, tween the nurse and the physician, is associated with patients other difficulties stood out as the lack of these instruments undesired outcomes, specifically prolonged hospital stay and and the absence of notes and interventions of the nursing injuries resulting from delays and errors in treatment18,19. staff. As a result, knowledge deficits and the lack of pain mea- The work overload of the nursing professionals was also a dif- surement instruments are barriers for these professionals to ficulty mentioned in the studied material. It should be em- provide effective care with quality to patients. Some profes- phasized that the nurse task is not only to assist the patient. It sionals are unaware of the instruments to measure pain and, also includes the training and qualification of nursing profes- therefore, they rely on common sense, religious beliefs, and sionals, the management of materials and supplies, to inter- practices experienced by other professionals in the manage- face with other health and administration professionals, pro- ment of pain15,26. vide information to patients and family members, therefore The absence of nursing notes related to the patient’s pain may promoting a multiprofessional management for the benefit of compromise the assistance. Therefore, improving the records the patient20. Very often, these professionals have more than is a goal to be achieved. These notes are also considered a way one job with a high turnover in the workplace due to the low of communication between the teams and the different shifts, remuneration and the high level of stress21. enabling better assistance27. Another difficulty found in the present review was to under- Other difficulties found in the articles include the lack of stand the patient’s pain. Health professionals, including the time to assess pain, failure to remember to assess pain, their nursing staff, may, in some situations, undervalue the pa- saying that pain cannot be measured, not considering pain tients’ pain reports, thereby stimulating them to tolerate a lit- as a vital sign, and inadequate pain assessment. The lack of tle more pain. There is a lack of openness in listening to them time of these professionals, especially of the nursing team and these factors interfere in the measurement and assessment that performs several activities during the work shift, the lack of pain4,22. Considering that pain is a unique, subjective and of knowledge of pain measurement techniques, and the lan- individual experience, it is up to the healthcare team to re- guage used when questioning pain, which may be difficult to spect this condition, to interpret and intervene accordingly12. understand by the patient, are also factors that contribute to Other complicating factors found in the articles included in an inadequate assessment28. this study were the lack of understanding of the intensity scale According to a study, the results showed that the nurses of by patients and professionals, and many times, the profession- the studied hospital had incipient knowledge about the ways 69 BrJP. São Paulo, 2019 jan-mar;2(1):67-71 Valério AF, Fernandes KS, Miranda G and Terra FS to assess pain and did not consider pain as the fifth vital sign environment as a mechanism/action to minimize these dif- since their practice did not include its systematic assessment15. ficulties, in partnership with all health professionals and Continuing with the other difficulties found in the present with the use of case studies. The professional should en- review, we noticed that nursing staff often provides pain man- courage the team to rethink their roles and attributions, agement care in a limited way, not mastering the mechanism based on the reference of care with the purpose of achiev- of the painful picture. Handling pain in a limited way may ing efficiency in the nursing work32. The nurse should also lead to inadequate management of the pain symptom and guide, perform and encourage the team about the need to may cause harm to the patient. Frequently, nursing profes- carry out case studies, to evaluate the issue of pain in their sionals rely on verbal and non-verbal reports to identify pa- professional practice so that the results of these studies are tients’ pain14. used as parameters that can be adopted in the assistance provided33. Mechanisms and actions adopted to minimize the diffi- Finally, the mechanism/action regarding the use of scales is culties faced by the nursing staff to use pain as the fifth of great relevance for the clinical practice. It should be em- vital sign phasized, therefore, that medical and nursing educational The most cited mechanism/action was to establish education- institutions should offer disciplines or courses with the ob- al processes with continuous pain management courses, and, jective of teaching and disseminating the use of instruments sometimes, in a state of emergency. The literature shows the and/or scales to measure and assess pain with a humanistic need to train nurses and the entire nursing team about sev- perspective10. eral topics related to professional practice. Thus, to promote education in favor of care ensuring the development of differ- CONCLUSION entiated and more qualified assistance. Education is the base that may encourage the nurse to adopt approaches that are There are few studies in this subject, and many nurses have diffi- beneficial to his/her own knowledge and to the patient who culties in using pain as the fifth vital sign, but some mechanisms/ is being assisted29. actions can be adopted by all health professionals to minimize Another mechanism/action found in the articles is the reorga- these difficulties. nization of the curriculum of the graduate program, includ- Due to the difficulties presented in this study about the use ing pain and subjects alike. It should be noted that some un- of pain as the fifth sign, it is recommended to establish a con- dergraduate courses are not properly preparing future nurses tinuous education program for health professionals in the for pain management, that is, the subject is superficially ad- workplace. Other actions recommended are to conduct more dressed in the academic environment. Thus, it is necessary to research, to restructure the undergraduate program curricu- mobilize efforts to prepare future nursing professionals with lum to include the subject of pain, and the use of a more a focus on pain as the fifth vital sign, connecting the holistic holistic perspective in care, as well as the use of scales in the care to the development of technical and behavioral skills that clinical practice. recognize teamwork and interdisciplinarity30. There is also the need to raise the awareness of the nursing team Among other mechanisms/actions found in the articles, it is and all health professionals about the importance of their com- worth mentioning the understanding about the importance mitment. Together with the multidisciplinary team, they can of the working relationship among health professionals, be successful in controlling and managing the patient’s pain, which can have a significant effect on the barriers to manage addressing it as the fifth vital sign, provide a humanized care pain better. Therefore, it is necessary to improve education in that may influence the improvement of patients’ health and communication in the undergraduate course to enrich their quality of life. understanding of the role of each of them in front of the patient. In this way, it will be possible to broaden their skills to REFERENCES convey appropriate and important information about patient 31 1. Purser L, Warfield K, Richardson C. Making pain visible: an audit and review of do- care with verbal and non-verbal communication . cumentation to improve the use of pain assessment by implementing pain as the fifth Other points mentioned refer to realizing the importance of vital sign. Pain Manag Nurs. 2014;15(1):137-42. 2. Campbell JN. The fifth vital sign revisited. Pain. 2016;157(1):3-4. the multidimensional knowledge on pain management, and a 3. Saça CS, Carmo, FA, Arbuleia JP, Souza RC, Alves SA, Rosa BA. A dor como 5° sinal more holistic approach to care. The nurse and all healthcare vital: atuação da equipe de enfermagem no hospital privado como gestão do Sistema único de Saúde (SUS). J Health Sci Inst. 2010;28(1):35-41. professionals play a fundamental role in the control of pain 4. Nogueira MF. Dor: identificando os métodos de avaliação e descrevendo o cuidado de performing a diagnostic evaluation, intervention, monitoring enfermagem. Rev Enferm UFPE. 2012;6(1):1556-65. of the results of the treatment and communicating the infor- 5. Nascimento LA, Kreling, MC. Avaliação da dor como quinto sinal: opinião de profissionais de enfermagem. Acta Paul Enferm. 2011;24(1):50-4. mation about pain. Therefore, the theoretical and practical 6. Souza MT, Silva MD, Carvalho R. Revisão integrativa: o que é e como fazer. Einstein. knowledge should be associated with the purpose of provid- 2010;8(1):102-6. 7. Fernandes DL. Representações sociais de adolescentes sobre o câncer de colo do útero ing more qualified care to the patient with pain, that is pro- [dissertação]. Recife: Universidade Federal do Pernambuco; 2011. viding humanized care10.15. 8. Niekerk LM, Martin F. The impact of the nurse-physician relationship on barriers encountered by nurses during pain management. Pain Manag Nurs. 2003;4(1):3-10. Some articles mentioned the nurses’ participation in the 9. Vallerand AH, Templin T, Hasenau SM. Barriers to pain management by home care implementation of pain as the fifth vital sign in their work nurses. Home Health Nurse. 2004;22(12):831-40. 70 Difficulties faced by nurses to use pain as the fifth vital sign BrJP. São Paulo, 2019 jan-mar;2(1):67-71 and the mechanisms/actions adopted: an integrative review

10. Pedroso RA, Celich KL. Dor: Quinto sinal vital, um desafio para o cuidar em Enfer- 22. Andrade FA, Pereira, LV, Sousa FA. [Pain measurement in the elderly: a review]. Rev magem. Rev Texto Contexto Enferm. 2006;15(2):270-6. Lat Am Enfermagem. 2006;14(2):271-6. Portuguese. 11. Blondal K, Halldorsdottir S. The challenge of caring for patients in pain: from the 23. Rampanjato RM, Florence M, Patrick NC, Finucane BT. Factors influencing pain nurse’s. J Clin Nurs. 2009;18(20):2897-906. management by nurses in emergency departments in Central Africa. Emerg Med J. 12. Bottega FH, Fontana RT. A dor como quinto sinal vital: Utilização da escala de avaliação 2006;24(7):475-6. por enfermeiros de um Hospital geral. Rev Texto Contexto Enferm. 2010;19(2):283-90. 24. Ribeiro NC, Barreto SC, Hora EC, Sousa, RM. O enfermeiro no cuidado à vítima de 13. Wang HL, Tsai YF. Nurses’ knowledge and barriers regarding pain management in trauma com dor: o quinto sinal vital. Rev Esc Enferm USP. 2011;45(1):146-52. intensive care units. J Clin Nurs. 2010;19(21):3188-96. 25. Pessini L. Humanização da dor e sofrimento humanos no contexto hospitalar. Rev 14. Araujo LC, Romero B. Dor: Avaliação do 5º sinal vital. Uma reflexão teórica. Rev Dor. Bioética. 2002;10(2):51-72 2015;16(4):291-6. 26. Linhares MB, Fernanda NP. Dor em neonatos e crianças: avaliação e intervenções não 15. Queiróz DT, Carvalho MA, Carvalho GD, Santos SR, Moreira AS, Silveira MF. Dor farmacológicas. Temas Psicol. 2010;18(2):307-25. - 5º sinal vital: conhecimento de enfermeiros. Rev Enferm UFPE. 2015;9(4):7186-92. 27. Rigotti MA, Ferreira AM. Intervenções de enfermagem ao paciente com dor. Arq 16. Aston J, Shi E, Bullôt H, Galway R, Crisp J. Qualitative evaluation of regular morning Ciênc Saúde. 2005;12(1):50-4. meetings aimed at improving interdisciplinary communication and patient outcomes. 28. Kazanowski MK, Laccetti MS. Dor: Fundamentos, abordagem clínica, tratamento. Int J Nurs Pract. 2015;11(5):206-13. Rio de Janeiro: Guanabara Koogan; 2005. 165p. 17. Vaismoradi M, Salsali M, Esmaeilpour M, Cheraghi MA. Perspectives and experiences 29. Andrade KC, Aires RD, Kangussu LM. Atuação do enfermeiro na avaliação da dor of Iranian nurses regarding nurse-physician communication: a content analysis study. e na administração de fármacos opióides: Uma revisão bibliográfica. Revista NBC. Jpn J Nurs Sci. 2011;8(2):184-9. 2015;5(9):1-10. 18. Ellison D. Communication skills. Nurs Clin North Am. 2015;50(1):45-57. 30. Romanek FA, Avelar MC. Percepção dos docentes acerca do ensino da dor para grad- 19. O’Daniel M, Rosenstein AH. Professional Communication and Team Collaboration. uandos em enfermagem. Rev Eletr Enf. 2013;15(2):463-70. In: Hughes RG (Ed.). Patient safety and quality: an evidence-based handbook for 31. Bandboni M, Vaismoradi M, Salsali M, Snelgrove S. Iranian physicians’ perspectives nurses. Rockville: Agency for Healthcare Research and Quality; 2008. 1403p. regarding nurse-physician professional communication: Implications for nurses. Res 20. Novaretti MC, Santos EV, Quitério LM, Gallotti-Daud RM. Sobrecarga de trabalho Theory Nurs Pract. 2017;31(3):202-18. da enfermagem e incidentes e eventos adversos em pacientes internados em UTI. Rev 32. Bernardes A, Ramos BM, Betela-Junior J, Paiva PN. Supervisão do enfermeiro no Bras Enferm. 2014;67(5):692-9. atendimento pré-hospitalar móvel: visão dos auxiliares de enfermagem. Ciênc Cuid 21. Van PB, Timmermans O, Weeks SM, Van HD, Wouters K, Franck E. Nursing unit Saude. 2009;8(1):79-85. teams’ matter: impact of unit-level nurse practice environment, nurse work character- 33. Pagani R, Andrade LO. Preceptoria de Território, Novas práticas e saberes na Estraté- istics, and burnout on nurse reported job outcomes, and quality of care, and patient gia de Educação Permanente em Saúde da Família: o estudo do caso de Sobral, CE. adverse events-a cross-sectional survey. Int J Nurs Stud. 2014;51(8):1123-34. Saúde Soc. 2012;21(1):94-106.

71 BrJP. São Paulo, 2019 jan-mar;2(1):72-80 REVIEW ARTICLE

Non-pharmacological therapies for postpartum analgesia: a systematic review Terapias não farmacológicas para analgesia no pós-parto: uma revisão sistemática

Larissa Ramalho Dantas Varella Dutra1, Alane Macatrão Pires de Holanda Araújo1, Maria Thereza Albuquerque Barbosa Cabral Micussi1

DOI 10.5935/2595-0118.20190014

ABSTRACT RESUMO

BACKGROUND AND OBJECTIVES: Abdominal and pelvic JUSTIFICATIVA E OBJETIVOS: Dor abdominal e pélvica são pain is a prevalent condition among women in the immediate condições prevalentes entre as puérperas no período pós-parto. postpartum period. Non-pharmacological therapies are of great As terapias não farmacológicas nesses casos são de grande impor- importance for the treatment of this condition since they do not tância, tendo em vista a ausência de efeitos adversos sistêmicos, cause systemic side effects, such as drowsiness, irritability, and tais como sonolência, irritabilidade e modificações no leite ma- changes in the composition of breast milk. This article aims to terno. O objetivo deste estudo foi identificar e avaliar a eficácia identify and evaluate the efficacy of non-pharmacological anal- das terapias analgésicas não farmacológicas utilizadas no puerpé- gesic therapies used in the immediate puerperium in abdomi- rio imediato na dor abdominal e pélvica. nal-pelvic pain. CONTEÚDO: Realizou-se buscas nas principais bases de da- CONTENTS: Searches were carried out in the main databases dos, no período de setembro a outubro de 2017, utilizando-se from September to October 2017 using the following descrip- as combinações: “treatment” AND “pain” AND “postpartum”; tors “treatment” AND “pain” AND “postpartum”; “Treatment” “treatment” AND “pain” AND “postpartum” AND “analgesics” AND “pain” AND “postpartum” AND “analgesics” AND AND “non-pharmacological”. Foram incluídos ensaios clínicos “non-pharmacological”. Controlled and randomized clinical tri- controlados e randomizados, publicados no período de janeiro als published between January 2007 and August 2017, in Portu- de 2007 a agosto de 2017, nos idiomas português, inglês e es- guese, English, and Spanish were included. Of the 1737 studies panhol. Dos 1.737 estudos encontrados nas bases de dados, 42 found in the databases, 42 were selected by the title. According foram selecionados pelo título. De acordo com os critérios de ele- to the eligibility criteria, 13 studies were included. The total sam- gibilidade, incluiu-se 13 estudos. O tamanho total das amostras ple size of the studies ranged from 21 to 266. In the intervention dos estudos variou entre 21 e 266. Nos grupos com intervenção, groups, the sample ranged from 11 to 126 women who under- a amostra variou entre 11 e 126 mulheres que foram submetidas went cryotherapy, transcutaneous electrical stimulation, LASER, a crioterapia, eletroestimulação elétrica nervosa transcutânea, acupuncture and ear acupressure. LASER, acupuntura e auriculoterapia. CONCLUSION: Interventional practices such as transcutane- CONCLUSÃO: As práticas intervencionistas como a eletroesti- ous electrical nervous stimulation and cryotherapy presented sig- mulação elétrica nervosa transcutânea e a crioterapia apresentaram nificant data relevant to the reduction of abdominal and pelvic dados significativos relevantes na redução da dor abdominal e pél- pain. The techniques of acupuncture and ear acupressure still vica. As técnicas de acupuntura e auriculoterapia ainda apresentam present inconclusive data. Despite the relief of perineal pain, la- dados inconclusivos. Apesar de provocar alívio da dor perineal, a ser therapy showed no statistically significant effect on pain relief laserterapia não mostrou efeito estatisticamente significativo para when compared to the placebo group. alívio da dor quando comparada com o grupo placebo. Keywords: Analgesics, Cesarean section, Pain, Physiotherapy. Descritores: Analgesia, Cesariana, Dor, Fisioterapia.

INTRODUCTION

Larissa Ramalho Dantas Varella Dutra - https://orcid.org/0000-0002-5441-5557; Alane Macatrão Pires de Holanda Araújo - https://orcid.org/0000-0002-3832-8808; In the immediate puerperium, abdominal and pelvic pain are Maria Thereza Albuquerque Barbosa Cabral Micussi - https://orcid.org/0000-0003-4140-5568. prevalent conditions among women1,2. A cohort study of 1,288 2 1. Universidade Federal do Rio Grande do Norte, Natal, RN, Brasil. women who underwent cesarean section and vaginal birth , identified a prevalence of pain of 10.9% in the first 36 hours af- Submitted in July 09, 2018. ter birth. The literature shows that women who underwent cesar- Accepted for publication in December 20, 2018. Conflict of interests: none – Sponsoring sources: none ean section reported 2.4 more complaints of pain compared to women undergoing vaginal birth3. Other research conducted in Correspondence to: Av. Senador Salgado Filho, s/n. Campus Universitário – Lagoa Nova Brazil showed that women who had vaginal birth were 82% less 59078-970 Natal, RN, Brasil. likely to experience intense pain in the immediate puerperium4. E-mail: [email protected] Another study reveals that postpartum pain may persist for up to © Sociedade Brasileira para o Estudo da Dor one year and is more common after cesarean section5. 72 Non-pharmacological therapies for postpartum BrJP. São Paulo, 2019 jan-mar;2(1):72-80 analgesia: a systematic review

In the postpartum after a vaginal birth, perineal pain was ob- October 2017, using the following combinations: “treatment” served due to an episiotomy or spontaneous perineal trauma that AND “pain” AND “postpartum”; “treatment” AND “pain” AND trigger a local inflammatory process with the presence of acute “postpartum” AND “analgesics” AND “non-pharmacological”. pain6. In the cesarean section, surgical wound pain is considered Inclusion criteria were complete articles published between Janu- the main complaint in women7, which impedes functionality in ary 2007 and August 2017 in the Portuguese, English and Spanish the immediate puerperium. Regardless of the mode of birth and languages; studies with the methodological design of randomized local tissue trauma, abdominal pain may also be present in most controlled clinical trial presenting a quantitative analysis of the women as a result of uterine contractions1. outcome pain; articles that presented in the title and abstract ap- The discomfort caused by painful condition relieves the qual- proach of a non-pharmacological intervention for analgesia in the ity of life, mobility, self-care, breastfeeding and eliminatory immediate puerperium. In cases where the title and the abstract functions of puerperium7,8. Pharmacological treatment is often were not enlightening, the search for the article was carried out in prescribed for analgesia, favoring patient recovery, reducing ma- full to avoid the inclusion of important studies. ternal distress and increasing the mother’s interactions with the The articles identified by the initial search strategy were inde- newborn8,9. pendently assessed and covered by two authors, strictly adhering Despite advances in the knowledge of pathophysiology, treat- to the eligibility criteria defined in the research protocol and as- ment for pain and the availability of new drug systems, it is still sessed methodologically based on the PEDro11 scale. Duplica- possible to find patients who are unable to use drugs, making tion studies were excluded from the databases. this therapy unfeasible1. In addition, Steen et al.10 reported that The systematic review was performed according to the guidelines the use of drug alone has not been enough to promote analgesia of the Cochrane Reviewer’s Handbook and the PRISMA guide- in these women. It is possible to identify in the literature several lines12 (Preferred Reporting Items for Systematic Reviews and non-pharmacological analgesic therapies used in acute processes Meta-Analysis). The steps of the research are demonstrated in the of tissue trauma, discussing the low cost for application and the flowchart (Figure 1), according to the methodological procedure wide possibility of indications. proposed in the study. In view of the painful symptoms in distinct regions such as the abdomen and pelvis due to the parturition process, whether by Selection of studies vaginal birth or cesarean section, present in the first days of the The results of the research are shown in figure 1. Initially, 1,737 puerperium, it is necessary to identify and assess the effectiveness studies were found in the databases, 13 of which were selected of the non-pharmacological analgesic therapies used in this pe- according to the eligibility criteria. riod, to better guide the clinical and scientific practice of health professionals working directly in obstetric care. Characteristics of the studies The total sample size of the studies ranged from 21 to 266 with CONTENTS the size of the intervention group ranging from 11 to 126 wom- en13,14. In the assessment of the methodological quality, an aver- This study was characterized as a systematic review, carried out in age score of 7 (range of 5 to 10) was verified, as shown in table 1. the main databases Pubmed; LILACS, Ovid EMBASE, Scielo, The resources found were cryotherapy15-18, TENS13,19-22, laser CAPES, IBECS, SCOPUS, SCIENCE DIRECT and CAPES therapy23,24, auriculotherapy14 and acupuncture25 and are de- thesis bank. The searches were carried out from September to scribed in table 2.

1,737 Abstracts in databases

1,695 Studies included by title

42 Selected studies

12 Duplicate and removed studies

30 Selected studies

1 Study excluded by design (exploratory)

29 Selected studies

16 Studies excluded further reading in full

13 Selected studies

Figure 1. Flowchart of the systematic review steps recommended by PRISMA

73 BrJP. São Paulo, 2019 jan-mar;2(1):72-80 Dutra LR, Araújo AM and Micussi MT

Table 1. Characteristics of included articles Authors Methodological/blind design Non-pharmacological Methodological quality resource used (PEDro scale) Lu et al.15 Quasi-randomized controlled experimental/unblinded trial Cryotherapy 5 Oliveira et al.16 Randomized controlled/unblinded clinical trial Cryotherapy 5 Kayman-Kose Randomized controlled/single-blind clinical trial (patient) TENS 8 et al.19 Pitangui et al.20 Randomized double-blind clinical trial TENS 8 Olsen et al.13 Randomized controlled/single-blind clinical trial (patient) TENS 6 Pitangui et al.21 Controlled randomized/unblinded clinical trial TENS 8 Santos et al.24 Randomized double-blind clinical trial Low-level laser therapy 9 Santos et al.23 Pilot, randomized clinical trial Low-level laser therapy 9 Kwan and Li14 Randomized controlled/double-blind trial Auriculotherapy 10 Leventhal Randomized, controlled, parallel-group/single-blind trial (evaluator) Cryotherapy 8 et al.17 Marra et al.25 Pilot placebo trial Acupuncture 5 Lima et al.22 Randomized, placebo-controlled/single-blind clinical trial TENS 10 Morais et al.18 Randomized controlled/double-blind clinical trial Cryotherapy 9 TENS = transcutaneous electrical nerve stimulation.

Table 2. Non-pharmacological analgesic resources for abdominal-pelvic pain relief in the immediate puerperium

Authors Objective of Intervention groups Intervention Assessment tools Effectiveness of the inter- the study / n = vention (p<0.05) * sample

Cryotherapy

Lu et al.15 To assess the The study was per- The IG underwent the For both groups, the pain BPI: significant reduction effect of a cold formed with two application of ice pack was measured in 4 mo- of pain 48 h after birth compress on groups containing 35 in the perineal region ments through BPI: 4h in the intervention group episiotomy women in each. with temperature ranging (immediately before the (p=0.002). pain reduction/ from 12 to 15˚C, lasting intervention), 12, 24 and DA questionnaire: signif- n=70. from 15 to 20 minutes 48h after birth. It was icant reduction of pain and encouraged to per- also assessed the in- interference on daily ac- form ice pack as many terference of pain in the tivities (p=0.001). times as possible in the ADL, through a question- first 4 hours postpartum. naire developed for the For the next three days, research. they should use at least 3 times a day. All IG and CG participants received routine care, consisting of nonsteroidal anti-inflammatory and hot-seat baths after 24 hours postpartum.

Oliveira To compare The research was Single application of ice The pain was measured The three groups pre- et al.16 the effect of done with three pack in the perineal rein 4 moments through the sented significant pain applying ice groups containing gion at -10˚C between 2 VAS: before, immediately reduction (p=0.001), with pack for 10, 38 patients each: and 56 hours postpar- after, 20 minutes and 40 no statistical difference 15 and 20 min- Group underwent tum after vaginal birth, in minutes after the inter- between them (p=0.066). utes in the per- 10 min interven- women with pain ≥3 as- vention. Application of 10 minutes ineal region in tion with ice packs; sessed by visual analog and 15 minutes of ice pain reduction/ Group underwent scale (VAS). pack has the same ben- n=114. 15 min interven- efits in reducing pain like tion with ice packs. that of 20 minutes. Control group underwent 20 min of ice.

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74 Non-pharmacological therapies for postpartum BrJP. São Paulo, 2019 jan-mar;2(1):72-80 analgesia: a systematic review

Table 2. Non-pharmacological analgesic resources for abdominal-pelvic pain relief in the immediate puerperium – continuation

Authors Objective of Intervention groups Intervention Assessment tools Effectiveness of the inter- the study / n = vention (p<0.05) * sample Cryotherapy Leventhal To assess the Participants included The packages were ap- The data were collected The use of an ice pack in et al.17 effectiveness nulliparous women plied in a single instance daily by 4 evaluators be- the perineum is useful in of an ice pack divided into 3 groups for 20 minutes in the per- tween 11:00 and 15:00. the treatment of perineal applied for 20 (n = 38 per group): ineal region, between 2 They were collected in the pain after vaginal birth. minutes to re- Experimental group and 48 hours postpartum. following sequence: inter- A comparison of mean lieve perine- underwent interven- The package consisted of view, initial assessment pain at baseline and af- al pain after tion with ice pack a plastic bag 8cm wide of perineal pain, random- ter 20 minutes showed spontaneous in the perineum; by 16cm long, filled with ization, body temperature significant pain reduction vaginal birth/ Placebo group un- 250mL of water. For the measurement, and peri- (p<0.001) in the 3 groups n=114. derwent intervention experimental group, the neal trauma length mea- and the experimental with water packs at pack was placed in the sured by the use of Per- group had a lower av- room temperature; freezer and removed as iruleTM. A numerical scale erage pain score com- Control group with- ice for the intervention. (zero to 10) was used for pared to the control group out intervention. The ice and water packs the assessment of pain. (p=0.032) were wrapped in 20×20 cm fine cotton fabric to avoid direct contact with the perineum. Morais et To assess the The volunteers were The experimental group They were assessed: per- There was no signifi- al.18 clinical effec- divided into 2 groups underwent 6 applications ineal pain and perineal cant difference for per- tiveness of containing 40 vol- of ice pack crushed in edema with assessments ineal pain and edema cryotherapy unteers in each: the perineum region, for performed immediately scores between groups to control pain Experimen- 20 minutes, reducing the before and at the end of with or without cryo- and perineal tal group under- temperature between 10 each application in each therapy up to 24 edema after went cryotherapy; and 15 ° C, with 60 min- group to determine the hours after birth. humanized Group without cryo- utes between the applica- immediate effects of the There was no differ- vaginal birth / therapy. tions. The group without therapy and were reas- ence between groups n=80 cryotherapy received a sessed at 24 hours post- when repeated measures water pack, which did not partum to verify the late were analyzed in all as- reduce the temperature at effects of cryotherapy. sessments, considering that level, respecting the The combined pain as- the median pain scores same protocol sessment scale (CSAP) (p=0.3) and perineal ede- of application of the ex- was used to assess pain ma (p=0.9). Perineal cryo- perimental group. level. therapy did not influence the amount of analgesics used (p=0.07) and no adverse effects were recorded. TENS Kayman- To assess the Participants were All participants in the inter- Pain was assessed before TENS is effective for Kose et efficiency andrandomized into vention groups received and immediately after ap- uterine pain relief and al.19 reliability of four groups: the application of TENS plication through VAS and operative wound. Pain TENS in the Cesarean section immediately after birth. VNS. reduction was significant treatment of group underwent A frequency of 100Hz for the groups that under- uterine pain intervention with and intensity according went TENS intervention. and surgical TENS switched off; to the patient’s sensitivity For cesarean section: incision after Cesarean sec- were used for the inter- VAS and visual numerical birth/n = 200. tion group under- vention groups. No pulse scale (VNS) (p<0.001). went intervention; width and time of ap- For vaginal birth: VAS Vaginal birth group plication were reported. (p=0.022) and VNS underwent inter- For vaginal birth patients, (p=0.005). vention with TENS the electrodes were po- switched off; sitioned in the region of Group of vaginal birth the lower abdomen cor- underwent interven- responding to the fundus tion. of the uterus. For those who underwent a cesarean section, the electrodes were positioned above and below the OW. Continue...

75 BrJP. São Paulo, 2019 jan-mar;2(1):72-80 Dutra LR, Araújo AM and Micussi MT

Table 2. Non-pharmacological analgesic resources for abdominal-pelvic pain relief in the immediate puerperium – continuation

Authors Objective of Intervention groups Intervention Assessment tools Effectiveness of the inter- the study / n = vention (p<0.05) * sample TENS Pitangui To assess the The volunteers The intervention was per- The pain was assessed TENS of low and high in- et al.20 effectiveness were randomized formed for all groups be- through the NRS before tensity are effective in of low-inten- into three groups: tween 6 and 24 hours the intervention, post-in- reducing perineal pain af- sity TENS and Group under- postpartum with the elec- tervention, 30 minutes ter episiotomy in the first high-intensity went intervention trodes in parallel, close to post-intervention and 60 24 hours postpartum. TENS in episi- with TENS of 5Hz; the episiotomy, following minutes post-intervention. Significant reduction of pain otomy pain re- Group underwent a pudendal and femoral between intervention and duction / n = 33. intervention with nerve region. The intensi- placebo groups immedi- TENS of 100Hz; ty of the device was pro- ately after resting (p=0.046) Placebo group on in- grammed according to the and sitting (0.008). tervention with the de- sensitivity of the patient, Significant reduction in pain vice switched off. and the pulse width was between intervention and 100μs. The intervention placebo groups at rest after lasted 30 minutes. 30 ‘(p=0.001) and after 60’ (p=0.001). Olsen et To compare the Participants were The intervention was per- The assessment of the High-intensity high-fre- al.13 effects of low randomized into two formed in all groups 24 pain was done through quency TENS had a better and high-inten- groups: hours after vaginal birth VAS before and after the outcome in reducing pain. sity high-fre- Group underwent in- without complications. application of TENS. The high-intensity group quency TENS tervention with TENS The device has been pro- presented a pain decline of in reducing ab- using intensity less grammed for a frequen- 49 (CI = 66.5 - 33.2), and dominal pain than 50mA performed cy of 70 to 100Hz and the low-intensity group had caused by uter- in 13 volunteers; a pulse width of 0.2ms. a decline of 21 (CI = 39.0 ine contractions Group underwent in- For the high-intensity - 20.0) during breast- tervention with TENS group, the application was feeding/n = 21. using intensity of 10 to performed for 1 ‘and re- 15mA in eight volun- peated if there was still a re- teers. port of pain. For the low-intensity group, the time of therapy was not reported. Pitangui To assess the The volunteers were All were between 6 and 24 The pain was assessed The high-frequency TENS et al.21 effectiveness of randomized into hours after a vaginal birth through NRS before ini- showed good results in high-frequency two groups with 20 and had a mediolateral tiating the intervention, the reduction of perine- TENS as a pain participants each: episiotomy. 60 minutes post-inter- al pain in the postpartum relief resource Group underwent invention and 120 min- period with episiotomy. for postpartum tervention with TENS utes post-intervention. For MPQ, PRI and NRS women with with high frequency; MPQ and PRI were also assessment, a significant episiotomy/ The group without in- used at baseline and 60 decrease (p <0.001) in the n=40. tervention. minutes after the current. scores in the intervention group. Lima et To assess the The patients were The participants were Pain intensity was as- The results demonstrated al. 22 analgesic effect randomly assigned, placed in dorsal decu- sessed by NRS before, a significant decrease of of TENS mod- in three treatment bitus position and re- immediately after and at the NRS in the G100 only ulation in high groups: mained in rest throughout 20-minute intervals (20, in relation to the pre-treat- (100Hz) and low G100: underwent the experiment so that 40 and 60’) after the elec- ment condition (p<0.05). In (4Hz) frequency TENS of 100Hz; there were no intercur- trostimulation period. the post-treatment inter- in post-cesare- G4: underwent TENS rences that interfered The initial assessment vals, the G100 presented an section pain of 4Hz; In the results. TENS was was performed respecting a significant decrease in / n = 34. GP: placebo group applied by medium of two a minimum interval of 8 pain during all the inter- underwent TENS channels with 4 siliconized hours postpartum to avoid vals (p<0.05). G4 showed switched off. rubber electrodes (5x3 cm) acute interferences of pos- a significant decrease only for individual use located tanesthetic recovery. in the 40 ‘and 60’ intervals; 1 cm above and below the and GP, only in the range of surgical incision, a pulse 60 ‘(p<0.05). TENS modula- duration of 100 μs and in- tion at a high pulse rate had tensity according to the a greater analgesic effect sensorial threshold of each than low-frequency TENS patient. The total TENS in post-cesarean section, application time was 30 postpartum women. minutes and performed in a single session.

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76 Non-pharmacological therapies for postpartum BrJP. São Paulo, 2019 jan-mar;2(1):72-80 analgesia: a systematic review

Table 2. Non-pharmacological analgesic resources for abdominal-pelvic pain relief in the immediate puerperium – continuation

Authors Objective of Intervention groups Intervention Assessment tools Effectiveness of the inter- the study / n = vention (p<0.05) * sample LASER Santos To assess the Participants were All volunteers were in the The pain was assessed The low-intensity la- et al.24 efficiency of randomized into range of 6 to 56 hours af- before, immediately after ser was not efficient Low-intensi- three groups with 38 ter vaginal birth with me- 3 and 30 minutes after in mediolateral episi- ty laser in the participants each: diolateral episiotomy and the application through otomy pain reduction. treatment of Group underwent had pain greater than VAS. There was a reduction perineal pain intervention with 3 on VAS. The device in pain in the interven- after episioto- LASER of 780nm used in the volunteers tion groups 30 and 60 my (n=114). of wavelength; underwent the interven- minutes after LASER Group undergo- tion was programmed application, but when ing laser interven- at a dose of 8.8J/cm2, a compared to placebo, no tion with 660nm spot of 0.04 cm2, pow- difference was observed of wavelength; er of 35mW, energy per (p=0.234 and p=0.111, Group underwent point of 0.35 and applied respectively). intervention with LA- punctually in the upper, SER switched off. the middle and lower point of the episiotomy for 10 seconds per application point. Santos To assess Participants were All underwent vaginal The pain assessment was LASER did not reduce et al.23 the effects of randomized into birth with mediolateral done through VAS before pain in the episiotomy. Low-intensity two groups with 26 episiotomy. The LASER and after each session. Up to 2 h after birth: laser therapy participants each: application was per- p=0.999 for perineal LASER interven- formed in three moments: Between 20 and 24 hours pain and heal- tion group with up to 2 hours after birth, postpartum: p=0.758 ing after episi- 660nm wavelength; between 20 and 24 hours Between 40 and 48 hours otomy / n=52. Group underwent after birth and between postpartum: p=0.662. intervention with LA- 40 and 48 hours post- SER switched off; partum. The device used in the volunteers underwent the intervention was programmed for a dose of 3.8J/cm2, a spot of 0.04mW, a spot of 0,04 cm2, the power of 15mW energy per point of 0.15 and applied punctually in the episiotomy for 10 seconds per application point. Auriculotherapy and Acupuncture Kwan To assess the Participants were Participants could The pain was assessed Apparently, there are no and Li14 effects of auri- randomized into two take pain medication through VDPS and VAS: positive results regarding cle pressure in groups: (500mg paracetamol/4 12, 24 and 36 h after the use of auricle pres- reducing acute Intervention group with hours) if necessary. birth. Also, the average sure. perineal pain 126 women; In the two groups, the fol- consumption of parac- No difference in pain was in the first 48 Group without in- lowing stimulation points etamol was analyzed. observed through AVA hours postpar- tervention with 130 were chosen: “Apex of in the first two assess- tum / n=266. women. the auricle, Anus, ex- ments (p=0.11, p=0.30, ternal genital organs, respectively). In the third Shenmen.” The volun- assessment, there was teers should press the pain difference between points for 30”, 1x / 4h. the groups (p=0.02). In the intervention group, In the analysis of pain a seed adhesive was through VDPS no dif- used while in the control ference was observed group a seedless adhe- between the groups at sive was used. any time (p=0.49, p= 0.27, p=0.06). As for paracetamol consumption (p=0.13, p=0.42, p=0.37).

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77 BrJP. São Paulo, 2019 jan-mar;2(1):72-80 Dutra LR, Araújo AM and Micussi MT

Table 2. Non-pharmacological analgesic resources for abdominal-pelvic pain relief in the immediate puerperium – continuation Authors Objective of Intervention groups Intervention Assessment tools Effectiveness of the inter- the study / n = vention (p<0.05) * sample Auriculotherapy and Acupuncture Marra et To assess the The patients were The intervention con- Acupuncture was con- Wrist-ankle acupuncture al.25 effectiveness divided into 2 equal sisted of wrist-ankle sidered ineffective when is a simple and effective of acupunc- groups with 21 acupuncture by insert- women treated with nee- method to reduce pain ture in relieving volunteers each: ing a needle in the right dles required one or more referred by episiotomy perineal pain Intervention group ankle. The needles were oral analgesics during after birth. Requests for after mediolat- underwent acu- inserted within 2 hours hospitalization (data were oral analgesics were sig- eral episiotomy puncture treatment; after birth by an acu- extracted from the medical nificantly more frequent in during birth/ Group without inter- puncturist physician in records by the acupunctur- the control group (p<0.01). n=42 vention that was not 21 patients. The group ist). treated with acupunc- without intervention ture. was monitored during the hospitalization and oral analgesic request. For additional pain relief, volunteers could request oral medication at any time during hospitalization. * p<0.05 accepted as significant. IG = Intervention Group; CG = Control Group. BPI = Brief Pain Inventory; ADL: activities of daily living; VAS = visual analog scale; CSAP = combined scale to assess pain that integrates VAS, face pain scale, categorical scale and numerical scale, and ranges from zero to 10, with zero indicating total absence of pain and 10 indicating extreme pain that can be felt. OW = operative wound; VNS = verbal numeric scale of pain; NRS = numeric rating scale; MPQ = McGill Pain Questionnaire; PRI = Pain Rating Index; VDPS = Verbal Descriptive Pain Scale (no pain, mild pain, moderate pain, severe pain). CI = confidence interval.

Non-pharmacological resource promote the analgesic effect. In this case, it is more recommend- 1) Transcutaneous electrical nerve stimulation - TENS ed for chronic painful condition28. Of the studies found, five (38.4%) treated TENS as an effec- In the literature can be found a study comparing the application tive therapy for the abdominal and pelvic pain relief in post- of TENS in the immediate postoperative period of gynecologi- partum women13,19-22. Of these, three analyzed abdominal pain, cal surgery with the use of opioids. In this study29, women were and post-cesarean section wound13,19,22 and two in an episiotomy randomly divided into two groups, in which they underwent region20,21. pain reduction intervention after surgery. One group received Two of these studies assessed the effectiveness of TENS at high high-frequency TENS and the other group, opioids. Both groups frequency19,21. One13 also assessed the high frequency comparing presented satisfactory pain relief results (p<0.001), indicating different intensities. The other two studies20,22 compared the ef- that non-pharmacological therapy is an excellent alternative for fectiveness of high and low frequency for pain reduction. Table these patients, minimizing the adverse and systemic effects of 2 shows the protocols used in each study. From these studies it pharmacological resources. is evidenced that the TENS presents a satisfactory result in the control of the pain in postpartum women, being the two inten- 2) Laser therapy sities able to produce benefits in the reduction of the painful Two studies (15.5%) investigated low-level laser therapy (LLLT) condition. for analgesia in an episiotomy region in postpartum women. It is possible to find described in the literature different types In the intragroup assessment, a statistical difference was found of TENS, for example conventional, burst, acupuncture, and before and after the intervention. However, no difference was brief-intense. According to the frequency, high (10 to 200Hz), found in the comparison between the intervention group and or low (2 to 4Hz), its application is indicated for acute and placebo23,24. chronic pain, respectively26. It is possible that this difference in results occurred due to the The use of high-frequency TENS is based on the pain gate the- protocols used in the studies in question. The first published ory proposed by Melzack and Wall in 196527. This theory ex- study24 was a pilot used as the basis for the second article23. San- plains that the electrical stimulus emitted by the device causes tos et al.24 presented results that did not provide accurate infor- excitation of the Aβ-afferent nerve fibers in the posterior horn of mation on the effect of LLLT on episiotomy using parameters the spinal cord and it rapidly inhibits the transmissions of pain- with a wavelength of 660nm, a dose of 3.8J/cm2 in three sessions ful impulses by the nerve conductors of pain through the spinal with a range of 20 to 24 hours between them. The authors concord. Therefore, its indication for the management of acute and cluded that the effect might not have occurred due to the ap- postoperative pain may be justified, as the higher the intensity plication of laser therapy since the control group also presented of the TENS current, the more units of receptor fibers will be significant results. Subsequently, one more group was added to recruited. In turn, the use of low-frequency TENS acts on the the study using a dosage of 8.8J/cm2; the groups with different stimulation of the release of endogenous opioids by the brain to wavelengths (660nm and 780nm) were compared to the placebo 78 Non-pharmacological therapies for postpartum BrJP. São Paulo, 2019 jan-mar;2(1):72-80 analgesia: a systematic review group21. The authors identified that regardless of wavelength ap- the same for the three groups. However, it is understood that the plied the primary outcome was not different between the groups. 20’ time is well established in the literature, bringing the expected It is believed that the result can be justified by the natural process benefits of cryotherapy over perineal pain15,17,18. of tissue recovery favoring the improvement of phlogistic signs/ Regarding the frequency of application, in the studies by Lu et al.15 pain, as well as by the Hawthorne phenomenon, in which there and Morais et al.18 participants were encouraged to apply com- is a change in the patient’s perception due to the special attention presses at least 3 times a day. The objective of these studies was to given by the team at the time of research23,24. investigate the long-term effect, and there are divergences between Despite the statistically insignificant results of laser therapy in the the results, unlike the studies by Leventhal et al.17 and Oliveira et reduction of pain in perineal trauma of postpartum women pre- al.16 that investigated the immediate effect and found significant sented by the studies23,24, there is an article29 that already shows results for pain relief after the achievement of a single application. promising results, indicating the effectiveness of laser therapy in Similar to the study by Morais et al.18, Lu et al.15 also assessed the perineal recovery and reduction of acute pain. An experimental patient 24 hours after birth and found no significant reduction of study30 demonstrated the analgesic effect after the application of pain at that time, however, they demonstrated a good result 48h laser therapy. The application of LLLT is expected to promote after birth. It is known that in the first hours after the tissue injury changes in cell membrane permeability, wound healing, muscle the inflammatory process is higher, causing an increase in local relaxation, immune system modulation, and nerve regeneration. metabolism, the release of inflammatory factors and a greater pain- In addition, it is also expected that in the intracellular environ- ful condition16. In this context, despite decreasing the local metab- ment a state of cellular hyperpolarization occurs that may inhibit olism, it is believed that the single application of cryotherapy, is the transmission of painful stimuli to the central nervous system31. not able to decrease the pain after 24 hours of birth. However, the As a consequence of the change of polarity added to the release use of several compresses in the first few hours postpartum15,18 may of histamine, serotonin, bradykinin and prostaglandins, there lead to an increase in the patient’s pain threshold due to a decrease will be a reduction of the inflammatory process and pain relief32. in metabolism and a decrease in the sensitivity of nerve endings34, For such effects to occur, wavelengths between 600 and 1000nm a fact that justifies long-term analgesia (48 hours). have been suggested and powers of 1mW to 5W/cm2. The au- According to the review performed by Malanga, Yan and Stark35, thors also emphasize that very low (2.5 W/cm2) or very high (25 cryotherapy acts in the reduction of pain after injury by sever- W/cm2) potencies can cause inverse effects33. al mechanisms of action. Initially, it promotes a decrease in the Few studies address LLLT in the immediate puerperium phase local temperature, provokes the sympathetic reflex of vasocon- with the aim of analgesia. Thus, it is prudent to suggest new striction with consequent diminution of the local circulation studies with different wavelengths, time and duration of applica- that culminates with the reduction of the inflammatory agents tion, dose and potency, before establishing any guidelines on the and reduction of the secondary hypoxia. The local temperature effectiveness of LASER in the treatment of pain in the region of reduction also causes localized anesthesia through a neuropraxia episiotomy in postpartum women. induced by a decrease in the activation threshold of the nocicep- tors and a decrease in the conduction velocity of the pain signal; 3) Cryotherapy a good result of cryotherapy for postoperative. Of the studies on analgesic resources for postpartum women, Based on the data described, it is evident that cryotherapy pro- four (30.7%) investigated the use of cryotherapy for the perineal vides good results in the momentary relief of perineal pain in the pain relief after vaginal birth. Of these, three15-18 presented statis- immediate postpartum period and is, therefore, a good resource tically significant results of the analgesic effect whereas only one to be used in the treatment of puerperal pain. It is still important showed the non-effectiveness of the use of ice for the pain relief to note that the compresses should be made for approximately in postpartum women18. 20 minutes and repeated times throughout the day, given their The divergence of the result found by Morais et al.18 in relation local physiological effect. to the other studies is explained throughout the study. The authors emphasized that initially, the patients presented very low 4) Acupuncture and Auriculotherapy levels of pain due to the absence of tissue injury, which may have Two studies (15.3%) analyzed the effects of Chinese medicine interfered in the final statistical result. The other studies15-17 as- techniques, acupuncture23, and auriculotherapy12 on reducing sessed patients who presented some degree of perineal lesion and, pain in postpartum women. consequently, developed an inflammatory picture, generating According to the review by Murakami, Fox and Dijkers36 auric- initially greater pain scores. ulotherapy has shown good immediate results in reducing pain, The application of cryotherapy varied among the studies. Three used has few adverse effects, is quick and easy to apply, and is a low- ice pack16-18, and one applied ice packs with temperature ranging be- cost therapy that must, therefore, be stimulated for use and re- tween 12ºC and 15ºC15. All articles applied cryotherapy in the per- search by health professionals. ineal region. Regarding the time of therapy, three15,17,18 studies used In the study of Kwan and Li14, after an adjusted analysis of the 20 minutes of application and one16 compared different times: 10’, data, a significant result of auriculotherapy was observed in the 15’ and 20’. Oliveira et al.16 identified that there was no difference reduction of pain 36h postpartum, but there was no reduction in the effects caused by cryotherapy with the time of application of after 12 and 24h. The study data are not conclusive about the 10’, 15’ and 20’, that is, from the 10’ of application, the effect was effectiveness of auriculotherapy in the treatment of pain. No 79 BrJP. São Paulo, 2019 jan-mar;2(1):72-80 Dutra LR, Araújo AM and Micussi MT statistical difference was found regarding paracetamol consump- 9. Abbaspoor Z, Akbari M, Najar S. Effect of foot and hand massage in post-cesarean section pain control: a randomized control trial. Pain Mang Nurs. 2014;15(1):132-6. tion and pain analysis through the Verbal Descriptive Pain Scale 10. Steen M, Cooper K, Marchant P, Griffiths-Jones M, Walker J. A randomized control- (VPDS) in the placebo and intervention groups. Thus, more led trial to compare the effectiveness of icepacks and Epifoam with cooling maternity gel pads at alleviating postnatal perineal trauma. Midwifery. 2000;16(1):48-55. studies on the application of auriculotherapy to postpartum 11. Verhagen AP, de Vet HC, de Bie RA, Kessels AG, Boers M, Bouter LM, et al. The Delphi women are recommended. list: a criteria list for quality assessment of randomised clinical trials for conducting syste- Auriculotherapy is a method of treatment of physical and psycho- matic reviews developed by Delphi consensus. J Clin Epidemiol. 1998;51(12):1235-41. 12. Moher D, Liberati A, Tetzlaff J, Altman DG. The PRISMA Group. principais itens somatic dysfunctions that acts by stimulating specific points in the para relatar revisões sistemáticas e meta-análises: a recomendação PRISMA. Epidemiol ear, promoting repercussions on neurological reflexes, neurotrans- Serv Saúde. 2015;24(2):335-42. 37 13. Olsén MF, Elden H, Janson ED, Lilja H, Stener-Victorin E. A comparison of high- ver- mitters, cytokines, immune system, and inflammatory processes . sus low-intensity, high-frequency transcutaneous electric nerve stimulation for painful According to a review37, the technique has good results in pain postpartum uterine contractions. Acta Obstet Gynecol Scand. 2007;86(3):310-4. 14. Kwan WS, Li WW. Effect of ear acupressure on acute postpartum perineal pain: a control in different situations; however, analgesia after operative randomised controlled study. J Clin Nurs. 2014;23(7-8):1153-64. procedures still has a controversial effect. This data corroborates 15. Lu YY, Su ML, Gau ML, Lin KC, Au HK. The efficacy of cold-gel packing for relieving the study by Kwan and Li14 that argues that vaginal birth with episiotomy pain – a quasi-randomised control trial. Contemp Nurse. 2015;50(1):26-35. 16. Oliveira SM, Silva FM, Riesco ML, Latorre Mdo R, Nobre MR. Comparison of appli- episiotomy can be considered a type of surgical intervention. cation times for ice packs used to relieve perineal pain after normal birth: a randomi- Regarding acupuncture, one study25 used the wrist-ankle region to sed clinical trial. J Clin Nurs. 2012;21(23-24)3382-91. 17. Leventhal LC, de Oliveira SM, Nobre MR, da Silva FM. Perineal analgesia with an treat perineal pain after vaginal birth with episiotomy, and the re- ice pack after spontaneous vaginal birth: a randomized controlled trial. J Midwifery sults were significant. The stimuli were performed in region 1 of Womens Health. 2011;56(2):141-6. 18. Morais I, Lemos A, Katz L, Melo LF, Maciel MM, Amorim MM. Perineal pain ma- the right ankle, local to pain located in the lower part of the body. nagement with cryotherapy after vaginal delivery: a randomized clinical trial. Rev Bras The study presented a significant result in the reduction of perineal Ginecol Obst. 2016;38(7):325-32. pain assessed through the reduction of oral analgesic use. Despite 19. Kayman-Kose S, Arioz DT, Toktas H, Koken G, Kanat-Pektas M, Kose M, et al. Transcutaneous electrical nerve stimulation (TENS) for pain control after vaginal de- the positive result, the study did not present quantitative data on livery and cesarean section. J Matern Fetal Neonatal Med. 2014;27(15):1572-5. pain in the perineal region, the primary outcome of the study. The 20. Pitangui AC, Araújo RC, Bezerra MJ, Ribeiro CO, Nakano AM. Low and high-frequency TENS in post-episiotomy pain relief: a randomized, double-blind clinical use of analgesic during the puerperal period may be associated with trial. Braz J Phys Ther. 2014;18(1):72-8. other complaints such as uterine or breast pain. Thus, although the 21. Pitangui AC, de Sousa L, Gomes FA, Ferreira CH, Nakano AM. High-frequency TENS in post-episiotomy pain relief in primiparous puerpere: A randomized, con- study presents good results, it is prudent to perform further studies trolled trial. J Obstet Gynaecol Res. 2012;38(7):980-7. analyzing the effect of the technique on perineal pain. 22. Lima, LE, Lima AS, Rocha CM, dos Santos GM, Bezerra AJ, Hazime AF, et al. High and low frequency transcutaneous electrical nerve stimulation in post-cesarean pain intensity. Fisioter Pesqui. 2014;21(3):243–8. CONCLUSION 23. Santos JdeO, de Oliveira SM, da Silva FM, Nobre MR, Osava RH, Riesco ML. Low- -level laser therapy for pain relief after episiotomy: a double-blind randomised clinical trial. J Clin Nurs. 2012;21(23-24):3513-22. Several non-pharmacological analgesic resources/methods used 24. Santos JdeO, Oliveira SM, Nobre MR, Aranha AC, Alvarenga MB. A randomised in postpartum woman care in the immediate postpartum peri- clinical trial of the effect of low-level laser therapy for perineal pain and healing after episiotomy: A pilot study. Midwifery. 2012;28(5):e653-9. od were assessed in this systematic review. Of these, only TENS 25. Marra C, Pozzi I, Ceppi L, Sicuri M, Veneziano F, Regalia AL. Wrist-ankle acupunc- and cryotherapy presented well-established data regarding the ture as perineal pain relief after mediolateral episiotomy: a pilot study. J Altern Com- significant effect on the reduction of abdominal/pelvic pain in plement Med. 2011;17(3):239-41. 26. Han JS, Chen XH, Sun SL, Xu XJ, Yuan Y, Yan SC, et al. Effect of low- and high- postpartum women. -frequency TENS on Met-enkephalin-Arg-Phe and dynorphin A immunoreactivity in human lumbar CSF. Pain. 1991;47(33):295-8. REFERENCES 27. Melzack R, Wall PD. Pain mechanisms: a new theory. Science. 1965;150(3699):971-9. 28. Mello LF, Nóbrega LF, Lemos A. Estimulação elétrica transcutânea no alívio da dor do trabalho de parto:revisão sistemática e meta-análise. Rev Bras Fisioter. 2011;15(3):175-84. 1. Woods AB, Crist B, Kowalewski S, Carroll J, Warren J, Robertson J. A cross-sectional 29. Platon B, Mannheimer C, Andréll P. Effects of high-frequency, high-intensity trans- analysis of the effect of patient-controlled epidural analgesia versus patient controlled cutaneous electrical nerve stimulation versus intravenous opioids for pain relief after analgesia on postcesarean pain and breastfeeding. J Obstet Gynecol Neonatal Nurs. gynecologic laparoscopic surgery: a randomized controlled study. Korean J Anesthesi- 2012;41(3):339-46. ol. 2018;71(2):149-56. 2. Mathias AE, Pitangui AC, Vasconcelos AM, Silva SS, Rodrigues PS, Dias TG. Pe- 30. Kymplová J, Navrátil L, Knízek J. Contribution of phototherapy to the treatment of rineal pain measurement in the immediate vaginal postpartum period. Rev Dor. episiotomies. J Clin Laser Med Surg. 2003;21(1):35-9. 2015;16(4):267-71. 31. Bertolini GR, Silva TS, Ciena AP, Trindade DL. Efeitos do laser de baixa potência sobre 3. Mascarello KC, Matijasevich A, Santos ID, Silveira MF. Early and late puerperal com- a dor e edema no trauma tendíneo de ratos. Rev Bras Med Esporte. 2008;14(4):362-6. plications associated with the mode of delivery in a cohort in Brazil. Rev Bras Epide- 32. Chow RT, Johnson MI, Lopes-Martins RA, Bjordal JM. Efficacy of low-level laser therapy miol. 2018;21:e180010. [English, Portuguese; Abstract available in Portuguese from in the management of neck pain: a systematic review and meta-analysis of randomised, the publisher]. placebo and active-treatment controlled trials. Lancet. 2009;374(9705):1897-908. 4. Cardoso PO, Alberti LR, Petroianu A. [Neonatal and maternal morbidity related to 33. Huang YY, Chen AC, Carroll JD, Hamblin MR. Biphasic dose response in low level the type of delivery]. Cien Saude Colet. 2010;15(2):427-35. light therapy. Dose Response. 2009;7(4):358-83. 5. Kainu JP, Sarvela J, Tiippana E, Halmesmäki E, Korttila KT. Persistent pain after cae- 34. Knight KL. Cryotherapy in Sport Injury Management. Champaign: Human Kinetics; sarean section and vaginal birth: a cohort study. Int J Obstet Anesth. 2010;19(1):4-9. 1995. 6. Christianson LM, Bovbjerg VE, McDavitt EC, Hullfish KL. Risk factors for perineal 35. Malanga GA, Yan N, Stark J. Mechanisms and efficacy of heat and cold therapies for injury during delivery. Am J Obstet Gynecol. 2003;189(1):255-60. musculoskeletal injury. Postgrad Med. 2015;127(1):57-65. 7. Çitak Karakaya I, Yüksel I, Akbayrak T, Demirtürk F, Karakaya MG, Ozyüncü Ö, et 36. Murakami M, Fox L, Dijkers MP. Ear Acupuncture for immediate pain relief-a al. Effects of physiotherapy on pain and functional activities after cesarean delivery. systematic review and meta-analysis of randomized controlled trials. Pain Med. Arch Gynecol Obstet. 2012;285(3):621-7. 2016;18(3):551-64. 8. Buhagiar L, Cassar OA, Brincat MP, Buttigieg GG, Inglott AS, Adami MZ, et al. 37. Hou PW, Hsu HC, Lin YW, Tang NY, Cheng CY, Hsieh CL. The History, mecha- Predictors of post-caesarean section pain and analgesic consumption. J Anaesthesiol nism, and clinical application of auricular therapy in traditional Chinese medicine. Clin Pharmacol. 2011;27(2):185-91. Evid Based Complement Alternat Med. 2015;2015:495684.

80 BrJP. São Paulo, 2019 jan-mar;2(1):81-7 REVIEW ARTICLE

Adherence to fibromyalgia treatment: challenges and impact on the quality of life Adesão ao tratamento da fibromialgia: desafios e impactos na qualidade de vida

José Oswaldo de Oliveira Júnior1, Júlia Villegas Campos Ramos2

DOI 10.5935/2595-0118.20190015

ABSTRACT RESUMO

BACKGROUND AND OBJECTIVES: Fibromyalgia is a JUSTIFICATIVA E OBJETIVOS: A fibromialgia é uma sín- chronic and idiopathic syndrome, characterized by a general drome crônica e idiopática, caracterizada por queixa dolorosa de distributed pain, more prevalent in women. Its pathophysiolo- distribuição generalizada, mais prevalente em mulheres. A sua gy remains unclear. Its chronicity implies an exclusively symp- fisiopatologia continua não totalmente esclarecida. Sua cronici- tomatic treatment, often unsatisfactory. The lack of adherence to dade implica em tratamento exclusivamente sintomático e mui- the established treatment is quite common. The objective of this tas vezes insatisfatório. A falta de adesão ao tratamento instituído study is to present a review of the adherence to the fibromyalgia é bastante comum. O objetivo deste estudo foi apresentar uma syndrome treatment. revisão sobre a adesão do tratamento da síndrome fibromiálgica. CONTENTS: The concept of adherence to the fibromyalgia CONTEÚDO: O conceito de adesão ao tratamento da sín- syndrome treatment, its classification, the identification of its drome fibromiálgica, sua classificação, a identificação das opções measurement options, and the detection of its causes are de- de sua mensuração, e a detecção de suas causas são detalhados, tailed, revised and updated. revisados e atualizados. CONCLUSION: The review of the literature regarding the ad- CONCLUSÃO: A revisão da literatura referente à adesão ao trat- herence to the fibromyalgia syndrome treatment points to a large amento da síndrome fibromiálgica mostra um grande contingen- number of nonconformity of prescription, in general with the te de inconformidade de prescrição, em geral predominando a prevalence of the adoption of the reduction of the recommended adoção da redução da dose orientada e a interrupção do próprio dose and the interruption of the treatment, over possible overdoses and self-medication. The study of the causes that led to the tratamento, sobre possíveis sobredoses e automedicações. O es- non-adherence to the treatment elects the characteristics of the tudo das causas que levaram à falta de adesão ao tratamento elege syndrome as the great villain for its occurrence. However, other as características da própria síndrome como a grande vilã para associated factors such as the age of the subject with fibromyal- sua ocorrência; embora, tenham sido também elencados outros gia, the intensity of the pain, the established polypharmacy, the fatores associados como a idade do portador da síndrome fibro- quality of the doctor-patient relationship and the socioeconomic miálgica, a intensidade da dor, a polifarmácia instituída, a quali- variables were also listed. The patient’s quality of life was always dade da relação médico-paciente, e as variáveis socioeconômicas. higher in patients with higher adherence to treatment and per- A qualidade de vida dos pacientes sempre foi maior naqueles cuja sistence. Patients’ quality of life indices may indicate the level of adesão e persistência ao tratamento foram maiores. Os índices de commitment to treatment adherence, and vice versa. qualidade vida dos pacientes podem indicar o nível de compro- Keywords: Adherence, Compliance, Fibromyalgia, Nonphar- metimento com a adesão ao tratamento, e vice-versa. macologic treatment, Persistence, Pharmacologic treatment, Descritores: Adesão, Conformidade, Conformidade terapêuti- Therapeutic conformity. ca, Fibromialgia, Persistência, Tratamento farmacológico, Trata- mento não farmacológico.

INTRODUCTION

José Oswaldo de Oliveira Júnior - https://orcid.org/0000-0003-1748-4315; Julia Villegas Campos Ramos - https://orcid.org/0000-0003-4674-2459. Fibromyalgia (FM) is a chronic pain syndrome with complex, multifactorial, and yet not fully understood etiopathogenesis. 1. Hospital A C Camargo, São Paulo, SP, Brasil. 2. Hospital do Servidor Público Estadual de São Paulo, São Paulo, SP, Brasil. The most striking FM feature is generalized musculoskeletal pain, associated with a sleep disorder, fatigue, cognitive alter- Submitted in October 23, 2018. Accepted for publication in January 18, 2019. ations, and psychic disorders. Conflict of interests: none – Sponsoring sources: none FM prevalence ranges from 0.2 to 6.6% in the general popula-

Correspondence to: tion, with women more affected than men, in a ratio of 9:1, be- José Oswaldo de Oliveira Júnior ing more frequent in the age group between 40 and 55 years. The E-mail: [email protected] prevalence of psychic disorders, especially depression, among © Sociedade Brasileira para o Estudo da Dor FM patients ranges from 49 to 80%1. 81 BrJP. São Paulo, 2019 jan-mar;2(1):81-7 Oliveira Júnior JO and Ramos JV

Treatment adherence of fibromyalgia syndrome (FMS) can be the treatment, pharmacological or not, he will not be cured; defined as the extent to which the patient’s behavior is in line and moreover, although making him suffer, it will not kill with the recommendations of the health care professional (or him: “He will die with it, not because of it”. In this scenario, group of professionals)2 regarding drug use, a proper diet up or the possible benefits and risks inherent to adherence seem to changes in lifestyle. Such recommendations aim at the remission lose relevance from the point of view of the treatment target. or control of the syndrome, and the consensual obedience can It is important to invest in the education of the medical care make the difference between success or failure. team to clarify each prescribed item. An example is an orientation not to use a particular drug which, although providing THE CONCEPT OF ADHERENCE AND ITS EVOLUTION identifiable analgesia, may pose a risk to the integrity of vital organs. Research and discussion on adherence have evolved from a Several studies agree that partial or total failure of adherence to one-dimensional approach limited to the follow-up of a phar- pharmacological prescription regimes results in increased mor- macological regimen, to the understanding of the factors in- bidity and mortality due to a wide variety of diseases, as well volved in the treatment success or failure. The focus has been as increased costs involved with the respective medical care4-8. extended beyond the patient. Nowadays, it is widely recognized that several factors mediate the treatment of a disease Measuring the adherence to the fibromyalgia treatment by or health condition. patients The adherence model proposed by the World Health Orga- A number of non-compliance modalities have been compiled, nization (WHO) illustrates the participation of some factors among them, the lack of pharmacological compliance (also in the adherence process, namely aspects related to the health known as lack of adherence to pharmacotherapy), which cor- care team, factors related to the treatment itself, aspects re- responds to the disobedience to the recommendations made lated to the disease, the patient and socioeconomic factors2. by the prescriber regarding time, dose and/or frequency of one or a set of drugs. Thus, on the other hand, pharmacologi- Fibromyalgia characteristics and the importance symp- cal adherence can be defined as “the extent to which a patient toms refractiveness respects the use (by the expressly oriented route) of the drug Aspects related to fibromyalgia are particularly crucial factors (without substitutions, even if by similarity), at the recom- in adherence to its treatment. mended dose and in the respective time interval prescribed”. The acceptance of the diagnosis of a non-curable disease is far Adherence, or compliance, can be measured over a period from tacit and is often associated with the denial of both the and reported as a percentage. The definition is operational- disease and its treatment. Even in the medical field, there are ized in prospective dose assessments and relates them to what still questions about considering FM as an isolated entity. The was originally prescribed. The standardization of compliance poor findings in the physical examination of these patients are is prepared for a patient whose prescription conceives the remarkable, being restricted to the presence of diffuse points once-daily administration of the drug. of pain and often with itinerant preferential commitment. Electronic monitoring provides sufficient detail to calculate One of the main reasons that lead a patient not to adopt or the number of doses taken daily, as well as whether doses have interrupt a prescription, whether pharmacological, dietary, been taken at appropriate intervals (e.g., approximately 12 behavioral or the combination of one or more previous rec- hours for a dose twice a day). Additional details can be ob- ommendations, is the persistence of symptoms, especially tained, such as the number of days with extra doses or the painful ones. number of days in which none of them were administered9. The remarkable FM prevalence in 2% of the world population, associated with the suffering attributed to it, to its Persistence in adherence pathophysiology not yet completely revealed, to the progno- Another non-compliance modality is the abandonment of a sis regarding the possibility of cure, and to the unsatisfactory particular treatment before the end of the prescribed period. results in the control of its symptoms3, especially the painful So, the persistence of pharmacological adherence can be de- ones, make it a huge challenge when it comes to treatment fined as “the time duration from the beginning of the therapy adherence. to its discontinuation”. The continuity in taking any amount of drug is consistent Adherence to pharmacological treatment in fibromyalgia with the definition of persistence. This definition can be op- Inadequate adherence and persistence in pharmacological erationalized in prospective and retrospective assessments, treatment are old problems. When the patient fails faithful determining the beginning of the treatment (or a point in obedience and adherence to the prescribed dosage, changes time during a chronic treatment), and another point in the may occur, consequently changing the relationship between timeline defined as the end of the observation period. probable benefits and respective risks. In FM, there is a large Patients with FM can receive drugs whose stable analge- gap to be shared with the patient about his/her diagnosis, ill- sic effects are expected only after a relatively long period of ness, possible risks, and benefits on whether or not to adhere administration. The therapeutic outcome obtained by these to a proposed treatment. Patient has in mind that whatever is drugs should consider the persistence of treatment adherence. 82 Adherence to fibromyalgia treatment: challenges BrJP. São Paulo, 2019 jan-mar;2(1):81-7 and impact on the quality of life

Often, patients need clarification about the drug and are un- scription, especially when the patient administers the drug13. aware of the elapsed time between start taking the drug and Treatment duration, with no fixed time as in the case of FM, the analgesic effect. After a short period without the desired seems to have significant influence for the discontinuation or relief, they end up quitting the treatment. The history data lack of adherence. provided by those patients in future medical visits erroneous- The non-compliance transcends the limit of the categories ly reports such drugs as ineffective, not being considered for of diseases and age group. However, this is more prevalent further testing9,10. during adolescence, when the transition process from parents’ Persistence, by definition, is reported as a continuous variable dependence to autonomy produces confusion over who is rein terms of the number of days for which the therapy was avail- sponsible for administering the drug. able. Persistence can also be reported as a dichotomous variable Non-compliance may result in misjudgment of the efficacy of measured at the end of a predefined period (e.g., 12 months), a drug or regimen that may require additional testing, dose considering patients as “persistent” or “non-persistent”. modification, treatment course, and hospitalization. Currently, in oncology referral centers, such as the AC Cam- Definitions and standardizations for persistence assess- argo Cancer Center and the MD Anderson Cancer Center, ment and treatment adherence a large percentage of pediatric cancer patients are treated ac- Clinical results of treatment are affected not only by how pa- cording to research protocols. In these scenarios, non-con- tients take their drugs but also by the period they are taken. formity may result in erroneous or inconsistent discoveries, Thus, adherence from one side and persistence from another potentially affecting the survey results and consequently its should be defined and measured separately to characterize the conclusions13. behavior of comprehensively taking a prescribed drug. With the availability of venous accesses and sophisticated but The adherence and persistence approaches provide a richer easy-to-operate pumps, it is increasingly possible to admin- understanding of behavior versus drug treatment. The adop- ister parenteral drugs at home. This adds a new dimension tion of the proposed definitions focuses on the promotion of to self-administration that previously involved primarily oral consistent terminology and methodology that may assist the therapy. conduct, analysis, and interpretation of scientific data collect- Several factors relating to patient, disease, health providers ed in studies on pharmacological adherence11. and treatment characteristics determine how well a given reg- Definitions focus on future standardization in surveys to al- imen is followed. As it involves a significant number of de- low comparisons between reports and use of adherence and terminants, it is not often possible to identify non-compliant persistence data for drug-economic analyzes. Standardization patients or to predict the patient’s level of adherence to treat- may contribute to future health policy decisions based on ment with any degree of certainty. The main factors in any consistent evidence. successful therapy include the availability of effective drugs The definition is operationalized in retrospective assessments and adherence to the therapeutic regimen13. such as the number of doses dispensed in relation to the dis- With the advent of more successful treatments for cancer in pensing period. Conformity with prescription is assumed childhood and adolescence, the compliance factor is becom- when the drug is dispensed11. ing more important because today, therapy has a curative rather than palliative intent. However, this does not apply Advantages of supervised home-administration regimens to FM, where therapies remain exclusively symptomatic. The Compliance with drug regimens and follow-up visits of psy- availability of questionnaires, tests, and devices can help, to chiatric patients was evaluated, and the criteria for good ad- some degree, to examine the patient’s degree of adherence13. herence were met12 in less than one-third of them. Adherence was significantly related to the positive belief about the drug Characteristics of the treated disease or syndrome and ad- usefulness, treatment duration shorter than five years, phar- herence macological dosage once or twice a day and drug supervision Family and social support, individualized programs, remind- at home. When those with low adherence received the same ers to reduce forgetfulness, personalized needs assessment and dosage regimen, home supervision and when they received education can reduce non-compliance. Compliance is a com- convincing counseling about the drug usefulness and possible plex and multifaceted issue that is still poorly understood and efficacy, there was an improvement in adherence and a conse- requires additional research13. quent reduction in the rate of relapse, significantly lower than Regarding the aspects related to the disease, it is possible to in the controlled group at the end of one-year follow-up. The highlight the symptoms magnitude, the disease characteristics importance of family support and understanding the patients’ and its evolution, chronicity and the impact on the patient’s cultural histories to ensure compliance were highlighted12. life. Regarding chronic pain, a recent literature review showed that the rate of non-adherence to prescriptions for chronic pain The probable prognosis of the treated disease or syndrome ranged from 8 to 62%. It is in this universe that FMS falls14,15. and adherence Underuse was more frequent than overuse and was associat- Even in diseases with potentially deadly outcomes such as ed with active coping strategies and self-medication in most cancer, there is a significant non-compliance rate of the pre- studies. Age, pain intensity, dosage, polypharmacy, quality 83 BrJP. São Paulo, 2019 jan-mar;2(1):81-7 Oliveira Júnior JO and Ramos JV of the physician-patient relationship, the class of drugs pre- a physical activity program and, in those patients with mood scribed and the perception of the need for a continuous anal- disorder, or without coping strategies, the cognitive-behavioral gesic drug were factors associated with non-adherence14. therapy13. Socioeconomic variables also interfere with adherence. Pharmacological treatment includes pain moderators such as Among the several factors, we can list the cost of the drug, selective serotonin reuptake inhibitor antidepressants (alone) health policies, access to health service, waiting time versus and so-called dual (serotonin and noradrenaline), non-se- service time, gender, educational level, and social class. lective tricyclic agents (such as amitriptyline and cycloben- Factors associated to the patient include lifestyle, social network, zaprine) and anticonvulsant agents (such as pregabalin and family context, age group, emotional state, associated diseases, gabapentin)3,18. cognitive aspects (e.g., dysfunctional beliefs and disbeliefs) to Adherence to FM pharmacological treatment is considered low previous experience with the disease. Regarding beliefs, many worldwide, and varies among the different drugs, with tricyclic patients resist the use of opioids, antidepressants, and anticon- agents being the most rapidly abandoned, and adherence was vulsants by the associated myths or stigmas. higher in the group that received more selective antidepres- The aspects related to the healthcare team are the team-patient sants18-20,22. Among the more selective, noradrenaline and sero- relationship, communication, professionals’ beliefs, among oth- tonin reuptake inhibitors, also known as dual inhibitors, similar ers. This myriad of elements clearly indicates the complexity of to tricyclics, produce central analgesia acting on descending in- the adherence process. hibitory nerve pathways. In general, duals have a better tolerabil- Regarding treatment, its positive or undesirable effects, access ity and adverse effects profile than tricyclics, which may explain to treatment, and complex therapeutic schemes are important their adherence and persistence rates3. factors to be highlighted. The discontinuity rate in the general use of the standard tricyclic, The communication skills of the physician and the healthcare amitriptyline (AMT), is around 35%, and the greatest motiva- team are essential in this context. The operation and effects of the tor for discontinuity is its adverse effects. However, these stud- drug or procedure should be clearly explained and the prescrip- ies included high doses of AMT, as in the case of treatment for tions clear and legible. depression. Also, in the case of very low doses, the unit dose Despite the importance of the theme, and although theoretical method may overestimate the low adherence19. Another motiva- discussions have been taking place since the 1950s, the subject is tor for discontinuation or non-initiation of AMT use and other little investigated16 and it is even less investigated when it comes tricyclics for analgesic purposes is the absence of official label specifically to FM, whose consensus and unified terminological documentation for this particular indication. The exclusive label adoption occurred only in the late 1980s. of antidepressant may induce the potential reader to interpret Chronic pain is a public health problem and is classified as a dif- that the prescriber may consider the pain, therapeutic targets, as ficult-to-control pain, characterized by frequent treatment fail- of primary or predominantly psychoactive origin. Despite scien- ure. In the clinical context of the patients with FMS it is possible tific evidence of the tricyclics’ analgesic effect, in many countries, to more easily perceive some elements, among them the reduced the leaflet remains obsolete, unchanged, due to costs of a review effect of the drug, in many cases not occurring the complete re- and update, incompatible with the low unit marketing price of mission of the symptoms, the adverse effects (e.g. drowsiness, these drugs. loss of libido, numbness, constipation), and its high cost17. The FDA approved only three drugs for the FM treatment. One is pregabalin, and the other two are dual antidepressants: dulox- Impact on the quality of life of patients with fibromyalgia etine and milnacipran. Duloxetine has the best efficacy evidence Patients with FM have a tremendous negative impact on their for FM treatment, usually in a single daily dose of 60mg (ranging quality of life (QoL), they feel a high degree of disability, even from 30 to 120mg), mainly when there is depressive morbidity in daily tasks. This increase or predisposes to symptoms of de- associated, with or without anxiety. In addition to anxiety, depression and anxiety, which in turn worsens pain and closes the pression is also another morbidity that can prevent the patient to chronicity cycle. This impact on QoL is directly related to the adhere to treatment. Di Matteo et al.4 concluded that the risk of general economic cost of the disease. non-adherence is 27% higher in this group, regardless the under- Compared to other chronic diseases, FM has been shown as a lying disease to be treated. condition that mostly demands health care. The high costs gen- Cui et al.20 evaluated the adherence of patients with fibromyalgia erated by this condition are indirect. They involve loss of pro- to the treatment with duloxetine and showed that one-third of ductivity, decrease in the number of hours and days worked, them had a strong adherence, and among them, the predictive unemployment and early withdrawal from the labor market. factors for better adherence were age above 35 years and previous Direct and indirect costs increase according to the severity of use of selective antidepressants (serotonergic inhibitors or sero- the disease17. tonergic and noradrenergic). The same group of investigators, in a study involving more than 18,000 patients, concluded that ad- Adherence and persistence to the pharmacological treatment herence and persistent use of duloxetine were similar in groups of of fibromyalgia. patients with depressive disorder, FM and osteoarthritis, and sig- FM treatment includes non-pharmacological and pharmacolog- nificantly higher than the results found for patients with chronic ical approach. The non-pharmacological approach consists of lower back pain21. 84 Adherence to fibromyalgia treatment: challenges BrJP. São Paulo, 2019 jan-mar;2(1):81-7 and impact on the quality of life

A group of anticonvulsants called gabapentinoids are useful as It is not uncommon for the fibromyalgia patient to feel frustrat- analgesics in several situations. They act on the alpha2-delta sub- ed by not finding the expected explanation for his/her symp- units of receptors that control ionic channels of dynamic perme- toms. In an attempt to reduce such frustration, Hyland et al.24 ability to voltage-dependent calcium. Inhibitory action in these studied an original narrative to explain to the patient the FM’s subunits reduces the release of excitatory neurotransmitters in dysfunctional pain. painful pathways, resulting in analgesia. The approval provid- Hyland et al.24 studied the physician-patient relationship in the ed by the official US Food and Drug Administration (FDA) for chronic pain research context of Kenny25, which stated that po- these drugs in the FM treatment allowed the inclusion of that tentially curative interactions between physicians and their pa- indication in the leaflet and the lay advertisement. tients, which are not based on the biogenic model of the visible Sanchez et al.22 recorded data on the adherence and persistence body or the psychogenic model of invisible pain, are needed to of patients with FM, post-herpetic painful neuropathy and di- aid communication between patients with chronic pain and abetic peripheral polyneuropathy treated with gabapentinoid their physicians. known as pregabalin. The narrative proposes that the patient’s body is comparable to a Sanchez et al.22 showed that the majority of patients prescribed computer, with FM being a predominant problem of program- with pregabalin received lower doses than those considered ideal ming (or “software”) rather than structure (or “hardware”). This for the best response (450mg). Costs with the pharmacy were low- narrative invites the patient with FM to engage in non-pharma- er due to the use of lower doses. However, both the therapeutic re- cological measures that may contribute to reprogram the “com- sult and adherence were significantly lower in the same group. The puter”. The strategy also favors the patient by communicating total medical costs among the group using recommended doses that he/she can be the protagonist in a struggle that he/she will and those using lower doses were comparable, suggesting that the continue to face despite the difficulties. prescription of the recommended therapeutic dose can increase The authors evaluated the patients’ opinions regarding the pro- adherence without increasing the costs involved. posed narrative and found great acceptance with a welcome perception25-27. Adherence to the treatment of fibromyalgia and the physi- Several studies on adherence to treatment agree on the impor- cian-patient relationship tance of the physician-patient relationship. The multidisciplinary Dobkin, Sita and Sewitch23 evaluated 142 patients with FM re- team should clearly and patiently explain the diagnosis, the lim- cruited from tertiary and community centers. They measured itations of the medicine regarding the FM etiopathogenesis and adherence, pain, psychological changes, coping, the perception the treatment of other chronic diseases. of social support, and the number of associated diseases. The flexibility of access to the physician for clarification of ques- They also compared the physician’s and the patient’s interpretations that may arise regarding the dosage or adverse effects of the tion regarding the state of health of the FM-carrier. The results prescribed drug is a safety factor that may increase adherence to showed that the greater adherence to treatment is related to the the treatment. lower psychological changes degree and the lower physician/pa- The proportion of patients who show significant improvement tient disagreement regarding the patient’s health state23. (reduction of at least 50% in pain) with currently available phar- Data on health status differed between therapist and patient macological treatment is low, generally 10 to 25% higher than perspectives. The physician generally attributed less attention placebo, and it is necessary to treat 4 to 10 patients to obtain to the patient’s emotional well-being in relation to the note he/ the mentioned improvement. Therefore, dose optimization and she attributed to himself/herself in his/her own assessment. Such the emphasis on the association of non-pharmacological therapy discrepancy may lead to a lack of confidence by the patient, be- may motivate persistence when obtaining better results. lieving that the physician attributed his/her symptoms not to an organic cause but to an “emotional problem”23. Quality of life of patients with fibromyalgia Regarding the presence of psychological changes such as depression QoL indicates the level of the basic and supplementary condi- and anxiety, the study is in agreement with others that also showed tions of the human being. These conditions involve physical, the negative association of these factors with the adherence. mental, psychological and emotional well-being, social rela- Lack of hope and self-motivation, present in these cases, may tionships such as family and friends, as well as health, educa- impair the patient’s commitment to any change, including tion and other parameters affecting human life. The economist treatment23. Galbraith created the concept in 1958, which conveys a different view of the priorities and effects of quantitative economic Patient’s faithfulness or achievement and his/her adherence objectives. to treatment According to Galbraith, political-economic and social goals The challenge of “win the patient” for his/her own disease’s treat- should not be marked in terms of quantitative economic growth ment, in the case of FM, begins with the diagnosis. and material growth in living standards, but rather in qualitative Fibromyalgia, or fibromyalgia syndrome, is a diagnosis of ex- improvement of human living conditions, which would be pos- clusion, and it is only given after thorough medical history and sible only through a better development of social infrastructure physical examination, and a series of unchanged complemen- and the elimination of disparities, both regional and social, and tary tests. to the defense and preservation of the environment. 85 BrJP. São Paulo, 2019 jan-mar;2(1):81-7 Oliveira Júnior JO and Ramos JV

Obtaining a good QoL depends on the adoption of healthy tive impact on QoL and the ability to manage their symptoms habits, body care, balanced nutrition, healthy relationships, effectively18,42. time for leisure and several other habits that make the individ- When asked what they expected from their professional care- ual feel good. As a consequence, the individual can use humor givers (physicians, nurses, physiotherapists, psychologists, to deal with stressful situations, giving the sense of control over technicians, and attendants), more than half expected their his/her own life. support and access to further and better information about QoL is different from the standard of living, although there their illness. Nearly a third of FM patients simply wanted to is confusion between these two terms. Standard of living is a know if they actually believed that the disease with which they measure that quantifies the quality and quantity of goods and were diagnosed really existed. These desires took precedence services that a particular person or group may have access to. over the development of more effective drugs, more funding for FM, as already described, is a condition that is not yet fully research and better diagnosis18,24,43. understood, persistent, without cure, with an exclusively symp- Patients are more satisfied when their physicians adopt a thera- tomatic treatment28,29 and that certainly does not promote a peutic set, not limited to the prescribed drugs, and use a greater good level of QoL. variety of methods to deal with FM symptoms, showing more Pharmacological and non-pharmacological measures to mini- concern with them. The use of positive coping strategies can mize pain, relieve depression and improve sleep, provide lim- be therapeutic and reduce the severity of symptoms. Exercises ited success and are associated with adverse effects30. Even al- and stress management techniques such as relaxation exercis- ternative forms of treatment do not bring great relief31. Many es, meditation, prayer, hobby, and conversation with friends, people have never experienced complete relief from their family, or healthcare professionals are forms of therapy for symptoms, even ephemerally31. Thus, what remains for those FM18,24,44. who suffer from FM is limited to managing the syndrome, i.e., The detection of the possibility of the domino effect or even a learning to live and dealing with a wide variety of symptoms in- “vicious circle” that QoL problems can produce, and their clear cluding diffuse pain, fatigue, non-restorative sleep, depression, communication, have a positive impact. For example, these ef- anxiety, irritable bowel syndrome, multiple chemical sensitivity fects are felt in the restrictions of daily activities caused by FM syndrome, premenstrual syndrome, stiffness, cognitive impair- symptoms, which in turn can lead to a state of depression, and ment, and restless legs syndrome. depression can progressively limit their activities, producing an Several studies have examined the QoL of patients with FM even more pronounced depression24,45. and found that their QoL is extremely low compared to other The lack of support and trust between FMS patients and their groups32-37. In Brazil, a sample of women with FM was stud- healthcare providers only increases the stress. When comparing ied and revealed a lower pain threshold and worse QoL than a other chronic pain conditions, the population suffering from control group of healthy women, although no correlation was FM is the one that receives less professional and social support. found between pain measurements and QoL38. Not only the Support groups, whether traditional or using modern electron- lack of adherence to pharmacological treatment schemes occurs ic means, can help46. and implies a worse FM control, but physical activity programs Fibromyalgia patients plead and need to be empowered to are also affected by the lack of commitment in its execution manage their symptoms. Such empowerment involves provid- and assiduity. ing support, teaching on how to deal with strategies, and also People with FM seem to have smaller social support networks opportunities to explore nontraditional therapies to manage than patients with other chronic diseases39,40, which probably their syndrome47. contribute to lower QoL rates. The ability to work also has an impact on QoL. People with FM CONCLUSION lose it due to their symptoms. Such patients report a considerable negative impact on their QoL, and their level of perceived The current review of the literature regarding adherence to FMS disability also seems to be influenced by their mental health treatment shows a large contingency of prescription non-con- condition. The psychological distress is greater compared with formity, with the predominance of target dose reduction and patients with other pain conditions41. discontinuation of treatment when compared to the rare cases A significant number of fibromyalgia patients may use alcohol of overdoses and self-medication. or other drugs in an attempt to obtain a bearable distance from The study of the causes leading to the lack of adherence and reality, while others, unfortunately, choose suicide. The risk of persistence to the treatment selects the characteristics of the these outcomes can be predicted and at least reduced with the syndrome itself as the great villain for its occurrence; although evaluation and multiprofessional follow-up during patients’ other associated factors such as the age, pain intensity, the poly- monitoring41. pharmacy instituted, the quality of the physician-patient relationship and the socioeconomic variables were also listed. Fibromyalgia patients’ needs under their own perspectives The QoL of the patient was always higher in those whose ad- The satisfaction or non-satisfaction of patients in relation to herence and persistence to the treatment was higher. Patients’ their healthcare providers can have an impact on their attitudes QoL indexes may indicate the level of commitment to adhere and on how they deal with the disease, and thus have a nega- to treatment, and vice versa. 86 Adherence to fibromyalgia treatment: challenges BrJP. São Paulo, 2019 jan-mar;2(1):81-7 and impact on the quality of life

REFERENCES ned pain to fibromyalgia patients: finding a narrative that is acceptable to patients and provides a rationale for evidence based interventions. Br J Pain. 2016;10(3):156-61. 25. Kenny DT. Constructions of chronic pain in doctor-patient relationships: bridging 1. Lorente GD, Stefani LF, Martins MR. Cinesiofobia, adesão ao tratamento, dor e quali- the communication chasm. Patient Educ Couns. 2004;52(3):297-305. dade de vida em indivíduos com síndrome fibromiálgica. Rev Dor. 2014;15(2):121-5. 26. Asbring P, Närvänen AL. Ideal versus reality: physicians perspectives on patients with 2. Sabaté E. Adherence to long-term therapies: evidence for action. World Health Orga- chronic fatigue syndrome (CFS) and fibromyalgia. Soc Sci Med. 2003;57(4):711-20. nization. 2003. 27. Perrot S, Choy E, Petersel D, Ginovker A, Kramer E. Survey of physician experiences 3. Oliveira Jr JO, Almeida MB. The current treatment of fibromyalgia. Br J Pain. and perceptions about the diagnosis and treatment of fibromyalgia. BMC Health Serv 2018;1(3):255-62. Res. 2012;12:356. 4. DiMatteo MR, Giordani PJ, Lepper HS, Croghan TW. Patient adherence and medi- 28. Clauw DJ. Fibromyalgia: more than just a musculoskeletal disease. Am Fam Physi- cal treatment outcomes: a meta-analysis. Med Care. 2002;40(9):794-811. cian. 1995;52(3):843-51, 853-4. Erratum in: Am Fam Physician. 1996;54(6):1896. 5. Cramer JA. Partial medication compliance: the enigma in poor medical outcomes. Am 29. Buckelew SP. Behavioral interventions and fibromyalgia. J Musculoskel Pain. J Manag Care. 1995;1(1):45-52. 1994;2:153-61. 6. Zyczynski TM, Coyne KS. Hypertension and current issues in compliance and patient 30. McCain GA. Treatment of fibromyalgia syndrome. J Musculoskel Pain. 1994;2:93-104. outcomes. Curr Hypertens Rep. 2000;2(6):510-4. 31. Pioro-Boisset M, Esdaile JM, Fitzcharles MA. Alternative medicine use in fibromyal- 7. Avorn J, Monette J, Lacour A, Bohn RL, Monane M, Mogun H, et al. Persistence of use gia syndrome. Arthritis Care Res 1996;9(1):13-7. of lipid-lowering medications: cross-national study. JAMA. 1998;279(18):1458-62. 32. Burckhardt CS, Clark SR, Bennett RM. Fibromyalgia and quality of life: a compara- 8. Howell N, Trotter R, Mottram DR, Rowe PH. Compliance with statins in primary tive analysis. J Rheumatol. 1993;20(3):475-9. care. Pharm J 2004;272:1-40. 33. Ryan S. Fibromyalgia: what help can nurses give? Nurs Stand. 1995;9(37):25-8. 9. Burrell A, Wong P, Ollendorf D, Cramer JA. Defining compliance/adherence and per- 34. Uveges JM, Parker JC, Smarr KL, McGowan JF, Lyon MG, Irvin WS, et al. Psycho- sistence: ISPOR Special Interest Working Group. Value Health. 2005;8(6):A194-5. 10. Peterson AM, Nau DP, Cramer JA, Benner J, Gwadry-Sridhar F, Nichol M. A checklist logical symptoms in primary fibromyalgia syndrome: relationship to pain, life stress, for medication compliance and persistence studies using retrospective databases. Value and sleep disturbance. Arthritis Rheum. 1990;33(8):1279-83. Health. 2007;10(1):3-12. 35. Wolfe F, Hawley DJ. Measurement of the quality of life in rheumatic disorders using 11. Cramer JA, Roy A, Burrell A, Fairchild CJ, Fuldeore MJ, Ollendorf DA, et al. Me- the EuroQoL. Br J Rheumatol. 1997;36(7):786-93. dication compliance and persistence: terminology and definitions. Value Health. 36. Henriksson CM. Longterm effects of fibromyalgia on everyday life. A study of 56 2008;11(1):44-7. patients. Scand J Rheumatol. 1994;23(1):36-41. 12. Razali MS, Yahya H. Compliance with treatment in schizophrenia: a drug interven- 37. Schaefer KM. Struggling to maintain balance: a study of women living with fibromy- tion program in a developing country. Acta Psychiatr Scand. 1995;91(5):331-5. algia. J Adv Nurs. 1995;21(1):95-102. 13. Tebbi CK. Treatment compliance in childhood and adolescence. Cancer. 1993;71(10 38. Marques AP, Ferreira EA, Matsutani LA, Pereira CA, Assumpção A. Quanti- Suppl):3441-9. fying pain threshold and quality of life of fibromyalgia patients. Clin Rheuma- 14. Timmerman L, Stronks DL, Groeneweg JG, Huygen FJ. Prevalence and determi- tol. 2005;24(3):266-71. nants of medication non-adherence in chronic pain patients: a systematic review. Acta 39. Bolwijn PH, van Santen-Hoeufft MH, Baars HM, Kaplan CD, van der Linden S. The Anaesthesiol Scand. 2016;60(4):416-31. social network characteristics of fibromyalgia patients compared with healthy controls. 15. Cardoso MG, Weinstock JG, Sardá Júnior JJ. Adhesion to neuropathic pain treat- Arthritis Care Res. 1996;9(1):18-26. ment. Rev Dor. 2016;17(Suppl 1):S107-9. 40. Bolwijn PH, van Santen-Hoeufft MH, Baars HM, van der Linden S. Social net- 16. Kurita GP, Pimenta CA. [Compliance with the treatment of chronic pain and health work characteristics in fibromyalgia or rheumatoid arthritis. Arthritis Care Res. locus]. Rev Esc Enferm USP. 2004;38(3):254-61. Portuguese. 1994;7(1):46-9. 17. Mastroianni PC, Oliveira AR, Nadai TR, Lucchetta RC. Economic indicators for 41. Verbunt JA, Pernot DH, Smeets RJ. Disability and quality of life in patients with drug acquisition. J Bras Econ Saúde. 2017;9(2):177-84. fibromyalgia. Health Qual Life Outcomes. 2008;6:8. 18. Heymann RE, Paiva Edos S, Helfenstein M Jr, Pollak DF, Martinez JE, Provenza 42. Boisset-Pioro MH, Esdaile JM, Fitzcharles MA. Sexual and physical abuse in women JR, et al. Brazilian consensus on the treatment of fibromyalgia]. Rev Bras Reumatol. with fibromyalgia syndrome. Arthritis Rheum. 1995;38(2):235-41. 2010;50(1):56-66. English, Portuguese. 43. Yi TI, Kim BK, Ha SA, Lim JY. The relationships between determination of treatment 19. Bordson SJ, Atayee RS, Ma JD, Best BM. Tricyclic antidepressants: is your patient ta- success and emotional factors in patients with chronic musculoskeletal pain. Ann king them? Observations on adherence and unreported use using prescriber-reported Rehabil Med. 2014;38(1):77-83. medication lists and urine drug testing. Pain Med. 2014;15(3):355-63. 44. Strömbeck B, Ekdahl C, Manthorpe R, Wilkström I, Jacobsson L. Health-related qua- 20. Cui Z, Zhao Y, Novick D, Faries D. Predictors of duloxetine adherence and persisten- lity of life in primary Sjögren’s syndrome, rheumatoid arthritis and fibromyalgia com- ce in patients with fibromyalgia. J Pain Res. 2012;5:193-201. pared to normal population data using SF-36. Scand J Rheumatol. 2000;29(1):20-8. 21. Able S, Cui Z, Shen W. Medication adherence and persistence in patients treated with 45. Culos‐Reed SN, Brawley LR. Fibromyalgia, physical activity, and daily functio- duloxetine. Value Health. 2012;15(4):A1-256. ning: the importance of efficacy and health‐related quality of life. Arthritis Care 22. Sanchez RJ, Mardekian J, Clair AG, Cappelleri JC. Therapeutic and subtherapeutic Res. 2000;13(6):343-51. dosing of pregabalin: medication adherence, healthcare resource utilization, and costs. 46. Moretti FA, Silva SS, Novoa CG. Characteristics and perception of social support by Am J Pharm Benefits. 2012;4(4):158-64. patients with fibromyalgia in Facebook. Br J Pain. 2018;1(1):4-8. 23. Dobkin PL, Sita A, Sewitch MJ. Predictors of adherence to treatment in women with 47. van Uden-Kraan CF, Drossaert CH, Taal E, Shaw BR, Seydel ER, van de Laar MA. fibromyalgia. Clin J Pain. 2006;22(3):286-94. Empowering processes and outcomes of participation in online support groups for pa- 24. Hyland ME, Hinton C, Hill C, Whalley B, Jones RC, Davies AF. Explaining unexplai- tients with breast cancer, arthritis, or fibromyalgia. Qual Health Res. 2008;18(3):405-

87 BrJP. São Paulo, 2019 jan-mar;2(1):88-92 CASE REPORT

Effects of hydrokinesiotherapy in pain, trophism and muscle strength in a child with juvenile idiopathic arthritis. Case report Efeitos da hidrocinesioterapia na dor, no trofismo e na força muscular de uma criança com artrite idiopática juvenil. Relato de caso

Matheus Santos Gomes Jorge1, Sabrina Casarin Vogelmann2, Lia Mara Wibelinger3

DOI 10.5935/2595-0118.20190016

ABSTRACT Keywords: Chronic pain, Hydrotherapy, Juvenile arthritis, Mus- cle strength, Musculoskeletal system, Physiotherapy. BACKGROUND AND OBJECTIVES: Juvenile idiopathic arthritis is a childhood rheumatic disease, which can interfere with RESUMO the trophism and muscular strength of the individual due to persistent pain. Hydrokinesiotherapy may be an alternative in the JUSTIFICATIVA E OBJETIVOS: A artrite idiopática juvenil é management of this disease. The objective of this study was to uma doença reumática da infância, que pode interferir no trofis- verify the effects of hydrokinesiotherapy on pain, trophism and mo e na força muscular do indivíduo, devido à dor persistente. A muscular strength of a child with juvenile rheumatoid arthritis. hidrocinesioterapia pode ser uma alternativa no manuseio dessa CASE REPORT: Female patient, 12 years old, diagnosed with doença. O objetivo deste estudo foi verificar os efeitos da hidro- juvenile rheumatoid arthritis one year ago. The pain was evalu- cinesioterapia na dor, no trofismo e na força muscular de uma ated by the visual analog scale and the body pain map, the mus- criança com artrite reumatoide juvenil. cular trophism by the perimetry of the arms and thighs, and the RELATO DO CASO: Paciente do sexo feminino, 12 anos de muscular strength by isokinetic dynamometry at a speed of 240º. idade, diagnosticada com artrite reumatoide juvenil há um ano. The hydrokinetic therapeutic intervention program (adaptation, Avaliou-se a dor por meio da escala analógica visual e do mapa warm up, mobility and flexibility, muscle strengthening, cardio- de dor corporal; o trofismo muscular, por meio da perimetria dos respiratory fitness, balance and proprioception, and relaxation) braços e das coxas; e a força muscular, por meio da dinamometria was carried from October to December 2017, once a week, for isocinética em velocidade de 240º. O programa de intervenção hi- 1 hour, totaling 10 sessions. At the end, there was a decrease in drocinesioterapêutica (adaptação, aquecimento, mobilidade e fle- pain by 2.7 points (moderate to mild), an increase in muscle xibilidade, fortalecimento muscular, condicionamento cardiorres- trophism of the arms and right thigh in 1cm and an increase in piratório, equilíbrio e propriocepção e relaxamento) foi realizado the torque peak (progress ranging from 12.3 to 37.9%) and total nos meses de outubro a dezembro de 2017, uma vez por semana, work (progress ranging from 18.6 to 76.7%) in all muscle groups durante 1 hora, totalizando 10 sessões. Ao fim, houve diminuição analyzed in both knees. da dor em 2,7 pontos (de moderada a leve), aumento do trofismo CONCLUSION: The hydrokinetic therapeutic intervention muscular dos braços e da coxa direita em 1cm e aumento do pico plan shown to be an effective strategy to alleviate the pain and de torque (progresso que variou entre 12,3 e 37,9%) e do trabalho increase trophism and muscle strength of the individual with ju- total (progresso que variou entre 18,6 e 76,7%) em todos os gru- venile idiopathic arthritis. pos musculares analisados, de ambos os joelhos. CONCLUSÃO: O plano de intervenção hidrocinesioterapêutica mostrou-se como uma estratégia eficaz para o alívio da dor e au- Matheus Santos Gomes Jorge - https://orcid.org/0000-0002-4989-0572; mento do trofismo e da força muscular do indivíduo com artrite Sabrina Casarin Vogelmann - https://orcid.org/0000-0002-2460-8067; idiopática juvenil. Lia Mara Wibelinger - https://orcid.org/0000-0002-7345-3946. Descritores: Artrite juvenil, Dor crônica, Fisioterapia, Força 1. Universidade de Passo Fundo, Faculdade de Educação Física e Fisioterapia, Programa de muscular, Hidroterapia, Sistema musculoesquelético. Pós-Graduação em Envelhecimento Humano, Bolsista Prosuc/CAPES. Soledade, RS, Brasil. 2. Universidade de Passo Fundo, Faculdade de Educação Física e Fisioterapia, Curso de Fisioterapia. Passo Fundo, RS, Brasil. INTRODUCTION 3. Universidade de Passo Fundo, Faculdade de Educação Física e Fisioterapia, Programa de Pós-Graduação em Envelhecimento Humano, Curso de Fisioterapia. Passo Fundo, RS, Brasil. Juvenile idiopathic arthritis (JIA) is a pediatric rheumatic disease Submitted in August 30, 2018. characterized by persistent inflammation of the joints, with onset Accepted for publication in December 20, 2018. Conflict of interests: none – Sponsoring sources: none before the child reaches the age of 16. The annual occurrence varies from 2 to 20 cases per 100,000 people, with a prevalence of 15 Correspondence to: 1,2 Rua Rio de Janeiro, 797 – Ipiranga to 150 cases per 100,000 people . Even though its etiology is as 99300-000 Soledade, RS, Brasil. yet unknown, evidence points to genetic predisposition3. E-mail: [email protected] The clinical conditions may include systematic manifestations, to- © Sociedade Brasileira para o Estudo da Dor gether with fever and inflammatory musculoskeletal bouts, including 88 Effects of hydrokinesiotherapy in pain, trophism and muscle BrJP. São Paulo, 2019 jan-mar;2(1):88-92 strength in a child with juvenile idiopathic arthritis. Case report evidence of inflammation of the joints (pain, heat, redness, swelling, patient identifies the points where he or she feels pain at the mo- and loss of function), stiffness, cramp, tenosynovitis, contractures, ment of the evaluation3,8. atrophies, and muscular weakness, thereby leading to functional in- Muscular trophism was evaluated through perimetry, a test which capacity and general malaise3-5. As a rule, these patients also show dys- uses a measuring tape to establish the circumference of a specific functions and defects of the lower limbs2, especially on the knees, the body segment3. In the study, the muscular trophism in the arms ankles, the hips, and the minor joints of hands and feet5. (10 and 15cm above the olecranon) and the thighs (10 and 15cm Approaches seeking the rehabilitation of children and teenagers with above the center of the patella), standards mentioned in another JIA have been exploited, but lack standardization in their protocols2. study conducted on an individual with rheumatoid arthritis9. Hydrokinesiotherapy is considered one of the most promising inter- Muscular strength was analyzed by isokinetic dynamometry, using ventions, bringing relief of pain, muscular relaxation, flexibility, and the Biodex™ Multi-Joint System 3 Pro computerized isokinetic dy- preservation or restoration of the functional capacity. The properties namometer, which is considered to be the gold standard for eval- of water allow movement of the painful musculature, mobilizing uation of muscular strength3. Preliminary studies10,11 have shown and strengthening it through specific exercises3, being considered a that this equipment could even be used among the pediatric popu- safe strategy for this segment of the population6. lation, as it shows good reliability and can be easily applied for this The purpose of this study was to check the effects of hydrokinesio- procedure, with its limitations being easily overcome. therapy on pain, trophism, and muscular strength, in a child with JIA. Initially, the child had a five-minute pre-warming up session on a Movement BM 2700 electromagnetic bicycle, with no load, and CASE REPORT with the seat adjusted to the appropriate height for the child. Next, the child received information about the procedure that would be This is a longitudinal and interventionist case report which is part carried out. The dynamometer was moved along the horizontal of a project named “The Effects of Physiotherapeutic treatment in plane and positioned on the external side of the unaffected lower patients with rheumatic diseases. ”The study was approved by the limb. The accessory of the knee was then connected to the dyna- Research Ethics Committee for Research with Human Subjects, at mometer, and the rotation axis of the subject’s knee was brought the University of Passo Fundo, State of Rio Grande do Sul, Brazil, into alignment with the axis of the dynamometer. The height of the under protocol number 348,381, as established by resolution No. seat was also adjusted, in the direction of the dynamometer. The 466/2012 passed by the Brazilian National Health Council (CNS) patient was then stabilized by a pair of elbow belts, a pelvic belt, and and the Helsinki Declaration. a belt for the contralateral thigh. After the preparation, the child per- The Free and Informed Consent Form (FICT) was signed by the formed three movements of extension and bending of the knee, at girl’s mother, after an explanation of the procedure and elucidation the speed of 180° to learn the test procedure. The action took place of any questions. Next, the participant was referred to the Rheu- through a series of five movements of extension and bending of the matology Physiotherapy Department of the Physiotherapy Clinic, knee, in a concentric way, always assessing the extensor and flexor which is part of the School of Physical Education and Physiother- muscles of the knee, considering the average peak torque (maximum apy of the University of Passo Fundo (UPF), in the city of Passo strength) and the total value of isokinetic muscular work, at a speed Fundo, State of Rio Grande do Sul, Brazil. of 240°. The procedure was repeated, on the other side. Female patient, aged 12, and diagnosed with JIA a year ago. She After evaluations, the child was then subjected to 10 individual lived in the city of Passo Fundo, State of Rio Grande do Sul and sessions of hydrokinesiotherapy of approximately one hour (10 was attending the 7th year of primary education. At the initial weeks), from October to December 2017. The intervention took evaluation, her mother reported that “the child started with fever, place in a therapeutic pool, heated to a temperature of 36°C, based pain, and swelling in her joints, back in October 2016. At that on referenced studies12,13, to produce effects on the situation of time, she was hospitalized for five days and diagnosed with JIA. In pain, trophism, and the muscular force of the individual. Table 1 May, she had a crisis and almost lost her ability to walk due to the shows the hydrokinesiotherapy schedule. pain and the swelling” (according to information collected). The The patient was advised to exhale during muscular contraction, child also complained of pain in her right foot, of the “pressing” to better recruitment of muscle fibers, which improves the perfor- type, with a score of 7, which got worse during the night and then mance of the exercise. There was an interval of 30 seconds to one improved during movement (according to information collected). minute between the series or cycles, but the patient could inter- She was taking five different drugs of continuous use: Predsim®; rupt the activity for a rest whenever needed, conduct adopted in a Methotrexate®; folic acid; calcium; vitamin D; and Omeprazole®). previous study14. After the 10 sessions of hydrokinesiotherapy, all She did not show any associated diseases, and neither any family parameters were reassessed. Table 2 shows the reference values for history of rheumatic disease. the child’s pain, in phases before and after hydrokinesiotherapy. The pain was analyzed through the visual analog pain scale (VAS) There was a reduction of the score and the intensity of the pain, after and also through the map of body pain. The first consists of a the intervention. However, pain started to be reported in more than horizontal straight line numbered from zero (no pain) to 10 (the one place. Table 3 shows the reference values for the muscular trophism worst pain you can imagine)7. The pain is classified as light (zero of the patient, before and after intervention with hydrokinesiotherapy. to 2), moderate (3 to 7) or intense (8 to 10). After the physiotherapy, the patient showed an increase of 1cm The latter is an instrument that included a graphic representation in all measurements of muscle trophism of the arms, and 15cm of the human body from anterior and posterior view, where the above the anatomical reference point of the right thigh, after the 89 BrJP. São Paulo, 2019 jan-mar;2(1):88-92 Jorge MS, Vogelmann SC and Wibelinger LM

Table 1. Hydrokinesiotherapy schedule, Passo Fundo, Rio Grande do Sul, Brazil, 2018

Phases Exercises Progression Phase 1 – Adaptation Walking around the pool, facing forward, sideward and 3 rounds, in each direction (from the 1st to the 3rd backward. session) Diaphragmatic respiratory exercise, where the individual 3 series with 5 repetitions each. should exhale under water. Phase 2 – Warming Up Slow muscular stretching, maintained, in either an acti- 30 seconds for each muscle group ve-assisted or passive mode, using the main muscular groups of the upper limbs, lower limbs, and trunk. Circular movements of shoulders, neck, wrists, and ankles 30 seconds for each joint Phase 3 – Mobility and Rotation of trunk with floaters around the arms 1st to 5th session: 2 series with 10 repetitions each → 6th Flexibility to 10th session: 3 series with 8 repetitions each Mobilization of wrists (active movements of flexion and 1st to 5th session: 2 series with 10 repetitions each → 6th extension) with floaters p 10th session: 3 series with 8 repetitions each Mobilization of ankles (movements of dorsiflexion and 1st to 5th session: 2 series, with 10 repetitions each → plantar flexion) on a submerged step 6th to 10th session: 3 series with 8 repetitions each Phase 4 – Muscular Strengthening of the hands (movements of manual 1st to 5th session: 2 series, with 10 repetitions each → strengthening prehension and also finger tweezers) with a “mild” pro- 6th to 10th session: 3 series with 8 repetitions prioceptive ball (1st to 5th session) and “moderate” (6th to 10th session) Strengthening of the adductor and abductor muscles of 1st to 5th session: 2 series, with 10 repetitions each → the elbows, with floaters 6th to 10th session: 3 series with 8 repetitions Minicrouches on bipedal support (1st to 7th session) and 1st to 5th session: 2 series, with 10 repetitions each → unipodal support (8th to 10th sessions) 6th to 10th session: 3 series with 8 repetitions Phase 5 – Cardiac and Stationary running 1st to 5th session: 1 series of 60 seconds → 6th to 10th respiratory conditioning session: 2 series of 60 seconds each Side jumps along a length of 5 meters 1st to 5th session: 1 series, with 10 repetitions → 6th to 10th session: 2 series of 8 repetitions Lateral jumping jacks 1st to 5th session: 1 series, with 10 repetitions → 6th to 10th session: 2 series of 8 repetitions Phase 6 – Balance and Stationary bicycle with two floaters between the legs 1st to 5th session: 60 seconds → 6th to 10th session: 2 proprioception series of 8 repetitions Lift the lower limb with a floater, under the foot, first with 1st to 5th session: 2 series of 10 repetitions → 6th to 10th the knee bent (1st to 7th session) and then progressing to session: 3 series of 8 repetitions exercise with the knee outstretched (8th to 10th session) Phase 7 – Relaxation Massotherapy on the cervical region, joint mobilizations 1st to 5th session: 15 minutes → 6th to 10th session: 10 on the ankle and the spine, and movements of the Watsu minutes Method3. → = progression of the exercise.

Table 2. Pain experienced before and after the hydrokinesiotherapy. Passo Fundo, Rio Grande do Sul, Brazil, 2018 Variables Before intervention After intervention Point score according to VAS 5.0±2.86 (0-8) points 2.3±1.94 (0-4) points Intensity of pain Moderate Light Location of pain Metatarsi and phalanges of the right foot Posterior region of the right and left ankles Mean ± standard deviation (minimum – maximum); VAS = visual analog scale.

Table 3. Muscular trophism of the patient, before and after hydrokinesiotherapy. Passo Fundo, Rio Grande do Sul, Brazil, 2018 10cm above the center of the patella 15cm above center of the patella Before intervention After intervention Before intervention After intervention Right Arm* 24cm 25cm 26cm 27cm Left Arm 24cm 25cm 26cm 27cm Right Thigh** 43cm 43cm 45cm 46cm Left Thigh 44cm 42cm 48cm 46cm cm = centimetres; * = dominant side; ** = dominant and affected side.

90 Effects of hydrokinesiotherapy in pain, trophism and muscle BrJP. São Paulo, 2019 jan-mar;2(1):88-92 strength in a child with juvenile idiopathic arthritis. Case report

Table 4. Muscle strength of the patient’s knees, before and after the hydrokinesiotherapy. Passo Fundo, Rio Grande do Sul, Brazil, 2018 Peak of torque Knee Muscle Group Before intervention After intervention Progress Right* Extensor muscles 62.6 N m 70.3 N m 12.3% Flexor muscles 23.8 N m 32.8 N m 37.9% Left Extensor muscles 58.9 N m 70.4 N m 19.4% Flexor muscles 22.9 N m 25.8 N m 12.7% Total Work Knee Muscle Group Before intervention After intervention Progress Right* Extensor muscles 242.3 J 287.4 J 18.6% Flexor muscles 94.1 J 132.4 J 40.6% Left Extensor muscles 153.9 J 272.0 J 76.7% Flexor muscles 70.0 J 101.5 J 45.0% N m = Newton-metre; J = Joule; % = relative value; * = dominant and affected side. hydrokinesiotherapy. Table 4 shows the values for muscle strength The beneficial effects upon pain in the child with JIA also con- on the patient’s knees, before and after the hydrokinesiotherapy. firm the findings of other studies12,13 that use hydrokinesiothera- We see that the patient showed an increase in muscle strength in py as a plan for treatment of pain, observing a reduction among all parameters analyzed, after hydrokinesiotherapy. With regards the individuals treated, stressing the use of strengthening exercis- to the peak of torque, the flexor muscles of the right knee had es in their protocols, as adopted in this study. the best performance, followed by the extensor muscles of the left Confirming the results presented in this study, the literature says knee, flexors of the left knee, and extensors of the right knee. Con- that hydrokinesiotherapy does not influence muscle strength in cerning total work, the extensor muscles of the left knee had the people with lower limbs disorders, due to the inconsistent meth- best performance, followed by the flexor muscles of the left knee, odologies in most studies, especially those related to the prescrip- the flexors of the right knee, and the extensors of the right knee. tion of resistance exercises in a water22. The methodological design used in this study that analyzed the ef- DISCUSSION fects of hydrokinesiotherapy on muscle strength in a child with JIA by isokinetic dynamometer was observed in only one similar study. Children and adolescents with JIA show a reduction in muscle It was a study where 30 children with JIA were randomly distributed strength in the knees when compared to their peers who do not between a control group (n=15), subjected to conventional physio- have the disease15. In addition, these people are also subject to therapy on the ground, and an intervention group (n=15), which biomechanical consequences on the joints, such as a higher risk was subjected to a specific hydrokinesiotherapy programme for low- of cartilage lesions16, as the muscles involved in this joint play a er limbs (5 minutes warming up, then 20 minutes of resisted exer- key role for stability and the prevention of lesions17. cise, and 5 minutes of cooling off), associated with the interferential The muscle weakness as shown may be related to arthritis (which current in the muscles of the anterior, posterior, medial and lateral causes constant pain) and muscle atrophy due to lack of use of sections of the hips (frequency of 100Hz, pulse duration of 125 Ksec the affected joint6. This was the situation observed in this specific at the sensorial threshold of the individual). After the intervention, case, where the muscle weakness present in the patient’s clinical the intervention group showed superior results when compared to condition was accompanied by pain, and these conditions could the control group, regarding the increase in the peak torque of lower also influence the patient’s muscular trophism. In addition, we limbs and the reduction of the levels of pain23. In the present study, can say that there is a consensus among professionals specialized we confirmed that the plan for the hydrokinesiotherapy increased in pediatric rheumatology, that regular physical exercises are a the peak of torque and also the total effort made by the extensor and safe approach. Physical exercises also promote the child’s gen- flexor muscles of the knees, as well as easing the patient’s intensity of eral skills and the normal development in early childhood, not pain, without the need for any additional resources. to mention the handling of musculoskeletal symptoms, such as The present report does have its limitations. Even though we reduction in muscle force, physical resistance, and aerobic ca- have observed an improvement in muscle force and a reduction pacity18-20, with hydrokinesiotherapy being one of the main ap- in pain intensity, we believe that the number and frequency of proaches used in rehabilitation in cases of JIA21. However, they the sessions, which were lower than in most of the evidence pre- also highlight that exercises on the floor bring better results in sented in the literature, could have contributed to the fact that terms of muscle force, the execution of tasks, and functional there was no evidence of an improvement in most measurements state, compared with exercises in water18, which is largely due to of muscle trophism of the patient’s thighs. However, these cir- the significant heterogeneity in the results of the studies already cumstances did not hinder the generation of the data presented, produced. These studies stress the need for standardized evalua- seeking to contribute so that new studies are carried out, based tion or a basic set of functional and physical measures well suited on a more significant number of individuals, thereby allowing to research in the health field20. the solution of any questions that may have remained. 91 BrJP. São Paulo, 2019 jan-mar;2(1):88-92 Jorge MS, Vogelmann SC and Wibelinger LM

CONCLUSION estudo de caso. ConScientiae Saúde. 2007;6(2):341-50. 13. Santoni FC, Pereira de Freitas SC, Oliveira J, Mesquita RA. Hidroterapia e qualidade de vida de um portador de artrite reumatoide juvenil - estudo de caso. Fisioter Mov. The plan for intervention through hydrokinesiotherapy showed 2007;20(1):101-8. 14. Jorge MS, Wibelinger LM, Knob B, Zanin C. Physiotherapeutic intervention on to be an effective strategy for pain relief and the increase of tro- pain and quality of life of systemic sclerosis elderly patients. Case reports. Rev Dor. phism and muscle strength in a patient with JIA. 2016;17(2):148-51. 15. Sandstedt E, Fasth A, Eek MN, Beckung E. Muscle strength, physical fitness and well-being in children and adolescents with juvenile idiopathic arthritis and the effect REFERENCES of an exercise programme: a randomized controlled trial. Pediatr Rheumatol Online J. 2013;11(1):1-7. 1. Thierry S, Fautrel B, Lemelle I, Guillemin F. Prevalence and incidence of juvenile 16. Myer GD, Brunner HI, Melson PG, Paterno MV, Ford KR, Hewett TE. Specialized idiopathic arthritis: a systematic review. Joint Bone Spine. 2014;81(2):112-7. neuromuscular training to improve neuromuscular function and biomechanics in a 2. Fellas A, Coda A, Hawke F. Physical and mechanical therapies for lower-limb pro- patient with quiescent juvenile rheumatoid arthritis. Phys Ther. 2005;85(8):791-802. blems in juvenile idiopathic arthritis. A systematic review with meta-analysis. J Am 17. Batista JS, Martins AD, Wibelinger LM. Avaliação da força muscular (torque Podiatr Med Assoc. 2017;107(5):399-412. muscular) de flexores e extensores de joelho de indivíduos jovens. EFDeportes. 3. Wibelinger LM. Fisioterapia em Reumatologia. 2ª ed. Rio de Janeiro: Revinter; 2015. 2012;17(168):1-3. 4. Tugal-Tutkun I, Quartier P, Bodaghi B. Disease of the year: juvenile idiopathic arthri- 18. National Health and Medical Research Council. Clinical guideline for the diagnosis tis-associated uveitis--classification and diagnostic approach. Ocul Immunol Inflamm. and management of juvenile idiopathic arthritis August 2009. Royal Australia Col- 2014;22(1):56-63. lege of General Practitioners. 2009. Available from: https://www.nhmrc.gov.au/_fi- 5. Ravelli A, Martini A. Juvenile idiopathic arthritis. Lancet. 2007;369(9563):767-78. les_nhmrc/file/publications/synopses/cp119-juvenile-arthritis.pdf. Accessed June 13, 6. Gualano B, Pinto AL, Perondi MB, Roschel H, Sallum AM, Hayashi AP, et al. [The- 2018. rapeutic effects of exercise training in patients with pediatric rheumatic disease]. Rev 19. Baydogan SN, Tarakci E, Kasapcopur O. Effect of strengthening versus balance- Bras Reumatol. 2011;51(5):490-6. English, Portuguese. -proprioceptive exercises on lower extremity function in patients with juvenile idio- 7. Martinez JE, Grassi DC, Marques LG. [Analysis of the applicability of different pain pathic arthritis: a randomized, single-blind clinical trial. Am J Phys Med Rehabil. questionnaires in three hospital settings: outpatient clinic, ward and emergency unit]. 2015;94(6):417-28. Rev Bras Reumatol. 2011;51(4):299-308. English, Portuguese. 20. Takken T, Van Brussel M, Engelbert RH, Van Der Net J, Kuis W, Helders PJ. Exercise 8. Wenngren A, Stålnacke BM. Computerized assessment of pain drawing area: a pilot therapy in juvenile idiopathic arthritis: a Cochrane Review. Eur J Phys Rehabil Med. study. Neuropsychiatr Dis Treat. 2009;5:451-6. 2008;44(3):287-97. 9. Knob B, Jorge MS, Bresolin FL, Bolzan LA, Ribeiro DS, Zanin C, et al. Reabilitação 21. Cavallo S, Brosseau L, Toupin-April K, Wells GA, Smith CA, Pugh AG, et al. Ot- cinesioterapêutica em um homem com artrite reumatoide. Saúde Rev. 2017;17(46):35-45. tawa Panel Evidence-Based Clinical Practice Guidelines for Structured Physical Ac- 10. Tsiros MD, Grimshaw PN, Shield AJ, Buckley JD. The Biodex isokinetic dynamo- tivity in the Management of Juvenile Idiopathic Arthritis. Arch Phys Med Rehabil. meter for knee strength assessment in children: advantages and limitations. Work. 2017;98(5):1018-41. 2011;39(2):161-7. 22. Heywood S, McClelland J, Mentiplay B, Geigle P, Rahmann A, Clark R. Effectiveness 11. Tsiros MD, Grimshaw PN, Schield AJ, Buckley JD. Test-retest reliability of the Bio- of aquatic exercise in improving lower limb strength in musculoskeletal conditions: a dex System 4 Isokinetic Dynamometer for knee strength assessment in paediatric po- systematic review and meta-analysis. Arch Phys Med Rehabil. 2017;98(1):173-86. pulations. J Allied Health. 2011;40(3):115-9. 23. Elnaggar RK, Elshafey MA. Effects of combined resistive underwater exercises and 12. Félix TL, Jorge LM, Oliveira J, Mesquita-Ferrari RA. Efeito da hidroterapia, utilizan- interferential current therapy in patients with juvenile idiopathic arthritis. A randomi- do o Método dos Anéis de Bad Ragaz, no tratamento da artrite reumatóide juvenil: um zed controlled trial. Am J Phys Med Rehabil. 2016;95(2):96-102.

92 BrJP. São Paulo, 2019 jan-mar;2(1):93-6 CASE REPORT

Learning pain neuroscience education from the WHOQOL-Bref instrument in the classroom. Case reports Aprendendo a educação em neurociência da dor por meio do instrumento WHOQOL-Bref em sala de aula. Relato de casos

Kênia Fonseca Pires1, Tatiana Andrade Cacho1, Luiza Nolêto dos Santos1

DOI 10.5935/2595-0118.20190017

ABSTRACT RESUMO

BACKGROUND AND OBJECTIVES: During the undergrad- JUSTIFICATIVA E OBJETIVOS: Durante a graduação, os aca- uate course students have the opportunity to learn and under- dêmicos têm a oportunidade de aprender e compreender sobre stand health promotion and prevention, quality of life and other promoção e prevenção de saúde, qualidade de vida, entre outros concepts, but they rarely learn about health education, let alone conceitos, mas raramente a educação em saúde é colocada nas pain. Knowing that there are gaps in the training of health pro- salas de aula, em especial o entendimento da dor. Sabendo que fessionals regarding pain, and in the use of pedagogical meth- há lacunas na formação de profissionais de saúde relacionadas ao odologies that encourage the active construction of knowledge, conhecimento da dor e à utilização de metodologias pedagógicas the objective of this study was to provide an experience about que incentivem a construção ativa do conhecimento, o objetivo the process of understanding pain neuroscience education from deste estudo promoveu um relato de experiência sobre o processo an instrument and the role-playing technique in the academic de entendimento e educação em neurociência da dor, por meio environment of Physiotherapy students. de um instrumento e da técnica de dramatização na vivência aca- CASE REPORTS: During a Basic Complexity class, Physio- dêmica de estudantes de Fisioterapia. therapy students from the Ceilândia campus of the University RELATO DOS CASOS: Durante a realização de uma aula de of Brasília were invited to provide care to a fictitious population Básica Complexidade, alunos do curso de Fisioterapia da Uni- and develop explanations and lessons about pain and its process- versidade de Brasília - Campus Ceilândia, foram convidados a es in the human body using the WHOQOL-Bref questionnaire vivenciarem um atendimento à uma população fictícia e desen- to evaluate the quality of life of the individual and target the care volverem explicações e ensinamentos sobre a dor e seus processos accordingly. no corpo humano, utilizando o instrumento WHOQOL-Bref CONCLUSION: The experience provided by the simulation of para avaliar a qualidade de vida do indivíduo e direcionar o seu clinical cases was important for the analysis and discussion of atendimento. challenging issues such as psychological, social and behavioral CONCLUSÃO: A experiência vivenciada por meio de simula- factors in the health education process in multi and interdisci- ções de casos clínicos na disciplina foi importante para a análise plinary interventions. e discussão de questões desafiadoras como fatores psicológicos, Keywords: Pain neuroscience education, Quality of life, Simula- sociais, e comportamentais no processo de educação em saúde tion of clinical cases, WHOQOL-Bref. em intervenções multi e interdisciplinar. Descritores: Educação em neurociência da dor, Qualidade de vida, Simulações de casos clínicos, WHOQOL-Bref.

INTRODUCTION

Educational interventions around the theme of pain refer to the us- ability of knowledge of anatomy, physiology, and pharmacology of Luiza Nolêto dos Santos - https://orcid.org/0000-0001-5360-9088; Tatiana Andrade Cacho - https://orcid.org/0000-0001-8523-5527; pain, and also to understanding how the correct approach and the Kênia Fonseca Pires - https://orcid.org/0000-0001-5176-4025. treatment of the syndrome can reduce the physical and emotional 1,2 1. Universidade de Brasília, Faculdade de Ceilândia, Curso de Fisioterapia, Brasília, DF, Brasil. consequences resulting from the pain process . Studies with a systematic review on education in pain neuroscience Submitted in August 16, 2018. (EPN) for musculoskeletal pain supply evidence that EPN improves Accepted for publication in January 07, 2019. Conflict of interests: none – Sponsoring sources: none the appropriate classification of pain, incapacity, mobility, the use of health services, and also attitudes and patterns of behavior related to Correspondence to: 3 Campus Universitário - Centro Metropolitano, Ceilândia Sul pain, including catastrophization, fear, and avoidance . 72220-275 Brasília, DF, Brasil. On the other hand, one issue that has called the attention of inves- E-mail: [email protected] tigators is the fact that nociception is not sufficient to evoke pain, © Sociedade Brasileira para o Estudo da Dor but also psychological and social factors are important for the de- 93 BrJP. São Paulo, 2019 jan-mar;2(1):93-6 Pires KF, Cacho TA and Santos LN velopment of chronic illnesses4. In this regard, the teaching of pain of the spine, the doctor said that the patient had spinal problems issues has become necessary as part of the qualification of health and she would need to do physical exercises. She believed and re- professionals, and for the careful handling of the symptom5. ported that she could have a disc herniation. The patient did not In this context, one of the courses in the health area that goes show the X-ray, as she didn’t know where it was. She also reported through this process of change, to qualify the professionals who that she does not like to do physical exercises and does not under- work with the Brazilian Unified Health System (SUS), is the Phys- stand why things improve with exercises. She also said that she is iotherapy course. unable to pay to work out at a fitness center and that her dream was Starting from this premise and considering that the SUS is a major to be a ballerina. She showed great difficulty when getting down employer of workers in the health sector, the education of students and when carrying her supermarket shopping. She is 155cm tall should be encouraged to aim at a humanist style of action, which is and weighs 105kg. critical, reflexive and generalist. This means that, with the constant union of theory and practice within the University environment, Case 3. This patient is 65 years old, retired, and cares for her 95-year- one can produce conscientious professionals, who are engaged in old mother. Together with her mother, she carries out all household seeking to modify the environment in which they live, also having chores and especially special care: bathing her mother, cooking and an attitude that may change the ills in the health sector6. the routine walks. She complains of muscular fatigue in general and The multidimensional construct of quality of life (QoL) known as joint pain. She does not sleep well, and only gets some 4 hours of the World Health Organization Quality of Life (WHOQOL-Bref) sleep a night. She does not have any time to herself, to enjoy the was proposed as an indicator of the general health of the population. company of her friends. However, she heard of the group and went The application of this instrument is used to encourage actions for the over to understand more about pain, and also to know what can be promotion of health. It is speculated that the use of the questionnaire, done at home to make her more energetic. together with the EPN tool, could add knowledge when interpreting the different dimensions of human health, such as psychological The WHOQOL-Bref questionnaire was used to evaluate the quality health, the degree of independence, the social relationships, the envi- of life (QoL) of the clinical cases, through a battery of 26 questions. ronment, and spiritual standards. They can also be used in academic Questions 1 and 2, about general QoL and perception of health circles after the elaboration of problem situations, and also to promote respectively, with a score from 1 to 5. The other 24 questions re- changes in the teaching and learning process, with regards to pain7,8. ferred to the four domains: Physical, Psychological, Social Relations, From this perspective, the study promoted a report on experiences and the Environment, also with a score from 1 to 5 points, it being regarding the process of understanding and education within the necessary to reencode the point values of questions 3, 4 and 26. study of pain, through an instrument and the role-playing tech- The mean of the values obtained shall be calculated from the total nique within the academic experience of Physiotherapy students. point score, divided by the number of questions present in the same domain7 (Annex 1). CASE REPORTS For the lived-experience report, the participants produced a video, approximately 10 minutes long, and then simulated a physiothera- An academic study based on real-life experiences was carried out at peutic appointment for a fictitious patient, with the following ob- the Ceilândia Campus of the University of Brasília to achieve the jectives: proposed goal. • Instruct the patient to understand his or her pain (possible causes, For this purpose, the academic students of the 6th semester of the and which neural and brain mechanisms were activated); Physiotherapy course were initially separated into two groups, • Improve the QoL through understanding pain. namely physiotherapist student (PhS) and patient-student (PtS). Later on, after this division, they were asked to simulate the care to Thus, the PtS group was given the clinical case of the teacher of the three clinical cases, so that they could provide grounds for teachings subject, and the guidance was to take the clinical case, presenting the and explanations about pain and neurophysiological processes in the current and past history of the disease, symptoms, facial expressions, human body. deficits of movement, falls from own height, feelings, emotions, beliefs, and catastrophization. Case 1. Patient aged 70 years old, had pain when moving the joints Similarly, the PhS group was advised, by the teacher, to evaluate of the shoulders and knees, making it much more difficult to carry and apply the questionnaire and then proceed with the calculations out daily activities such as cleaning the house, taking care of the dog, and discuss interventions for each case. At the same time, the PhS and putting clothes out to dry on the clothesline. This patient said group was asked to plan and execute EPN, with a neurophysiolog- that he could not understand why the pain was present, and why ical explanation of the clinical case and guidance on the ongoing his health did not improve with the drugs taken daily. This patient education process for activities at home. also heard about a physical activity group that had sessions twice a During the academic experience, the PhS group should then make week, and showed significant interest, believing that physical activ- use of the data obtained through the WHOQOL-Bref question- ities could help to improve the loss of strength of the lower limbs. naire, and interpret the values for each domain as described above: WHOQOL-Bref - case 1: the physical domain had the smallest Case 2. This patient is a 45-year-old homemaker and reported that mean (1.83) when compared with the psychological, social relations she had spinal pain for 15 years. Two years ago, after having an X-ray and environment domains. 94 Learning pain neuroscience education from the WHOQOL- BrJP. São Paulo, 2019 jan-mar;2(1):93-6 Bref instrument in the classroom. Case reports

WHOQOL-Bref - case 2: the physical domain had the lowest mean the perception of quality of life was neither good nor bad. This data is (1.71) when compared with cases 1 and 3, and in the environmental linked to the study of three Basic Health Units (UBSs), in the Brazil- domain the mean obtained was 2.0. ian state of Rio Grande do Sul, that analyzed the means of the physical WHOQOL-Bref - case 3: the domain of the social relation showed domain and concluded that they were lower in female patients who a much lower mean (1.0) when compared to the physical, psycho- did not live with a partner and had some chronic disease14,15. logical, and environment domains. As observed in Case 2, there was a low score for the environmental After the interpretation of the domains, guidance was aimed at bet- domain for the questions related to financial resources and the phys- ter catering to the needs of the PtS group. Also, this being an expe- ical environment. This analysis corroborates studies where patients rience within an environment of Basic Complexity, the PhS group of lower social classes showed a worse quality of life, highlighting should encourage the individual’s participation and also present the the fact that, in Brazil, the unequal distribution of wealth, together funds offered and which best fit the individual needs as presented with illiteracy, low educational level, poor housing conditions, and by the PtS group. precarious environment, all had a negative impact on the quality of life and the health of the subjects11,16. DISCUSSION The lowest score observed for the domain of the personal relations, in case 3, confirmed other results that described the perception that Simulations with clinical cases were based on the handling of EPN, there was a lower quality of life among women, people of more ad- in a move to check the altered perceptions of knowledge of the neu- vanced age, people of lower social strata, who did not live with a rophysiology of pain, and how beliefs could trigger the increase in partner, and having some chronic disease. From there, one can con- chronic pain3,9,10. clude that the absence of a partner can trigger feelings of solitude The QoL is a multidimensional construct proposed as an indica- and isolation, in turn causing a lower level of well-being13,14. tor of the general health of the population, and the interpretation In this way, through experience stimulated by clinical cases, this in- thereof is used to encourage actions in the promotion of health11 as strument allows one to discuss the possible subjective perception of presented by the PtS group. his or her physical and psychological health, as well as social relations From this standpoint, the WHOQOL-Bref instrument guided the and the environment in which the person lives7,11. educational approach, giving priority to the physical and personal rela- Educational strategies based on simulations have been commonly tions domains, and their issues, to be worked upon by the PhS group. used for teaching Communication and Relationship Skills, especial- The instrument also values individual perception and can assess QoL ly in the health area17. These strategies seek to get the students in- in different groups and situations, regardless of the educational level7. cluded in the teaching process through assisted and guided practice. On considering the means within the physical domain, for the cases Simulation allows the students to experience the representation of involved (1, 2 and 3), we obtained a variation from 1.71 to 2.85, a real event, to practice, learn, appraise, test, or understand human with Case 2 presenting the lowest of the results, with 1.71. This systems or actions10,17. domain includes issues such as pain and discomfort, energy and fa- It is within this understanding that it was possible to analyze and dis- tigue, mobility, activities of daily life, dependence on drugs or treat- cuss skills among the students, in issues involving the interpretations ment, ability to work. of the physical and psychological health dimensions, level of indepen- The evaluation of the physical domain showed a need to monitor dence, social relationships, the environment, and spiritual level11,18. the indices of quality of life (QoL) in patients with chronic diseas- The videos that reproduce the EPN were analyzed through oral pre- es, and plan strategies for intervention, as these provide important sentations, followed by a debriefing which is considered the most information about the user, allowing the identification of priorities important part of the simulation, and which allows the critical anal- and also offering grounds for health programmes to implement ef- ysis of the planning process and the relationship established between fective action and thus provide a better quality of life to users, within the PhS and PtS18. primary health care. The requests for debriefing consisted of acting out the scene, high- This applies to the interpretation of the issues raised in Case 1, lighting how they were feeling during the physiotherapeutic evalua- which showed a lower level of QoL in the physical domain when tion and as Physiotherapy professionals, and also listing the strengths compared with the other domains: psychological, personal relations, of their actions and points that could be improved. The purpose of and the environment. In the opinion of many specialists, this aspect the academic experiences described was to meet what is set forth in is key when considering the quality of life of the elderly, which is the National Curriculum Guidelines for the Physiotherapy course, influenced as age increases11,12. using methodologies and criteria to monitor and evaluate the teach- We found no cut-off points in the literature that would establish ing-learning process19. scores above or below. In this study, we analyzed copies of the individual scores obtained by each respondent within each domain, in the CONCLUSION 3 cases studied, and then an association was established with a Likert scale with 5 items (1= very poor, 2= poor, 3= average; 4= good and 5= The results of the reports on the experiences in the classroom suggest very good) for the 24 questions that make up the instrument13. that possibly the simulation of clinical cases allowed the students to With regards to the evaluation of case 2, we saw that it has the lowest experience the representation of a real event and that the WHO- mean within the physical domain and lower levels of means for the QOL-Bref instrument gave value to the individual perception, mak- psychological and environmental domains; the general assessment of ing it possible to evaluate QoL in different groups and situations. 95 BrJP. São Paulo, 2019 jan-mar;2(1):93-6 Pires KF, Cacho TA and Santos LN

Annex 1. The WHOQOL-Bref Test Questions 1 and 2 Case 1 Case 2 Case 3 1. Perception of quality of life 3 3 2 2. Satisfaction with state of health 3 3 3

Domain I - Physical Case 1 Mean Case 2 Mean Case 3 Mean 3.Pain and discomfort 2 2 3 4.Energy and fatigue 2 2 4 5.Sleep and rest 2 2 4 1.83 6.Mobility 1 1 1.71 3 2.85 7.Activities of daily life routine 2 2 1 8.Dependence on drugs or treatments 1 2 3 9.Ability to work 1 1 2 Domain II - Psychological Case 1 Mean Case 2 Mean Case 3 Mean 10. Positive feelings 2 3 1 11. Thinking, learning, memory, and concentration 3 3 3 12. Self-esteem 3 2 4 2.66 2.33 2.83 13. Body image and appearance 3 1 4 14. Negative feelings 1 2 2 15. Spirituality, religion and personal beliefs 4 3 3 Domain III – Social relationships Case 1 Mean Case 2 Mean Case 3 Mean 16. Personal Relationships 2 3 1 17. Social Support 2 3.0 1 2..33 1 1.0 18. Sexual Activity 2 3 1 Domain IV - Environment Case 1 Mean Case 2 Mean Case 3 Mean 19. Physical security and protection 2 2 3 20. Home environment 2 2 4 21. Financial resources 2 1 2 22. Health care and social care: availability and quality 3 2 2 2.5 2.0 2.75 23. Opportunities to acquire new information and skills 2 2 3 24. Participation and opportunities for, recreation and leisure 3 3 4 25. Physical environment: pollution/noise/traffic/weather 4 1 2 26. Transportation 2 3 2

REFERENCES pain: practice guidelines. Man Ther. 2011;16(5):413-8. 10. Louw A, Puentedura EL, Zimney K. Teaching patients about pain: it works, but what should we call it? Physiother Theory Pract. 2016;32(5):328-31. 1. Moseley GL, Butler DS. Fifteen years of explaining pain: the past, present, and future. 11. Almeida-Brasil CC, Silveira MR, Silva KR, Lima MG, Faria CD, Cardoso CL, et al. [Qua- J Pain. 2015;16(9):807-13. lity of life and associated characteristics: aplication of WHOQOL-BREF in the context of 2. Moseley L. Combined physiotherapy and education is efficacious for chronic low back Primary Health Care]. Cien Saúde Colet. 2017;22(5):1705-16. English, Portuguese. pain. Aust J Physiother. 2002;48(4):297-302. 12. Freitas EV. Tratado de geriatria e gerontologia. 3ª ed. Rio de Janeiro: Guanabara Koo- 3. Louw A, Zimmey K, Puentedura EJ, Diener I. The efficacy of pain neuroscience gan; 2011. 1750p. education on musculoskeletal pain: a systematic review of the literature. Physiother 13. Pedroso B, Pilatti LA, Gutierrez GL, Picinin CT. Cálculo dos escores e estatística Theory Pract. 2016;32(5):332-55. descritiva do WHOQOL-bref através do Microsoft Excel. Rev Bras Qual Vida. Ponta 4. Moseley L. Unravelling the barriers to reconceptualization of the problem in chronic Grossa. 2010;2(1):31-6. pain: the actual and perceived ability of patients and health professionals to unders- 14. Castro, DFA. A. Qualidade de Vida de Gestantes assistidas pela Estratégia Saúde da tand the neurophysiology. J Pain. 2003;4(4):184-9. Família [dissertação]. USP – Área de concentração: saúde coletiva. 2010. 196p. 5. Louw A, Zimney K, O’Hotto C, Hilton S. The clinical application of teaching people 15. Azevedo AL, Silva RA, Tomasi E, Quevedo LA. Doenças crônicas e qualidade de vida about pain. Physiother Theory Pract. 2016;32(5):385-5. na atenção primária à saúde. Cad. Saúde Pública, 2010;29(9):1774-82. 6. Figueiredo TC, Rhoden EC. “Fisioterapia e a promoção da saúde”: o saber em saúde a 16. Buss PM. Promoção da saúde e qualidade de vida. Ciênc Saúde Coletiva 2000;5:163-77. partir do ensino acadêmico. Rev Epidemiol Control Infect. 2014;4(1):32-3. 17. Rabelo L, Garcia VL. Role-Play para o desenvolvimento de habilidades de comunica- 7. Fleck MP, Louzada S, Xavier M, Chachamovich E, Vieira G, Santos L, et al. [Appli- ção e relacionais. Rev Bras Educ Med. 2015;39(4):586-96. cation of the Portuguese version of the abbreviated instrument of quality life WHO- 18. Wijma AJ, van Wilgen CP, Meeus M, Nijs J. Clinical biopsychosocial physiotherapy QOL-bref]. Rev Saude Publica. 2000;34(2):178-83. Portuguese. assessment of patients with chronic pain: the first step in pain neuroscience education. 8. DeSantana JM, Souza JB, Reis FJ, Gosling AP, Paranhos E, Barboza HF, et al. Currí- Physiother Theory Pract. 2016;32(5):368-84. culo em dor para graduação em Fisioterapia no Brasil. Rev Dor. 2017;18(1):72-8. 19. Conselho nacional de educação câmara de educação superior resolução CNE/CES 4, de 9. Nijs J, Paul van Wilgen C, Van Oosterwijek J, van Ittersum M, Meeus M. How to 19 de fevereiro de 2002. Institui Diretrizes Curriculares Nacionais do Curso de Gradua- explain central sensitization to patients with ‘unexplained’ chronic musculoskeletal ção em Fisioterapia. Diário Oficial da União, Brasília, 4 de março de 2002. Seção 1, 11p.

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Br J Anaesth 1993;70(1):434-9. of Medical Journal Editors – ICMJE policies for the registry of clinical - More than 6 authors - Barreto RF, Gomes CZ, Silva RM, Signorelli trials, acknowledging the importance of such initiatives for international AA, Oliveira LF, Cavellani CL, et al. Pain and epidemiologic evalu- disclosure of information about clinical research with open access. So, ation of patients seen by the first aid unit of a teaching hospital. Rev as from 2012, preference shall be given to the publication of articles or Dor. 2012;13(3):213-9. studies previously registered before a Platform of Clinical Trials Registry meeting the requirements of the World Health Organization and of the Article with published erratum: International Committee of Medical Journal Editors. The list of Platforms Sousa AM, Cutait MM, Ashmawi HA. Avaliação da adição do tra- of Clinical Trials Registry may be found at http://www.who.int/ictrp/en, madol sobre o tempo de regressão do bloqueio motor induzido pela from the International Clinical Trials Registry Platform (ICTRP). Among lidocaína. Estudo experimental em ratos Avaliação da adição do tra- them there is the Brazilian Registry of Clinical Trials (ReBEC), which is madol sobre o tempo de regressão do bloqueio motor induzido pela a virtual platform with free access for the registry of experimental and lidocaína. Estudo experimental em ratos. Rev Dor. 2013;14(2):130- non-experimental studies carried out with human beings, in process or 3. Erratum in: Rev Dor. 2013;14(3):234. closed, by Brazilian and foreign researchers, which may be accessed at http://www.ensaiosclinicos.gov.br. The registry number of the study shall Supplement article: be published at the end of the abstract. Walker LK. Use of extracorporeal membrane oxygenation for preop- erative stabilization of congenital diaphragmatic hernia. Crit Care Use of Abbreviations: Med. 1993;2(2Suppl1):S379-80. Title, summary and abstract shall not contain abbreviations. When long expressions are present in the text, they do not have to be repeated after Book: (when strictly necessary) INTRODUCTION. Doyle AC, editor. Biological mysteries solved, 2nd ed. London: Sci- After their first mention in the text, which shall be followed by the ence Press; 1991. 477 80p. initials in brackets, it is recommended that their initials in capital letters Book chapter: replace them.