Vol. 02 No 04 Oct/Nov/Dec. 2019

ISSN 2595-3192

BrJPBRAZILIAN JOURNAL OF PAIN Vol. 02 No 04 Oct/Nov/Dec. 2019

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

Volumen 2 – nº 4 EDITORIAL October to December, 2019 Some reflections on Pain and Suffering ______307 Trimestral Publication Durval Campos Kraychete

ORIGINAL ARTICLES SOCIEDADE BRASILEIRA PARA O Clinical evaluation and prevalence of fibromyalgia in hepatitis C patients______308 ESTUDO DA DOR João Batista Santos Garcia, Silvia Amália de Melo Moura, Durval Campos Kraychete, Anita DIRECTORY Perpetua Carvalho Rocha Castro, Marilia Arrais Garcia Biennium 2018-2019 Pain: the impulse in the search for health by means of integrative and complementary President practices ______316 Eduardo Grossmann Miraíra Noal Manfroi¹, Priscila Mari dos Santos Correia, Wihanna Cardozo de Castro Vice-President Franzoni, Letícia Baldasso Moraes, Francine Stein, Alcyane Marinho Paulo Renato Barreiros da Fonseca Scientific Director Back pain in adolescents: prevalence and associated factors______321 José Oswaldo de Oliveira Junior Mirna Namie Okamura, Wilma Madeira, Moisés Goldbaum, Chester Luiz Galvão Cesar Administrative Director Clinical manifestations in patients with musculoskeletal pain post-chikungunya_____326 Dirce Maria Navas Perissinotti Ben-Hur James Maciel de-Araujo, Patricia Bueno Nestarez Hazime, Francisca Joyce Treasurer Vasconcelos Galeno, Laís Nascimento Candeira, Mayare Fortes Sampaio, Fuad Ahmad Juliana Barcellos de Souza Hazime Secretary Janaina Vall Knowledge of the nursing team about the newborn’s pain ______331 Nayara Freitas Azevedo, Thiago Dias, Maria Paula Custódio Silva, Mayline Verônica Av. Conselheiro Rodrigues Alves, 937 Rocha Sampaio, Jesislei Bonolo do Amaral, Divanice Contim Cj. 2 – Vila Mariana 04014-012 São Paulo, SP The impact of chronic pain on the quality of life and on the functional capacity of cancer patients and their caregivers______336 Phone: (55) 11 5904-2881/3959 Juliana Martins Izzo, Ana Marcia Rodrigues Cunha, Claudia Bernardi Cesarino, www.dor.org.br Marielza Regina Ismael Martins E-mail: [email protected] Chronic low back pain and walking speed: effects on the spatiotemporal parameters and Quotations of Brazilian Journal of Pain in gait variability______342 shall be abbreviated to BrJP. Alberito Rodrigo Carvalho, Ronaldo Valdir Briani, Welds Rodrigo Ribeiro Bertor, José Roberto Svistalski, Alexandro Andrade, Leonardo Alexandre Peyré-Tartaruga BrJP is not responsible whatosever by opinions. Acupuncture in the treatment of temporomandibular muscle dysfunction______348 Evelyn de Freitas Boscaine, Elenir Rose Jardim Cury Pontes, Daisilene Baena Castillo, Lirane da Silva Carneiro Suliano, Nelson Talatoci Oshiro Filho Advertisements published in this edition do no generate conflict of interests. REVIEW ARTICLES Auriculotherapy: neurophysiology, points to choose, indications and results on musculoskeletal pain conditions: a systematic review of reviews______356

Indexada na SciELO Indexada na LILACS Indexada na Latindex Dérrick Patrick Artioli, Alana Ludemila de Freitas Tavares, Gladson Ricardo Flor Bertolini

Methods of diagnosis and treatment of complex regional pain syndrome: an integrative Publication edited and produced by literature review ______362 MWS Design – Phone: (055) 11 3399-3038 Sheila Bortagaray, Thais Fadel Gonçalves Meulman, Henrique Rossoni Junior, Tiago Perinetto Journalist In Charge Marcelo Sassine - Mtb 22.869 Atypical odontalgia: pathophysiology, diagnosis and management ______368 Art Editor André Hayato Saguchi, Ângela Toshie Araki Yamamoto, Cristiane de Almeida Baldini Anete Salviano Cardoso, Adriana de Oliveira Lira Ortega SCIENTIFIC EDITOR Pharmacological treatment of pain in pregnancy ______374 Durval Campos Kraychete Federal University of Bahia, Salvador, BA – Brazil. Fábio Farias de Aragão, Alexandro Ferraz Tobias

CO-EDITORS Ângela Maria Sousa University of São Paulo, São Paulo, SP – Brazil. Instruments that evaluate the functioning in individuals affected with chikungunya and Dirce Maria Navas Perissinotti the International Classification of Functioning. A systematic review ______381 University of São Paulo, São Paulo, SP – Brazil. Eduardo Grossmann Marina Carvalho Arruda Barreto, Bárbara Porfírio Nunes, Shamyr Sulyvan de Castro Federal University of Rio Grande do Sul, Porto Alegre, RS – Brazil. Irimar de Paula Posso University of São Paulo, São Paulo, SP – Brazil. Janaina Vall In vivo methods for the evaluation of anti-inflammatory and antinoceptive potential _ 386 Federal University of Ceara, Fortaleza, CE – Brazil. Silvio de Almeida Junior José Aparecido da Silva University of São Paulo, Ribeirão Preto, SP - Brazil. José Oswaldo Oliveira Júnior University of São Paulo, São Paulo, SP – Brazil. CASES REPORTS Juliana Barcellos de Souza Notalgia paresthetica and neuropathic itch. Case report______390 Federal University of Santa Catarina, Florianópolis, SC – Brazil. Lia Rachel Chaves do Amaral Pelloso Thiago Alves Rodrigues, Eduardo José Silva Gomes de-Oliveira, João Batista Santos Garcia Federal University of Mato Grosso, Cuiabá, MT, Brazil. Maria Belén Salazar Posso Christian University Foundation, Pindamonhangaba, SP – Brazil. Sandra Caires Serrano Sphenopalatine ganglion block for post-dural puncture headache after invasive Pontifícia Universidade Católica de Campinas, São Paulo, SP – Brazil. cerebrospinal fluid pressure monitoring. Case report______392 Telma Regina Mariotto Zakka University of São Paulo, São Paulo, SP – Brazil. Felipe Chiodini Machado, Gilson Carone Neto, Hazem Adel Ashmawi

EDITORIAL COUNCIL Abrahão Fontes Baptista Federal University of Pernambuco, Recife, PE – Brazil. INSTRUCTIONS TO AUTHORS______395 Alexandre Annes Henriques General Hospital of Porto Alegre, Porto Alegre, RS – Brazil. Fábio Henrique de Gobbi Porto University of Sao Paulo, São Paulo, SP - Brazil. Guilherme Antônio Moreira de Barros School of Medicine of Botucatu, Botucatu, SP – Brazil. Hazem Adel Ashmawi University of São Paulo, São Paulo, SP – Brazil. Ismar Lima Cavalcanti University Iguacu, Rio de Janeiro, RJ – Brazil. Jamir Sardá Junior University of Vale do Itajaí, Itajaí, SC – Brazil. João Batista Santos Garcia Federal University of Maranhão, São Luiz, MA – Brazil. José Geraldo Speciali University of São Paulo, Ribeirão Preto – Brazil. José Tadeu Tesseroli de Siqueira University of São Paulo, São Paulo, SP – Brazil. Josimari Melo de Santana Federal University of Sergipe, Aracaju, SE – Brazil. Juliane de Macedo Antunes National Institute of Traumatology and Orthopedics, Rio de Janeiro, RJ – Brazil. Karina Gramani Say Federal University of São Carlos, São Carlos, SP - Brazil. Kátia Nunes Sá Bahia School of Medicine and Public Health, Salvador, BA – Brazil. Manoel Jacobsen Teixeira University of Sao Paulo, São Paulo, SP - Brazil. Mauro Brito de Almeida Federal University of Pará, Belém, PA - Brazil. Miriam Seligman de Menezes Federal University of Santa Maria, Santa Maria, RS – Brazil. Mirlane Guimarães de Melo Cardoso Federal University of Amazonas, Manaus, AM – Brazil. Onofre Alves Neto Federal University of Goiás, Goiânia, GO – Brazil. Oscar Cesar Pires University of Taubaté, Taubaté, SP - Brazil. Paulo Cesar Rodrigues Conti School of Dentistry of Bauru, Bauru, SP – Brazil. Renato Leonardo de Freitas University of Sao Paulo, Ribeirão Preto, SP – Brazil. Rosana Maria Tristão Federal University of Brasilia, Brasilia, DF - Brazil. Silvia Regina Dowgan Tesseroli de Siqueira University of Sao Paulo, Sao Paulo, SP – Brazil. Vania Maria de Araújo Giaretta University of Taubaté, Taubaté - SP. Brazil. Walter Lisboa de Oliveira Federal University of Sergipe, Aracaju, SE – Brazil.

INTERNATIONAL 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 https://www.gnpapers.com.br/brjp/default.asp BrJP. São Paulo, 2019 oct-dec;2(4):307 EDITORIAL

Some reflections on Pain and Suffering Algumas reflexões sobre a Dor e o Sofrimento

DOI 10.5935/2595-0118.20190056

Over 30 years working with the Pain Management Clinic, and after almost four years as Editor-in-Chief of a scientific journal that has been gradually improving its technical quality, I wonder how pain, as a physical symptom, changes the course of the subject’s history. Surely the patient suffers. I emphasize that pain and suffering are words that translate distinct meanings and are surrounded by an ocean of meanings. Existential suffering from what a person is, ends up creating physical pain. And physical pain causes suffering. I remember one patient I cared for earlier in my career who had her legs and two fingers amputated and lost her memory, financial status, social position, and body image. Undoubtedly, there was physical pain throughout the amputation process, and the suffering was of the order of my imagination1. There is pain when there is empathy. Fortunately, the patient did not evolve with phantom limb pain, either on the amputation stump, which could have had more dramatic consequences. All of this after a gastrointestinal infection, followed by septicemia and systemic vasculitis. The impact of this incident, however, at the peripheral and central neuronal level, is still a major challenge for researchers2,3. After all, any mnemic record that causes pain, suffering, and changes the natural course of the subject’s history is still hermetically treated in psychotherapy offices, and after, on average eight years comes to the care of a specialized physician4. Contemporary ephemerality, the reason for so many absences, including that of love and compassion for others, besides the desperate search for a position of strong social representation, move the patient away from the caregiver and health professional5. Perhaps, the consequences over time of the recording in the nervous system of pain and suffering in newborns and premature infants, currently reported in publications as anxiety, abdominal pain, reduction in intelligence coefficient score, among others, alert health professionals about the importance of avoiding pain and suffering at any level6-8. I emphasize that this binomial does not make a person better but worse9. The burdens and aggression imposed by the modern world interfere with the course of the subject’s history, depending on individual genetics, environment, social, economic, and psychic history, and are modulated by their ability to cope. So that patient-centered pain education programs have clearly aided treatment adherence and outcome10. I conclude this reflection by emphasizing that caring for the body, soul, and spirit is fundamental to the correct flow of a full life: - without pain and suffering. Life is to be happy.

Durval Campos Kraychete Scientific Editor (2016-2019) Universidade Federal da Bahia, Salvador, BA, Brasil. https://orcid.org/0000-0001-6561-6584 E-mail: [email protected]

REFERENCES

1. Zaki J, Wager TD, Singer T, Keysers C, Gazzola V. The anatomy of suffering: understanding the relationship between nociceptive and empathic pain. Trends Cogn Sci. 2016;20(4):249- 59. 2. Bartkowska W, Samborski W, Mojs E. Cognitive functions, emotions and personality in woman with fibromyalgia. Anthropol Anz. 2018;75(4):271-7. 3. Chisari C, Chilcot J. The experience of pain severity and pain interference in vulvodynia patients: The role of cognitive-behavioural factors, psychological distress and fatigue. J Psycho- som Res. 2017;93:83-9. 4. van Hecke O, Torrance N, Smith BH. Chronic pain epidemiology and its clinical relevance. Br J Anaesth. 2013;111(1):13-8. 5. Bruman Z. Vida líquida. 2ª ed. Rio de Janeiro: Jorge Zahar Ed; 2009. 6. Beggs S. Long-term consequences of neonatal injury. Can J Psychiatry. 2015 ;60(4):176-80. 7. van Ganzewinkel CJ, Been JV, Dieleman JP, Katgert T, Boelen-van der Loo T, van der Pal SM, et al. Pain coping strategies: Neonatal intensive care unit survivors in adolescence. Early Hum Dev. 2016;103(1):27-32. 8. van Ganzewinkel CJ, Been JV, Verbeek I, van der Loo TB, van der Pal SM, Kramer BW, et al. Pain threshold, tolerance and intensity in adolescents born very preterm or with low birth weight. Early Hum Dev. 2017;110(1):31-8. 9. Porreca F, Navratilova E. Reward, motivation, and emotion of pain and its relief. Pain. 2017;158 (Suppl 1):S43-9. 10. Bodes Pardo G, Lluch Girbés E, Roussel NA, Gallego Izquierdo T, Jiménez Penick V, Pecos Martín D. Pain neurophysiology education and therapeutic exercise for patients with chronic low back pain: a single-blind randomized controlled trial. Arch Phys Med Rehabil. 2018;99(2):338-47.

307 BrJP. São Paulo, 2019 oct-dec;2(4):308-15 ORIGINAL ARTICLE

Clinical evaluation and prevalence of fibromyalgia in hepatitis C patients Avaliação clínica e prevalência de fibromialgia em pacientes portadores de hepatite C

João Batista Santos Garcia1, Silvia Amália de Melo Moura2, Durval Campos Kraychete3, Anita Perpetua Carvalho Rocha Castro4, Marilia Arrais Garcia5

DOI 10.5935/2595-0118.20190057

ABSTRACT CONCLUSION: In females, there was a positive relationship between hepatitis C virus infection, fibromyalgia, and extrahe- BACKGROUND AND OBJECTIVES: The worldwide distri- patic symptoms, which translates into a higher prevalence of bution and etiology of fibromyalgia are poorly understood. It is anxiety and depression and impaired quality of life. believed that different factors are involved, such as hepatitis C Keywords: Chronic pain, Fibromyalgia, Hepatitis C. virus infection. The aim of this study was to estimate the prevalence of fibromyalgia in hepatitis C virus infected patients, trying RESUMO to identify the occurrence of liver injury, extrahepatic clinical manifestations, anxiety, depression, and the impact on the qual- JUSTIFICATIVA E OBJETIVOS: A fibromialgia tem distri- ity of life. buição mundial e etiologia pouco compreendida. Acredita-se no METHODS: This is a cross-sectional study of patients (n=118) envolvimento de diferentes fatores, como a infecção pelo vírus with hepatitis C virus infection who were compared with a da hepatite C. O objetivo deste estudo foi estimar a prevalência group of clinically stable patients not infected with the hepati- de fibromialgia em pacientes infectados pelo vírus da hepatite C, tis C virus (n=118). The Anxiety and Depression Questionnaire procurando identificar a ocorrência de lesão hepática, manifesta- was applied, and for those diagnosed with fibromyalgia, the Fi- ções clínicas extra-hepáticas, ansiedade, depressão e o impacto na bromyalgia Impact Questionnaire. Liver biopsies were analyzed qualidade de vida. according to the METAVIR classification. The Schirmer test was MÉTODOS: Trata-se de um estudo de corte transversal com pa- performed to investigate abnormal tear production in the stud- cientes (n=118) portadores de infecção pelo vírus da hepatite C ied patients. Data analysis was performed using the Statistical que foram comparados a um grupo composto de pacientes clinica- Package for Social Sciences (SPSS) software, v.10.0. mente estáveis e não infectados pelo vírus da hepatite C (n=118). RESULTS: The prevalence of fibromyalgia in infected patients Foi aplicado o Questionário de Ansiedade e Depressão, e para os was 7.6%. In patients infected with fibromyalgia, a significant que obtivessem o diagnóstico de fibromialgia, o Questionário de prevalence of anxiety and depression was observed. Fibromyal- Impacto da Fibromialgia. As biopsias hepáticas foram analisadas gia Impact Questionnaire scores were higher in infected patients de acordo com a classificação METAVIR. Foi realizado o teste de with fibromyalgia. When comparing the complementary tests in Schirmer para a pesquisa de lacrimejamento anormal nos pacien- infected patients with and without fibromyalgia, no significant tes estudados. A análise dos dados foi realizada através do progra- differences were found for the Schirmer test, viral genotype, and ma Statistical Package for Social Sciences (SPSS) v.10.0. degree of fibrosis and liver inflammation. RESULTADOS: A prevalência de fibromialgia em pacientes infectados foi de 7,6%. Nos pacientes infectados com fibromialgia observou-se prevalência significativa de ansiedade e depressão. A pontuação do Questionário de Impacto da Fibromialgia foi maior João Batista Santos Garcia - https://orcid.org/0000-0002-3597-6471; Silvia Amália de Melo Moura - https://orcid.org/0000-0002-1607-371X; nos pacientes infectados e com fibromialgia. Quando se relacio- Durval Campos Kraychete - https://orcid.org/0000-0001-6561-6584; nou os exames complementares em infectados com e sem fibro- Anita Perpetua Carvalho Rocha Castro - https://orcid.org/0000-0002-2957-6770; mialgia, não foram constatadas diferenças significativas para o teste Marilia Arrais Garcia - https://orcid.org/0000-0003-1624-239X. de Schirmer, genótipo viral e grau de fibrose e inflamação hepática. 1. Universidade Federal do Maranhão, São Luiz, MA, Brasil. CONCLUSÃO: Nos indivíduos do sexo feminino, observou-se 2. Hospital Santa Cruz, São Paulo, SP, Brasil. 3. Universidade Federal da Bahia, Salvador, BA, Brasil. uma relação positiva entre a infecção pelo vírus da hepatite C, 4. Hospital Santa Izabel, Salvador, BA, Brasil. fibromialgia e sintomas extra-hepáticos, que se traduz em maior 5. Faculdade do ABC, Santo André, SP, Brasil. prevalência de ansiedade e depressão e em comprometimento na Submitted on May 08, 2019. qualidade de vida. Accepted for publication on October 09, 2019. Descritores: Dor crônica, Fibromialgia, Hepatite C. Conflict of interests: none – Sponsoring sources: none.

Correspondence to: INTRODUCTION Durval Campos Kraychete Rua Rio de São Pedro 327/401 - Graça 40150-350 Salvador, BA, Brasil. Fibromyalgia (FM) is a chronic disease that affects approximately E-mail: [email protected] 0.2-6.6% of the world’s population, with a prevalence of 0.7 to © Sociedade Brasileira para o Estudo da Dor 11.4% in urban areas and from 0.1 to 5.2% in rural areas1. In 308 Clinical evaluation and prevalence of fibromyalgia in hepatitis C patients BrJP. São Paulo, 2019 oct-dec;2(4):308-15

Brazil, it is also present in 2.5% of the population2. FM is more This variation may occur due to the diagnostic criteria chosen prevalent in young women and has a variable behavior depend- for the definition of FM22. Regardless of its prevalence, it is im- ing on the evaluation period and the diagnostic criterion. portant to note that HCV infection may be associated with the FM was defined by the American College of Rheumatology etiology of FM12. (ACR) in 19903 as a musculoskeletal pain syndrome lasting This study aimed to estimate the prevalence of FM in HCV-in- more than three months in which the patient reports pain at fected patients from a university service located in northeast- 11 of the 18 possible painful points on both sides of the body, ern Brazil. Secondary objectives are to identify the occurrence above and below the waist, and pain in the axial skeleton3. of liver injury, extrahepatic clinical manifestations, psychiatric This concept, however, has changed over time. In 20104, the disorders, as well as the impact on the quality of life of patients diagnostic criterion considered widespread pain index (WPI) infected or not with FM. ≥7; symptom severity scores (SS) ≥5 or WPI between 3-6 and SS ≥9; pain for more than three months and no other disease MÉTODOS that explained the pain. Fatigue, non-restful sleep, and cognitive disorders were evaluated as absent, mild, moderate, and This was a study of patients with HCV infection who were com- severe on a scale from zero to 3. Somatic complaints such as pared to a group of clinically stable and non-HCV uninfected paresthesia, headache, depression, anxiety, irritable bowel syn- patients. The calculated sample was 118 with infection and 118 drome, mouth and/or eye symptoms and Raynaud’s phenom- without infection for a power of 80%; α=5%, considering a enon, among others, were classified according to the number prevalence of FM in infected individuals around 14% versus an of symptoms (0=no symptoms; 1=few symptoms (10-20); average of 3% found in the population without infection23. 2=moderate number of symptoms (20 to 30); 3=large number To start the evaluation, the patients were asked about their in- of symptoms (30 to 41). In 2011, after reviewing the 2010 cri- terest in participating in the research by signing a Free and In- teria5, only the somatic symptoms that persisted for six months formed Consent Term (FICT). were considered as headache, pain, or colic in the lower abdo- The HCV group consisted of patients treated at the Liver Nu- men and depression with a score between zero and 3. Finally, cleus, linked to the University Hospital of the Federal University in 20166, the 2011 criteria were further revised, and it was val- of Maranhão (HUUFMA), from January 2009 to January 2010, idated that the WPI should be between 4-6 and the SS scale≥9. who had the ELISA (Enzyme-Linked Immunosorbent Assay) Pain is also required in 4 of 5 regions (4 quadrants and axial positive test and subsequent confirmation of viral RNA in pe- skeleton), except for the face and abdomen, and there may be ripheral blood. another causal relationship morbidity with FM. Despite all the Patients in the HCV infection group completed questionnaires, reflection on the diagnostic concept, the different definitions underwent a physical exam and laboratory tests, were over 18 only contributed to the increase of FM diagnosis in males7. years, had no other liver or infectious disease, neurological, psy- FM may be related to genetic predisposition and inadequate chiatric, neuromuscular, rheumatological, autoimmune diseases activation of the hypothalamic-pituitary-adrenal axis and auto- and had not used interferon during the last six months. nomic nervous system (ANS) in response to stress8. It can also The group without infection consisted of randomly selected pa- occur after infectious and autoimmune diseases, physical and tients from the medical clinic, with the same mean age, gender psychic trauma, systemic diseases, and viral infections, such as ratio, and characteristics already mentioned, with serology for hepatitis C virus (HCV) infection9. hepatitis C negative, according to the ELISA test15. Hepatitis C is a chronic infection caused by a Flaviviridae RNA Participants had medical records reviewed, and epidemiological virus, whose transmission occurs through contact of contami- data such as age, gender, and monthly income were recorded. nated biological materials with continuity solutions10,11. It is For those infected, data were recorded regarding risk factors for estimated a prevalence of 1.0% for HCV infection worldwide. infection and viral genotype. During the interview, the following HCV causes hepatic inflammation and steatosis, changes that symptoms were investigated in both groups: fatigue, Raynaud’s may progress to liver fibrosis, cirrhosis and hepatocellular car- phenomenon, myalgia, arthralgia, subjective complaints of dry cinoma, or may be associated with extrahepatic manifestations eye (sicca), paresthesia, diabetes, hypertension, purpura, and such as essential mixed cryoglobulinemia, membranous prolifer- pruritus15. ative glomerulonephritis, systemic vasculitis, Sjögren’s syndrome, To diagnose dry eye, all patients underwent the Schirmer test rheumatoid arthritis, systemic lupus erythematosus, myalgia, (ST), which was performed using a millimeter tape made with arthritis, and FM12,13. The role of HCV infection in the patho- an absorptive paper. The tape was left for five minutes in contact physiology of FM is not yet established14-17; however, possible with the patient’s lower ocular mucosa at the junction of the autoimmune18, inflammatory10,19, and/or psychogenic disorders middle third with the lateral. The test was read after 10s of its have been suggested as essential elements in this process. Patients removal from the ocular mucosa. In this study, only values lower with HCV infection develop anxiety and depression generated than 5mm were considered as a positive criterion for dry eye24. by the presence of chronic disease. This can also contribute to The diagnosis of FM was based on the 1990 ACR criteria, recom- global illness and FM development16. mended at the time of the study. Generalized pain was evaluated The prevalence of FM in patients with chronic HCV infection is quantitatively via verbal numeric scale (VNS), and qualitatively 1.9 to 57%20, a finding that is not confirmed by other authors21. through characteristics attributed by the patient himself (sting- 309 BrJP. São Paulo, 2019 oct-dec;2(4):308-15 Garcia JB, Moura SA, Kraychete DC, Castro AP and Garcia MA ing, stabbing, etc.). We also studied the presence of FM-related Table 1. Sociodemographic characteristics in HUPD patients with and symptoms such as headache, paresthesia, non-restorative sleep, without hepatitis C virus. São Luís, MA, 2009 fatigue, sicca, colds, and subjective edema, among others. Variables HCV+ HCV- p-value n=118 or % n=118 or % The emotional impact caused by the chronic disease was evaluated through the Hospital Anxiety and Depression Scale Ques- Age (years old) 52.44 52.34 0.9 tionnaire (HADS)25 and the Fibromyalgia Impact Questionnaire Gender 1 (FIQ), the latter for those individuals diagnosed with FM26. Female 42 35.6 42 35.6 Both questionnaires have already been validated in the national Male 76 64.4 76 64.4 27,28 territory, with their respective socio-cultural adaptations . Income 0.62 The HADS consists of 14 questions, of which seven score for the No income 23 19.5 24 20.3 diagnosis of anxiety and seven for the diagnosis of depression. Up to 1MW 33 28 41 34.7 The answers have weights ranging from zero to 3 points. The cutoff point considered was 9 for anxiety and 9 for depression. 1-5 MW 52 44 44 37.4 The FIQ consists of 10 items that evaluate (1) functional capac- >5MW 10 8.5 9 7.6 ity, (2) well-being, (3) work absences, (4) work difficulties, (5) Marital status 0.99 pain, (6) fatigue, (7) stiffness, (8) sleep, (9) anxiety, (10) depres- Married 81 68.7 80 67.8 sion. The total score ranges from 0 to 100, being stratified by Divorced 9 7.6 9 7.6 scores above or equal to 70 for a degree of intense FM involve- Single 17 14.4 20 16.9 ment, and between 50-70 for a moderate degree. Widower/widow 11 9.3 9 7.6 Liver biopsy results were recorded if the patient had a test per- n = number of patients; % = percentage; *p<0.05 for statistically significant formed less than or equal to a year ago, and were analyzed ac- values; = average. cording to the METAVIR classification, which shows degrees of fibrosis and hepatic necroinflammatory activity. The degree of fibrosis was stratified from 0 to 4, where F0 = absence of fibrosis, agnosis of liver cirrhosis. Thus, a total of 62 patients with known F1 = portal fibrosis without septa, F2 = few septa, F3 = numer- hepatic fibrosis were classified according to the METAVIR crite- ous septa without cirrhosis, F4 = cirrhosis. Necroinflammatory ria. It was observed that 21 (33.87%) were in F4; one (1.60%) activity was also measured in A0 = absence of inflammatory ac- in F3; 11 (17.7%) in F2; 16 (25.8%) in F1; 13 (20.96%) in tivity, A1 = mild activity, A2 = moderate activity, A3 = intense F0. When analyzing the necroinflammatory degree, it was found activity29. that of the 42 known, 18 (42.8%) patients were in stage A0; 20 This study was approved by the UFMA Research Ethics Com- (47.6%) in A1; 3 (7.1%) in A2 and 1 (2.38%) in A3. mittee, protocol 001911/2008. Of the 118 infected patients, 74 had viral genotypes distributed as follows: 52 (70.27%) had genotype 1; six (8.3%) geno- Statistical analysis type 2 and 16 (22.22%) genotype 3. Data analysis was performed using the Statistical Package for Regarding the symptoms reported by the patients, complaints Social Sciences (SPSS) v.10.0 program. The Chi-square test was of arthralgia, fatigue, myalgia, dizziness, subjective edema, pru- used to compare categorical variables (sociodemographic charac- ritus, and headache were statistically significant, with a higher teristics, symptoms, genotypes, ST biopsies, Student’s t for age predominance in the HCV positive group (Table 2). between the group with and without infection, and those infect- There was no statistical difference between groups when anxiety ed with and without FM. A descriptive analysis was performed was evaluated (p=0.772). On the other hand, there was a high- for the other variables. Variables with p <0.05 were considered a er prevalence of depression in the infected group (p=0.051). significant difference. There was a significant difference between the groups when the ST was applied, with 23.7% of the infected presenting dry eye RESULTS (p=0.001). A significant relationship was found between HCV infection and FM. Of those infected, 9 had FM (7.6%), while A total of 336 patients (118 with HCV and 118 without HCV) in the uninfected group, only one patient (0.8%) had FM were analyzed, evaluated for their sociodemographic character- (p=0.01). The only patient in the FM group without infection istics, which did not differ significantly between the groups was female, married, with a monthly income of less than one (Table 1). minimum wage. Of the infected patients, 47 (40%) reported not being exposed The infected group was then divided into patients with and to risk factors for HCV. Twenty-eight subjects (24%) reported without FM, and the sociodemographic data were compared having had blood transfusion, nine (7.5%) had a history of (Table 3). drug use and/or tattoos, 16 (13.5%) had used glass syringes, Females were statistically significant in the FM group. The six (5%) had reported occupational exposure, six (5%) had analyses were performed, taking into consideration only the contacts with infected and six (5%) reported other risk factors. female group. There were no differences in mean age between Of the 118 infected patients, 42 underwent liver biopsy less than infected women with and without FM, nor regarding other de- or equal to one year ago. In addition, 20 patients already had a di- mographic data. 310 Clinical evaluation and prevalence of fibromyalgia in hepatitis C patients BrJP. São Paulo, 2019 oct-dec;2(4):308-15

Table 2. Prevalence of symptoms in hepatitis C virus-infected compa- Table 3. Epidemiological profile of hepatitis C virus patients with and red to uninfected treated at HUPD in São Luís, MA, 2009 without fibromyalgia treated at the HUPD Liver Nucleus in São Luís, MA, 2009 Variables HCV+ HCV- p-value n=118 (%) n=118 (%) Symptoms HCV+ Paresthesia 37(31.4) 27 (22.9) 0.143 FM- % FM+ p-value Sicca 22(18.6) 16(13.6) 0.288 n=109 or % n=9 or % Arthralgia 54(45.8) 22(18.6) <0.001* Age (years old) 59.70 57.06 0.83 Myalgia 43(36.4) 29(24.6) 0.048* Gender 0.007* Purple 7(5.9) 11(5.9) 0.367 Female 36 33 7 77.8 Raynaud’s Syndrome 1(0.8) 1(0.8) 1 Male 73 67 2 22.2 Pruritus 20(16.9) 7(5.9) 0.008* Income 0.810 Fatigue 46(39) 27(22.9) 0.015* No income 21 19.3 2 22.2 Subjective edema 29(24.6) 15(12.7) 0.019* Up to 1MW 30 27.5 3 33.3 Headache 5(4.2) 0 0.024* 1-5 MW 48 44 4 44.4 Constipation 26(22) 28(23.7) 0.594 >5MW 10 9.2 0 Nonrestorative sleep 22(18.6) 20(16.9) 0.734 Marital status 0.232 Morning stiffness 25 20(16.9) 0.474 Married 76 69.7 5 55.6 Urinary Urgency 21 12(10.2) 0.183 Divorced 7 6.4 2 22.2 Difficulty concentrating 20(16.9) 15(12.7) 0.360 Single 15 13.8 2 22.2 Bad memory 40(33.9) 39(33.1) 0.890 Widower/Widow 11 10.1 0 Dizziness 40(33.9) 26(22) 0.042* Activity 0.039* Cold sensitivity 19(16.1) 30(25.4) 0.078 n = number of patients; % = percentage; * p<0.05 for statistically significant No activity 45 41.3 2 22.2 values. Remunerated 44 40.4 2 22.2 Retired 8 7.3 3 33.3 In evaluating exposure to risk factors in FM-infected individuals, Pensioners 12 11 2 22.2 blood transfusion was the most common route (4/9), followed and others by the unknown route (2/9) and subsequently by occupational n = number of patients; % = percentage; * p<0.05 for statistically significant values; = average. exposure, tattooing, and other forms in equal proportions (1/9). Of the patients infected with FM, two had a liver biopsy, and two already had the diagnosis of cirrhosis. Regarding the degree of liver fibrosis, according to the METAVIR criteria, it was ob- When analyzing only women infected with FM, it was observed that one (25%) patient presented with F1, 1(25%) with served that the most significant complaints had a similar pat- F2, and two cirrhotic (50%) with F4. Regarding the inflamma- tern to the previous group regarding pain complaints, fatigue, tory degree, one patient was A1 and the other A0. When com- paresthesia, dizziness, sleep alteration, and morning stiffness. paring the degrees of fibrosis and necroinflammatory activity In the infected group, when comparing those who did not have between those infected with and without FM, no statistically FM with those who had FM, there were no statistically signif- significant differences were observed. icant differences regarding ST (p=0.206), although there was a Regarding the viral genotype of FM-infected patients, of the significance regarding the complaint of dry eye by those infect- 118 infected patients, 74 had viral genotype distributed as fol- ed with FM. lows: 52 (70.27%) had genotype 1, 6 (8.3%) genotype 2, and In infected patients, there was a significant prevalence of 16 (22.22%) genotype 3. When these patients were compared anxiety in 77.7% and depression in 66.7% in the FM group to those infected without FM, no statistical significance was (p<0.001). Similar results were found when considering only observed between the groups (p=0.097). women in the FM-infected group compared to the group with- No statistical differences were found for viral genotype out, with an association with anxiety and depression in 71.4% (p=0.225) and degree of liver fibrosis (p=0.722) when consid- (p=0.047) and 57.1% (p=0.005), respectively. For ST, no asso- ering only women infected with and without FM. ciations were found (p=0.455). Regarding the symptoms reported by the patients, complaints Regarding pain intensity, the average grade obtained by VNS of arthralgia, fatigue, myalgia, non-restorative sleep, dizziness, was 7.5 in FM-infected patients. Regarding the quality of paresthesia, sicca, constipation, cold sensitivity, subjective ede- pain in patients with FM, 77.7% of patients complained of ma, purpura, headache, and complaints of Raynaud’s phenom- stabbing pain; 66.6% stinging pain; 55.5% throbbing pain; enon were statistically significant with higher prevalence in 44.4% pain in weight; 22.2% burning pain; 22.2% other those infected with FM (Table 4) types (Figure 1). 311 BrJP. São Paulo, 2019 oct-dec;2(4):308-15 Garcia JB, Moura SA, Kraychete DC, Castro AP and Garcia MA

Table 4. Reported symptoms of patients with positive hepatitis C virus, Table 5. Reported symptoms of patients with positive hepatitis with and without fibromyalgia, treated at HUPD, São Luís, MA, 2009 C virus with and without fibromyalgia treated at HUPD, São Luís, MA, 2009 Symptoms HCV+ Symptoms Women HCV+ FM- % FM+ % p-value n=109 n=9 FM- % FM+ % p-value n=35 n=7 Arthralgia 45 41.3 9 100 0.001* Arthralgia 15 42.9 7 100 0.006* Fatigue 38 34.9 8 88.9 0.001* Fatigue 15 45.9 6 85.7 0.038* Myalgia 36 33 7 77.8 0.007* Myalgia 15 42.9 6 85.7 0.038* Nonrestorative sleep 15 13.8 7 77.8 0.000* Nonrestorative sleep 4 11.4 6 85.7 0.000* Dizziness 33 30.3 7 77.8 0.004* Dizziness 14 40 6 85.7 0.012* Paresthesia 30 27.5 7 77.8 0.002* Paresthesia 12 34.3 6 85.7 0.012* Sicca 16 14.7 6 66.7 0.000* Sicca 5 14.3 5 71.4 0.001* Constipation 20 18.3 6 66.7 0.001* Constipation 12 34.3 4 54.1 0.256 Morning stiffness 19 17.4 6 66.7 0.001* Morning stiffness 7 20 6 85.7 0.001* Cold sensitivity 14 12.8 5 55.6 0.001* Cold sensitivity 6 17.1 3 42.9 0.130 Subjective edema 24 22 5 55.6 0.025* Subjective edema 8 22.9 4 57.1 0.067 Bad memory 36 33 4 44.4 0.487 Bad memory 19 54.3 3 43.9 0.580 Pruritus 17 15.6 3 33.3 0.173 Pruritus 5 14.3 1 14.3 1 Purple 4 3.7 3 33.3 0.000* Purple 3 8.6 2 28.6 0.136 Urinary urgent 18 16.5 3 33.3 0.205 Urinary urgency 7 20 3 42.9 0.195 Concentration 17 15.6 3 33.3 0.173 difficult Concentration difficulty 6 17.1 2 28.6 0.482 Headache 3 2.8 2 22.2 0.005* Headache 11 31.4 5 71.4 0.061 Raynaud’s Syndrome 0 0 1 11.1 0.000* Raynaud’s Syndrome 0 0 n = number of patients; % = percentage; *p<0.05 for statistically significant n = number of patients; % = percentage; * p<0.05 for statistically significant values. values.

In the patient with FM without infection, the pain characteristic DISCUSSION was stabbing, with VNS of 8. When the FM impact on the quality of life questionnaire was Although not having a well-defined etiological factor, FM evaluated, an average of 59.77 points was observed in the HCV has an established association with infectious diseases such as group and 43.58 points in the group without infection. Of the chronic Lyme disease, hepatitis C, coxsackievirus, parvovirus, patients with FM and HCV, seven (77.44%) had a moderate to and human immunodeficiency virus9,12. intense FIQ score (score above 50). Regarding the only patient This study examined 118 chronically HCV-infected patients, with FM and without HCV, this one had a score below 50 in the with an average age above 50 years. Of the sample, 35.6% were FIQ, a value related to a mild impact. The means for each item women. The route of contamination was unknown in 40% of in the FIQ are shown in table 5, highlighting a higher average for cases, followed by blood transfusion, similar to that described the difficulty in working due to pain. in the literature for developing countries30,31. Several studies with a similar design in different parts of the world have found a positive association between HCV infection and FM. Bus- kila et al.15 observed a significant prevalence of FM (16%) in 90% 78% the infected group when compared to the group without HCV 80% 66.60% (3%). Rivera et al.16, in a study conducted in Spain, found 10% 70% 55.50% of those infected with FM compared to 1.72% of the group 60% 19 50% 44.40% without infection. Kozanoglu et al. , in Turkey, observed that 40% 18.9% in the group with hepatitis C had FM, compared to 30% 22.20% 22.20% 5.3% without the syndrome. In a similar study, Goulding, 20% O’Connell and Murray17 found 5% of FM in infected individ- 10% 0% uals, considering a frequency of almost twice the local popula- Stinging Stabbing Throbbing Weight Burning Others tion and statistically significant compared to the control group. In Brazil, a non-comparative cross-sectional study by Loureiro 24 Figure 1. Percentage of widespread pain quality in infected fi- et al. showed a prevalence of FM in infected individuals of bromyalgia patients treated at HUPD Liver Nucleus, São Luís- 12%. In this study, a positive association was found between C -MA, 2009 virus infection and FM, with results of 7.6% of HCV positive 312 Clinical evaluation and prevalence of fibromyalgia in hepatitis C patients BrJP. São Paulo, 2019 oct-dec;2(4):308-15 patients with FM compared to 0.9% of HCV negative group. patient’s emotional state at the news of a chronic infection, As can be seen, a lower percentage when compared to the other influence of the viral genotype14,37, or the reduction of liv- studies already described. This result could be explained by the er-produced substances (IGF-1), the lack of which would be different proportions of women who composed each study. The responsible for musculoskeletal injuries14. Another element to study with FM prevalence of 18.9% had 65% of the sample consider is the difference in the design of the studies used for consisting of women18. As for the 16% prevalence of FM in discussion. All studies with a similar design were in agreement infected patients, 46% of the study population was women. to find a relationship between FM and HCV14-16,18. Howev- The reflection of female significance in the genesis of the rela- er, those who researched HCV infection in patients known to tionship between FM and HCV was observed in this study and have FM had different results12,20,21,38. reinforced by several authors1,5,14,18,20. Few studies address the evaluation of the role of anxiety and de- In addition to FM, it is known that other extrahepatic symp- pression in patients with hepatitis C and FM. Rivera et al.16 put toms may be observed in patients with hepatitis C. Musculo- the emotional factor on a secondary level, since when research- skeletal pain complaints are common, with a prevalence of 50- ing the C virus infection in patients with FM, they observed 81%32. In a study by Poynard et al.34, fatigue was highlighted that this infection is more prevalent in this group than in the in 53% of patients, followed by arthralgia (23%), paresthesia control group. This points to the viral role in the genesis of pain (17%), and myalgia (15%). In this study, the most reported syndrome. It is important to note that most patients did not symptoms among infected people were arthralgia (45.8%), know about the infection and/or that it would have a chronic fatigue (39%) and myalgia (36.4%). In the group of HCV course. Therefore, they would not have the emotional impact patients with FM, it was observed that pain complaints were established by this news15. A similar conclusion was found in a significantly more frequent. study conducted in Paraná by Silva et al.40. Dry syndrome, also known as sicca, is characterized by com- Goulding, O’Connell and Murray17 present a study that eval- plaints of dry eye and/or mouth that can be objectively ob- uates the degree of anxiety and depression in HCV and FM served with specific tests such as Schirmer’s. This syndrome patients, revealing higher anxiety in this group when com- may be part of the Sjögren’s syndrome (SS), which makes up pared to healthy patients. They also show that the high degree the picture of rheumatologic manifestations associated with presented by these patients is independent of the presence or the C virus. The diagnosis of SS is given along with specif- absence of circulating viral RNA in the blood and the route ic patterns in serological and histopathological exams of the of infection. In this study, there was a tendency for a higher salivary glands. Experimental and epidemiological studies have prevalence of depression in HCV patients than in those with- already found a high prevalence of such histological patterns out HCV. There was no significant difference between anxiety in HCV-positive salivary glands34,35. Lormeau et al.35 found a levels. When comparing those infected with and without FM, positive association between sicca and HCV infection in 10 to it was observed that 78% of FM had anxiety and 66.7% de- 20% of patients. In this study, only the presence of sicca and pression compared to 23 and 13% for anxiety and depression the ST were evaluated. Significant changes were found for ST infected without FM. This difference, being statistically signif- in HCV patients, but there were no significant differences re- icant, supports the emotional influence on the genesis of FM. garding dryness complaints. When comparing the number of However, one cannot rule out the role of the infection itself in patients who reported sicca with the number of positive ST, a the generation of FM, since in this group it is not known what discrepancy was observed between such numbers in the unin- the initial event was: pain or depression. fected group, in which 14 reported sicca and only eight had Two studies evaluating the quality of life presented by fibro- a positive ST; while in the infected, 22 reported sicca and 25 myalgic patients with HCV according to the FIQ showed an had positive ST. The results found in this study were similar to average of 52.123 and 85.9 points16. These values are considered those obtained by Goulding, O’Connell and Murray17, who moderate and severe, respectively40. In the study in question, observed a degree of dry eye by ST in patients with HCV. As the impact was more intense in patients with virus C, with an found by other authors, there was no association between the average of 59.77 points, a value considered moderate. Unfortu- positivity of ST for infected fibromyalgia16,18. However, com- nately, it was not possible to make a comparison with the group plaints of dry eye were significant. Thus, the association of FM without infection, as it presented only one fibromyalgia patient with this extrahepatic manifestation was not established to es- with mild impact (43.58 points). timate a common pathophysiological mechanism. It is believed When the items were discriminated, the ones with the highest that dryness complaints, restricted only to the subjectivity of score were related to difficulties in performing tasks and work, the patient, could contain an association with the psychological pain intensity, fatigue, alteration of well-being, alteration in characteristics of this population with such significant degrees functional capacity, work absences, anxiety, depression, stiff- of anxiety, depression and pain complaints. ness and morning fatigue. Given the relevance of pain and fa- Several theories have been proposed to explain extrahepat- tigue in the worsening of quality of life in positive HCV and, ic complaints in patients with C virus infection. Thompson knowing that these are common extrahepatic manifestations, and Barkhuizen37 suggested that changes in cytokine dynamics C virus infection is now considered an important factor in FM could be involved in these extrahepatic manifestations. Oth- genesis. Other evidence supporting this theory is that when er theories for the causes of such manifestations would be the comparing the group with and without HCV, there are similar 313 BrJP. São Paulo, 2019 oct-dec;2(4):308-15 Garcia JB, Moura SA, Kraychete DC, Castro AP and Garcia MA degrees of anxiety and depression, but more prominent pain REFERENCES complaints in the group that has the infection as a differential. Among those infected, pain complaints become more prevalent 1. Marques AP, Santo ASDE, Berssaneti AA, Matsutani LA, Yuan SLK. Prevalence of fibromyalgia: Literature review update. Rev Bras Reumatol. 2017;57(4):356-63. En- in those patients with FM, as well as a higher number of anxi- glish, Portuguese. ety and depression cases. 2. Senna ER, De Barros AL, Silva EO, Costa IF, Pereira LV, Ciconelli RM, et al. Pre- valence of rheumatic diseases in Brazil: a study using the COPCORD approach. 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315 BrJP. São Paulo, 2019 oct-dec;2(4):316-20 ORIGINAL ARTICLE

Pain: the impulse in the search for health by means of integrative and complementary practices Dor: o impulso na busca pela saúde por meio de práticas integrativas e complementares

Miraíra Noal Manfroi¹, Priscila Mari dos Santos Correia1, Wihanna Cardozo de Castro Franzoni2, Letícia Baldasso Moraes1, Francine Stein2, Alcyane Marinho2

DOI 10.5935/2595-0118.20190058

ABSTRACT RESUMO

BACKGROUND AND OBJECTIVES: This study investigated JUSTIFICATIVA E OBJETIVOS: Este estudo investigou as re- the relations between the playful component and the process of lações estabelecidas entre o componente lúdico e o processo de rehabilitation, treatment, and promotion of health in the context reabilitação, tratamento e promoção da saúde no contexto de um of a group that treats the pain, located in Florianópolis (Brazil). grupo que trata da dor, localizado em Florianópolis (SC). METHODS: The research followed a qualitative approach, a de- MÉTODOS: A pesquisa seguiu uma abordagem qualitativa, ten- scriptive-exploratory field research. A matrix-guided systematic do sido realizada por meio de uma investigação de campo, confi- observation was conducted for two months by the group leader, gurando-se como descritivo-exploratória. Foi realizada observação two volunteers and about 15 participants. A field diary was used sistemática, durante dois meses, guiada por uma matriz, envolven- to register complementary information. Besides two semi-struc- do a responsável pelo grupo, duas voluntárias e cerca de 15 inte- tured interview guides were used, applied to four members and grantes. Para o registro de informações complementares, utilizou- the person responsible for the group after the two-month obser- -se um diário de campo. Além disso, foram utilizados dois roteiros vational period. The data were organized and analyzed in three de entrevistas semiestruturadas, aplicados com quatro integrantes topics: “Characterization of the investigated group and dynamics e com a responsável pelo grupo, ao final do período dos dois me- of the meetings,” “The group as healing potential” and “Lian ses de observações. Os dados foram organizados e analisados em Gong/Qi Gong as a possibility to look at the pain.” três tópicos: “Caracterização do grupo investigado e dinâmica dos RESULTS: The participants pointed out that working on Lian Gong/ encontros”, “O grupo como potencial de cura” e “Lian Gong/Qi Qi Gong, meditation and auriculotherapy contemplating the playful Gong como uma possibilidade de olhar para a dor”. component the group becomes a place of recognition of each one’s RESULTADOS: Os participantes indicaram que ao trabalhar Lian pain subjectivity, by the individual that suffers and by the collective, Gong/Qi Gong, meditação e auriculoterapia, contemplando o ele- which has fostered the recovery of specific pain and good sensations to mento lúdico, o grupo tornou-se um local de reconhecimento da those involved, such as happiness, enthusiasm and pleasure. subjetividade da dor de cada um, pelo indivíduo que sentia e pelo CONCLUSION: The creation of the group and people’s engage- coletivo, gerando melhoras nas dores específicas e trazendo boas sen- ment has decreased the number of specific requests for physio- sações aos que estão envolvidos, como alegria, entusiasmo e prazer. therapy sessions and provided greater autonomy to the partici- CONCLUSÃO: A criação do grupo e o engajamento das pessoas pants to handle their own pain. diminuiu o número de pedidos específicos de sessões de fisiotera- Keywords: Group, Lian Gong/Qi Gong, Pain, Recreational. pia e proporcionou maior autonomia do participante em atender a sua própria dor. Descritores: Dor, Grupo, Lian Gong/Qi Gong, Lúdico. Miraira Noal - https://orcid.org/0000-0003-0135-0697; Priscila Mari dos Santos Correia - https://orcid.org/0000-0002-5411-595X; Wihanna Cardozo de Castro Franzoni - https://orcid.org/0000-0002-5845-3059; INTRODUCTION Letícia Baldasso Moraes - https://orcid.org/0000-0002-6095-9235; Francine Stein - https://orcid.org/0000-0001-6501-0259; Alcyane Marinho - https://orcid.org/0000-0002-2313-4031. The sensation of pain is fundamental to survival, even though it

1. Universidade Federal de Santa Catarina, Centro de Desportos, Florianópolis, SC, Brasil. is described as an unpleasant subjective sensory and emotional 2. Universidade do Estado de Santa Catarina, Centro de Ciências da Saúde e do Esporte, experience. It is an important and complex phenomenon that Florianópolis, SC, Brasil. originates from injuries or stimuli, such as heat, cold, pressure, Submitted on January 16, 2019. chemical irritants, sudden movements. These stimuli can be Accepted for publication on September 17, 2019. modified by the memory, expectation, and emotions experienced Conflict of interests: none – Sponsoring sources: Fontes de fomento: CAPES - Coordenação 1 de Aperfeiçoamento de Pessoal de Nível Superior. by each person . All sensations experienced from pain are part of important physiological, sensory, affective, cognitive, behavioral, Correspondence to: 2 R. Bráulio de Souza, 258 and sociocultural domains of human experience . 79042-030 Campo Grande, MS, Brasil. To talk about pain is to talk about life, for one is inherent in the E-mail: [email protected] other, sometimes in memory or in the personal experience of © Sociedade Brasileira para o Estudo da Dor those who felt or feel, except for rare exceptions. Pain is generally 316 Pain: the impulse in the search for health by means BrJP. São Paulo, 2019 oct-dec;2(4):316-20 of integrative and complementary practices not the same as it lasts, with varying intensity, and may change From this perspective, this study aimed to investigate the rela- from time to time, from day to day, characteristic that can be tionships established between the playful component and the linked to the context, the time of day, a gesture, a drug, among process of rehabilitation, treatment, and health promotion in many other objective and subjective aspects that are part of the the context of a group that treats pain. This group is located pain experience3. in Florianópolis (SC) and has been developed by residents and Even if they are considered expressions of withdrawal from a health professionals. condition considered healthy, pain and functional disability are elements reported below expectations and not specifi- METHODS cally recorded by the Basic Health Units (BHU) in Brazil. Due to its high prevalence, more attention is needed from With a qualitative approach, carried out through a field inves- professionals working at the BHU to treat it efficiently4, tigation, it is configured as descriptive-exploratory research. since one of the primary care strategy responsibilities in Bra- The qualitative research was chosen because it did not seek to zil is to maintain a preventive attitude to the population’s generalize the findings, but rather to deepen the aspects of the health-disease problems. context of the participants in their daily living12. The description In Brazil, it is estimated that chronic pain affects around 30 to was used, trying to go deep into the details that characterize the 40% of the population, being described as one of the leading studied phenomenon, with no intention of testing or building causes of sick leave, early retirement, labor compensation, and theoretical models13. low productivity, and can be pointed as a public health prob- It is important to emphasize that, according to the Internation- lem5,6. In the Brazilian reality, especially in the context of the al Association for the Study of Pain (IASP), the qualitative re- BHUs, the word “pain” is said and heard practically every day search enables, with its resources, an individualized contact with in the routine of care. Listening to these types of reports, a patients, giving voice to the experiences of those who live with physiotherapist, working in a BHU in the south of Florianópo- pain. Thus, qualitative knowledge allows the understanding of lis (SC), founded an open group, aiming to promote autonomy the patient as a whole, not just as body parts, thus contributing in the treatment of pain (acute and chronic). Pain starts to be to the decision-making regarding health care14. viewed according to each person, taking into account the social The group investigated, entitled the Pain Group, worked in one condition, the cultural context, and their history3. of nine BHU selected to participate in a broader research, of With initiatives such as this, it is, therefore, possible to think of which this study is part, entitled “The playfulness and rehabili- humanized care, which means listening, capturing, and meet- tation in public and private institutions in Florianópolis (SC)”. ing, as thoroughly as possible, people’s health needs, always The Pain Group met at the Residents’ Association headquarters seeking quality care7,8. Complementing this idea, the Minis- in a neighborhood located in the southern region of Florianópo- try of Health (MOH) advocates that the individuals assisted lis on Wednesdays, from 9 am to 10 am, being coordinated by should not be reduced to purely technical intervention objects9. a physiotherapist, accompanied by a nutritionist, two health According to the National Health Promotion Policy (PNPS), agents, and two physiotherapy residents. actions and services in the health area should aim at the equity The data collection started by the systematic observation tech- and quality of life of people to reduce vulnerabilities and health nique, applied during two months, in seven meetings, with a to- risks arising from social, economic, political, cultural, and en- tal duration of 10h30 minutes. The systematic observation ma- vironmental determinants. trix referred to the activities developed in the group, including: The structuring and strengthening of attention in Integrative playful activities, forms of appropriation of the playfulness by and Complementary Practices (PIC) in SUS occurs through the responsible (the playfulness as vehicle, object or work meth- the insertion in all levels of care, with emphasis on primary od), results and forms of playfulness appropriation by the group care, multi-professional development, as well as the establish- members (implicit and explicit expressions). The observations ment of financing mechanisms, elaboration of technical and applied as a data collection instrument through the systematic operational standards for the implementation and articulation matrix involved the group leader, two volunteers and about 15 with the other policies of MOH10. members. To record complementary information to this ma- As a result of initiatives such as these, more humanized re- trix, a field diary (FD) was used to verify and obtain an accurate lationships developed by the BHUs are being established, in description of the situations/phenomena that met the research which the playful component presents itself as a fertile path, objectives15, as well as the records of emotions and details that which can be understood as the anima (soul) that moves the overflowed the matrix. human being11, and unproductive pleasure, that is, what drives In addition, two semi-structured interview scripts16 were used, or feeds playing, partying, and other activities marked by the applied to four members, and the group leader at the end of end in themselves. In this sense, it is believed that health care the observation period. The script for the members comprised that takes into account the playful component would be expe- of questions that besides the identification data, included the rienced in its entirety, in which professional and user would be following elements: reasons for participation and permanence immersed at the moment, beyond a set of activities or a list of in the project; meaning given to the group/project; changes idealized qualities as spontaneity, fun, joy, creativity, pleasure, (personal and/or health) from joining; possible changes to the dream or immediacy. professional, location, activities or methods; and perception of 317 BrJP. São Paulo, 2019 oct-dec;2(4):316-20 Manfroi MN, Correia PM, Franzoni WC, Moraes LB, Stein F and Marinho A

Table 1. Identification of participants Participants Fictitious name Marital status Age (years old) Health problem Profession Gender Group participation time Part. 1 Julieta Widow 69 Yes Housewife F 5 months Part. 2 Carlos Did not inform 61 Yes Retired M 4 months Part. 3 Clóvis Did not inform 65 Yes Retired M 4 months Part. 4 Adelaide Married 59 Yes Housewife F 1 year Leader Rosa Married 32 - Physical therapist F Founder Source: Own authorship (2019). playful activities in the group/project. In turn, the interview locomotion around the room, to look at each other, verbal script for the leader included: identification data; professional communication, even briefly. career; understanding of the term “playfulness”; working time In a second moment of the meetings, the Lian Gong/Qi with playful activities; characteristics of the public served by the Gong guided exercise practice from the Traditional Chinese groups/projects (gender, age, places); choice of contents and how Medicine (TCM) was performed aimed at developing the use they are developed; expected and achieved results; evaluation of vital energy. It was divided into four phases: a) Unlocking, mechanisms; and possible differences in working with playful responsible for releasing the channels to capture the energy activities inside and outside the institution. more efficiently, thus strengthening the bone structure and Since the participation in the group was open, there was no marrow; b) Uptake, in which external energy is captured; c) attendance control, with participants continually joining and Circulation, movements are made to favor the circulation of quitting. Thus, after the observations, the members of the group the energy captured through the channels, in order to clean, were chosen to participate in the interview with the help of the nourish and strengthen the internal organs; and, finally, d) leader, especially considering their frequencies. Table 1 presents Storage, when the energy reserve occurs with the intention to the characteristics of the research participants. use when needed17. All interviews were conducted in a quiet and reserved place. While one of the leaders demonstrated the sequence of move- Before starting the interviews, the participants and the leader ments to the group, the other two walked around, observing signed the Free and Informed Consent Form (FICT) and the and, if necessary, giving individual orientation to each of the Consent Form for Photographs, Videos, and Recordings. An participants to improve the quality of the movement. Next, the audio recorder was used to record the interviews. The partici- leader conducted a meditation session in which participants pants’ names have been replaced by fictitious names to preserve imagined hugging a tree. From this image/sensation, they were their identities. led to carry an imaginary light that went throughout their body The data obtained through observations, field diary, and inter- to unlock the energies that were disturbing and producing the views were analyzed by thematic analysis, which consists of or- pain; and embrace the energies that helped them reduce their ganization, preparation, reading, coding, and description of the pain. Soon after, a sentence from the leader, the trainees or data, followed by representation and interpretation of the analy- participants, such as “bad thoughts destroy the opportunities sis12. At the end of this process, the thematic topics were reached: and plant the suffering of tomorrow” was read and repeated, “it “the group as a healing potential” and “Lian Gong/Qi Gong as a is wonderful to come home when so many have nowhere to go” possibility to look at pain”. (FD 21/10/2015),“none of us is as good as all of us together” This study was approved by the Ethics Committee of the Santa (FD 7/11/2015), among others. Catarina State University, under number 916.511 of 2014. In the end, the participants had auriculotherapy, a method also coming from the TCM, using points located in the pinna to RESULTS treat various body disorders18. In this case, the stimulus was made by mustard seeds stuck in the specific ear points of the During the meetings, it was possible to notice elements that are patients and changed every 15 days. This ended up being the permanent during the period of the activity, such as lit incense, most intimate moment between patients and professionals below music with slow melody, and soft but well-intoned voices cause when asked what they felt, they ended up having brief of the leader and the trainees that mediated the action. consultations, placing the seeds where needed, and sometimes The work of the group investigated was characterized by an ini- venting about something that bothered them regarding the var- tial welcoming moment, in which some dynamics usually oc- ious aspects of their life. cur so that the members get closer and know each other better, From the observations and interviews conducted, it was ob- as the dynamics where each one, in a circle, makes a movement served that the audience over 50 years was the most frequent, and the others follow. Gradually, this exercise made people less since the time and day of the meetings may have been a barrier embarrassed even to perform their own movements. Another for more people to participate. A fact confirmed in the response activity was the distribution of sentence fragments to differ- of the leader in relation to the public served by the project: ent people who should look for, among the other participants, “Everyone wanted to participate, but due to the schedule, we had those with the complementation. This dynamic stimulated the more old people. But all who wanted to participate could come”. 318 Pain: the impulse in the search for health by means BrJP. São Paulo, 2019 oct-dec;2(4):316-20 of integrative and complementary practices

The professional responsible for the group informed that the saying that she liked it a lot, especially the music. [...]. (FD participants adhered to the project both by medical indication 7/11/2015). and willingness, respecting their interests and needs. Through- This attention to the playful element is shown as one of the out the collection period, the climate variation was intense, but reasons for the participants’ engagement in the group, making with little change in the group frequency, demonstrating the them think that doing in-group becomes more relevant than motivation of the participants to integrate this group. doing in the group. That is, the group is as important as the suggested practice itself, as put by a participant: DISCUSSION [...] the environment we form in the group is so good. The day I miss the meeting, I feel something is missing and on Wednesdays The attendance of participants to the group was something that I don’t have it, I’m sorry. For me it was very important, I that has drawn our attention and can be justified by the re- had never participated in a group and I am loving it (José Círio markable presence of the playful element during the devel- Floreiro). opment of the proposed activities, as noted in the FD, in In the positive repercussions in the physical spheres, the feel- relation to spontaneity: “[...] observing Juliet and Clovis, ing of belonging to a group was perceived, the creation of an they talked how good it was to come to the group, until she identity as being part of something that transcends individ- said, ‘I do things here that I’ve always felt like doing, but I was ualism, corroborating the evidence of improvement and re- ashamed of, now I do it spontaneously,’ and he nodded.”(FD lief of chronic pain, promoting quality aging, through group 11/11/2015). This fact meets the response of Rosa, profes- practices that enable socialization23. Thus, the group’s routine sional responsible for the Pain Group. She stated that play- has become a meeting point, creating moments of coexistence fulness can be any activity characterized by “[...] relaxation, so for the members, in which they can know the realities of other that people feel comfortable in what they are doing and are happy people who also have similar or different pain and talk about and not an imposed thing; but, yes, something that makes them such experiences. In this sense, it was very sensitive to under- feel good” (Rosa). stand the welcome to a new member, as described below: Rosa believed that activities aimed at pain management, [...] at the time of auriculotherapy, [...] the members were when permeated by the playful element, even favored people’s already giving their opinions about what they thought and participation in relating the group to good feelings, happi- encouraging a new member of the group to also participate ness, and relaxation. Thus, studies that advocate humanized in this activity, saying it was wonderful and stating that she treatment through welcoming environments that use playful would not regret [...]. (FD 11/11/2015). activities as a form of health recovery and pain distraction19,20 From these statements, it was noted that the group has become are, therefore, restated. a place for the sharing of various pains, since the forms of re- Professionals’ conceptions about health and care regarding action to pain are never identical because they are loaded with practices are varied. Some related the PICs to the individu- multiple social and cultural conditions, besides the history of alization of care, the professional-patient relationship, self- each person3. Therefore, it is necessary to consider the particu- care, light technologies, and the patients’ biopsychosocial and larities of each individual, because even if the pain is installed spiritual context. In turn, the professionals who do not have in only one body fragment, changes in relationships transcend training in PICs did not describe any relationship with these the individual physical body, reaching the totality of the rela- practices, nor with the therapeutic and natural stimulation tionship with the world. In this way, it is important for those of the organism21. PICs are applicable as non-pharmacologi- who suffer, even if the most banal pain, to have their experience cal measures using therapeutic touch, reike, herbal medicine, recognized by the other, in the other and from the other. There- flower therapy, acupuncture, body therapies, meditation and fore, the Pain Group becomes a place of recognition of the relaxation practices. Using these practices in pain control may subjectivity of each one’s pain by the collective, corroborating contribute to a lower potential for toxicity that may be caused the idea that the group itself is a potential space for healing. by the use of pain-relief drugs22. In a study conducted in another context, which aimed to From this perspective, Rosa reported that she worked at BHU evaluate the presence of chronic pain in elderly practitioners and a year ago founded the Pain Group, realizing that there of Chinese gymnastics (Lian Gong/Qi Gong) and sedentary are more opportunities for integration and bonding with par- elderly, the result shows that the practice was related to the ticipants, particularly considering the way activities are de- decrease in the use of medication, the positive perception of veloped, which favor the active role of participants. Although their own health, the inclusion of autonomy practices in self- observations have shown that there is a “script” to follow in care and the impression of less impairment to perform daily the meetings, the participants find a space to be heard and to activities15. These findings confirm the data found from the share their views on group activities. interviews and observations of this research, being possible That day, the group started the activity with a circular dance. to understand the importance of all the activities that make They played very calm music, and the steps were simple, but up the Pain Group, especially the practice of Lian Gong/Qi as someone always forgot some movement, everyone ended Gong, as reported by Claudio: “For me, it was a very good up laughing, including the person who made a mistake. [...] thing, I have never exercised at home. Now I come here. When In the end, one lady gave her opinion about that meeting, I can’t come, during the week I do some of these exercises, and 319 BrJP. São Paulo, 2019 oct-dec;2(4):316-20 Manfroi MN, Correia PM, Franzoni WC, Moraes LB, Stein F and Marinho A it helps a lot my health” and by Adelaide: “All exercises are very REFERENCES favorable, important, rewarding, and the seed also helps a lot.” In addition, the observations made it possible to capture mo- 1. Silva JA, Ribeiro-Filho NP. A dor como um problema psicofísico. Rev Dor. 2011;12(2):138-51. ments of explanations of the leader to the participants, demon- 2. Frutuoso JT, Cruz RM. Relato verbal na avaliação psicológica da dor. Rev Psicol. strating the importance of the movements stating: “[...] they 2004;3(2):107-14. 3. Le Breton D. Compreender a dor: um estudo sobre a relação do homem com a dor física serve not only for the body but for the circulation of energy” (FD em diversos tempos e em diversas culturas. 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320 BrJP. São Paulo, 2019 oct-dec;2(4):321-5 ORIGINAL ARTICLE

Back pain in adolescents: prevalence and associated factors Dor nas costas em adolescentes: prevalência e fatores associados

Mirna Namie Okamura1, Wilma Madeira2, Moisés Goldbaum3, Chester Luiz Galvão Cesar1

DOI 10.5935/2595-0118.20190059

ABSTRACT RESUMO

BACKGROUND AND OBJECTIVES: Back pain is one of the JUSTIFICATIVA E OBJETIVOS: Dor nas costas é uma das most common pain in humans. It impacts the health and quality dores mais comuns do ser humano. Afeta a saúde e a qualidade of life and can be disabling. Diseases detected in adolescence and de vida, podendo ser incapacitante. Doenças detectadas na ado- poorly managed may get worse in adulthood. The objective of lescência e mal manejadas podem se agravar na vida adulta. O this study is to estimate the prevalence, the associated factors and objetivo deste estudo foi estimar a prevalência, fatores associados the characteristics of back pain in adolescents living in the city e características de dor nas costas em adolescentes da cidade de of São Paulo. São Paulo. METHODS: A cross-sectional population-based study – Health MÉTODOS: Estudo transversal de base populacional – In- Survey in São Paulo (2015) with 539 adolescents of both gen- quérito de Saúde da Capital 2015, com 539 adolescentes de ders between 15 and 19 years old was used. The information ambos os sexos e entre 15 e 19 anos. As informações foram was collected through home interviews and the participants were coletadas por meio de entrevistas domiciliares e os participan- selected by probabilistic sampling. Frequencies, Chi-square test, tes foram selecionados a partir de amostragem probabilística. and logistic regression analysis were used in this analysis. The Frequências, teste do Qui-quadrado e análise de regressão lo- level of significance was 5%. gística foram utilizados na análise. O nível de significância RESULTS: The estimated prevalence of back pain in adolescents adotado foi 5%. in the city of São Paulo was 22.4%. Back pain in adolescents RESULTADOS: A prevalência estimada de dor nas costas em had the following associated factors: dizziness (OR 3.1), com- adolescentes da cidade de São Paulo foi de 22,4%. Dor nas costas mon mental disorder (OR 2.4), insomnia (OR 2.6) and perform em adolescentes apresentou fatores associados com: tontura (OR household chores (OR 1.8). To relieve the pain, 46.6% of ado- 3,1), transtorno mental comum (OR 2,4), insônia (OR 2,6) e lescents do nothing, 17.3% use self-medication and 8.9% use realizar atividades físicas domésticas (OR 1,8). Na busca por prescribed medication. alívio da dor, 46,6% dos adolescentes não fazem nada, 17,3% CONCLUSION: Acknowledging back pain as a public health buscam automedicação e 8,9% usam fármaco prescrito. problem requires strategies that allow us to learn the origins, CONCLUSÃO: Entender a dor nas costas como um problema associated factors and coping strategies that may influence new de saúde pública obriga a pensar em estratégias que permitam ways of prioritizing and organizing healthcare. compreender origens, fatores associados e estratégias de enfren- Keywords: Adolescent, Back pain, Cross-sectional studies, Low tamento que podem influenciar novas formas de priorizar e or- back pain, Prevalence. ganizar a atenção à saúde. Descritores: Adolescente, Dor lombar, Dor nas costas, Estudos transversais, Prevalência.

INTRODUCTION Mirna Namie Okamura - https://orcid.org/0000-0002-4547-7836; Wilma Madeira - https://orcid.org/0000-0003-3885-7723; Moisés Goldbaum - https://orcid.org/0000-0002-8049-7824; Back pain is known as a major cause of disability1 in work and Chester Luiz Galvão Cesar - https://orcid.org/0000-0002-6999-1506. daily activities. Its origin, in part, refers to the use of the human 1. Faculdade de Saúde Pública da Universidade de são Paulo, Departamento de Epidemio- body, which begins in childhood but starts to show its signs of logia, São Paulo, SP, Brasil. 2. Hospital Alemão Oswaldo Cruz, Departamento de Filantropia, São Paulo, SP, Brasil. use (or misuse) more intensely in adolescence. There is evidence 3. Faculdade de Medicina da Universidade de São Paulo, Departamento de Medicina Pre- that earlier intervention in this problem would bring more effec- ventiva, São Paulo, SP, Brasil. tive results in adulthood. Submitted on July 18, 2019. There are few studies on back pain, despite being a frequent Accepted for publication on September 17, 2019. health problem in the world population. Swain et al.2, in a Conflict of interests: none – Sponsoring sources: O ISA-Capital 2015 foi financiado pela Secretaria Municipal da Saúde de São Paulo (Processo 0.235.936-0, de 2013). systematic review of adolescents (9 to 17 years old), estimated the worldwide prevalence of back pain at 37%. In local Correspondence to: Rua Doutor Eduardo Amaro, 99 – apto 805 – Bairro Paraiso studies in Brazil, the prevalence found of back pain was in 04104-080 São Paulo, SP, Brasil. adults in the cities of Campinas-SP, 30.6%3 and Pelotas-RS, E-mail: [email protected] [email protected] 63.1%4, and in adolescents (10 to 17 years old), in Uru- © Sociedade Brasileira para o Estudo da Dor guaiana-RS, 16.1%5. 321 BrJP. São Paulo, 2019 oct-dec;2(4):321-5 Okamura MN, Madeira W, Goldbaum M and Cesar CL

“Back pain” is a broad term, used colloquially3. Its importance 4. Variables related to chronic diseases and symptoms: all self-reis based on its high worldwide prevalence, its impact on people’s ported were considered and tested. quality of life, and its potential for disability to work. Given the 5. Emotional variables, those who answered ‘yes’ to eight or more breadth of the term, several studies prefer to treat only low back questions from the 2015 Health Survey of São Paulo Block E, pain. In this study, the term “back pain” will be used, considering composed of questions from the Self Report Questionnaire 20 it as the grouping of the terms neck pain, upper back pain and (SRQ20), an instrument with 20 questions for Common Mental low back pain. Disorder (CMD) and can be used in primary care, validated by This study aimed to estimate the prevalence, associated factors, Gonçalves, Stein and Kapczinski10. and characteristics related to back pain in adolescents in the city 6. Characteristics of back pain: location, frequency, intensity, of São Paulo in 2015. and attitudes for pain relief. For the analysis of surveys based on complex designs, the survey METHODS module of the STATA14 program was used, which allowed the incorporation of the different weights. The data from the 2015 Health Survey of São Paulo were ana- The analysis was constructed by a logistic regression model to lyzed, a population-based cross-sectional study, with data collec- test the isolated association among the dependent variables (back tion conducted between September 2014 and December 2015. pain) and each independent one, besides analyzing those that The 2015 Health Survey of São Paulo is a study consisting of entered the final model. a sample composed of people aged as of 12 years old, living in All participants, or their guardians, signed Free Informed Con- permanent private housing units, in the urban area of the city of sent Form (FICF) in which the research objectives and the in- São Paulo, which is the largest city and makes up the largest and formation that would be requested were explained, ensuring the most complex metropolitan region in Brazil. In this study, the confidentiality of the information obtained. The research proto- stratified probabilistic sampling was used, with a two-stage draw: col was approved by the Ethics Committee of the Department of (1) census sectors; and (2) households6,7. Epidemiology, School of Public Health, University of São Paulo The prevalence refers to the population of the 2015 Health Sur- - Opinion 1.420.473 (2015). vey of São Paulo study, which considered only the population living in urban areas, 9,349,890 inhabitants6. Statistical analysis The study domains consisted of: (a) regions and (b) respondents The prevalence between categorical variables was quantified by in the 12-19-year old age group, 60 years old or older, and gen- Pearson’s chi-square test (p); those selected for the model were der and age range of 20-59 years by gender (male and female). those with p<0.20. In the final model, after selection tests, only For the purpose of statistical inference, each individual in the variables with p<0.05 remained in the model. Associations sample was associated with a sample weight. The final weight was among variables were measured by the Odds Ratio (OR). The calculated according to three components: (1) design weight, adjustment of the regression model was evaluated by the Archer which takes into account the sampling fractions of the two-stage and Lemeshow test11. draw; (2) non-response fit; and (3) post-stratification, which ad- justs the distribution of the sample by gender, age group and RESULTS region of residence, according to the population distribution in the municipality and according to the population estimate6. Of the 554 adolescents (aged 15-19 years) interviewed at the For this study, 539 (98.4%) respondents were selected, a sample 2015 Health Survey of São Paulo, 539 (98.4%), who responded composed of adolescents aged between 15 and19 years, part of to all the variables in this study, were identified as the studied the age group of 12-19 years of the 2015 Health Survey of São population. Paulo. The 12-14-years old adolescents were removed from the Of the 539 adolescents interviewed, 50.5% were male and sample because the questions related to the Self Report Ques- 49.5% female, so the proportion was quite approximate. The tionnaire (SRQ), an integral part of 2015 Health Survey of São age distribution of this sample showed differences between 17.0 Paulo, were not applied to children under 15 years old. and 22.1%, here also with approximate proportions. All other The following dependent variable was considered: characterization variables of this population were homogeneous 1. back pain. (Table 1). The following independent variables were considered: When studying the population that identified as having prob- 2. Sociodemographic variables: gender, age, race/color, and ed- lems related to back pain – which in this study includes low ucation; back, neck and upper back pain – it was possible to verify sig- 3. Variables related to health and lifestyle conditions: nutri- nificant prevalence differences between females 28.1% (95% CI tional status8; smoking, alcohol use, and physical activity 22.6 – 34.2) and males 16.8% (95% CI 12.2 – 22.7), meaning recommended by the World Health Organization (WHO). that girls have almost twice as much back pain as boys. (Table 2) Physically active are those who have complied with the WHO It was also possible to verify the existence of significant differ- recommendation to engage in light or moderate physical activ- ences between self-perception of health. Those with ‘not good’ ity for at least 150 minutes per week or vigorous activity for at self-perception health were found to have a prevalence of 36.4% least 75 minutes per week9. (95% CI 28.6 – 45.0), while 19.0% (95% CI 14.9 – 23.9) had 322 Back pain in adolescents: prevalence and associated factors BrJP. São Paulo, 2019 oct-dec;2(4):321-5

Table 1. Demographic profile of adolescents living in São Paulo city self-perception ‘good’ health, as might be expected. What has in 2015 drawn our attention was precisely 19.0% of adolescents who Demographic characterization % total (95% CI) n identified themselves with back pain problems, but with self-per- Gender ception of ‘good’ health (Table 3). Male 50.5 (46.3 – 54.7) 269 Regarding the symptoms, diseases and other health problems, Female 49.5 (45.3 – 53.7) 270 adolescents with back pain problems have a higher prevalence Age (years) of associated factors such as headache 33.3% (95% CI 27.0 – 15 21.2 (18.1 – 24.6) 116 40.3), anxiety 34.1% (95% CI 21.9 – 49.1), sinusitis 34.7% 16 17.0 (13.6 – 21.0) 91 (95% CI 24.2 – 46.8), insomnia 46.4% (95% CI 36.0 – 57.1), 17 21.0 (17.3 – 25.3) 112 CMD 49.0% (95% CI 38.6 – 59.4) and dizziness 49.9% (95% 18 18.7 (15.4 – 22.6) 104 CI 37.3 – 62.4). It meant that of the total of adolescents inter- 19 22.1 (18.4 – 26.5) 116 viewed, at least one third reported comorbidities (Table 3). Race/color The estimated prevalence of back pain among adolescents in the White 44.8 (39.7 – 50.1) 230 city of São Paulo aged 15-19 years old was 22.4% (95% CI 18.4 Black 14.2 (11.1 – 18.0) 78 – 26.9) (Table 4). Brown 37.0 (32.3 – 41.8) 206 The characteristics of back pain for adolescents were related to Others 4.0 (2.4 - 6.4) 22 greater identification with the location of pain in the lower back Education 42.9% (95% CI 34.5 – 51.8). As for the frequency of pain, it Complete elementary school II 33.3 (29.4 – 37.3) 180 was found that 58.2% reported having back pain at least twice a week (41.0% have pain some days of the week, and 17.2% Complete elementary school I 54.1 (49.3 – 58.8) 287 have every day). Regarding the intensity of the pain felt, 21.8% Incomplete elementary school 12.6 (9.6 – 16.4) 72 CI = Confidence Interval. Table 3. Adolescents with back pain: prevalence of characterizations lifestyle and self-reported health problems in residents of the city of Table 2. Adolescents with back pain: prevalence of demographic São Paulo, 2015 and lifestyle characterizations of residents in the city of São Paulo, 2015 Variables % Adolescents with P-value back pain (95% CI) Variables % Adolescents with P-value Lifestyle Characterization back pain (95% CI) Nutritional status 0.0862 Demographic Characterization Normal and underweight 20.3 (15.8 – 25.6) Gender 0,0028 Overweight 26.0 (17.3 – 37.0) Male 16.8 (12.2 – 22.7) Obese 36.1 (21.5 – 53.8) Female 28.1 (22.6 – 34.2) Physical activity with leisure and transportation 0.7389 Age (years) 0.3329 Does not comply with the 22.8 (18.3 – 28.1) 15 25.3 (18.1 – 34.1) recommendation 16 14.1 (8.2 – 23.3) Complies with recommendation 21.7 (16.2 – 28.4) 17 24.0 (17.2 – 32.4) Physical activity work 0.812 18 24.2 (16.4 – 34.1) Does not comply with the 22.5 (18.2 – 27.4) 19 22.8 (15.5 – 32.4) recommendation Race/color 0.2178 Complies with recommendation 21.4 (14.0 – 31.1) White 19.5 (14.3 – 25.9) Physical activity household chore 0.0019* Black 28.0 (19.0 – 39.2) Does not comply with the 19.0 (15.1 – 23.7) recommendation Brown 24.7 (19.1 – 31.2) Complies with recommendation 32.9 (24.6 – 42.3) Others 13.3 (4.6 – 32.7) Health perception 0.0001* Education 0.5989 ‘Good’ 19.0 (14.9 – 23.9) Complete elementary school II 22.8 (16.4 – 30.8) ‘Not good’ 36.4 (28.6 – 45.0) Complete elementary school I 21.0 (15.9 – 27.2) Characterization of health problems Incomplete elementary school I 27.3 (18.4 – 40.3) Reported disease: rhinitis 23.4 (16.7 – 31.8) 0.6200 Lifestyle Characterization Reported disease: sinusitis 34.7 (24.2 – 46.8) 0.0107* Smoking 0.7368 Reported disease: anxiety 34.1 (21.9 – 49.1) 0.0374* Do not smoke 22.7 (18.6 – 27.2) Reported problem: headache 33.3 (27.0 – 40.3) <0.0001* Currently smokes 17.5 (8.0 – 34.3) Insomnia 46.4 (36.0 – 57.1) <0.0001* Alcohol use 0.6195 Dizziness 49.9 (37.3 – 62.4) <0.0001* Do not drink 26.3 (20.5 – 33.1) Common Metal Disorder 49.0 (38.6 – 59.4) <0.0001* Currently drinks 33.1 (20.0 – 49.4) CI = Confidence Interval; P-value = Pearson’s correlation coefficient; CI = Confidence Interval * Selected variables for the logistic regression model.

323 BrJP. São Paulo, 2019 oct-dec;2(4):321-5 Okamura MN, Madeira W, Goldbaum M and Cesar CL reported having severe or unbearable pain, and 62.3% report- related to household chore (Table 3), and characterization of ed that this pain did not prevent them from performing their health status: sinusitis, anxiety, headache, insomnia, dizziness daily activities. Attitudes toward seeking back pain relief: drug and CMD (Table 3). use was reported by 26.5% (8.9% prescription drug and 17.6% For the logistic regression model, the independent variables asso- self-medication). Other reported non-pharmacological practices ciated with back pain were: dizziness (OR 3.1), CMD (OR 2.4), were: 11.2% do rest, 9.6% do physical activities, and 46.6% say insomnia (OR 2.6) and doing household chore-related physical they do nothing (Table 4). activities (OR 1.8) (Table 5). From the univariate analysis, the following variables were select- To check the predictive capacity of the logistic regression model, ed: gender (Table 2), nutritional status and physical activities the Archer and Lemeshow test11 was applied, which indicated a 96.4% chance of an adolescent presenting back pain in the Table 4. Prevalence and distribution of reported back pain characte- presence of these factors. ristics of adolescents living in São Paulo city, 2015 Prevalence % (95% CI) DISCUSSION Back pain 22.4 (18.4 – 26.9) 12 Distribution by location The study by O’Sullivan et al. recognized that back pain – low back, neck, and upper back pain - in adolescents is multifactorial Neck 16.7 (11.6 – 23.3) and may be due to biological, psychological, physical, anatomi- Upper back 23.2 (16.1 – 20.4) cal, lifestyle, and comorbidities. Low back 42.9 (34.5 – 51.8) Swain et al.2, in a study with data from 28 countries, estimated Diffuse (1 or more locations) 17.2 (11.6 – 24.8) the worldwide prevalence of back pain in adolescents (9 to 17 Frequency of back pain years old) at 37%, with the lowest prevalence in Poland (27.7%) Less than once a month 14.7 (8.5 – 24.2) and the highest prevalence in the Czech Republic (50.5%). In A few times a month 27.2 (20.4 – 35.3) this study, the estimated prevalence of back pain in adolescents Some days of the week 41.0 (31.8 – 50.8) (15 to 19 years) in the city of São Paulo, Brazil, is 22.4% (95% Every day 17.2 (11.7 – 24.4) CI 18.4 - 26.9), a result below other countries. The association between CMD and back pain has been found in Pain intensity different studies12,13. This study also identified a significant associ- Weak 38.6 (30.0 – 48.0) ation between CMD and back pain in adolescents from the city of Moderate 39.6 (30.7 – 49.2) São Paulo (OR 2.4, 95% CI 1.4 - 4.4). Viana et al.14 concluded in Intense 11.9 (7.6 – 18.2) their study that individuals with CMD are at higher risk of devel- Unbearable 9.9 (5.4 – 17.5) oping back pain, which may mean that the experience of physical Limits daily activities and emotional pain in adolescents may not be independent, em- Does not limit 62.3 (51.9 – 71.7) phasizing the importance of detecting such associations. Little bit 30.6 (21.7 – 41.1) Dizziness as the primary association with back pain in adoles- Very limited 7.2 (3.9 – 12.8) cents from the city of São Paulo has not been presented as an associated factor when studying back pain, although it was found Attitudes for back pain relief in this study. In a survey, Janssens et al.15 published on American Does nothing 46.6 (35.9 – 57.6) and Dutch adolescents, in which they identified an association Self-medication 17.6 (11.7 – 25.6) between pubertal delay and back pain, excessive tiredness and Prescription drug 8.9 (4.8 – 16.1) dizziness. In this study, the association appears simultaneously, Rest 11.2 (6.6 – 18.4) but it is not possible to confirm the direct association. Physical activity 9.6 (4.6 – 18.7) Insomnia is an inability to sleep properly, therefore a symptom of Massage 4.0 (1.8 – 9.0) poor sleep quality. Auvinen et al.16 and Dey, Jorm, and Mackin- 17 Others 2.1 (0.5 – 8.1) non found an association between poor sleep quality and back CI = Confidence Interval. pain. In these studies, there is a significant association between back pain and insomnia (OR 2.6 - 95% CI 1.6 - 4.3). It is difficult Table 5. Logistic regression analysis for adolescents with back pain to identify the origin of this association; if back pain leads to poor living in the city of São Paulo in 2015 sleep quality (insomnia), or if insomnia contributes to back pain. Variables Gross OR Adjusted OR P-value The health problem related to back pain refers in part to the use (95% CI)* and disuse of the human body. The association between back pain Dizziness 4.5 (2.5 – 8.1) 3.1 (1.6 – 5.9) 0.001 in adolescents from the city of São Paulo and the performance Common Metal Disorder 4.3 (2.7 – 7.1) 2.4 (1.4 – 4.4) 0.002 of domestic physical activity was identified (OR 1.8 - 95% CI Insomnia 3.7 (2.3 – 6.1) 2.6 (1.6 – 4.3) <0.001 1.1 - 2.9). However, the classification related to the Physical Ac- Physical activity at 2.1 (1.3 – 3.3) 1.8 (1.1 – 2.9) 0.027 tivity block of 2015 Health Survey of São Paulo presented only home results related to compliance or not with WHO recommenda- * Fit variables; OR = Odds Ratio; CI = Confidence Interval. tions9, which became an important limitation of this study, since 324 Back pain in adolescents: prevalence and associated factors BrJP. São Paulo, 2019 oct-dec;2(4):321-5 such classification does not have a range that allows recognizing REFERENCES the excess of adolescents in relation to the performance of such physical activities. 1. Duthey B. Low Back Pain. 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325 BrJP. São Paulo, 2019 oct-dec;2(4):326-30 ORIGINAL ARTICLE

Clinical manifestations in patients with musculoskeletal pain post-chikungunya Manifestações clínicas em pacientes com dores musculoesqueléticas pós-chikungunya

Ben-Hur James Maciel de-Araujo1, Patricia Bueno Nestarez Hazime2, Francisca Joyce Vasconcelos Galeno1, Laís Nascimento Candeira1, Mayare Fortes Sampaio1, Fuad Ahmad Hazime3

DOI 10.5935/2595-0118.20190060

ABSTRACT CONCLUSION: The chronic phase of the chikungunya virus infection is characterized by persistent moderate-intensity pain, both BACKGROUND AND OBJECTIVES: Chronic clinical mani- in sensory and affective levels, with moderate kinesophobia, wors- festations of the chikungunya virus infection are associated with ening of quality of life, perception of poor post-infection recovery, high rates of disability and worsening of quality of life, repre- and a decrease in the pain descending inhibitory pathways. senting one of the major challenges for global public health. Keywords: Chikungunya virus, Chronic pain, Clinical evolu- The objective of this study was to investigate the clinical-psy- tion, Signals and symptoms. cho-functional presentation of the chikungunya virus-infected individuals with complaints of chronic musculoskeletal pain. RESUMO METHODS: Twenty-two individuals with a diagnosis of chikungunya virus infection and a complaint of persistent muscu- JUSTIFICATIVA E OBJETIVOS: As manifestações clínicas loskeletal pain (≥3 months) participated in the study. The clin- crônicas da infecção pelo vírus chikungunya estão associadas a ical-psycho-functional evaluation was performed through the altos índices de incapacidade e piora da qualidade de vida, repre- intensity and affective-emotional aspect of pain, quality of life, sentando um dos grandes desafios para a saúde pública mundial. kinesophobia, global perception of post-infection pain recov- O objetivo deste estudo foi investigar a apresentação clínica-psi- ery and emotional functionality. In the end, the pressure pain co-funcional de indivíduos infectados pelo vírus chikungunya threshold and the conditioned pain modulation were evaluated. com queixas de dores musculoesqueléticas crônicas. RESULTS: The clinical presentation of pain revealed long MÉTODOS: Participaram do estudo 22 indivíduos com diag- persistence 17.5±7.4 months; predominant in the lower limbs nóstico de infecção pelo vírus chikungunya e queixa de dor (45.5%); mean intensity (5.5±2.1); mild to moderate affec- musculoesquelética persistente (≥3 meses). A avaliação clínica- tive-emotional changes; moderate kinesophobia (46±6.5) and -psico-funcional foi realizada por meio da intensidade e aspecto low overall perception of improvement (1.5±2.5). The Beck De- afetivo-emocional da dor, qualidade de vida, cinesiofobia, per- pression Inventory and the visual analog scale for anxiety showed cepção global de recuperação da dor pós-infecção e funcionalida- little change. Quality of life presented mild to moderate impair- de emocional. Ao final foi avaliado o limiar de dor por pressão e ment, and pain modulation showed a slight increase in the pres- a modulação condicionada da dor. sure pain threshold (6.3%). RESULTADOS: A apresentação clínica da dor revelou longa persistência, 17,5±7,4 meses; predominância nos membros infe- riores (45,5%); intensidade média (5,5±2,1); alterações afetiva- -emocionais leves a moderadas; moderada cinesiofobia (46±6,5) Ben-Hur James Maciel de-Araujo - https://orcid.org/0000-0003-2414-8571; e baixa percepção global de melhora (1,5±2,5). O Inventário Patricia Bueno Nestarez Hazime - https://orcid.org/0000-0002-4287-6540; de Depressão de Beck e a escala analógica visual para ansiedade Francisca Joyce Vasconcelos Galeno - https://orcid.org/0000-0002-5824-5524; Laís Nascimento Candeira - https://orcid.org/0000-0002-7744-3526; apresentaram pouca alteração. A qualidade de vida apresentou Mayare Fortes Sampaio - https://orcid.org/0000-0002-4665-6369; prejuízos leves a moderados, e a modulação da dor revelou pouco Fuad Ahmad Hazime - https://orcid.org/0000-0001-7729-1203. aumento do limiar de dor por pressão (6,3%). 1. Universidade Federal do Piauí, Departamento de Fisioterapia, Parnaíba, PI, Brasil. CONCLUSÃO: A fase crônica da infecção pelo vírus chikun- 2. Prefeitura de Taboão da Serra, Serviço de Assistência Especializada DST/AIDS, Taboão gunya tem como apresentação clínica dor persistente de mode- da Serra, SP, Brasil. 3. Universidade Federal do Piauí, Programa de Pós-Graduação em Ciências Biomédicas, rada intensidade, em nível sensorial e afetivo, além de moderada Parnaíba, PI, Brasil. cinesiofobia, piora na qualidade de vida, percepção de pouca

Submitted on June 03, 2019. recuperação pós-infecção e diminuição da ativação inibitória Accepted for publication on September 23, 2019. descendente da dor. Conflict of interests: none – Sponsoring sources: none. Descritores: Dor crônica, Evolução clínica, Sinais e sintomas, Correspondence to: Vírus chikungunya. Departamento de Fisioterapia, Universidade Federal do Piauí Campus de Parnaíba Avenida São Sebastião, 2819 – Bairro Nossa Senhora de Fátima INTRODUCTION 64202-020 Parnaíba, PI, Brasil. E-mail: [email protected] Chikungunya is an arboviral disease of the Togaravidae family © Sociedade Brasileira para o Estudo da Dor transmitted by the bite of the mosquito of the species Aedes, Ae. 326 Clinical manifestations in patients with BrJP. São Paulo, 2019 oct-dec;2(4):326-30 musculoskeletal pain post-chikungunya

Aegypti and Ae. Albopictus1. Since the first outbreak of chikun- perception of pain recovery after infection, and emotional func- gunya reported in Tanzania in mid-19532, there has been an in- tionality were evaluated. In the end, the pressure pain threshold crease in infection in Asian3,4 and African5,6 countries. In Brazil, and the conditioned pain modulation were assessed. Pain inten- the first indigenous cases were confirmed in Oiapoque (AP) in sity was assessed using an 11-point numerical scale (zero-10), 20147. Since then, there has been a significant increase in con- with zero being considered no pain and 10 the worst possible firmed notifications in all states of the country, either by labora- pain15. The sensory and affective aspect of pain were verified by tory or clinical criteria. the McGill questionnaire, short version (SF-MPQ) containing The main clinical manifestations in the acute phase are similar to 15 pain sensation descriptors (11 sensory and 4 affective), with those of dengue: high fever, headache, chills, nausea, vomiting, each descriptor classified on a 4-point scale, zero = none, 15 = fatigue, back pain, myalgia, and arthralgia8. The acute or febrile mild, 25 = moderate, and 35 = intense16. phase lasts until the 14th day, but in some cases, there is a per- The quality of life was assessed using the EQ-5D questionnaire, sistence of symptoms such as joint pain for up to three months, which covers five health domains: mobility, personal care, ev- characterized as the sub-acute phase. When complaints of mus- eryday activities, pain/malaise, anxiety/depression. This ques- culoskeletal pain persist for more than three months, the chronic tionnaire also includes a visual analog scale (VAS), where zero phase sets in9. The mechanisms involved in the chronic char- indicates the worst imaginable state of health, and 100 indicates acteristic of musculoskeletal pain are not fully understood, but the best imaginable state of health17. some risk factors have been pointed out: genetic predisposition; Kinesophobia was assessed using the Tampa Scale for Kinesopho- pre-existing arthropathy or other comorbidities; tissue damage bia. This scale contains 17 items that seek to measure excessive fear induced directly by the virus; long-term persistence of chikun- or aversion to movement and physical activity. Each item has four gunya infection in tissues with inflammation and activation of answer options: strongly disagree (1 point), partially disagree (2 autoimmune responses10. Besides complaints of musculoskeletal points), partially agree (3 points), and fully agree (4 points). The pain, the chronic phase is associated with a physical disability sum of the items answered may indicate lower (17 points) or high- and worsening of quality of life11,12. er kinesophobia (68 points)15. The overall perception of recovery Although current treatments have some results for symptom re- after the infection was assessed by the numerical global perception lief13, clinical manifestations of this chronic characteristic may scale (GPS). This scale contains 11 points, ranging from -5 to +5, still be present years after the infection14. In this context, the clin- where -5 is the perception of being extremely worse, zero: no mod- ical-functional assessment of the disease is extremely important for ification, and +5 the perception of being fully recovered15. the planning of effective prevention and treatment strategies. The pain threshold was assessed with the manual pressure al- This study aimed to investigate the clinical-psycho-functional gometer (FORCE TEN FDX, USA). The algometer tip, about presentation of patients infected with the chikungunya virus 1 cm2 thick, was applied perpendicular to the skin surface on complaining about chronic musculoskeletal pain. the dominant arm over the tendon of the extensor carpi radi- allis brevis muscle, 2cm distal to the lateral epicondyle. Three METHODS measurements were taken, and in each test, participants were instructed to respond “stop” to the first pain sensation caused by This is a cross-sectional, descriptive, and exploratory study, con- the mechanical stimulation of the algometer18. ducted from January 2018 to June 2019. Individuals with a med- Conditioned pain modulation (CPM) was assessed by the tissue ical diagnosis of chikungunya and complaints of post-infection cooling test19. Participants remained seated with the dominant fore- musculoskeletal pain were recruited through social networks and arm over a support, and the contralateral forearm immersed in a printed communication in public and private health services in bucket of ice and water at 10°C (conditioning stimulus). The pres- the city of Parnaíba-PI. The sample size calculation considered sure pain threshold (PPT) (test stimulus) was measured during four the number of probable cases reported (n = 825), according to intervals: (1) before immersion, (2) after 30 seconds of immersion, the 52nd Epidemiological Week Bulletin (2017) released by the (3) after 1min 30s of immersion, and (4) 1 minute after withdraw- Piauí State Government, and the population of the city of Par- ing the immersed hand from the cooling system. The CPM was es- naíba (n=137,485). Adopting a confidence interval and a preci- timated by the difference in the PPT between the baseline condition sion value of 95% and ±0.07, respectively, the minimum sample (pre-immersion) and post-immersion conditions18. size was estimated in 41 subjects. Symptoms of anxiety and depression were assessed by the Bra- The inclusion criteria were: 1) confirmed medical diagnosis of zilian version of the Beck Depression Inventory (BDI) and the chikungunya virus infection; 2) both genders; 3) persistent com- VAS for anxiety, respectively. The BDI is a self-rated measure plaint of musculoskeletal pain (symptoms ≥ 3 months). Partici- of depression that uses a 21-item questionnaire, the intensity of pants with pain complaints related to previous diseases, such as which ranges from zero to 3 (higher scores indicate more depres- inflammatory rheumatic disease, musculoskeletal lesions, neuro- sive symptoms)20. The VAS for general anxiety is assessed by a logical diseases, or diabetic neuropathy, were excluded. 100mm long horizontal line. The far-left end means no anxiety, After fulfilling the inclusion criteria, participants answered an and the far-right end means the worst possible anxiety21. unstructured questionnaire containing personal data and anthro- The study was approved by the Ethics Committee of the Federal pometric characteristics. Then, the intensity and affective-sen- University of Piauí (UFPI) under No. 2,883,331/2018. All par- sation aspect of pain, quality of life, kinesophobia, the overall ticipants signed the Free Informed Consent Form (FICT). 327 BrJP. São Paulo, 2019 oct-dec;2(4):326-30 Araujo BJ, Hazime PB, Galeno FJ, Candeira LN, Sampaio MF and Hazime FA

Statistical analysis Table 2. Participants’ quality of life – continuation The data were input in the Microsoft Excel software version 2010 EQ-5D Domains Levels n (%) for Windows. The descriptive analyses of the investigated vari- Personal care 2 1(4.5) ables were performed through means, frequencies (absolute and 3 7(31.8) relative), and standard deviations. All data were analyzed using 4 - the IBM SPSS software v.20 for Windows. 5 - RESULTS 1 8(36.4) Common activities 2 7(31.8) Forty-nine individuals were recruited for clinical evaluation. 3 6(27.3) However, 27 individuals were excluded because they no longer 4 1(4.5) complained of pain (n=8); no medical diagnosis (n=9) and 10 5 - subjects refused to participate in the study. Twenty-two individu- 1 - als (86.4% female) with a medical diagnosis of chikungunya virus Pain/discomfort 2 10(45.5) infection participated in the study. The mean (±SD) age, weight, height and body mass index (BMI) were 46.4 years (12.0), 3 11(55) 63.3kg (17.5), 1.6m (0.1) and 26.1kg/m2 (4.4), respectively. The 4 1(4.5) predominant level of education was high school (31.8%) and 5 - primary (31.8%), followed by college education (27.3%) and no 1 8(36.4) education (9%). Most participants did not practice physical ac- Anxiety/depression 2 7(31.8) tivity (59.1%), and all denied smoking. The mean period of pain 3 7(31.8) was 17.5 months (7.4), and the areas of major complaints were 4 - the lower limbs (45.5%), lower limbs and upper limbs (45.5%), and upper limbs (9.1%). The clinical characteristics, quality of 5 - EQ-5D = EuroQol quality of life questionnaire with five dimensions. Level 1 = no life and conditioned pain modulation are described in tables 1, problem; Level 2 = mild problem; Level 3 = moderate problem; Level 4 = serious 2, and 3, respectively. problem; Level 5 = Disable.

Table 1. Participants’ clinical characteristics Table 3. Conditioned Pain Modulation Mean Standard deviation Pressure pain threshold Pre Post CPM (Test stimulus) (kgf) (kgf) (%) Pain intensity (0-10) 5.5 2.1 Baseline 3.2 (0.9) - - PRI-T (0-45) 17.3 8.4 30s immersion - 3.4 (1.0) 6.3 PRI-S (0-33) 12.2 5.5 1.5min immersion - 3.4 (1.0) 6.3 PRI-A (0-12) 5.1 3.3 1 min post/immersion - 3.2 (0.9) 0 Kinesophobia (17-68). 43.6 6.5 CPM = conditioned pain modulation kilogram-force values (Kgf) expressed as mean and standard deviation. Overall perception (-5 to +5) 1.5 2.5 Depression (0-63) 10.9 5.9 Anxiety (0-100) 3.1 2.4 DISCUSSION PRI-T = total pain index, PRI-S = sensory aspect of pain, PRI-A = affective aspect of pain; Kinesophobia = assessed by the Tampa Scale for Kinesopho- bia. High scores on intensity, pain sensory aspect, and kinesophobia indicate Data analysis showed that infection with the chikungunya virus worsening of pain and aversion to movement or physical activity. Overall perception assessed by the overall effect perception scale. Low scores indicate a leads to persistent pain, with temporal characteristics of chronic- worsening overall effect. ity and medium to high-intensity magnitudes. The sensory and affective aspects of pain ranged from mild to moderate. Although symptoms of depression and anxiety have not been previously Table 2. Participants’ quality of life assessed, nor have they included inclusion/exclusion criteria, EQ-5D Domains Levels n (%) overall participants did not have clinically relevant changes in 1 7(31.8) symptoms of depression [(10.9±5.9) score of 0-63] and anxiety [(3.1±2.4) score of 0-100]. On the other hand, the depression 2 5(22.7) and anxiety domains, assessed by the EQ-5D quality of life ques- Mobility 3 10(45.5) tionnaire, showed that these psychiatric morbidities were present 4 - in mild to moderate magnitudes. There are few reports in the lit- 5 - erature on psychiatric morbidities associated with chikungunya, 1 14(63.6) which makes it difficult to compare with the current results. A Continue... preliminary Indian study found the presence of psychiatric mor- 328 Clinical manifestations in patients with BrJP. São Paulo, 2019 oct-dec;2(4):326-30 musculoskeletal pain post-chikungunya bidity in 20 infected individuals, mainly in the form of episodes CONCLUSION of depression (n=5) and anxiety disorders (n=3)22. Despite the differences in the assessment of depression and The clinical presentation of the chronic phase of the chikungunya anxiety symptoms, a moderate level of kinesophobia was ob- virus infection is persistent pain of moderate intensity in sensory served, indicating that complaints of persistent pain may in- and affective level, moderate kinesophobia, decrease in the quality duce a higher perception of excessive fear or aversion to move- of life, perception of poor recovery after infection, and decrease in ment and physical activity. However, as it is a single assessment, the activation of the pain descending inhibitory pathways. it is possible that these changes were already present before the clinical evaluation. In the context of physical rehabilitation, REFERENCES the presence of kinesophobia may indicate a poor prognosis 1. Pialoux G, Gaüzère BA, Jauréguiberry S, Strobel M. 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330 BrJP. São Paulo, 2019 oct-dec;2(4):331-5 ORIGINAL ARTICLE

Knowledge of the nursing team about the newborn’s pain Conhecimento da equipe de enfermagem sobre a dor do recém-nascido

Nayara Freitas Azevedo1, Thiago Dias2, Maria Paula Custódio Silva2, Mayline Verônica Rocha Sampaio2, Jesislei Bonolo do Amaral2, Divanice Contim2

DOI 10.5935/2595-0118.20190061

ABSTRACT RESUMO

BACKGROUND AND OBJECTIVES: To describe the knowl- JUSTIFICATIVA E OBJETIVOS: Descrever o conhecimento edge of the nursing team about the evaluation and treatment of da equipe de enfermagem sobre a avaliação e o tratamento da dor pain in newborns hospitalized at the Neonatal Intermediate Care em recém-nascidos internados na Unidade de Cuidado Interme- Unit of a university hospital in the state of Minas Gerais, due to diário Neonatal de um hospital universitário do estado de Minas the relevance of the issue regarding the quality of the neonatal Gerais, pela relevância da temática no que se refere à qualidade care. da assistência neonatal. METHODS: A descriptive and exploratory qualitative research MÉTODOS: Pesquisa de abordagem qualitativa do tipo descritiva with 13 professionals from a Neonatal Intermediate Care Unit. e exploratória, com 13 profissionais de uma Unidade de Cuidados The data were collected through a semi-structured interview, and Intermediários Neonatal. Os dados foram coletados por meio de en- the data analysis was guided by the Content Thematic Analysis trevista semiestruturada e a análise de dados foi orientada pela Aná- from January to June 2018. lise Temática de Conteúdo nos meses de janeiro a junho de 2018. RESULTS: Four categories were elaborated: pain identification; RESULTADOS: Foram elaboradas quatro categorias: identifica- methods for assessing pain; interventions of the nursing team to ção da dor; métodos para a avaliação da dor; intervenções da relieve pain, and nursing learnings in pain management. equipe de enfermagem para o alívio da dor; aprendizado da en- CONCLUSION: The knowledge of this team is based on the fermagem no manuseio da dor. individual experience, showing the need for changes in the ed- CONCLUSÃO: O conhecimento dessa equipe está baseado na ucational structures to reach better results and nursing practices experiência individual e registram necessidades de mudanças nas based on scientific methods for quality assistance. estruturas formativas para o alcance de melhores resultados e Keywords: Infant, Knowledge, Neonatal nursing, Newborn, práticas de enfermagem, fundamentadas em métodos científicos Nursing team, Pain. para uma assistência de qualidade. Descritores: Conhecimento, Dor, Equipe de enfermagem, En- fermagem neonatal, Recém-nascido.

INTRODUCTION

The International Association for the Study of Pain (IASP)1 defines pain as an unpleasant sensory and emotional experience associated with a tissue injury, real or not. Its assessment requires skill, training, and humanized treatment, especially Nayara Freitas Azevedo - https://orcid.org/0000-0001-7748-4777; Thiago Dias - https://orcid.org/0000-0003-4343-2287; of nursing staff professionals, as they stay longer in contact 1,2 Maria Paula Custódio Silva - https://orcid.org/0000-0001-8694-1589; with the newborn (NB) . Mayline Verônica Rocha Sampaio - https://orcid.org/0000-0002-0522-1174; Exposure to severe or prolonged pain may increase neonatal Jesislei Bonolo do Amaral - https://orcid.org/0000-0002-0591-7972; Divanice Contim - https://orcid.org/0000-0001-5213-1465. morbidity. Infants who experienced pain during the neonatal period respond differently to subsequent painful events. 1. Universidade de São Paulo, Departamento de Enfermagem, São Paulo, SP, Brasil. 2. Universidade Federal do Triângulo Mineiro, Departamento de Enfermagem, Uberaba, Given these consequences, studies started to be conducted to MG, Brasil. improve treatment strategies to prevent and treat NB pain 1-4 Submitted on June 27, 2019. and discomfort . Accepted for publication on October 08, 2019. The NB expresses pain through crying, facial mimics, body Conflict of interests: none – Sponsoring sources: none. movement, sleep disturbance, and physiological changes. This Correspondence to: demonstrates that professionals need to recognize these sig- Divanice Contim nals, assess them and treat them correctly. In this process, the Universidade Federal do Triângulo Mineiro Rua Frei Paulino, 30 use of scales that take these behaviors into consideration may 38025-180 Uberaba, MG, Brasil. prove to be a viable resource3. E-mail: [email protected] Pain is recognized as a vital variable to be assessed in the © Sociedade Brasileira para o Estudo da Dor clinical practice of NB treatment, and its non-recognition 331 BrJP. São Paulo, 2019 oct-dec;2(4):331-5 Azevedo NF, Dias T, Silva MP, Sampaio MV, Amaral JB and Contim D is a matter of concern. Scientific productions on the theme analysis of the relationships established in the research envi- demonstrate the importance of knowledge of nursing profes- ronment and the understanding of meanings and systems10. sionals, in order to avoid the occurrence of iatrogenesis, since Data analysis was guided by Thematic Content Analysis, re- NB when hospitalized in neonatal units, are exposed to pain- specting its stages11. In the pre-analysis, performed through ful sensation due to the disease itself, which can be potentiat- the fluctuating reading of the printed interviews, the points ed due to physiological stress and invasive procedures, often of interest are highlighted, followed by the exploration of the without pain relief interventions5-7. material in a thorough and exhaustive way, performing the From this perspective, the assessment and control of pain in classification and coding of the interviews, with apprehension NB constitute a significant challenge for health professionals, of the nuclei of meaning, which were grouped, generating including those of the nursing staff, who live with the particu- the empirical thematic categories responsible for the theme larities of the neonatal period, seeking ways to prevent and/or specification. Finally, the interpretation of the obtained re- mitigate it4, respecting the right of the NB not to feel pain8. sults was performed, which were discussed and analyzed with The production of the knowledge developed here may help the literature on the theme, to answer the objective proposed nurses to identify gaps in the nursing staff’s knowledge about in this research. neonatal pain, contributing significantly to the improvement The development of the study complied with the national and of the quality of care provided to this population group. international standards of Ethics in Research involving hu- This study aimed to describe the knowledge of the nursing man beings, complying with Resolution MS/CNS 466/2012, staff on pain assessment and treatment in NB admitted to a and signing the Free and Informed Consent Form (FICT), Neonatal Intermediate Care Unit (NICU). in two copies, after approval by the UFTM Research Ethics Committee according to CAAE: 63030416.1.0000.5154 and METHODS Opinion No. 1.974.515.

A descriptive exploratory study with a qualitative approach9 RESULTS was conducted in a NICU of a teaching hospital located in the Southern Triangle of the state of Minas Gerais. During Thirteen professionals of the nursing staff were interviewed, the study, the nursing staff was composed of 24 professionals, all female, four nurses and nine nurse practitioners, aged being eight certified nurses, and 16 nurse practitioners. between 28 and 62 years, with an average of 45 years. The The inclusion criterion to select the participants was profes- professional experience ranged from five to 40 years, with an sionals who have been working for more than a year in the average of 17.8 years. Of the participants, one nurse is spe- study unit, understanding that this environment requires time cialized in neonatology. After analyzing the interview tran- to know the constituent elements of the work process of the scripts, the speech categorization was performed, emerging unit. Professionals in sick leave and vacation were excluded. four categories: The entire nursing staff was invited to participate in the study after the presentation of the objectives. After verbal accep- Identification of the newborn pain tance, date, time, and place were scheduled, according to the All professionals reported that the NB experiences painful ex- professional’s preference for the interviews. perience in situations of manipulation for procedures such The information was collected from January to June 2018, as venipuncture, positioning, intubation, blood glucose test, through semi-structured interviews in two stages. The first and heel prick test. Pain has been reported to be associated stage contained sociodemographic data, and the second was with the clinical picture, such as diagnosis of hydrocephalus, guided by the following open questions: do you believe the fever, postoperative situations, thermal variations, and the de- NB feels pain? What situations cause pain in the NB? What livery itself, as follows: methods do you use to assess the NB pain? Do you use scales Manipulation... procedures, especially those that pierce the skin to identify the NB pain? Have they helped identify pain? as venipuncture ... blood collection for tests, heel prick test, var- What are the signs and symptoms that lead you to interpret ious invasive procedures such as probing, catheterization, intu- that the NB is in pain? What are the interventions (phar- bation (N4). macological and non-pharmacological) that nursing uses to Discomfort, any kind of discomfort, whether high or low tem- control NB pain? perature... noise... the absence of the mother (NP9). Upon consent, data were collected individually and privately, It depends on the picture... that little baby there has hydroceph- and the interviews were recorded with the prior consent of alus... feels a lot of pain, we believe it is the pressure on her head the participants, later transcribed, and with an average du- because she has a lot of fluid(NP5) . ration of 15 minutes. In order to maintain anonymity, they were identified with the letter N of “nurse” and NP of “nurse Methods for assessing newborn pain practitioner” and subsequent numbers, according to the or- According to the reports, pain is assessed using signs and der in which data collection was performed, for example, N1, symptoms presented by the NB, such as crying, facial and N2, NP1, NP2 ... The number of participants was defined body expressions, the degree of agitation, and assessment of by the data saturation criterion that allows a more detailed the vital signs, such as the presence of tachycardia. 332 Knowledge of the nursing team about the newborn’s pain BrJP. São Paulo, 2019 oct-dec;2(4):331-5

The irritability, the face itself..., the restlessness, the kind of des- Nursing learning in newborn pain management perate crying, is a cry that does not calm down (N1). In the interviews, the participants pointed out that NB pain Every time he starts debating his arms and his little hands, his management is not a curricular component during vocational little legs, we know he’s in pain (N3). training. The speeches show that the handling is performed It’s a different cry...he gets angry, gives a tachycardia(NP9). due to the professional experience gained over time. Insecu- In the speech analysis, it was noticed that in the service, vali- rity and even despair in dealing with the NB pain were ob- dated scales for the measurement of NB pain are not yet used. served due to this previous unfamiliarity. Some reports point to a graphic scale of pain in the vital signs The other speeches revolve around the experience as mothers sheet, but not intended for the target audience. and the years of working with NB and children. As we do not have an instrument, we look a lot at the intensity of It’s with no scales, right? (laughs), as we learn. It seems that the crying and pain faces (N2). more experience you get in practice, it seems that you are be able We are not currently using any pain scale, any scientific method. to assimilate better. At first, it is a bit despairing! Everyone is So today, we assess by perception, right (N4). crying! Everyone is in pain! (N1). Look, we have those little scales with faces, but I don’t take much Well, I’m a mother (laughs), after I started working here, it was into account ... not that, because actually... I think that you can’t with the experience from the other professionals (N2). talk about 1 to 10 what is the baby’s pain (NP7). That’s 25 years of experience; we have to learn from living togeth- In the speeches, it was possible to identify that the team er, with daily life, with work (NP7). knows the physiological changes that the NB presents when There was also a report in which a professional believes that feeling pain, but the use of a measurement protocol was not there is no way to avoid pain. Pain, for her, is treated after reported. One of the nurses interviewed cited the NB assess- interventions and procedures performed with NB: ment scales used in the institution she had previously worked. No, I didn’t learn it. Actually, we can’t handle the pain. What we In the other institution where I worked, we worked with child do is, after the child has felt all the pain that the procedure brings pain protocol ... non-pharmacological measures for child pain to him/her, is to cherish him/her (E3). relief ... and we also worked with the NIPS scale and the CHE- OPS scale, which is the assessment of the child’s pain, but it has DISCUSSION not yet been institutionalized here (N4). The painful experience was identified by the nursing staff Nursing staff interventions for newborn pain relief professionals in observing behavioral characteristics such as Among the interventions used by the nursing staff are phar- crying, facial mimic, motor activity in invasive procedures, macological and non-pharmacological. It was observed in and the clinical picture of the NB. They considered the need the reports that the most prescribed drugs by doctors are to systematize pain assessment; however, in the unit studied, analgesics and anti-inflammatory drugs. They mentioned no strategies are used in this regard. dipyrone, acetaminophen, and simethicone as the most Pain may be associated with impaired neurological, physical, used. Sucrose was pointed and associated with suction, de- and behavioral development. A multimodal approach to NB spite the routine use, there were differences to which type of pain management improves prognosis, reduces suffering and method it belongs. stress12,13. The IASP1 indicates as key elements in pain man- Pharmacological only when there is a medical prescription, right. agement the quality of care provided, the presence of institu- So, it would be the painkillers that doctors prescribe, acetamino- tional protocols, continued education for health teams, and phen, dipyrone, or simethicone (N2). standards of registration14. There is very little time here in the institution we are using su- The assessment and treatment of pain in NB face several bar- crose, right. Then the little finger with the sucrose glove(N3). riers, such as its inability to verbalize and the absence of stan- The medications that sometimes the doctor gives are dipyrone, dards of care, which imply empirical and distinct treatment tilenol®, dimethicone®, depending on the case. And according by the professionals15. It is believed that scientific knowledge to the case of the child, sometimes even a stronger medication and clinical practice management are the hurdles to assess and (NP3). measure pain in the NB, indicating the need for training of Among the non-pharmacological interventions, the correct multidisciplinary teams and the increase of routines/proto- positioning of the NB, cuddling, swaddling, and non-nutri- cols to assess and control pain in this population12-16. tive sucking were observed in the speeches. It is not recommended to assess pain in this life cycle with So, it’s the same thing, the swaddling, sometimes that baby is in graphical and numerical scales because it does not include pain, is very agitated, you swaddle, non-nutritive sucking, put adequate indicators. This study identified the non-systemati- the gloved finger a few drops of glucose(N1). zation of the use of specific scales for pain assessment in the The comfort that is to swaddle the newborn makes it more com- NB. The existence of gaps regarding the knowledge of nurs- fortable, minimal handling and non-nutritive suction (N2). ing professionals about pain management and assessment is The first method we use is to position it correctly, to cuddle with evidenced14-17. Despite the several scales, they are not applied our own hands, and if it does not improve, what are we doing? or used correctly14. A study conducted in a neonatal unit in Give a pacifier sometimes, here we make a glove pacifier(NP3). the Midwest Region observed that most professionals report- 333 BrJP. São Paulo, 2019 oct-dec;2(4):331-5 Azevedo NF, Dias T, Silva MP, Sampaio MV, Amaral JB and Contim D ed knowing some pain assessment scale, and the most known vent or hinder professionals from applying the acquired knowl- and applied was the Neonatal Infant Pain Scale (NIPS)18. edge. Teaching pain management to health professionals at all Prolonged exposures to painful stimuli are known to have levels of education has been identified as an important measure long-term consequences on the NB’s brain response, rein- to change the ineffective practices performed. However, most forcing the need to assess and treat pain adequately, and the educational programs, especially for undergraduates, include promptness in meeting the NB needs16. It is believed that to minimum or no content on the theme19,20,22. The literature reduce the NB pain, we should limit the number of invasive lacks studies on pain during academic education. Among the procedures, assess the safety and efficacy of drugs, and com- findings, a research conducted with medical students regarding bine them with non-pharmacological therapies14. The drugs the recognition of pain in NB is highlighted22. mentioned by the participants were dipyrone, paracetamol, IASP1 establishes curriculum guidelines for teaching acute and simethicone, the most cited in the literature3,14,19. It was and chronic pain, in undergraduate and postgraduate courses, observed that its use is the first choice when not using an with an emphasis on interdisciplinarity. This recommenda- assessment instrument3,14. tion is important in directing the curriculum matrix of nurs- The non-pharmacological methods indicated were non-nutri- ing courses. However, it is observed that learning occurs in tive sucking, the use of sucrose, the positioning of the NB, daily practice, depending on the concepts and prejudices in swaddling, the cuddling and minimum manipulation. The daily life1,17. kangaroo-mother care method, the little package, and cud- It is understood that the study results contribute to the ad- dling, much used in pain relief20, are considered soft tech- vancement of scientific knowledge in neonatal nursing and nologies to care for the babies. Other measures such as NB the planning of local actions. It is relevant and necessary to massage and bath therapy may be employed to promote re- review the nursing undergraduate curricula based on IASP1 laxation, improve sleep quality and minimize the effects of recommendations and guidelines to apply appropriate inter- painful stimuli, and can be applied by the nursing staff. Many ventions aimed at the quality of care. nurses are unaware of such techniques, so these themes should be included in the education of nurses in neonatal units20. The CONCLUSION stimulation of the mother’s voice before and during painful procedures, such as heel-stick puncture, has a positive effect The study made it possible to identify that the staff knowledge on the vital signs of NB, being a practice to be considered for is based on the personal experiences acquired with the time of this type of procedure21. service at the NICU. The reports show the absence of institu- Regarding the divergence in considering sucrose a pharma- tional protocols for pain assessment with scales and identify the cological method, the literature refers to it as non-pharma- need to incorporate pain assessment into the curriculum plans cological interventions3,17,18,22. 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335 BrJP. São Paulo, 2019 oct-dec;2(4):336-41 ORIGINAL ARTICLE

The impact of chronic pain on the quality of life and on the functional capacity of cancer patients and their caregivers O impacto da dor crônica na qualidade de vida e na capacidade funcional de pacientes oncológicos e de seus cuidadores

Juliana Martins Izzo1, Ana Marcia Rodrigues Cunha2, Claudia Bernardi Cesarino3, Marielza Regina Ismael Martins4

DOI 10.5935/2595-0118.20190062

ABSTRACT CONCLUSION: The presence of chronic pain impacts, negatively and significantly, the quality of life and functional capacity BACKGROUND AND OBJECTIVES: Pain for cancer pa- of cancer patients extending this impact to the caregiver. tients might represent a worsening prognosis, decreased auton- Keywords: Cancer pain, Caregivers, Quality of life. omy, well-being and quality of life, affecting all spheres of life of cancer patients and their repercussions on caregivers. Therefore, RESUMO this study aimed to evaluate the impact of chronic pain on the quality of life and functional capacity of cancer patients and their JUSTIFICATIVA E OBJETIVOS: A dor para o paciente onco- caregivers. lógico pode representar agravamento do prognóstico, diminui- METHODS: Eleven caregivers and 15 cancer patients from a ção da autonomia, do bem-estar e qualidade de vida, afetando Pain Clinic were evaluated. To assess the functional capacity of todas as esferas da vida do paciente com câncer e sua repercussão the patients, we used the physical and instrumental activities of no cuidador. Assim, este estudo objetivou avaliar o impacto da daily living scale and, for quality of life, we used the European dor crônica na qualidade de vida e na capacidade funcional de Organization for Research and Treatment of Cancer Quality of pacientes oncológicos e de seus cuidadores. Life Questionnaire (EORTC QLQ-C30), which indicated im- MÉTODOS: Foram avaliados 11 cuidadores e 15 pacientes pairment in social and emotional functions and prevalence of oncológicos de uma Clínica da Dor. Para avaliar a capacidade symptoms fatigue and insomnia. funcional dos pacientes foi utilizada a escala de atividades físicas RESULTS: The average of the instrumental activities of daily e instrumentais da vida diária e, para a qualidade de vida, foi living scores indicated a semi-dependence of the patients. There utilizado o European Organization for Research and Treatment of was a female predominance in patients (60%) and caregivers Cancer Quality of Life Questionnaire, que indicou prejuízo nas (72.2%). The average pain by the visual analog scale was 6.8. The funções social e emocional e prevalência dos sintomas fadiga e Zarit Caregiver Overload Scale indicated that 36.3% of caregiv- insônia. ers had moderate to severe overload and a positive correlation RESULTADOS: A média dos escores das atividades básicas e between functional capacity and overload (p=0.003). instrumentais da vida diária indicaram semi-dependência dos pacientes. Houve predominância feminina em pacientes (60%) e cuidadores (72,2%). A média de dor pela escala analógica visual foi 6,8. A Escala de Sobrecarga do Cuidador de Zarit, indicou

Juliana Martins Izzo - https://orcid.org/0000-0003-2174-2233; que 36,3% dos cuidadores apresentaram de moderada a grave Ana Marcia Rodrigues Cunha - htps://orcid.org/0000-0001-9503-6337; sobrecarga e correlação positiva entre capacidade funcional e so- Claudia Bernardi Cesarino - https://orcid.org/0000-0002-8701-9163; Marielza Regina Ismael Martins - https://orcid.org/0000-0002-1140-7581. brecarga (p=0,003). CONCLUSÃO: A presença de dor crônica impacta de forma ne- 1. Faculdade de Medicina de São José do Rio Preto, Acadêmica de Medicina, São José do gativa e significante a qualidade de vida e a capacidade funcional Rio Preto, SP, Brasil. 2. Faculdade de Medicina de São José do Rio Preto, Hospital de Base, Clínica da Dor, De- dos pacientes com câncer, estendendo esse impacto para a figura partamento de Anestesiologia, São José do Rio Preto, SP, Brasil. do cuidador. 3. Faculdade de Medicina de São Jose do Rio Preto, Curso de Pós-Graduação em Enferma- gem, São José do Rio Preto, SP, Brasil. Descritores: Cuidadores, Dor do câncer, Qualidade de vida. 4. Faculdade de Medicina de São Jose do Rio Preto, Departamento de Ciências Neurológi- cas, São José do Rio Preto, SP, Brasil. INTRODUCTION Submitted on July 23, 2019. Accepted for publication on October 11, 2019. The World Health Organization (WHO) considers neoplasia-as- Conflict of interests: none – Sponsoring sources: Bolsa de Iniciação Cientifica /CNPq. sociated pain a worldwide medical emergency1. In oncology, it is Correspondence to: one of the most frequent complaints and one of the most feared Avenida Brigadeiro Faria Lima 5416 Departamento de Ciências Neurológicas phenomena among patients with cancer. This becomes even 15090-000 São José do Rio Preto, SP, Brasil. more relevant as these patients face adverse emotional impact E-mail: [email protected] and discomfort at all stages of the disease, from diagnostic tests © Sociedade Brasileira para o Estudo da Dor to conventional therapeutic procedures2. 336 The impact of chronic pain on the quality of life and on the BrJP. São Paulo, 2019 oct-dec;2(4):336-41 functional capacity of cancer patients and their caregivers

The multidimensional nature of oncologic pain is identified as Consent Term (FICT). Patients with limiting sensorial or cogni- Total Pain3. This conceptualization takes into account not only tive deficits were excluded (screened by the Mini-Mental exam), or the dimension of physical suffering but also the emotional, social, when refused to participate. For the caregivers, the inclusion criteria and spiritual consequences of exposure to the experience of pain. were taking care of a patient with chronic oncologic pain for at least The concept of Total Pain includes the assessment of physical as- 6 months, and accepting the caregiver FICT. Those who have re- pects (injury and disease progression, and reaction to treatment), fused to participate were excluded. psychological aspects (depression, mood swings, apathy), social The following instruments have been used: a clinical and so- aspects (impaired social relationships, isolation and discourage- ciodemographic interview with patient and caregiver, as well ment), and spiritual aspects (change in the relationship of indi- as the physical and instrumental activities of the daily life scale viduals with their beliefs, principles and values, doubts about faith (OARS)11 to evaluate the functional capacity of both. The Qual- and the meaning of life, feelings of helplessness and hopelessness)3. ity of Life Questionnaire European Organization for Research About 50% of people with cancer experience pain during treatment, and Treatment of Cancer Quality of Life Questionnaire (EO- 10-15% of them with relevant intensity at an early stage4. With the RTC-QLQ-C30)12 was used to assess patients’ quality of life, onset of metastasis, the prevalence of pain increases by 25 to 30% and the caregiver’s burden was assessed with the Zarit Caregiver and, in the advanced stages of the disease, from 60 to 90%. Pain is Burden Interview (ZBI)13. The sample consisted of 15 patients the most common symptom of cancer in advanced stages2,4. and 11 caregivers, which was estimated by the sample calculation For the oncologic patient, pain may represent worsening prog- of 5% (error=0.05) and with a reliability level of 95% (α=0.05 nosis or near death, decreased autonomy, decreased well-being, which provided z0.05/2=1.96), considering the true proportion and quality of life, the threat of increased physical suffering, and as 50% (p=0.50). The sample size was calculated based on the to- a challenge to dignity. It can also harm cognitive functions, daily tal number of patients undergoing clinical follow-up at the Pain physical and social activities, the appetite, and sleep, which is Clinic of a teaching hospital, with a total of 20 patients/month interrupted by pain in 58% of the patients5. with oncologic pain. The experience of chronic pain impacts not only patients but This study was approved by the FAMERP Human Research Ethics also people around them, like family members, friends, caregiv- Committee, under protocol CAAE 86689518.8.0000.5415. The ers, and the team that treats them6. This experience has repercus- participation in the study was voluntary and made effective by sign- sions in the social, emotional, and spiritual aspects of life, such ing the FICT. Participants were informed about their rights, accord- as restrictions on work and leisure activities, greater financial ing to Resolution 466/2012 of the National Health Council. burden, psychological distress in the face of the discomfort of a loved one, and metaphysical questions, among others6.7. Statistical analysis Despite the high incidence in cancer patients, especially in The Statistical Package for Social Science (SPSS)® application was patients on advanced stages of the disease, one of the biggest used. To achieve the proposed objectives, two statistical tech- challenges is the fact that pain is still misdiagnosed. This is due niques were applied. The correlation analysis was performed to many factors, such as the lack of qualification for efficient using the Student test t, and the analysis of the EORTC QLQ‒ handling by health professionals, who often underestimate or C30 instrument was performed according to the instructions neglect patient pain, the use of ineffective assessment strategies, provided by the group responsible for the standardization of the and patients’ difficulty or reluctance in expressing their pain. instrument in Brazil12. Also, the lack of adherence is associated with the patient’s concern about being hooked on analgesic drugs and the fear of their RESULTS adverse effects8. Thus, the present work is justified by the importance of elucidat- Fifteen patients with chronic oncologic pain who were undergoing the impacts of prolonged pain in all aspects of life of cancer ing treatment at the Pain Clinic of the São José do Rio Preto Base patients and the impact on the caregiver, considering that the Hospital were evaluated. Table 1 describes the sociodemographic clarification of these impacts can be decisive for efficiency and and clinical characteristics of these patients. patient’s acceptance of the therapeutic procedures, as well as to About functional capacity for basic daily life activities, ob- promote physical and emotional well-being for the patient and tained by the “OARS” scale, the average scores can be observed those around him/her, including their caregivers. in table 2. Regarding instrumental activities, 60% (n=9) of the participants METHODS reported being unable to clean and housekeeping, while 20% (n=3) claimed to need some help, and 20% (n=3) performed It is a cross-sectional, descriptive exploratory study, conducted at the the task without help. In instrumental activities of daily living Clinic of Pain Service of São José do Rio Preto Base Hospital. This (IADL), there was a statistically significant difference (p=0.048), study included patients diagnosed with chronic oncologic pain and while in physical activities of daily living (PADL), this did not their caregivers. The inclusion criteria of the patients were the pres- occur (p=0.052). When asked about activities as of shopping, ence of chronic pain lasting at least 6 months, and intensity greater 25% (n=4) had considered themselves incapable of performing, than or equal to 3 (screened by the visual analog scale - VAS)9, and 60% (n=9) need some help, and 15% (n=2) do it without help agree to participate in the study by signing the Free and Informed (Figure 1). 337 BrJP. São Paulo, 2019 oct-dec;2(4):336-41 Izzo JM, Cunha AM, Cesarino CB and Martins MR

Note that the three symptoms with the highest scores were: fa- Table 2. Average scores of the physical and instrumental daily activity tigue (49.5), insomnia (37.4), and loss of appetite (30.6). By OARS of patients and caregivers stratifying the group by gender, in table 3, it was observed that Domains Groups n Mean±SD P-value female patients had better averages in overall health and role per- Instrumental activity Patient 11 9.54±3.44 of daily life 0.048* formance scales, while male patients presented better averages in Caregiver 7 13.4±1.5 cognitive function (Tables 3 and 4). Physical activity of Patient 11 12.45±1.86 daily life 0.052 Caregivers also had their sociodemographic and clinical charac- Caregiver 7 14±0.0 teristics analyzed, as well as their overload and functional capaci- * Statistically significant value – p>0.05. Student’s t-test. ty for the basic activities of daily living (Tables 5 and 6). In the correlation between age, IADL, PADL, and caregiver burden, in this data crossover, there was a positive correlation between them; that is, the older the person, the higher the percep- 16 tion of burden, the lower the IADL index (p=0.003). There was 14 13.5 no correlation between gender, PADL, and education (p=0.75), 12 12.2 because in these cases, there was no significant difference (p-val- 10 9.6 9.4 Men 8 8.2 ue<0.05) of overload among categories. 7.5 Women 6 Total 4 2 Table 1. Socioeconomic and clinical characterization of the study pa- 0 tients (n=15) IADL PADL Variables % and n Mean ± SD Figure 1. Average scores related to instrumental activities of daily li- Gender ving and physical activities of daily living Female 60 (n=9) Male 40 (n=6) Average age (years) Female 64.6±8.8 60.7±9.5 Table 3. Average and standard deviation (±) of the EORTC QLQ30 Male 54.8±7.7 quality-of-life instrument scale scores of patients served at the Pain Clinic (n=15) Marital status Single 20 (n=3) Functional Scales Married 53.4 (n=8) Physical function 54.0±21.4 Widower 13.3 (n=2) Role performance 56.8±32.5 Separated 13.3 (n=2) Emotional function 53.7±15.5 Cognitive function 72.4±23.9 Education Level Social function 52.6±14.4 Incomplete primary education 60 (n=9) Complete primary education 13.3 (n=2) Symptom scales Incomplete high school education 6.7 (n=1) Fatigue 49.5±19.8 Complete high school education 13.3 (n=2) Nausea/Vomiting 19.1±12.4 Incomplete College 6.7 (n=1) Pain 27.5±25.4 Dyspnea 10±21.4 Household income Insomnia 37.4±22.5 1 to 2 MW 73.3 (n=11) Loss of appetite, 30.6±13.9 3 to 4 MW 6.7 (n=1) Constipation 22.0±16.4 Not reported 20 (n=3) Diarrhea 12.5±23.8 Drinker 6.7 (n=1) Financial difficulties 25.5±21.4 Smoker 6.7 (n=1) Quality of life overall health 58.4±22.0 How many times have you sought 2.2±1.08 the Emergency Service in the last 6 times months Average medical visits over the past 3.4±0.9 Table 4. Association between average quality of life scores and gen- 12 months times der of patients (n=15) Visual analog scale Scale items Average ± SD P-value Women 7.1±1.9 Quality of life overall health Men 6.8±1.7 Female 62.4±12.2 0.034* Total 6.8±1.9 Male 51.7±9.8 Has caregiver Role performance Yes 66.6 (n=11) Female 59.1±11.2 0.042* No 33.4 (n=4) Male 49.8±10.5 Employment situation Cognitive function Active 60 (n=9) Female 62.8±9.9 0.038* Inactive (retired) 40 (n=6) Male 79.5±11.2 MW = Minimum wage. * Chi-square test - p<0.05: a statistically significant difference.

338 The impact of chronic pain on the quality of life and on the BrJP. São Paulo, 2019 oct-dec;2(4):336-41 functional capacity of cancer patients and their caregivers

Table 5. Caregivers’ socioeconomic and clinical characteristics (n=11) that is, 77% of cancers are diagnosed in individuals over 55 Variables % and n Average and years. This higher average age is justified because aging is SD (±) linked to the increased incidence of cancer due to various Gender age-related physiological changes16. Female 72.2 (n=8) Education data (60% of patients had incomplete primary Male 27.8 (n=3) education) and income (72.2% of patients receive up to 2 Average age (years) Female 42±14.3 48.07±16.07 minimum wages) are consistent with studies that indicate Male 64.3±4.9 years greater use of services of the Unified Health System (SUS) Marital status by the population with the lowest level of education and Single 17.9 (n=2) lower income. The higher probability of using SUS by in- Married 72.2 (n=8) dividuals with lower education and lower per capita family Widower 9.9 (n=1) income indicates that the public system assists groups with Education Level a more precarious social insertion, fulfilling expectations Incomplete primary education 27.2 (n=3) regarding the performance of this public policy17. More- Complete primary education 9.9 (n=1) Incomplete high school education 16.7 (n=2) over, the low level of education present in this sample, also Complete high school education 36.3 (n=4) evident in other researches involving oncologic patients18, Non-literate 9.9 (n=1) reveals a scenario of concern, as studies indicate that low ed- Household income ucation is related to late diagnoses and worse care standards 1 to 2 MW 72.2 (n=8) to overall health, including resulting in higher mortality19. 3 to 4 MW 9.9 (n=1) Not reported 16.9 (n=2) Regarding the VAS results, the average was 6.8, indicating moderate to severe pain for patients. It is important to note Drinker 0 that most patients undergoing treatment at the Pain Clinic Smoker 9.9 (n=1) routinely use one or more prescribed pain control drugs. How many times have you sought the 1.4±0.68 Therefore, it is noteworthy that, despite the pharmacolog- Emergency Service in the last 6 months times ical treatment, the pain remained with significant intensity Average medical visits over the past 2.7±1.0 as a factor that aggravates the quality of life of these patients. 12 months times Studies report that the non-control of pain may occur due Employment situation Active 63.7 (n=7) to factors such as the potency of the analgesics used is lower Inactive (retired) 36.3 (n=4) than the pain intensity (negative pain control index), proposed analgesic schemes not compatible, or compatible with restrictions with the WHO analgesic scale pattern, or the Table 6. Average scores related to instrumental activities and incorrect use of drugs by patients, who use them only in physical activities of daily living, assessed by the “OARS” Sca- 20 le and the overload of caregivers assessed by the Zarit scale situations of pain aggravation . (n=11) Among the patients, 66.6% indicated that they have a per- Instruments Average % son who acts as their caregiver. The importance of the care- and SD (±) giver in the health care of oncologic patients is essential. “OARS” Scale The caregiver provides direct care, such as drug administra- Instrumental activity of daily life 13±2.3 tion, hygiene and food, and indirect care, accompanying the Physical activity of daily life 14,0±0 patient in all stages of the disease21. Overload Scale - ZBI Regarding functional capacity, the results obtained concern- Mild 63.7 (n=7) Moderate 18.15 (n=2) ing IADL (such as using the telephone, taking transporta- Serious 18.15 (n=2) tion to travel, shopping, preparing meals, cleaning, taking drugs, and dealing with the finances) were 8.2 for women and 7.5 for men, on a scale from zero to 14. According to DISCUSSION the proposed classification, these numbers indicate an intermediate level of independence for IADL, a result supported The data indicate a 60% prevalence of women among pa- by research that shows altered functional capacity in onco- tients seeking follow-up at the Pain Clinic services, versus logic patients due to semi-dependence for activities of daily 40% for men. The incidence of cancer between both gen- living, justified by abnormal performances in autonomy and ders is considered similar in developed countries, but in de- independence22. veloping countries, such as Brazil, some studies have found Still regarding functional capacity, the results obtained in a female prevalence of up to 25% higher14. In the analyzed relation to PADL (such as eating without help, dressing/ sample, this difference reaches 50%, which is aligned with taking off clothes, personal hygiene, walking, lying/getting the fact that care is not viewed as a male practice15. out of bed, taking a bath and getting to the toilet in time Regarding the average age (60.7 years), the figures are in when needed) were 13.5 for women and 9.4 for men, on agreement with the data of the American Cancer Society, a scale from zero to 14. Based on these numbers, women 339 BrJP. São Paulo, 2019 oct-dec;2(4):336-41 Izzo JM, Cunha AM, Cesarino CB and Martins MR were considered to have a high degree of functional inde- have historically been the caregivers of their children, par- pendence, while men had a significantly lower degree of ents, and family31. independence. 72.2% of the caregivers had an income of up to 2 minimum No studies were found to support these findings and justify wages, and 63.7% had an active work situation. These num- this less sensitive difference in IADL. However, contrary to bers indicate that the role of the caregiver may interfere with the findings, some studies indicate that older women are the individual’s personal and family financial situation, con- usually more dependent on IADL than men23,24, with a low- tributing to an overload scenario. In Siegel’s et al.28 study, er quality of life23,24 and a greater chance of incapacity25. 48% of caregivers had some sort of financial support, and Regarding the quality of life, analyzed by the EORTC 25% used their savings or borrowed money; Additionally, QLQ30 questionnaire, the social function was the most af- among the 79% of caregivers who were working, the main fected (52.6), followed by emotional (53.7), physical (54.0), burden reported was financial. performance of roles (56.8), and finally cognitive (72,4). Many caregivers need to abandon all or part of their work These results were partially corroborated by the 2008 EO- since they need, time after time, to accompany the patient RTC QLQ-C30 Global Benchmark Manual, in that cogni- to appointments or treatment sessions, or to give the patient tive function remains the least affected and emotional as the full attention and care. In this sense, it is once more the second most affected. Regarding symptoms, the three symp- women who end up prioritizing total dedication to caring, toms with the highest scores were: fatigue (49.5), insomnia thus harming not only their professional activities but also (37.4) and loss of appetite (30.6). Again, these results were their social life and leisure, resulting in a stressful overload partially corroborated by the Benchmark Values Manual, of uninterrupted and daily care32.33. which indicates the most frequent symptoms, in decreasing Regarding the ZBI scale, results were mild overload for order, fatigue, insomnia, and pain. 63.7% of respondents, moderate for 18.15%, and severe Oncologic patients report fatigue as the most common for 18.15%. There was a positive correlation between age, symptom in all stages of the disease26. However, there is still IADL, and overload: the older the caregiver, the higher the no consensus on its definition, only on its multicausal na- perception of overload and the lower the IADL index. The ture27. It is a very debilitating symptom that significantly Zarit Scale assesses, above all, the caregivers’ subjective over- limits daily activities and reduces working capacity. How- load, that is, their perception of the situation. Thus, lower ever, unlike other symptoms, especially pain, there are no scores are common and present in other studies34. The ex- known effective interventions for fatigue control and man- planation for this, as studies in psychology35 show, may be agement, further increasing its disabling potential28. coping strategies related to controlling emotional reactions. When analyzed by gender, there was a statistically significant difference in QoL Overall Health scores (an average of CONCLUSION 62.4 for women and 51.7 for men), role performance (59.1 for women and 49.8 for men), and cognitive function (62.8 The set of results showed that the presence of chronic pain nega- for women and 79.5 for men). tively and significantly impacts the quality of life and functional A research focused on gender differences in cancer coping29 capacity of cancer patients. This impact is more significant in revealed significant results for understanding these dif- IADL, resulting in the semi-dependence of these patients, espe- ferences observed in the present study. Men, faced with cially men. a diagnosis of cancer, assume a self-controlling attitude, It was also possible to conclude that this impact also extends to suppressing emotional manifestations to fulfill their social the figure of the caregiver. Older caregivers with relative func- problem-solving role. Perhaps this attitude is decisive for tional disability showed a higher perception of overload. maintaining a higher score of the cognitive function of men compared to women. On the other hand, women adopt a REFERENCES more emotionally positive coping strategy, seeking social 1. World Health Organization Collaborating Center for Policy and Communications in support and physical help to make the burden of the disease Cancer Care. 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341 BrJP. São Paulo, 2019 oct-dec;2(4):342-7 ORIGINAL ARTICLE

Chronic low back pain and walking speed: effects on the spatiotemporal parameters and in gait variability Dor lombar crônica e velocidade de caminhada: efeitos nos parâmetros espaço-temporais e na variabilidade da marcha

Alberito Rodrigo Carvalho1,2, Ronaldo Valdir Briani3, Welds Rodrigo Ribeiro Bertor1, José Roberto Svistalski1, Alexandro Andrade4, Leonardo Alexandre Peyré-Tartaruga2

DOI 10.5935/2595-0118.20190063

ABSTRACT was relatively consistent across speeds (~1.6 m∙stride-1.s) without statistical differences. The coefficients of variation were below 5%. BACKGROUND AND OBJECTIVES: Walking is described as CONCLUSION: The chronic nonspecific low back pain did not one of the abilities most affected by chronic low back pain. This affect the gait spatiotemporal profile, at least for those patients study aimed to determine if chronic nonspecific low back pain classified as chronic nonspecific low back pain according to the and walking speed affect the spatiotemporal parameters (stride signs and symptoms criteria. Although the preferred speed has af- length, swing time, contact time, stride time, stride frequency fected the spatiotemporal parameters, both groups patients were and walking ratio) and the coefficients of variation of stride able to adjust their kinematic parameters to each task demand. length and contact time. Keywords: Gait, Biomechanical phenomena, Locomotion, Spine. METHODS: Ten participants with chronic nonspecific low back pain (low back pain - LG) and ten healthy participants in the con- RESUMO trol group (CG) walked on the treadmill at preferred self-selected speed, slower and faster than the preferred speed. Spatiotemporal JUSTIFICATIVA E OBJETIVOS: A caminhada é descrita como parameters and coefficients of variation were determined by kine- uma das habilidades mais afetadas pela dor lombar crônica. Este estu- matic analysis. Main effects (group and speed) and their interactions do objetivou determinar se a dor lombar crônica não específica e a ve- were tested using generalized estimating equations method. locidade de caminhada afetam os parâmetros espaço-temporais (com- RESULTS: Our results showed that there were no significant dif- primento da passada, tempo de balanço, tempo de contato, tempo da ferences between groups or significant interaction between group passada, frequência da passada e razão de caminhada) e os coeficientes and speed factors. There was a speed effect. Stride frequency and de variação do comprimento da passada e do tempo de contato. length increased while contact and stride time decreased as the MÉTODOS: Dez participantes com dor lombar crônica não speed increased. The walking ratio (stride length/stride frequency) específica (grupo dor lombar GL) e 10 participantes saudáveis (grupo controle - GC) caminharam na esteira na velocidade preferida autosselecionada, e em velocidades mais lenta e mais rá- pida que a velocidade preferida. Parâmetros espaço-temporais e Alberito Rodrigo Carvalho - https://orcid.org/0000-0002-5520-441X; Ronaldo Valdir Briani - https://orcid.org/0000-0002-0452-7753; coeficientes de variação foram determinados por cinemetria. Os Welds Rodrigo Ribeiro Bertor - https://orcid.org/0000-0001-6861-1076; efeitos principais (grupo e velocidade) e as suas interações foram José Roberto Svistalski - https://orcid.org/0000-0001-6714-1412; Alexandro Andrade - https://orcid.org/0000-0002-6640-9314; testadas pelo método de equações de Estimativas Generalizadas. Leonardo Alexandre Peyré-Tartaruga - https://orcid.org/0000-0003-1742-5016. RESULTADOS: Não houve diferenças entre os grupos ou inte- ração entre os fatores (grupo e velocidade). Houve efeito da velo- 1. Universidade Estadual do Oeste do Paraná, Laboratório de Pesquisa do Movimento Hu- mano, Cascavel, PR, Brasil. cidade. A frequência e o comprimento de passada aumentaram, 2. Universidade Federal do Rio Grande do Sul, Laboratório de Pesquisa do Exercício, Porto enquanto o tempo de contato e de passada diminuíram à medida Alegre, RS, Brasil. 3. Universidade Estadual Paulista, Laboratório de Biomecânica e Controle Motor, Presidente que a velocidade aumentou. A razão de caminhada (comprimen- Prudente, SP, Brasil. to da passada/frequência da passada) foi relativamente consisten- 4. Universidade do Estado de Santa Catarina, Psicologia do Laboratório de Esporte e Exer- -1 cício, Florianópolis, SC, Brasil. te entre as velocidades (~1,6 m∙passada ∙s) sem diferenças estatís- ticas. Os coeficientes de variação ficaram abaixo dos 5%. Submitted on July 03, 2019. CONCLUSÃO Accepted for publication on September 16, 2019. : A dor lombar crônica não específica não afetou Conflict of interests: none – Sponsoring sources: Centro de Reabilitação Física da UNIOESTE os parâmetros espaço-temporais da caminhada, pelo menos para e Centro de Ciências Biológicas e da Saúde – CCBS, UNIOESTE, Cascavel, PR, Brasil. os pacientes classificados com dor lombar crônica não específica Correspondence to: pelos critérios de sinais e sintomas. Embora a velocidade prefe- Alberito Rodrigo de Carvalho rida tenha afetado os parâmetros espaço-temporais, os pacientes Clínica de Fisioterapia / Centro de Reabilitação Física (UNIOESTE) Rua Universitária, 2069 - Jardim Universitário de ambos os grupos foram hábeis para ajustar seus parâmetros 85819-110 Cascavel, PR, Brasil. cinemáticos às demandas da tarefa. E-mail: [email protected] / [email protected] Descritores: Coluna vertebral, Fenômenos biomecânicos, Loco- © Sociedade Brasileira para o Estudo da Dor moção, Marcha. 342 Chronic low back pain and walking speed: effects on the BrJP. São Paulo, 2019 oct-dec;2(4):342-7 spatiotemporal parameters and in gait variability

INTRODUCTION The hypothesis of this study was that participants with CLBP are less able to adjust the spatiotemporal parameters as a result Low back pain (LBP) is a syndrome-based condition with high of speed variation, but especially in the preferred self-selected prevalence in the world population. The global prevalence of speeds because these patients tend to choose speed rates slower LBP was reported as ranging from 5 to 65%1. In Brazil, the prev- than healthy people, and as it has recently been demonstrated, alence of chronic low back pain (CLBP) is 3.9 to 25.4%, and the at lower speeds the inter-strides variation is critical16,17. Based on prevalence in individuals aged between 20 and 59 years is around this, it is expected that participants with CLBP have their dy- 19,6%2. Although the specific causes of LBP can be identified, namical stability impaired (assessed by inter-stride variation) at the specific diagnosis is not possible in most cases, and a nonspe- all speeds tested. cific cause is frequently accepted as the diagnosis3. The recognition of the LBP etiology remains a challenge since METHODS there is still a poor correlation between anatomopathological and clinical presentation4. Nevertheless, CLBP is usually associated After the sample calculation, which was determined for the vari- with functional and psychosocial impairment5,6. A study that able “speed” (WinPepi version 11.18; power = 80%; significance identified the main activities performed with difficulty in pa- level 5%; SD control group = 0.16; SD low back pain group tients with CLBP pointed out more than 60 types of activities. = 0.21; difference to be detected = 0.3; at least n = 8 for each However, the most prevalent, around 56%, was a decrease in group), volunteers of both genders and aged over 25 years, with walking tolerance7. and without CLBP were recruited. The CG consisted of par- Walking is an activity of both clinical and functional relevance due ticipants without systemic or musculoskeletal disorders in the to its impact on independence and quality of life, and is often an lower limbs and spine, either chronic or acute, reported during integral part of rehabilitation programs, including those directed the last year. to patients with CLBP. However, the repercussion of LBP on the The chronic low back pain group (LG) consisted of volunteers walking parameters still needs further understanding, given the with CLBP, from a local Rehabilitation Center, and with no etiological complexity of this syndrome and the wide range of fac- musculoskeletal injuries in other joints on lower limbs and/or tors that can contribute to the loss of movement8. systemic illnesses which impairs the ability to walk. They were Spatiotemporal parameters of gait, such as speed, stride length, recruited intentionally and not probabilistically. The inclusion stride frequency, contact, and balance time, are not unvarying. criteria for the LG followed the recommendations of original or They interact in a coordinated manner to allow the displacement review articles that focused on the diagnosis and treatment of to be adequate to the task demands and environment and to LBP, according to the signs and symptoms indicated in the an- ensure that it is performed effectively. Therefore, individuals tend amnesis and physical examination3,18. Thus, volunteers should to determine these spatiotemporal parameters freely, although report LBP persisting for more than three months, without ra- dynamic and mechanical factors have a remarkable influence on diation to the lower limbs but with physical and clinical charac- this choice9. teristics compatible with Category 1 pain (nonspecific low back Some neurological diseases cause disturbance of gait spatio- pain) according to the guidelines for evaluation and treatment temporal synchronism10,11. In the major part of neurological that are proposed by the American College of Physicians and the impairments, the relation between the disease and motor dis- American Pain Society18. orders, although complex, is more apparent because the anato- Volunteers, from both groups, were excluded if they did systemat- mopathological disease basis involves the recognized damage to ically and routinely engage in physical exercise, two or more times the structures responsible for the generation and conduction of per week for at least 30 minutes; did show obvious differences in nerve stimuli12. Often, this framework does not apply to CLBP length of the lower limbs, postural misalignments and body mass since the maintenance of the chronic condition may persist even indexes greater than 30.0kg.m-2. For data processing, videos with when no physical reason justifies it13. bad technical quality were excluded from the analysis. Nevertheless, a possible explanation for motor impairment in chronic pain conditions may be the deleterious changes in brain Measures morphology. Recent studies have shown that individuals with The experimental design of this study involved the following symptoms of CLBP showed a loss in the volume and density of steps: 1) screening; 2) preferred self-selected speed determina- the gray matter of the dorsolateral prefrontal cortex, thalamus, tion; 3) spatiotemporal assessment; 4) data analysis. somatosensory cortex, and midbrain14,15. After the explanation about the procedures and objectives of the Walking is described as one of the abilities most affected by research, the volunteers underwent clinical screening to identify CLBP. Considering the possibility of motor changes arising from possible exclusion factors and collection of history and anthro- central changes, identifying changes in walking kinematics in pometric data. LBP becomes relevant. Therefore, the aim of this study was to To determine the preferred self-selected speed (PS), the partici- determine if CLBP and walking speed (WS) affect the spatio- pant underwent a familiarization period, for five minutes, on the temporal parameters (stride length, swing time, contact time, treadmill (Embrex 563-R3, Brusque, Brazil) and then the PS was stride time, stride frequency and walking ratio) and the coeffi- determined. The PS was determined as follows: a) the volunteer cients of variation (CoV) of stride length and contact time. was asked to choose the most comfortable speed, similar to the 343 BrJP. São Paulo, 2019 oct-dec;2(4):342-7 Carvalho AR, Briani RV, Bertor WR, Svistalski JR, Andrade A and Peyré-Tartaruga LA one used daily, that could be maintained over a long path; b) The spatiotemporal parameters analyzed, and their respective the treadmill speed was increased progressively up to a standard measurement units and definitions are presented in table 121,22. of 7 km.h-1 (or until before the volunteer felt insecure in walk- We also calculated the CoV of contact time and stride length, ing) and then reduced in the same pattern so that the volunteer obtained by the ratio between standard deviation and by the av- could choose his PS in each set; c) the PS of each patient was erage values arising from each step transformed into percentage determined by calculating the mean of the PSs from two sets of values16. The CoV is expressed in percentage values (CoV%). recording19. The present study was previously approved by the Research Re- A high-speed digital video camera (Casio High Speed – HS Ex- view Board of the Universidade Estadual do Oeste do Paraná ilim EX-FH25, Norderstedt, Germany) recorded the spatiotem- (Report 1433/2011), in accordance with resolution 466/12, and poral parameters. Data acquisition occurred at a frequency of it was classified as observational, ex-post-facto, exploratory-de- 240Hz. The camera was placed perpendicular to the treadmill scriptive, transversal study. All volunteers received clarification with a focus on the lower limbs, especially on legs and feet. regarding the study aims and procedures before inclusion, and all The test battery was divided into three sections according to provided formal consent to participate. WS intensity as follows: PS, and slower and faster than the PS. Only three intensities were proposed to avoid overloading Statistical analysis on the LG. In the first section, the participants walked at their Regarding variable stride length, we considered only normalized PS. The order of the next two sections was randomly selected values by lower limb length for statistical treatment. We tested so that in one case, the volunteers walked 0.5 km∙h-1 slower the data normality by the Shapiro-Wilk test. For all statistical than the PS, and the other the volunteers walked 0.5 km∙h-1 tests, we adopted α=0.05. faster than the PS. In each section, the participants walked for We compared the participants’ characteristics using the five minutes. The images were captured in the last 30s of each Mann-Whitney test (intergroup comparison). We verified if section to minimize variability between steps20. there was any difference in pain scores for LG between the During the treadmill walking tests, minute by minute, the par- speeds using the Friedman test. The verification of LBP effect ticipants were asked to grade the pain experienced at that exact (main group effect), walking speed effect (main effect of speed) moment using the visual analogue scale (zero to 10, where zero and their interactions were made using the Generalized Esti- represented absence of pain, and 10 the worst possible pain) mating Equation (GEE) method. In post-tests, we applied the making a total of six samples: from moment zero immediately Bonferroni test. before start walking until the moment five at the end of the last walking minute. The valid pain scores of each section for RESULTS statistical analysis was the arithmetic average of all measures of that section. In total, 20 volunteers were recruited, being five men and five women in each group. Statistical differences in age, PS, anthro- Data processing pometric characteristics were not observed between the groups, For kinematic analysis, the ‘Kinovea’ software (V0.8.15; Ki- but we found differences in pain scores (Table 2). The pain scores novea open source project, www.kinovea.org) was used to de- were not different between the speeds for LG (p=0.8302). termine the spatiotemporal parameters by visually identifying The descriptive statistic for the spatiotemporal variables is pre- the total of frames, computing frame by frame, corresponding sented in figure 1. No main group effect was found as well as to the touching of the heel on the ground (landing) and the interactions between group and speed, but we found the effect of moment when a foot lost contact with the ground (toe-off) speed. It can be observed that stride frequency and stride length for 16 strides analyzed in that last 30s time. Each stride cycle increased as the speed was higher. The contact time and stride comprised the interval between two consecutive take-offs of the time decreased as the speed was higher. We did not find effect of same foot21,22. speed on the walking ratio. The CoVs were below 5%.

Table 1. List of the spatiotemporal parameters analyzed in the present study, their units and definitions Parameters Units Definitions Speed m.s-1 Distance traveled per unit time Stride time s Number of frames of each cycle multiplied by the period

Stride length (normalized by the Lll) m Speed multiplied by (ST / Lll) Stride frequency Stride.s-1 Speed /SL Swing time s Number of frames in that the foot is not in contact with the ground during a stride multiplied by the period Contact time s Number of frames in that the same foot is in contact with the ground during a stride multiplied by the period Walking ratio m.stride-1∙s A speed-independent walking standard index. It is the ratio of SL per SF Period = reciprocal of the sampling rate (1.240-1).

344 Chronic low back pain and walking speed: effects on the BrJP. São Paulo, 2019 oct-dec;2(4):342-7 spatiotemporal parameters and in gait variability

Table 2. Presentation of descriptive statistics (median, 25%, and 75% percentile) and intergroup comparison between the variables of sample characterization Variables Descriptive statistics Intergroup comparison Median 25% percentile 75% percentile Age (year) p=.1984 CG 37 32 44 LG 44 33 53

Lll (m) p=.3215 CG 0.88 0.86 0.93 LG 0.87 0.76 0.91 Stature (m) p=.0634 CG 1.76 1.63 1.79 LG 1.69 1.56 1.75 Body mass (kg) p=.6305 CG 70.5 65.4 86.1 LG 70.4 56.6 85.0 PS (m s-1) p=.6305 CG 0.98 0.84 1.20 LG 0.91 0.84 1.09 Pain at slower speed (by VAS) p=.0014 CG 0 0 0 LG 1.6 0.3 1.7 Pain at PS (by VAS) p=.0014 CG 0 0 0 LG 0.9 0 1.9 Pain at faster speed (by VAS) p=.0014 CG 0 0 0 LG 1.5 0.6 2.1 LG =(low back pain; CG = control group; LII = length of lower limb, walking speed 0.5km.h-1 slower than the preferred self-selected speed (slower); PS = preferred self-selected speed; speed 0.5km.h-1 faster than the preferred self-selected speed (faster); VAS = visual analog scale; significance level=0.05.

Figure 1. Descriptive statistics (mean and 95% confidence interval) and inferential comparisons of the spatiotemporal variables by assessing the effect of speed

345 BrJP. São Paulo, 2019 oct-dec;2(4):342-7 Carvalho AR, Briani RV, Bertor WR, Svistalski JR, Andrade A and Peyré-Tartaruga LA

DISCUSSION Despite some mechanical reasons to believe that the gait in CLBP patients could be changed, it is possible that the spatio- We aimed to determine if CLBP and WS affect the spatiotempo- temporal features may not reflect the kinetics impaired. It is pos- ral parameters. The results of this study indicated that CLBP did sible to speculate that one should consider other relevant features not have a significant effect on the spatiotemporal parameters. involved in the etiology of LBP syndrome for that spatiotempo- However, the WS did affect them. ral changes to be present. The effect of speed on the spatiotemporal parameters has been Henchoz et al.31 did not observe differences in the spatiotemporal, reported before, as speed is accompanied by changes in the kine- mechanical, and metabolic variables in people with and without matic parameters23. Likewise, it is emphasized that the walking LBP, even with the self-selected speed for the lumbar group being speed is the product of stride length and frequency, but at the slower than the control group. One of the arguments suggested to same time, these parameters are also determined by the speed, explain these outcomes was that peripheral musculoskeletal disor- and this is a consequence of the complex interaction between ders, unlike central musculoskeletal disorders, may not be suffi- mechanical parameters, task demand, and motor control24. It ciently large to cause a less efficient walking pattern. means that changes in the spatiotemporal parameters observed One study suggested that CLBP patients seem to be more effec- in this study, by the influence of the speed, are supported by the tive at slow speeds than fast speeds (speed effect), although there scientific and technical literature. was no difference in free-pain participants32. The authors spec- As the relation choice between stride length and stride frequency ulated that the repercussion of neurophysiological adjustments tends to be spontaneous at a self-selected speed, and even at dif- due to painful stimuli could explain the motor behavior in peo- ferent speeds25, the walking ratio is considered as an index of the ple with CLBP and consequently the metabolic parameters. walking pattern which is independent of speed. Thus, a constant Indeed, the LBP is a syndrome-based condition, and the con- walking ratio at different speeds reveals a normal walking pat- tribution of psychosocial and neuropsychological factors on the tern26. As the walking ratio of the present study in both groups performance of motor tasks is still poorly understood and con- showed no statistical differences between the three intensities in fusing in the context of CLBP. The contemporary classification speed and no significant group effect, we concluded that all the system for this syndrome is yet not sensitive enough to include all studied participants were skilled enough to adapt their kinematic etiological aspects. Probably, the physical classification systems parameters to each task demand. for LBP do not consider relevant dimensions as pain character- Besides, the low values and the lack of statistical difference in the istics, psychophysical, psychological, social, lifestyle, movement CoV index reinforce our findings, indicating stable gait char- or comorbidities in an integrated manner to provide a diagnosis acteristics. Variability of both stride time and length are closely that allows recognizing single features in each case33. related to the control of the rhythmic stepping mechanism asso- Corroborating other papers, the researchers observed that pa- ciated with safe gait27. Variability, represented by CoV, provides tients with CLBP, although they had a lower level of strength additional information about the behavior of the gait concerning on dorsal and lower limb muscles or in psychosocial variables, average values of the kinematic variables and tends to be low in they did not show differences in the six-minute walk tests per- walks considered stable, being advocated percentage values for formance in comparison to healthy people5,6. It is important to normal coefficient variation lower than 3% among young adults. highlight that the speeds evaluated were self-selected. Also, variability tends to be higher at lower speeds and, on the We suggest future papers to include other etiological dimensions contrary, lower at higher speeds. The smaller the variability the in the analysis to compose groups functionally more homoge- greater the gait dynamic stability16,28. neous. The major limitation of this study is that we did not have In the present study, both groups were able to adjust their a fixed speed aiming to compare both groups under similar me- spatiotemporal parameters, and the LG reported low pain chanical conditions. scores at all speeds without difference between them. We be- In general, one cause of concern about CLBP rehabilitation relieve to be this the cause of the lack of statistical difference for lates to the improvement of walking ability; mainly because these PS between groups. patients tend to walk slower. According to two systematic reviews, Our initial hypothesis was that participants with CLBP are less walking is a recommended strategy to be used in the management of able to adjust the spatiotemporal parameters due to speed vari- CLBP to reduce pain and disability34, although there is low-quality ation. This hypothesis was based on the findings of other au- evidence to bespeak that walking is a strategy, in comparison with thors29. In the medical literature, some investigators have high- other non-pharmacological, and more effective, approaches35. lighted the impairment in the walking pattern in people with Our results make us think if the strategies used in rehabilitation, CLBP as a synchronous movement between trunk and pelvis aiming to correct the spatiotemporal parameter of gait for CLBP leading to “en bloc” style of walking, alteration of proprioceptive patients are necessary. The present findings show that the spatio- postural control, tendency to adopt ankle strategy for walking temporal profile of gait in this syndrome-based condition does and slower speed gait than people without CLBP. In general, it not change across slow, middle, and high walking speeds. The is accepted that those adaptations might happen as a protective gait variability is an indirect marker of dynamical stability and, reaction to avoid pain30,31. However, our data indicate the oppo- though previous evidence shows a greater step width in people site, and they do not support the theory that patients with CLBP with LBP, these changes are not enough to impair the global avoid moving due to the pain. stability parameters assessed here. 346 Chronic low back pain and walking speed: effects on the BrJP. São Paulo, 2019 oct-dec;2(4):342-7 spatiotemporal parameters and in gait variability

CONCLUSION Loss of white matter integrity is associated with gait disorders in cerebral small vessel disease. Brain. 2011;134(Pt 1):73-83. 15. Wood PB. Variations in brain gray matter associated with chronic pain. Curr Rheu- We conclude that CLBP does not affect the spatiotemporal pa- matol Rep. 2010;12(6):462-9. 16. Oliveira HB, Rosa RG, Gomeñuka NA, Peyré-Tartaruga LA. Estabilidade dinâmica rameters, at least for those patients classified as CLBP according da caminhada de indivíduos hemiparéticos: a influência da velocidade. Rev Educ Físi- to the signs and symptoms criteria. Although the WS has af- ca/UEM. 2013;24(4):559-65. fected the spatiotemporal parameters, both LG and CG patients 17. Hicks GE, Sions JM, Coyle PC, Pohlig RT. Altered spatiotemporal characteristics of gait in older adults with chronic low back pain. Gait Posture. 2017;55:172-6. were able to adjust their kinematic parameters to each task de- 18. Chou R, Qaseem A, Snow V, Casey D, Cross TJ, Shekelle P, et al. Diagnosis and treat- mand sustaining a low variability of gait. ment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147(7):478-91. 19. Dingwell JB, Marin LC. Kinematic variability and local dynamic stability of upper ACKNOWLEDGEMENTS body motions when walking at different speeds. J Biomech. 2006;39(3):444-52. 20. Zeni JA, Higginson JS. Gait parameters and stride-to-stride variability during familiarization to walking on a split-belt treadmill. Clin Biomech. 2010;25(4):383-6. UNIOESTE Physical Rehabilitation Center and Biological and 21. Racic V, Pavic A, Brownjohn JMW. Experimental identification and analytical modelling of human walking forces: literature review. J Sound Vib. 2009;326(1-2):1-49. Health Sciences Center CCBS/UNIOESTE, Cascavel, PR, Brazil. 22. Thomas EE, De Vito G, Macaluso A. 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347 BrJP. São Paulo, 2019 oct-dec;2(4):348-55 ORIGINAL ARTICLE

Acupuncture in the treatment of temporomandibular muscle dysfunction Acupuntura no tratamento da disfunção temporomandibular muscular

Evelyn de Freitas Boscaine1, Elenir Rose Jardim Cury Pontes1, Daisilene Baena Castillo1, Lirane da Silva Carneiro Suliano2, Nelson Talatoci Oshiro Filho1

DOI 10.5935/2595-0118.20190064

ABSTRACT CONCLUSION: The statistical results showed that acupuncture increased the muscle tension threshold, improved the BACKGROUND AND OBJECTIVES: Temporomandibular mouth opening and reduced pain, being as effective as the most dysfunction consists of frequent non-dental pain in the orofacial commonly used conventional therapies. region of multifactorial origin and interdisciplinary treatment, Keywords: Acupuncture, Orofacial pain, Temporomandibular among them, acupuncture. The treatment of temporomandibu- dysfunction. lar dysfunction acts both in muscle relaxation and pain control, trying to achieve the physical, mental, and emotional balance of RESUMO the patient, thus reducing anxiety and improving the quality of life. The objective of this study was to evaluate acupuncture as a JUSTIFICATIVA E OBJETIVOS: A disfunção temporoman- treatment for temporomandibular dysfunction. dibular consiste em dores não dentárias frequentes na região METHODS: A total of 34 volunteers screened and selected at orofacial, de origem multifatorial e de tratamento interdiscipli- the Federal University of Mato Grosso do Sul, diagnosed with nar. Entre esses tratamentos está a acupuntura. O tratamento muscle dysfunction according to the Research Diagnostic Crite- da disfunção temporomandibular atua tanto no relaxamento ria. They were randomly divided into two equal groups: group muscular quanto no controle da dor, sistemicamente buscando o 1 treated with occlusal plaque, massage, thermotherapy and self- equilíbrio físico, mental e emocional do paciente, diminuindo a care guidelines; and group 2 treated with six acupuncture ses- ansiedade e melhorando a qualidade de vida. Este trabalho teve sions lasting 30 minutes each. The pain was evaluated by the vi- como objetivo avaliar a acupuntura como tratamento da disfun- sual analog scale, and an algometer to assess the muscular tension ção temporomandibular. of the temporal and masseter muscles. The limitation of mouth MÉTODOS: Participaram do estudo 34 voluntários triados e opening was measured with the use of calipers. The Mann-Whit- selecionados na universidade de Mato Grosso do Sul, diagnosti- ney test was used for the non-normal distribution (visual analog cados com disfunção muscular pelo Research Diagnostic Criteria, scale and tension threshold) between the two groups (G1 and e foram divididos aleatoriamente em dois grupos iguais. O grupo G2), and the Friedman test to compare the assessment periods 1 foi tratado com placa oclusal, massagem, termoterapia e orien- (beginning of the treatment, after six weeks and four months) tações de autocuidado. O grupo 2 foi tratado com 6 sessões de with a significance level of 5%. acupuntura com duração de 30 minutos cada. A dor foi avaliada RESULTS: There was no difference in mouth opening, visual pela escala analógica visual e com auxílio de um algômetro para analog scale scores, or muscle tension threshold in relation to the avaliar a tensão muscular dos músculos temporal e masseter. A li- type of treatment used. Both groups improved after six weeks of mitação de abertura bucal foi medida com o uso do paquímetro. treatment. There was no statistical difference in the values ob- Para a distribuição não normal (escala analógica visual e limiar tained after six weeks and after four months. de tensão), entre os dois grupos (G1 e G2), foi utilizado o teste Mann-Whitney, e para a comparação entre os períodos de ava- liação (início do tratamento, após seis semanas e 4 meses), foi Evelyn de Freitas Boscaine - https://orcid.org/0000-0001-6469-3916; utilizado o teste de Friedman, ao nível de significância de 5%. Elenir Rose Jardim Cury Pontes - https://orcid.org/0000-0003-2711-0667; Daisilene Baena Castillo - https://orcid.org/0000-0003-4261-7503; RESULTADOS: Não houve diferença das medidas de abertura Lirane da Silva Carneiro Suliano - https://orcid.org/0000-0002-1590-0517; de boca, dos escores de escala analógica visual e de limiar de ten- Nelson Talatoci Oshiro Filho - https://orcid.org/0000-0002-3632-5929. são muscular segundo o tipo de tratamento utilizado. No entan- 1. Universidade Federal de Mato Grosso do Sul, Faculdade de Odontologia, Campo Grande, to, em ambos os grupos houve melhora nos parâmetros avaliados MS, Brasil. 2. Universidade Federal do Paraná, Curitiba, PR, Brasil. após seis semanas de tratamento. Não houve diferença estatística dos valores obtidos após seis semanas e ao final do tratamento, Submitted on February 13, 2019. após quatro meses. Accepted for publication on October 16, 2019. Conflict of interests: none – Sponsoring sources: none. CONCLUSÃO: Os resultados estatísticos mostraram que a acupuntura aumentou o limiar de tensão muscular, melhorou a aber- Correspondence to: Avenida Costa e Silva. S/nº - Bairro Universitário tura de boca e diminuiu a dor. Concluiu-se que a acupuntura foi 79070-900 Campo Grande, MS, Brasil. tão eficiente quanto as terapias convencionais mais utilizadas. E-mail: [email protected] Descritores: Acupuntura, Disfunção temporomandibular, Dor © Sociedade Brasileira para o Estudo da Dor orofacial. 348 Acupuncture in the treatment of temporomandibular muscle dysfunction BrJP. São Paulo, 2019 oct-dec;2(4):348-55

INTRODUCTION and health20,21. Because it is a natural technique and addresses the patient as a whole (physically, mentally, and emotional- Temporomandibular dysfunction (TMD) is a set of clinical ly), it acts in a noninvasive and reversible manner, both on signs and symptoms involving the masticatory muscles, the local and systemic factors, in which the most commonly used temporomandibular joint (TMJ) and associated structures1. therapeutic modalities fail to achieve efficiently. According to Currently, TMD is basically divided into two groups, which TCM, human beings must be viewed and treated in a holis- are joint and muscle dysfunction2. Symptoms most frequently tic, integral way, as they have an indivisible physical, mental, reported by patients are muscle fatigue, facial pain, headache, emotional origin and are an integral and active part of their TMJ pain, and chewing muscle pain. Ear pain, mandibular physical, natural, and psychosocial environment22-24. movement limitation, tinnitus may be present in some cases, Based on the literature, this study aimed to compare the ef- especially in joint dysfunction3. fects of acupuncture on occlusal splint in the treatment of It is important to know some of the factors that can contrib- patients with muscle TMD. ute to the development and maintenance of TMD, such as teeth clenching, bruxism (grinding or clenching), biting for- METHODS eign objects such as pens or nails, chewing gum, head posture or presenting factors related to stress, depression, and anxiety Thirty-four individuals were screened in the TMD extension or traumatic events, malocclusions and occlusal maladjust- project (SERDOF) of the School of Dentistry (FAODO) of ments, such as missing teeth4-6. the University of Mato Grosso do Sul, who presented a clini- Because TMD have a multifactorial etiology, they require cal picture of muscle TMJ pain and dysfunction. After being an interdisciplinary therapeutic approach through a team of evaluated by the Research Diagnostic Criteria (RDC/TMD) several specialties, or at least close collaboration7. The use of exam and signing the Free and Informed Consent Term interocclusal splints is the most used treatment in dentist- (FICT), the patients participated in the random selection of ry, as they cause local muscle relaxation and relief of muscle the research groups. pain. Others act presumably more centrally, including acu- The sample size was determined with the SPSS software ver- puncture8-10. sion 24.0 (SPSS, Inc., Chicago, IL, EUA) by the t-test cal- The use of occlusal splints comprises a treatment modality with culation, accepting a sample mean of pain score decrease a high success rate in reducing muscle TMD symptoms, but in the visual analog scale (VAS) after treatment of TMD of it is only effective when used correctly11-13. However, there are 5.29±0.43, population mean of 5.0, significance level of 5% still patients who do not respond to treatment with splints, and power of 80%, resulting in a minimum sample of 17 so it is necessary to institute other treatment modalities5,14,16. participants for each group. Occlusal splint therapy temporarily reduces muscle hyperac- The inclusion criteria were being diagnosed with muscle tivity through peripheral changes arising from afferent impulse TMD and being over 18 years old. The exclusion criteria were changes in the organic receptors, leading to an efferent response the previous treatment of TMD, have fibromyalgia, pregnant that reduces muscle tension in the region in question. The asso- women; individuals using neuromuscular drugs; cancer pa- ciation of the splint with other treatments has also been widely tients. used. It is necessary to offer the patient a treatment capable of The patients were randomized by simple draw into two reducing his/her limitations, relieving pain, and discomfort in groups: G1: n=17, who underwent massage treatment, ther- order to improve his/her quality of life17. Acupuncture is con- motherapy, counseling, and occlusal device. The patients were sidered as a holistic science and therapy that preaches mental instructed to use the myorelaxant splint at night (Figure 1). and emotional balance through the harmony of the patient’s energy flow in the energy channels. Energy channels are webs that run through the body, the internal organs, and viscera (Zang Fu) and coincide with the topography of nerve plexuses that control the body’s functioning18. Acupuncture, unlike the occlusal splint, acts through the central mechanism of pain inhibition, involving segmental blockage in the spinal cord. This causes the release of neuro- modulators, such as endorphins and serotonin, which alter pain sensitivity through the central mechanism of analgesia19. Acupuncture has anti-inflammatory, anxiolytic, myorelaxant, and immune function activating effects, being an alternative, integrative, and complementary therapy used to treat TMD. It is based on the principle of uniting, integrating and solidi- fying all dental technical and scientific knowledge with those of the Traditional Chinese Medicine (TCM), aiming at the best results for the patient, better quality of life, well-being Figure 1. Occlusal splint 349 BrJP. São Paulo, 2019 oct-dec;2(4):348-55 Boscaine EF, Pontes ER, Castillo DB, Suliano LS and Oshiro Filho NT

Participants received counseling and self-care guidance. The occlusal splints were of 2mm thick acetate from Bio.art brand, and all were reinforced with a mean 2mm thick acrylic layer to improve their strength and smoothness. No semi-adjustable ar- ticulator was used to make the splints. A single skilled and experienced RDC/TMD professional installed and adjusted the splints, carefully checking the highest number of contact points, and the protrusion and laterality of jaw movements. After the splints were installed, patients were instructed to use only at night and return for follow-up and possible adjustments every 15 days. Patients were reevaluated after six weeks and four months of treatment. G2 (n=17) underwent acupuncture sessions once a week for 30 minutes. There were six acupuncture sessions. The treatment was performed with 0.25x15mm disposable needles (acupuncture needles) of DongBang Xu li Ltda brand, at points called acupoints. The skin was previously cleansed with 70% ethyl alcohol by a specialized professional. In each session, the Figure 2. VG20 acupuncture point patients remained for 30 minutes lying down and relaxed. The selected points followed the TCM diagnostic protocol. The selected points were: a) for local pain, stomach meridian E7 (Xianguan); a local meridian point of the stomach that improves ear and TMJ functions, relieves muscle spasm of the masseter, decreases jaw motor imbalance and decreases pain25. b) systemic points: VG20 (Baihui) - governing vessel channel (Figure 2). A systemic point indicated to calm the mind, reduce stress, improve sleep, calm thoughts, soothe the spirit, relax muscles25. TA5 (Waiguan) - triple heater channel (Figure 3). Systemic point for the treatment of pain and irritability, treatment of otitis, tinnitus, reduces headache, treatment of neck and shoulder muscle pain25. IG4 (Hegu) - large intestine channel (Figure 4). A systemic point that strengthens the immune system, anti-inflammatory point of the upper limbs, analgesia, calms the mind, promotes labor (contraindicated in pregnant women), regulates the stomach and intestine channels, regulates the uterus, treats tinnitus and deafness, treats Figure 3. TA5 acupuncture point the flu, sinusitis, rhinitis, anxiety, and neck muscle pain25. E36 (Zusanli) - stomach channel (Figure 5). Systemic point regulates the immune system, regulates the intestines, increases energy. According to Chinese belief, this point is the point of vitality, strength, and long life, rebalances the mind, decreases fever, treats depressive disorders25. F3 (Taichong) - liver channel (Figure 6). A systemic point that regulates men- struation, treats menstrual cramps, calms the mind, treats headaches, treats irritability, treats insomnia, reduces worry, rebalances the mind25. The points are applied bilaterally, except for the central point VG20, totaling 11 points for pain, anxiety, and stress, following the TCM criteria. Patients were reevaluated after six weeks and four months of treatment. Both groups were evaluated and treated by the same professional, dental surgeon and acupuncture specialist by the Insti- tuto Brasileiro de Técnicas Médicas (IBRATE) and volunteer of SERDOF-DTM (Serviço de Dor Orofacial e Disfunção Tem- poromandibular) at UFMS. After the reevaluations, the results were statistically analyzed. Figure 4. IG4 acupuncture point 350 Acupuncture in the treatment of temporomandibular muscle dysfunction BrJP. São Paulo, 2019 oct-dec;2(4):348-55

The research was approved by the Ethics Committee of the Fed- eral University of Mato Grosso do Sul (CEP/UFMS) CAAE number: 89598418.6.0000.0021.

Statistical analysis Data were tabulated in a Microsoft Excel 2010 spreadsheet (Mi- crosoft Corporation, Redmond/Washington/Estados Unidos) and analyzed by the Statistical Package for Social Science Version 18.0 (SPSS Inc., Chicago/Illinois/ Estados Unidos). Initially, descriptive statistics of the collected data were performed using measures of central tendency and dispersion. In order to verify the association of quantitative variables between G1 and G2, the t-test was used for normal distribution (mouth opening) for independent samples; and for comparison between the evaluation periods (baseline of treatment, after six weeks and 4 months, two by two), the t-test for paired samples Figure 5. E36 acupuncture point was used. For the non-normal distribution (VAS and tension threshold), the Mann-Whitney test was used in the two groups, and for the comparison between the evaluation periods (baseline of treatment, after six weeks and 4 months), the Friedman test was used at a significance level of 5%.

RESULTS

Table 1 shows the mean and standard deviation of mouth opening measurements at baseline, after 6 weeks and after 4 months of treatment in G1 and G2. G1 was treated with massage, thermotherapy, counseling, and occlusal splint, and G2 underwent acupuncture. There was no difference in mouth opening measures according to the type of treatment used. However, in both groups (acupuncture and occlusal splint), there was an increase in mouth opening measures after 6 weeks of treatment. There was no difference in mouth opening values after 6 weeks and at the end of treatment after 4 months (Table 1). Figure 6. F3 acupuncture point Table 2 shows the mean and standard deviation of the VAS scores at baseline, after six weeks of treatment, and at the end, after 4 The visual analog scale (VAS) and the pressure algometer were months of treatment, in both groups. used to evaluate the pain perception of the volunteers. There was no difference in the VAS scores according to the type The VAS assists in the measurement of pain intensity in the of treatment used. However, in both groups (acupuncture and patient to check his/her evolution during treatment and each occlusal splint), scores decreased after six weeks of treatment. service, in a practical way. To use the VAS, the researcher must There was no difference in the VAS scores after six weeks and at ask the volunteer what his/her degree of pain is, zero means the end of treatment after four months (Table 2). no pain, and 10 the maximum tolerable pain level. The study Table 3 shows the mean and standard deviation of the masseter patients were instructed to mark their pain grade on the day of and temporal muscle tension threshold scores at baseline, after each evaluation. six weeks, and at the end of treatment in G1 and G2. The pressure algometer is a device designed to quantify and There was no difference in tension threshold scores between G1 document sensitivity levels by measuring the pressure threshold (acupuncture) and G2 (occlusal splint), except for the left tem- and pain sensitivity, measuring tolerance, to check the temporal poral muscle (Tb), in which the value obtained in G1 (4.7±1.2) muscle pain threshold (anterior and middle bundles), and the was higher compared to G2 (3.8±1.6) at evaluation after six masseter (medium and inferior fibers). weeks of treatment. However, after four months, there was no The patients’ mouth opening limitation was evaluated using difference in values. the caliper before treatment, after 6 weeks of treatment and 4 In the evaluation of the studied period of G1 and G2 separately, months after treatment. It is a very accurate tool that measures there was an increase in tension threshold scores for the evaluat- the distance between two symmetrically opposite sides of an ob- ed muscles, masseter, and temporal, after six weeks of treatment. ject. In the case of the mouth opening, the reference was the However, the values were similar to those obtained after four distance between the upper and lower incisors. months (Table 3). 351 BrJP. São Paulo, 2019 oct-dec;2(4):348-55 Boscaine EF, Pontes ER, Castillo DB, Suliano LS and Oshiro Filho NT

Table 1. Mean and standard deviation of mouth opening measurements at baseline, after 6 weeks and after 4 months of treatment by type of intervention Values (mm) G1 (n=17) G2 (n=17) (1) p-value Mean SD Mean SD Painless mouth opening Baseline a 36.6 7.8 a 35.5 6.3 0.651 After 6 weeks b 42.2 6.5 b 44.1 5.7 0.377 After 4 months b 41.4 7.2 b 42.9 6.6 0.539 p(2) (3)0.007; (4)0.046; (5)0.623 (3)<0.001; (4)0.001; (5)0.408 Maximum mouth opening Baseline a45.9 8.0 a44.1 6.3 0.479 After 6 weeks b50.4 6.6 b51.2 5.3 0.692 After 4 months b49.8 6.6 b50.6 7.9 0.743 p(2) (3)0.016; (4)0.048; (5)0.704 (3)<0.001; (4)0.004; (5)0.639 (1)t-test for independent samples (acupuncture versus occlusal splint); (2) t-test for paired samples. Different letters indicate statistically significant difference. Equal letters indicate statistically not significant difference; (3) p-value of t-test for paired samples (baseline versus after 6 weeks of treatment); (4) p-value of t-test for paired samples (baseline versus after 4 months of treatment); (5) p-value of t-test for paired samples (6 weeks of treatment versus after 4 months of treatment).

Table 2. Mean and standard deviation of visual analog scale sco- Table 3. Mean and standard deviation of tension threshold scores at res at baseline and after 6 weeks of treatment by type of inter- baseline, after 6 weeks and after 4 months of treatment according to vention the type of intervention and muscle evaluated – continuation VAS scores G1 (n=17) G2 (n=17) (1)p-value VAS scores G1 G2 (1) (n=17) (n=17) p-value Mean SD Mean SD Mean SD Mean SD Baseline a 6.2 2.6 a 5.9 1.7 0.679 Left masseter muscle (Md) After 6 weeks b 2.6 2.0 b 1.9 1.5 0.459 Baseline a 1.5 0.7 a 1.8 0.9 0.389 After 4 months b 1.2 1.1 b 1.5 1.3 0.959 After 6 weeks b 3.0 0.9 b 3.0 1.3 0.459 (2) p <0.001 <0.001 After 4 months b 3.0 1.1 b 3.5 1.7 0.491 (1)Mann-Whitney test for independent samples (acupuncture versus oc- p(2) <0.001 <0.001 clusal splint); (2)Friedman test for paired samples (baseline versus after 6 weeks of treatment; baseline versus after 4 months of treatment; 6 weeks Right temporal muscle (Ta) of treatment versus after 4 months of treatment); different letters indicate Baseline a 3.1 1.0 a3.3 1.1 0.796 statistically significant difference; equal letters indicate statistically not significant difference. After 6 weeks b 5.7 1.4 b5.0 1.9 0.185 After 4 months a.b4.7 1.6 b5.7 2.1 0.203 Table 3. Mean and standard deviation of tension threshold scores at p(2) <0.001 <0.001 baseline, after 6 weeks and after 4 months of treatment according to the type of intervention and muscle evaluated Right temporal muscle (Tb) Baseline a 2.6 1.1 a 2.8 1.1 0.836 VAS scores G1 G2 (1) (n=17) (n=17) p-value After 6 weeks b 4.6 1.2 b 4.3 2.0 0.263 Mean SD Mean SD After 4 months b 3.9 1.6 b 4.6 1.8 0.163 Right masseter muscle (Mc) p(2) <0.001 0.001 Baseline a 1.8 0.9 a 2.0 1.3 0.904 Left temporal muscle (Ta) After 6 weeks b 3.2 0.8 b 3.1 1.3 0.630 Baseline a 2.8 1.1 a 3.0 1.2 0.679 After 4 months b 3.3 1.3 b 3.7 2.1 0.679 After 6 weeks b 5.1 1.2 b 4.5 1.7 0.073 p(2) <0.001 0.001 After 4 months b 4.9 2.0 b 5.1 1.7 0.547 Right masseter muscle (Md) p(2) <0.001 <0.001 Baseline a 1.8 1.1 a 2.0 0.9 0.286 Left temporal muscle (Tb) After 6 weeks b 3.3 1.7 a.b2.8 1.2 0.294 Baseline a 2.4 1.1 a 2.5 1.2 0.960 After 4 months b 3.0 1.0 b 3.5 1.9 0.438 After 6 weeks b 4.7 1.2 b 3.8 1.6 0.040 p(2) <0.001 0.007 After 4 months b 4.0 1.8 b 4.7 1.7 0.191 Left masseter muscle (Mc) p(2) <0.001 <0.001 (1) Baseline a 1.8 0.8 a 1.8 0.7 0.836 Mann Whitney test for independent samples (acupuncture versus occlusal splint). p-value in bold indicates statistically significant difference;(2) Friedman b b After 6 weeks 3.1 0.9 3.2 1.5 0.810 test for paired samples (baseline versus after 6 weeks of treatment; baseline After 4 months b 3.3 1.1 b 3.5 1.6 0.959 versus after 4 months of treatment; 6 weeks of treatment versus after 4 months of treatment); different letters indicate statistically significant difference (p value (2) p <0.001 <0.001 in bold); equal letters indicate statistically non-significant difference (p value wi- Continue... thout bold).

352 Acupuncture in the treatment of temporomandibular muscle dysfunction BrJP. São Paulo, 2019 oct-dec;2(4):348-55

DISCUSSION tients who received treatment with physical therapy alone did not reset their pain after treatment; but there was an average Pain caused by TMD is musculoskeletal pain that affects deep decrease of 92.5% in pain. In patients who received treat- tissue and, in chronic cases, generates a biopsychosocial pro- ment with the occlusal splint, there was a 92% improvement cess that interferes with patients’ normal daily activities26-28. in the first week, and reset pain until the end of treatment. Chronic pain should be diagnosed and treated correctly, as This showed that the occlusal splint is as efficient as physical TMD pain can significantly compromise the person’s quality therapy treatments15. of life29-31. Acupuncture works to reduce the sensation of pain, and this In a randomized clinical study, 40 patients diagnosed with therapy has been shown effective with conventional TMD muscle TMD by RDC/TMD were treated. The patients were treatment techniques35. In one study, 20 TMD patients were divided into two groups. One group received placebo treat- treated. One group underwent acupuncture associated with ment, and the other, acupuncture. Patients were evaluated by occlusal splint, and one group used only the occlusal splint. the VAS to measure pain before and after treatment. The fol- The acupuncture group was treated with five sessions of 50 lowing acupuncture points were selected: E6, E7, ID18 (local minutes each and occlusal splint for night use. The splint points); VB20, VG20, B10 and IG4 (distance points). Patients group was instructed to use the device only at night. The lim- were treated for four weeks, with sessions lasting 30 minutes itation of mandibular movements before and after treatment each. The patients were reevaluated after 30 days. There was was also evaluated. The degree of pain was verified by the a significant difference between the groups (p=0.2261), and VAS. After the first week of treatment, pain and mandibu- in the acupuncture group, pain decreased from 5.3 to 1.8 on lar movements improved in the acupuncture group. After mean, according to VAS, while in the placebo group, pain five weeks of treatment, the patients were reevaluated, and remained stable or increased9. there was a significant reduction in the TMD symptoms, but Twenty TMD patients were evaluated before treatment, im- there were no statistical differences between the two groups mediately after treatment and 12 months after acupuncture (p>0.05). However, in the acupuncture group, pain decreased treatment using the VAS. At the initial consultation, an an- faster13,15. Just like these results, the UFMS study showed very amnesis was performed according to the TCM standards, and similar results. the patient’s pain intensity was identified. At the end of treat- After a systematic literature review, it was observed that there ment of six sessions of 20 minutes each, the patients were is no standard protocol for acupuncture for the treatment of reevaluated and after 12 months as well. The means for VAS0, TMD, that the choice of acupoints varies according to the VAS1, and VAS2 were respectively 5.9; 1.65; 2.45. There was degree of patient involvement36. Excellent results were ob- a statistical difference between VAS0 and VAS1 of p<0.01 and tained using as local points the stomach channel, such as E8; between VAS2 (p<0.01), but there was no difference between E7, E6; triple heater channel points such as TA21, TA17 and VAS1 and VAS (p>0.05). The authors pointed out that the gallbladder channel points such as VB2. These points were acupuncture treatment reduced pain after six weeks of treat- used to control local pain. The most frequently applied dis- ment and remained for a mean of 12 months32,33. This study tance points for the control of anxiety, muscle relaxation, presented results similar to the one conducted at UFMS, stress reduction, and sleep improvement were the large in- as patients showed improvement in pain in the acupunc- testine meridian IG4, stomach E36, triple heater TA5, liv- ture group in the 6-week reevaluation and remained in the er F3, gallbladder VB34, and governing vessel VG20. Based 4-month evaluation. on the literature, Souza e Silva32 found evidence of the use A descriptive study of 31 TMD patients used the VAS before of small intestine ID18, stomach E6, E7, governing vessel and after treatment to evaluate pain intensity. The patients VG20, gallbladder VB20, bladder B10 points. Other points underwent three acupuncture sessions, 20 minutes each per may also be employed, such as bladder B60 and gallbladder week. They underwent anamnesis and diagnosis of the TCM, VB3. The authors also emphasize that acupuncture is an ex- and the selected points were heart channel C7, pericardial cellent treatment method complementary to other therapies, channel PC6, small intestine channel ID3, gallbladder chan- or as a technique of choice for patients with intolerance to nel VB20, and triple heater channel TA23. The pain ceased occlusal splints18. (VAS=0) in 67.7% of the cases. There was a reduction in pain In a case report of a 32-year-old female patient diagnosed intensity with VASi of the 1st session (6.10±2.64) than VASf with muscular TMD and evaluated by VAS for pain, an an- of the 3rd session (1.16±1.98). The authors concluded that a amnesis of the TCM showed the patient’s tongue, pulse, and minimum of 3 acupuncture sessions is sufficient to reduce skin color characteristics. pain intensity, regardless of its degree34. When evaluating 20 patients who underwent six 30-minute In a clinical trial, ten patients with TMD, diagnosed by acupuncture sessions, it was observed after six weeks that the RDC/TDM, and using the VAS were treated. Patients were pain threshold and muscle tension evaluated by electromyog- randomly divided into two groups, the first group consisting raphy was statistically better than at baseline and that these of five patients treated only with physical therapy (massage) improvements remained for 12 months. Similar results were for three weeks and the second, also consisting of five patients observed in this study, which presented lower VAS index in treated with occlusal splint alone. The study showed that pa- pain, decreased muscle tension, and improvement in mouth 353 BrJP. São Paulo, 2019 oct-dec;2(4):348-55 Boscaine EF, Pontes ER, Castillo DB, Suliano LS and Oshiro Filho NT opening at 6 weeks and 4 months after treatment in patients 4. Castillo DB, Azato FK, Coelho TK, Pereira PZ, Silva MG. Clinical study on head and jaw position of patients with muscle temporomandibular disorder. Rev Dor. undergoing acupuncture with the same number of sessions 2016;17(2):88-92. and treatment time32,37,38. 5. Maydana AV, Tesch RS, Denardin OV, Ursi WJ, Dworkin SF. Possible etiological factors in temporomandibular disorders of articular origin with implications for diag- This action of acupuncture was also found in a study that nosis and treatment. Dental Press J Orthod. 2010;15(3):78-86. observed 40 patients treated with acupuncture and after 4 6. Torres F, Campos LG, Fillipini HF, Weigert KL, Vecchia GF. Efeitos dos tratamentos sessions presented decreased pain and lower muscle tension, fisioterapêutico e odontológico em pacientes com disfunção temporomandibular. Fi- sioter Mov. 2012;25(1):117-25. which was also observed in this study, in which patients were 7. Grillo CM, Canales Gde L, Wada RS, Alves MC, Barbosa CM, Berzin F, et al. Could evaluated at 6 weeks and 4 months. It was found that both acupuncture be useful in the treatment of temporomandibular dysfunction? J Acu- punct Meridian Stud. 2015;8(4):192-9. acupuncture and occlusal splint associated with massage and 8. Okeson JP. Tratamento das desordens temporomandibulares e oclusão. 7ª ed. Rio de thermotherapy provided muscle relaxation, improved jaw Janeiro: Elsevier; 2013. 101-29p. 9. Zotelli VL, Grillo CM, Gil ML, Wada RS, Sato JE, da Luz Rosário de Souza M. movements at mouth opening and decreased pain level of Acupuncture effect on pain, mouthopening limitation and on the energy meridians in 21 patients . These results were similar to the study as patients patients with temporomandibular dysfunction: a randomized controlled trial. J Acu- presented improvement in mouth opening, reduced pain and punct Meridian Stud. 2017;10(5):351-9. 10. Silva HB, Soares JL. Análise da abordagem fisioterapêutica no tratamento da disfun- muscle tension in both acupuncture and splint groups. ção temporomandibular: revisão integrativa. REAS/EJCH. 2019;19:1-7. In a randomized clinical study of 40 TMD patients diagnosed 11. Menezes MS, Bussadori SK, Fernandes KP, Biasotto-Gonzalez DA. Correlação entre cefaleia e disfunção temporomandibular. Fisioter Pesqui. 2008;15(2):183-7. by RDC/TMD, pain was evaluated by the VAS, and the chew- 12. Franco AL, Zamperini CA, Salata DC, Silva EC, Albino Júnior W, Camparis CM. ing muscles were evaluated by electromyography before and Fisioterapia no tratamento da dor orofacial de pacientes com disfunção temporomandibular crônica. Rev CubanaEstomatol. 2011;48(1):56-61. after treatment. The patients were randomly divided into two 13. Furlan RM, Giolvanardi RS, Britto AT, Britto DB. O emprego do calor superficial groups. The first was treated with acupuncture, underwent para tratamento das disfunções temporomandibulares: uma revisão integrativa.Co- anamnesis and diagnosis according to the TCM. The patients DAS. 2015a;27(2):207-12. 14. Furlan RM. O uso da crioterapia no tratamento da disfunção temporomandibular. Ver were treated with four acupuncture sessions lasting 20 min- Cefac. 2015b;17(2):648-55. utes each. The selected points were: large intestine meridian 15. Ferreira FM, Simamoto-Júnior PC, Soares CJ, Ramos AM, Fernandes-Neto. Effect of occlusal splints on the stress distribution on the temporomandibular joint disc. Braz IG4 and IG11, small intestine meridian ID19, liver meridian Dent J. 2017;28(3):324-9. F2, bladder meridian B2, conception vessel meridian VC23, 16. Florian MR, Meirelles MP, Souza ML. Disfunção temporomandibular e acupuntura: triple heater meridian TA23, gallbladder meridian VB21, uma terapia integrativa e complementar. Odontol Clín Cient. 2011;10(2);189-92. 17. Bontempo GG, Melo PB, Pizzol KE, Franco-Micheloni AL. Ear acupuncture asso- and VB34. The splint group was treated with a myorelaxant ciated to home self-care in the treatment of chronic temporomandibular disorders in splint, counseling, and self-care guidance. The splints were women. Case report. Rev Dor. 2016;17(3):236-40. 18. Boscaine EF, Suliano LS, Pontes ER, Castillo DB, Moraes JL, Nascimento VA. Effects conventionally made of acrylic and installed and adjusted by of acupuncture in the treatment of temporomandibular dysfunctions.Int J Develop a single professional. Patients were instructed to use the splint Res. 2018;8(3):19294-7. 19. Brahim CB, Araújo JO, Queiroz DA, Dessaune Neto N, Tinelli D, Cury SE. Eficácia at night and to return within four weeks. The patients were da técnica de agulhamento seco no controle da síndrome da dor miofascial: uma revi- reevaluated after 30 days of treatment. The electromyography são crítica da literatura. Cadernos UniFOA, Volta Redonda. 2017(34):105-24. of the masticatory muscles was lower in 40% in the acupunc- 20. Borin GS, Corrêa EC, Silva AM, Milanesi JM. Surface electromyography of masticatory muscles in individuals with temporomandibular disorder submitted to acupuncture group and 50% in the splint group. Pain decreased in ture. Rev Soc Bras Fonoaudiol. 2012;17(1):1-8. both groups, but there were no statistical differences between 21. Pereira MS, Silva BO, Santos FR. Acupuntura: terapia alternativa, integrativa e complementar na odontologia. R CROMG. 2015;19(1):19-26. the two. However, in the acupuncture group, pain reduction 22. Shueb SS, Nixdorf DR, John MT, Alonso MT, Durham J. “What is the impact of was faster, and the absence of pain lasted longer. Half of the acute and chronic orofacial pain on quality of life”? J Dent. 2015;43(10):1203-10. 23. Costa A, Bavaresco CS, Grossmann E. The use of acupuncture versus dry nee- patients in the acupuncture group had improved mandibular dling in the treatment of myofascial temporomandibular dysfunction. Rev Dor. limitations. The authors concluded that acupuncture was as 2017;18(4):342-9. efficient as occlusal splint21. 24. Luiz AB, Babinski MA, Ferreira AS. Neurobiologia da analgesia induzida por acupuntura. Manual e eletroacupuntura: revisão de literatura. J Naturol Compl Ther. 2012;1(1):71-84. CONCLUSION 25. Maciocia G. Os Fundamentos da Medicina Chinesa. 2ª ed. São Paulo: Roca;2014. 3-14p. 26. Porporatti AL, Costa YM, Stuginski-Barbosa J, Bonjardim LR, Conti PC. Acupunc- ture therapeutic protocols for the management of temporomandibular disorders. Rev Based on the results of this study, it was concluded that both Dor. 2015;16(1):53-9. 27. Ahmed NA, Poate T, Nacher-Garcia C, Pugh N, Cowgill H, Page L, et al. Temporoman- acupuncture and occlusal splint associated with massage and dibular joint multidisciplinar team clinic. Br J Oral Maxillofac Surg.2014;52(9):827-30. thermotherapy were effective in treating patients with muscle 28. Boleta-Ceranto DC, Alves T, Alende FL. O efeito da acupuntura no controle da dor TMD for six weeks and remained for a period after four months na odontologia. Arq Ciênc Saúde Unipar, Umuarama (PR). 2008;12(2):143-8. 29. Catão MH, Oliveira PS, Costa RO, Carneiro VS. Evaluation of the efficacy of low-le- of treatment. vel laser therapy (LLLT) in the treatment of temporomandibular disorders: a randomized clinical trial. Ver Cefac. 2013;15(6):1601-8. REFERENCES 30. Wang B. Princípio de Medicina Interna do Imperador Amarelo. São Paulo: Ícone; 2013. 21-34p 31. Menezes MS, Bussadori SK, Fernandes KP, Biasotto-Gonzalez DA. Correlação entre 1. Abouelhuda AM, Khalifa AK, Kim YK, Hegazy SA. Non-invasive different modalities cefaleia e disfunção temporomandibular. Fisioter Pesqui. 2008;15(2):183-7. of treatment for temporomandibular disorders: review of literature. J Korean Assoc 32. Souza LM, Silva IC. A utilização da acupuntura no tratamento da disfunção da articu- Oral Maxillofac Surg. 2018;44(2):43-51. lação temporomandibular: sugestão para protocolo clínico. Acta de Ciências e Saúde. 2. Fonseca Alonso B, Nixdorf DR, Shueb SS, John MT, Law AS, Durham J. Examining 2016;5(2):112-28. the sensitivity and specificity of 2 screening instruments: odontogenic or temporo- 33. Souza ML, Mashuda CS, Sato JE, Siqueira JT. Effect of acupuncture in adults with mandibular disorder pain? J Endod. 2017;43(1):36-45. temporomandibular disorders. Rev Dor. 2014;15(2):87-90. 3. Garbelotti TO, Turci AM, Serigato JMA, Pizzol KE, Franco-Micheloni AL. Effective- 34. Camargo BA, Grillo CM, Souza ML. Temporomandibular disorder pain impro- ness of acupuncture for temporomandibular disorders and associated symptoms. Rev vement with acupuncture: preliminary longitudinal descriptive study. Rev Dor. Dor. 2016;17(3):223-7. 2014;15(3):159-62. 354 Acupuncture in the treatment of temporomandibular muscle dysfunction BrJP. São Paulo, 2019 oct-dec;2(4):348-55

35. Ferreira LA, Grossmann E, Januzzi E, Gonçalves RT, Mares FA, de Paula MV, et al. 37. Vicente-Barrero M, Yu-Lu SL, Zhang B, Bocanegra-Pérez S, Durán-Moreno D, Ló- Ear acupuncture therapy for masticatory myofascial and temporomandibular pain: a pez-Márquez A, et al. The efficacy of acupuncture and decompression splints in the controlled clinical trial. Evid Based Complement Alternat Med. 2015;2015;342507. treatment of temporomandibular joint pain-dysfunction syndrome. Med Oral Patol 36. Zotelli VL, Meirelles MP, Souza ML. Uso da acupuntura no manejo da dor em pacien- Oral Cir Bucal. 2012;17(6):e1028-33. tes com alterações na articulação temporomandibular (ATM). Rev Odontol Univ São 38. Vera RMT, Grillo CM, Fortinguerra ML, Souza ML, Berzin F. Acupuncture to mana- Paulo. 2010;22(2):185-8. ge orofacial pain and tinnitus. Case report. Rev Dor. 2013:14(3):226-30.

355 BrJP. São Paulo, 2019 oct-dec;2(4):356-61 REVIEW ARTICLE

Auriculotherapy: neurophysiology, points to choose, indications and results on musculoskeletal pain conditions: a systematic review of reviews Auriculoterapia: neurofisiologia, pontos de escolha, indicações e resultados em condições dolorosas musculoesqueléticas: revisão sistemática de revisões

Dérrick Patrick Artioli1, Alana Ludemila de Freitas Tavares2, Gladson Ricardo Flor Bertolini2

DOI 10.5935/2595-0118.20190065

ABSTRACT an immense possibility of painful musculoskeletal conditions, with favorable and promising results. BACKGROUND AND OBJECTIVES: Auriculotherapy is Keywords: Auriculotherapy, Modalities of physiotherapy, Pain, widely used to relieve painful conditions, therefore, allowing sys- Physiotherapy, Rehabilitation, Traditional Chinese Medicine. tematic reviews on the subject. However, they did not propose a unified bank of points of possible choice, their possible combi- RESUMO nations or described the location of such points, thus making it the objective of this study. JUSTIFICATIVA E OBJETIVOS: A auriculoterapia é ampla- CONTENTS: The systematic review of revisions methodology mente utilizada para o alívio de condições dolorosas, portanto, (Overview) was chosen to achieve the proposed goal. The qual- com número considerável de estudos, permitindo a realização de ity of such material was ascertained by the tool Assessment of revisões sistemáticas no assunto. No entanto, não propuseram Multiple Systematic Reviews, and the databases consulted were um banco unificado de pontos de possível escolha, suas possíveis PEDro database, Pubmed, Scielo, and LILACS. The keywords combinações ou descreveram a localização de tais pontos, tor- and boolean index applied were: auriculotherapy AND pain; ear nando-se então, o objetivo deste estudo. acupuncture AND pain, ear acupressure AND pain; auricular CONTEÚDO: Optou-se por uma revisão sistemática de revi- therapy and pain; auricular medicine AND pain. A total of 242 sões (Overview). A qualidade de tal material foi realizada por in- studies were found, but only six were systematic reviews in hu- termédio da ferramenta Assessment of Multiple Systematic Reviews mans involving pain and auriculotherapy alone (without asso- e as bases de dados consultadas foram: PEDro, Pubmed, Scielo ciation with another technique). The methodological quality of e LILACS. As palavras-chaves e índice booleano aplicados como the studies was high (8-10/11 Assessment of Multiple Systematic a seguir: Auriculotherapy AND pain; ear acupuncture AND pain, Reviews). There is variability in the neurophysiological explana- ear acupressure AND pain; auricular therapy AND pain; auricular tion of action, many possible disorders that can be approached medicine AND pain. Foram encontrados primariamente 242 es- with auriculotherapy (acute, chronic, trauma, pre- and postop- tudos, mas apenas seis eram revisões sistemáticas em humanos, erative pain among others). Auriculotherapy showed to be prom- envolvendo dor e apenas auriculoterapia (sem associação a outra ising in the remission of the pain, adjunct to the conventional técnica). A qualidade metodológica dos estudos foi alta (8-10/11 treatment, low risk, cost, and easy administration. - Assessment of Multiple Systematic Reviews). Há variabilidade CONCLUSION: There are several ways of justifying its neuro- na explicação neurofisiológica de ação, muitas possibilidades de physiological effects, and the most used points were ShenMen, afecções que podem ser abordadas com auriculoterapia (dores the corresponding somatotopic region and the cavum conchae agudas, crônicas, por traumas, pré e pós-operatórias entre ou- region (vagal stimulation). Auriculotherapy meets the needs of tras). A auriculoterapia apresentou-se como promissora na re- missão da dor, meio adjunto ao tratamento convencional, baixo risco, custo e de fácil administração. CONCLUSÃO: A auriculoterapia apresenta diversas formas de Dérrick Patrick Artioli - https://orcid.org/0000-0003-3259-1725; justificar seus efeitos neurofisiológicos e os pontos mais utiliza- Alana Ludemila de Freitas Tavares - https://orcid.org/0000-0002-8687-1231; Gladson Ricardo Flor Bertolini - https://orcid.org/0000-0003-0565-2019. dos foram ShenMen, a região somatotópica correspondente e a região da concha cava (estimulação vagal). Atende uma imensa 1. Centro Universitário Lusíadas, Santos, SP, Brasil 2. Universidade Estadual do Oeste do Paraná, Cascavel, PR, Brasil. possibilidade de condições dolorosas musculoesqueléticas, com resultados favoráveis e promissores. Submitted on February 25, 2019. Descritores: Auriculoterapia, Dor, Fisioterapia, Medicina Tradi- Accepted for publication on May 20, 2019. Conflict of interests: none – Sponsoring sources: none. cional Chinesa, Modalidades da fisioterapia, Reabilitação.

Correspondence to: Rua Universitária, 2069 – Jardim Universitário INTRODUCTION 85819-110 Cascavel, PR, Brasil. E-mail: [email protected] Since 1978, the World Health Organization (WHO) recom- © Sociedade Brasileira para o Estudo da Dor mends the insertion of complementary and alternative medicine 356 Auriculotherapy: neurophysiology, points to choose, indications and BrJP. São Paulo, 2019 oct-dec;2(4):356-61 results on musculoskeletal pain conditions: a systematic review of reviews

(CAM) or integrative and complementary practices (ICP) in pub- sis of its relationship with pain modulation should be understood. lic health systems (e.g., Unified Health System, SUS). In Brazil, Neurophysiologically, stimuli at the nerve endings of the pinna are ICPs increased following the approval by the Ministry of Health transmitted via the spinal and cranial nerves (peripheral nervous (MS) in 2006 to include non-pharmacological and more natural system, PNS) to the central nervous system (CNS), releasing neu- therapies, such as Tai Chi, Qigong (Lian Gong), Yoga, Mat Pilates, rotransmitters that regulate the control mechanisms of endoge- workplace exercises, therapeutic exercises, manipulative resources, nous pain. When activated, the descending neural pathway releas- acupuncture, and meditation1. In 2017 there was an increase in es endogenous opioids (endorphins) in the posterior horn of spinal ICPs used, and auriculotherapy (AT) was included. Since AT can cord (PHSC), making it difficult for the CNS to spread and per- be applied at several levels of health care, such as basic, specialized, ceive the pain stimulus (pain descending inhibitory pathways, ex- and hospital, the proposal is to prevent health problems, to pro- tra segmental or supraspinatus mechanism). Another mechanism mote recovery, health, and the non-abandonment of the conven- of nociceptive modulation is the so-called Gate Control Theory tional medicine treatment2-5. Given the effectiveness and low cost (segmental or spinal mechanism), which transmits non-painful of AT, the Federal University of Santa Catarina, in partnership stimuli via myelinated afferent fibers (Aβ), as opposed to harmful with the MS, promoted throughout Brazil the “Training in Auric- stimuli from poorly myelinated (Aδ) or unmyelinated (C) fibers ulotherapy for Primary Care Health Professionals,” enabling and balancing painful sensation in PHSC15,16. Both routes are the most promoting the integration of this resource to ICP6. attributed to AT, aiming to justify their effects in pain conditions. AT, ear acupuncture and ear acupressure are synonymous with Inflammation control would be linked to points in the anatomical centuries-old therapy via stimulation of the pinna to relieve region of the cavum conchae (e.g., lung 1 and 2), which stimu- pathological conditions in the body. AT has two main lines of lates the vagus nerve by releasing acetylcholine, a neurotransmitter reasoning that explain its principles, the French school (Paul that inhibits the release of tumor necrosis factor-alpha (TNF-α, Nogier) and the Chinese school (Traditional Chinese Medicine proinflammatory cytokine) by macrophages, thereby minimizing - TCM)7. In 1957, in France, AT was driven by the cartography inflammation (cholinergic reflex)17-19. proposed by Paul Nogier, scheming an inverted fetus in the ear as AT points can be stimulated in a variety of ways such as seeds a somatotopic map representing reflex parts of body stimulation. (mustard or rapeseed), acupuncture needles (facial or systemic), Theorizing that symptoms and diseases are projected in specific magnetic pellets, semi-permanent needles, electrophototherapy regions in the ear, as it is one of the few anatomical structures (laser or transcutaneous electrical nerve stimulation (TENS) and formed by endoderm, mesoderm, and ectoderm (three embry- the fingers themselves. However, the seeds are low cost and have onic layers), which may hypothetically represent all parts of the the advantage that patients self-stimulate the points and thus body8. This triggered the study of its neurophysiological basis of have been the most used7,10. The seeds should be stimulated three action and its recognition by WHO in 1987, which identifies to four times a day, for a minute or until the site becomes sensi- it as an acupuncture microsystem capable of intervening in the tive, with weekly changes upon reassessment of the case. How- body as a whole. The standardization of an international nomen- ever, there are reports of staying with the same application for clature took place in 1990, with updates of such information up to one month, and the total treatment time ranges from 2-10 occurring to the present day, merging the two principles (French weeks7,10,14. A systematic review with meta-analysis concluded and Chinese)9-11. In addition to Paul Nogier’s view, for more than that AT might be effective in relieving acute and chronic pain, 2000 years, AT has been dated in Asian culture and explained by reducing its intensity within the first 48 hours of treatment ini- the regulation of “vital energy” (Qi), which circulates through tiation, and being a safe resource11. Another study describes pain the meridians and collateral channels. When there is an imbal- remission time ranging immediately up to 6 months10. Although ance of a person’s Qi, he/she becomes vulnerable to disease, and there are systematic reviews7,8,10,11,14 addressing AT and pain, they AT would be able to harmonize such flow by minimizing symp- did not propose a unified database of possible site choice, their toms (TCM concept)7,9,10. AT treatment may be isolated or in possible combinations, or describe the location of such sites, thus combination with another intervention (e.g., kinesiotherapy), becoming the goal of this study. In addition to mentioning the temporary, aiming at discharge, or referral to exercise groups1. main sites indicated for painful cases, the aim was to identify Pain, in its various forms of manifestation, is a common cause their locations, facilitating the clinical practice. of medical consultations and other health professionals (e.g., physiotherapists), and chronic pain is prevalent in the Brazilian CONTENTS population equal to or greater than worldwide (10.1-55.5%), representing one of the biggest challenges for public health12,13. It In order to achieve the proposed objective, a systematic review impacts the functionality, quality of life, productivity, generates of reviews that addressed AT and pain was chosen (Overview). economic damage (personal, family, business and government), PEDro, Pubmed, Scielo and LILACS databases were accessed in as well as the indiscriminate use of drugs and thus their possible February 2019. The keywords and Boolean indexes were used adverse effects. Therefore, complementary therapies are part of as follows: Auriculotherapy AND pain; ear acupuncture AND the list of pain control options, as they have lower risk, lower pain, ear acupressure AND pain; auricular therapy AND pain; cost, and are less invasive than the usual approach10,11,14. auricular medicine AND pain. These words should be present The concepts described serve as a starting point for AT studies. in the title or abstract for the articles to be selected. If in doubt, However, by focusing on the care of painful conditions, the analy- the studies were fully verified. Filters were applied seeking only 357 BrJP. São Paulo, 2019 oct-dec;2(4):356-61 Artioli DP, Tavares AL and Bertolini GR systematic reviews that were in humans, without restriction on the date of publication. Two evaluators made the selection and assessment by the Assessment of Multiple Systematic Reviews (AMSTAR)8 tool, discussing the score in case of divergence. Al- Helix though revisions on the theme are not an unpublished subject, the report of the points or which were the most used are not S.F. always described, making clinical practice and methodological reproduction difficult8,11. Therefore, books were also consulted to provide the best description of the use of points, as well as their location. Table 1 shows the results of the selection in the databases, and table 2 shows the studies with the application of Upper branchT. F. the AMSTAR tool in order of the highest score. Figure 1 shows the subdivision of the pinna necessary to under- Scapha stand and facilitate the interpretation of the description of the Lower branch sites in table 3. It is noteworthy that there are normal anatomical variations from person to person, so at first, the identification U.C. of the structures, as well as the search for specific sites, require Root practical training9. Antihelix Antihelix Table 3 shows the main points for the relief of painful conditions according to the unification of several studies, and figure 2 shows L.C. Tragus where they are anatomically6,10,14,22-25.

This does not mean that all should be applied in a single session Antitragus but rather selected according to the combinations already described and added to the painful area to be treated (Figure 3). Helix For example, ShenMen, Kidney, Sympathetic (auriculocybernet- I.N. ics) + lumbar (affected region - AR). However, a systematic re-

Table 1. Search and selection of studies in the databases Databases Found Repeated Deleted Final Lobule PEDro 20 2 13 5 Pubmed 112 11 100 1 Scielo 33 0 33 0 LILACS 77 0 77 0 Figure 1. Anatomical division of the pinna Total 242 13 223 6 SF = scaphoid fossa; TF = triangular fossa; UC = upper conchae or cymba; LC = lower conchae or cavum; IN = intertragical notch.

Table 2. Characteristics of systematic reviews and selected meta-analyzes Authors Objectives Most used AT points Results (p) Mean differen- AMSTAR ces in pain Yang et al.7 Effect of ear acupressure on ShenMen, subcortex, AR (lumbosacral, p<0.001 - 1.13 11/11 chronic low back pain spine, lumbar, sciatic nerve, hip, popli- teal fossa), liver, kidney, sympathetic, bladder, spleen, Ashi points Zhao et al.20 Assess the effectiveness of AT ShenMen, sympathetic, subcortex, thala- p<0.05 - 3.76 10/11 in chronic pain mus, liver, kidney, heart, bladder, spleen, lung, analgesia, AR and Ashi points. Yeh et al.10 AT effectiveness in pain mana- ShenMen, subcortex, lung, thalamus, p<0.05 1.59 10/11 gement compared to the pla- sympathetic, liver, kidney, analgesia, cebo group endocrine and AR. Asher et al.14 AT in pain management ShenMen, thalamus, lung, heart, zero p<0.05 1.56 10/11 point and AR. Murakami, Fox and Immediate pain relief (48h) ShenMen, thalamus, lung and AR. p<0.05 - 1.08 9/11 Dijkers11 Usichenko, Lehmann Assess the effectiveness of AT Not described Not Not described 8/11 and Ernst21 in postoperative pain control described AR = affected region, somatotopic correspondence of reflexively compromised body area; AT = auriculotherapy; Ashi point = most uncomfortable site; AMSTAR = Assessment of Multiple Systematic Reviews.

358 Auriculotherapy: neurophysiology, points to choose, indications and BrJP. São Paulo, 2019 oct-dec;2(4):356-61 results on musculoskeletal pain conditions: a systematic review of reviews

Apex

ShenMen Sympathetic

Kidney Bladder

Analgesia Zero-point

MR Liver L1 H Spleen L2 Adrenal

Thalamus Endocrine

Subcortex

External point Internal point

Figure 2. Location of the main analgesic points Figure 3. Somatotopic map of the reflex region affected and to be MR = muscle relaxation; L1 = lung 1; H = heart; L2 = lung 2. chosen to treat

Table 3. Main points to be combined with analgesic purposes Points Location Action ShenMen Apex of the angle formed by the upper and lower Anxiety, mental disorders, emotional stabilization, pain conditions and branch of the anthelix anti-inflammatory activity Sympathetic At the intersection of the lower branch of the an- Pain in general, nausea, vomiting, hyperhidrosis of the hands and feet. thelix and the helix, in the inner region Vegetative stabilization of the viscera Kidney In a fossa located below the beginning of the infe- Urogenital tract disorders, joint problems, menstrual complaints, ame- rior branch of the triangular fossa, in the superior norrhea, premenstrual tension, migraine and for the treatment of chemi- region of the cymba conchae cal dependence. General and chronic bone diseases Liver In the lower region of the cymba conchae, above Contributes to disorders of muscles and tendons in cases of pain, stiff- the beginning of the helix root, near the anthelix ness and injuries Spleen Located at the top of the cavum conchae, near the Treatment of painful and weak muscles anthelix and lower than the helix root Bladder Below the lower branch of the anthelix Urogenital tract disorders: infection, dysuria, polyuria, incontinence, ure- thral stone and acute nephritis. Idiopathic edema Analgesic or Vertically between kidney point and helix root Analgesia analgesia Ear apex At the apex of the ear, on the helix Hypertension, allergies, analgesia and emotional harmonization Zero-point In the ascending branch of the helix or root Spasmolytic, analgesic and relaxing action Muscle relaxa- Medially to the spleen point towards the root of Muscle relaxant, muscle tension or spasm and insomnia tion the helix Continue...

359 BrJP. São Paulo, 2019 oct-dec;2(4):356-61 Artioli DP, Tavares AL and Bertolini GR

Table 3. Main points to be combined with analgesic purposes – continuation Points Location Action Lung 1 and 2 In the conchae cavity surrounding the heart zone Respiratory tract and skin disorders such as colds, laryngitis, cough, asthma, bronchitis, dermatitis, urticaria and acne (vagus nerve stimulation) Heart Cavum conchae cavity center Hypertension, anxiety, depression, insomnia, palpitations, tachycardia and dyspnea, angina and bradycardia (vagus nerve stimulation) Adrenal In the prominence of the tragus Articular disorders, circulatory, inflammatory processes, rheumatism, ar- throsis, bursitis, allergic processes. Stimulates adrenocortical hormones and adrenaline Subcortex Lower region of the inner part of antitragus Pain, anxiety and depression Thalamus Above the subcortex point in the inner face and Low back pain and neck pain apex of the antitragus Endocrine At the inner base of the intertragical notch. Endocrine disorders, hypo, and hyperthyroidism, diabetes, gynecologi- cal and rheumatoid disorders. view demonstrated the possibility of choosing 15 different points systemic acupuncture. Contradicting another systematic review, only for the treatment of low back pain, with ShenMen and sub- which shows that AT was not superior to the placebo group and cortex being the most frequent7. This demonstrates considerable that its effects begin to diminish three months after the end of variability among the studies analyzed, as it is suggested to select its application, they nevertheless described it as promising and about 4-6 treatment points26. Therefore, it is impracticable to capable of reducing pain20. Jiang et al.18 found a positive and propose associations for each painful case in this format; a book lasting effect of AT on pain and that adverse effects are insuffi- would be needed to address this objective since more than 200 cient for patients to abandon treatment. In order to resolve these AT points were identified8. In any case, some previously used doubts, studies such as Moura et al.27, with 110 participants, combinations serve as the basis, such as the described auricu- treatment group, placebo, and control, should be encouraged, as locybernetics itself or the following combinations: ShenMen, they allow reliable conclusions to be based. thalamus, lung + affected region, somatotopic correspondence of The justification for the effects of AT seems to be linked not only reflexively compromised body area (AR)14; ShenMen + AR (10); to the penetration of the needle into the pinna but to the choice thalamus, analgesic + AR)23; ShenMen, subcortex + AR7. of ideal sites14. This is an extensive discussion, but four possible There have been many reported conditions where AT can help to explanations are elucidated: (1) AT acts by a mechanism other relieve the pain. Some of these indications are as follows: 1) can- than systemic acupuncture; (2) action similar to acupuncture, cer-associated pain, knee arthroscopy, femur fracture, hip arthro- which would activate meridians, regularization of organ func- plasty14; in dysmenorrhea, postoperative pain, hip fracture, low back tion, Qi and Blood, with consequent normalization of painful pain, bone marrow aspiration, acute and chronic pain10; 2) spinal pathways (TCM); (3) hypersensitive reflex neuronal pathways pain, lumbar sciatic pain, cramps, stiff neck, fibromyalgia, rheumat- that connect the auricular microsystem to the corresponding so- ic pain, phantom pain, amputation stump pain, herpes zoster, pain matotopic region in the brain, which through the spinal cord after fractures in general, trigeminal neuralgia, toothache, headache, reaches the corresponding painful area; (4) AT does not depend migraine and tension headache23; 3) chronic low back pain, mus- on specific points, but rather on the stimulated region7,10,14,20. cle spasm, whiplash injuries, traumatic pain, inflammation after The fourth explanation comes from the stimuli in the cavum joint sprains, osteoarthrosis, pelvic and abdominal pain, shoulder conchae region, innervated by the vagus nerve, to be able to in- impingement syndrome, adhesive capsulitis, bursitis, lateral epicon- duce parasympathetic stimulation. Therefore, analgesia would be dylitis , carpal tunnel syndrome and joint pain22. caused by the application site and not by the selection of points. Usichenko, Lehmann and Ernst21 did not state which AT points That is, AT can function via the central pain control mecha- were applied in the clinical trials analyzed and their results in nism. However, if the analgesia provided is by specific points or statistical terms, which hinders the interpretation and reproduc- stimulated region, it remains under discussion14. What is known ibility of new research. This study was conducted over a decade is that auricular stimulation is a scientifically validated method, ago, and others with the same methodological design came later, even by functional non-invasive magnetic resonance imaging of being more careful. Murakami, Fox and Dijkers11 highlighted brain neuromodulation17. The possibility of acting by central de- the fact that AT has results as good as their comparative groups, scending pain inhibitory mechanism was reinforced by the fact has temporary adverse effects and is less degrading than med- that the effects of AT are blocked by the use of the opioid antag- ications (pain in the site, which can make it difficult to sleep, onist naloxone. AT would still be able to increase pain tolerance. skin irritation, slight bleeding, dizziness, and nausea) and the Therefore, there is variability in the explanation that indicates application is quick and accessible. However, they expected a the action of AT in pain, but it shows the interest of the scientific more significant reduction in pain. Asher et al.14 came to a more community in this microsystem, making it the most studied7. positive conclusion than previous authors, stating superior pain Yeh et al.10 also reported significant pain relief with AT com- minimization results when AT was compared with a control pared to the control or placebo group, noting that the quality group or placebo compared to the same comparison made with of the studies was moderate to high. One of the difficulties with 360 Auriculotherapy: neurophysiology, points to choose, indications and BrJP. São Paulo, 2019 oct-dec;2(4):356-61 results on musculoskeletal pain conditions: a systematic review of reviews

AT effectiveness reported by these authors would be the limited 2012;36(3):442-51. 5. Clarke TC, Black LI, Stussman BJ, Barnes PM, Nahin RL. Trends in the use of com- number of placebo group studies, only 32% of studies involv- plementary health approaches among adults: United States, 2002-2012. Natl Health ing AT and pain. The patient expectation about the treatment, Stat Report. 2015;10(79):1-16. 6. UFSC UF de SC - Formação em auriculoterapia. In: Formação em auriculoterapia the relationship with the therapist, and the placebo effect itself para profissionais de saúde da atenção básica. 2018. may affect the results obtained with AT, but they are present 7. Yang LH, Duan PB, Hou QM, Du SZ, Sun JF, Mei SJ, et al. Efficacy of auricular acupressure for chronic low back pain: a systematic review and meta-analysis of rando- in any other treatment modality. The ShenMen point and the mized controlled trials. Evid Based Complement Alternat Med. 2017;2017:6383649. reflex points corresponding to the affected region are the most 8. Vieira A, Reis AM, Matos LC, Machado J, Moreira A. Does auriculotherapy have commonly used in practice, according to the authors mentioned, therapeutic effectiveness? An overview of systematic reviews. Complement Ther Clin Pract. 2018;33:61-70. information that corroborates the findings in table 2. 9. Alimi D, Chelly JE. New universal nomenclature in auriculotherapy. J Altern Com- In short, the need for blind, randomized, sample-based clinical plement Med. 2018;24(1):7-14. 10. Yeh CH, Chiang YC, Hoffman SL, Liang Z, Klem ML, Tam WW, et al. Efficacy of trials to define the number of participants should be encouraged auricular therapy for pain management: a systematic review and meta-analysis. Evid when investigating the effectiveness of any treatment method, as Based Complement Alternat Med. 2014;2014:934670. 11. Murakami M, Fox L, Dijkers MP. Ear acupuncture for immediate pain relief- well as the review of reviews. The possibility of using this study de- -a systematic review and meta-analysis of randomized controlled trials. Pain Med. sign, review of reviews, on a specific theme (AT and pain), demon- 2017;18(3):551-64. 12. Carvalho RC, Maglioni CB, Machado GB, Araújo JE, Silva JR, Silva ML. Prevalence strates the interest of the scientific community in the topic. So far, and characteristics of chronic pain in Brazil: a national internet-based survey study. the conclusions are cautious, but the systematic reviews that have BrJP. 2018;1(4):331-8. been included have shown high methodological quality (8-10/11 13. Vasconcelos FH, Araújo GC. Prevalence of chronic pain in Brazil: a descriptive study. BrJP. 2018;1(2):176-9. - AMSTAR) and agree on the following aspects: AT is an adjunct 14. Asher GN, Jonas DE, Coeytaux RR, Reilly AC, Loh YL, Motsinger-Reif AA, et al. technique to be used to manage pain; to reduce the use of analgesic Auriculotherapy for pain management: a systematic review and meta-analysis of randomized controlled trials. J Altern Complement Med. 2010;16(10):1097-108. drugs, minimizing tolerance and adverse effects. It is a treatment 15. Damien J, Colloca L, Bellei-Rodriguez CÉ, Marchand S. Pain modulation: from con- with low risk, low cost, and easy administration7,10,11,14,20,21. ditioned pain modulation to placebo and nocebo effects in experimental and clinical pain. Int Rev Neurobiol. 2018;139:255-96. 16. Quah-Smith I, Litscher G, Rong P, Oleson T, Stanton G, Pock A, et al. Report from CONCLUSION the 9th International Symposium on Auriculotherapy Held in Singapore, 10-12 Au- gust 2017. Medicines. 2017;4(3):46. pii: E46. 17. Mercante B, Deriu F, Rangon CM. Auricular neuromodulation: the emerging concept AT has favorable results regarding its effects on pain (although beyond the stimulation of vagus and trigeminal nerves. Medicines. 2018;5(1). pii E10. its mechanisms of action continue to be studied), showing to be 18. Jiang Y, Cao Z, Ma H, Wang G, Wang X, Wang Z, et al. Auricular vagus nerve stimulation exerts antiinflammatory effects and immune regulatory function in a 6-OHDA promising as adjunctive therapy to conventional treatment. The model of Parkinson’s disease. Neurochem Res. 2018;43(11):2155-64. ShenMen point, reflex points corresponding to the site in the 19. Mercante B, Ginatempo F, Manca A, Melis F, Enrico P, Deriu F. Anatomo-physiologic basis for auricular stimulation. Med Acupunct. 2018;30(3):141-50. affected body, and cavum conchae stimulation (e.g., lung point), 20. Zhao HJ, Tan JY, Wang T, Jin L. Auricular therapy for chronic pain management in seems to be the most favorable combination for better pain relief adults: a synthesis of evidence. Complement Ther Clin Pract. 2015;21(2):68-78. 21. Usichenko TI, Lehmann Ch, Ernst E. Auriculoterapia para el control del dolor post- results. operatorio: una revisión sistemática de ensayos clínicos aleatorizados. Rev Int Acu- punt. 2009;3(3):130-2. REFERENCES 22. Oleson T. Auriculotherapy Manual: Chinese and Western Systems of Ear Acupunc- ture. 4th ed. Churchill Livingstone; 2013. 23. Kajsa L. British Library Cataloguing in Publication Data. 1st ed. Churchill Living- 1. Tesser CD, Sousa IM, Nascimento MC. Práticas integrativas e complementares na stone; 2008. atenção primária à saúde brasileira. Saúde Debate. 2018;42(n. spe1):174-88. 24. Souza MP. Tratado de auriculoterapia. Look; 2000. 3p. 2. Jackson C. Trends in the use of complementary health approaches among adults in the 25. Garcia EG. Auriculoterapia. ROCA; 1999. 50p. United States: new data. Holist Nurs Pract. 2015;29(3):178-9. 26. Levy CE, Casler N, Fitzgerald DB. Battlefield acupuncture: an emerging method for 3. Organization WH. WHO Traditional Medicine Strategy. Alternative and Integrative easing pain. Am J Phys Med Rehabil. 2018;97(3):e18-9. Medicine. 2013. 1-78p. 27. Moura CC, Iunes DH, Ruginsk SG, Souza VHS, Assis BB, Chaves ECL. Action of ear 4. Schveitzer MC, Esper MV, Silva MJ. Práticas integrativas e complementares na acupuncture in people with chronic pain in the spinal column: a randomized clinical atenção primária em saúde: em busca da humanização do cuidado. Mundo Saúde. trial. Rev Lat Am Enfermagem. 2018;26:e3050. English, Portuguese, Spanish.

361 BrJP. São Paulo, 2019 oct-dec;2(4):362-7 REVIEW ARTICLE

Methods of diagnosis and treatment of complex regional pain syndrome: an integrative literature review Métodos de diagnóstico e tratamento da síndrome da dor regional complexa: uma revisão integrativa da literatura

Sheila Bortagaray1, Thais Fadel Gonçalves Meulman2, Henrique Rossoni Junior3, Tiago Perinetto4

DOI 10.5935/2595-0118.20190066

ABSTRACT RESUMO

BACKGROUND AND OBJECTIVES: The complex regional JUSTIFICATIVA E OBJETIVOS: A síndrome da dor regional pain syndrome is characterized by severe pain that affects one complexa é caracterizada por dor intensa que acomete uma ex- extremity of the body, in addition to edema, increased sensitivity tremidade do corpo, além de edema, aumento da sensibilidade to cold and touch, sweating, discoloration and decreased ability ao frio e ao toque, sudorese, alteração de coloração e diminui- to move. This study aimed to identify and analyze the methods ção da capacidade de movimento. O objetivo deste estudo foi of diagnosis and treatment of complex regional pain syndrome. identificar e analisar os métodos de diagnóstico e tratamento da CONTENTS: This is an integrative review of literature con- síndrome da dor regional complexa. ducted in April 2018, which used the electronic database and CONTEÚDO: Trata-se de uma revisão integrativa de litera- an academic search engine to select the studies. We sought to tura realizada no mês de abril de 2018, que utilizou bases de complement the survey with manual search of the citations of dados eletrônicas e um buscador acadêmico para a seleção dos the primary studies identified. As a search strategy, the authors estudos. Buscou-se complementar o levantamento com bus- used the descriptors: “complex regional pain syndrome”, “pain”, ca manual nas citações dos estudos primários identificados. “chronic pain”, “diagnosis” and “treatment” in Portuguese and Como estratégia de busca dos artigos, utilizou os descritores: English. A total of 416 references were identified, 11 of which “síndrome da dor regional complexa», «dor”, “dor crônica”, were selected for the present study. Most articles were published “diagnóstico” e “tratamento” nos idiomas português e inglês. in 2016, in English. In general, the articles present the patho- Foram identificadas 416 referências, sendo 11 artigos sele- physiology, methods of diagnosis and treatment of complex re- cionados para o presente estudo. A maioria dos artigos foi gional pain syndrome, and it is possible to identify and analyze publicado no ano de 2016 e em inglês. De modo geral, os ar- the consonance and divergence found in the scientific literature. tigos apresentam a fisiopatologia, os métodos de diagnóstico CONCLUSION: The basis for the diagnosis of regional com- e de tratamento da síndrome da dor regional complexa, sendo plex pain syndrome remains clinical, and there is no “gold stan- possível identificar e analisar a consonância e a divergência dard” to conduct the diagnosis as there are no accurate imaging encontrada na literatura científica. indicators or serum markers. The psychological evaluation and CONCLUSÃO: A base do diagnóstico da síndrome da dor re- the treatment of the disorders, when present, can ensure a better gional complexa permaneceu clínica e não se tem um “padrão patient’s compliance with the treatment instituted. ouro” para conduzir o diagnóstico, pois não há indicadores de Keywords: Chronic pain, Complex regional pain syndrome, Di- imagem ou marcadores séricos precisos. A avaliação psicológica agnosis, Pain, Therapeutics. e o tratamento de seus distúrbios, quando presentes, garantem melhor adesão do paciente ao tratamento instituído. Descritores: Diagnóstico, Dor, Dor crônica, Síndrome da dor Sheila Bortagaray - https://orcid.org/0000-0001-9621-3358; regional complexa, Terapêutica. Thais Fadel Gonçalves Meulman - https://orcid.org/0000-0001-8121-6994; Henrique Rossoni Junior - https://orcid.org/0000-0001-8032-554X; Tiago Perinetto - https://orcid.org/0000-0003-4314-1551. INTRODUCTION

1. Universidade de Caxias do Sul, Caxias do Sul, RS, Brasil. 2. Faculdade Ingá, Araras, SP, Brasil. Complex regional pain syndrome (CRPS), as it is currently 3. Universidade Federal de Santa Maria, Santa Maria, RS, Brasil. 4. Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil. called, is an entity that causes great distress, not only for the patient due to the disabling pain but also for health profes- Submitted on December 27, 2018. sionals. They are limited in their approach since the patho- Accepted for publication on May 24, 2019. Conflict of interests: none – Sponsoring sources: none. physiology of CRPS is not fully understood, and it is difficult to obtain positive treatment results1. Correspondence to: Rod. PR 317, 6114 - Parque Industrial 200 Until the last century, CRPS was also called causalgia. In 87035-510 Maringá, PR, Brasil. 1877, causalgia was first described as a chronic painful enti- E-mail: [email protected] ty with no neurological cause, accompanied by hitherto un- © Sociedade Brasileira para o Estudo da Dor named vasomotor changes2. Many terminologies have been 362 Methods of diagnosis and treatment of complex regional BrJP. São Paulo, 2019 oct-dec;2(4):362-7 pain syndrome: an integrative literature review used to designate it, such as minor causalgia, posttraumat- CONTENTS ic vasomotor disorder, Sudeck atrophy, and shoulder-hand syndrome. Then, it was suggested that all painful diseases This is an integrative review study of the scientific literature de- associated with vasomotor phenomena, usually preceded by veloped according to the proposition of two American authors9. trauma, should be called “reflex sympathetic dystrophy”, in Therefore, this research was conducted in order to obtain an- which the following characteristics should be present: pain, swers to the following question: How does the scientific litera- vasomotor changes of the skin, loss of function of the limb ture conceptualize and approach the diagnosis methods and type and trophic changes in various stages3. of treatment of CRPS in the national and international scenario? However, the controversy over the diagnosis continued to Quantitative or qualitative studies and clinical cases or case re- raise doubts. In 1993, the International Association for the ports that analyzed or proposed a theory and/or methodology Study of Pain developed a consensus defining the criteria for for the diagnosis and treatment of CRPS were included. Primary the diagnosis of this disease4. The term “complex regional studies using an integrative literature review as a methodology pain syndrome” or “CRPS” was used to designate the painful to support the diagnosis and treatment of CRPS were exclud- regional condition associated with sensory changes resulting ed; however, these studies were used to support the results. No from a noxious event. After a trauma, pain is the main symp- limits were set on the date of publication or the language of the tom and may be associated with abnormal skin coloration, primary studies. changes in limb temperature, abnormal sudomotor activity, The search strategy used electronic databases such as LILACS, or edema1. Science Direct, SCOPUS, Web of Sciences, Pubmed, which in- By consensus, two types of CRPS were defined: type I, for- cludes Medline, Scientific Electronic Library Online (Scielo) merly called “reflex sympathetic dystrophy”, follows disease digital library, and the academic search engine (Google Scholar). or injury that did not directly affect the nerves in the affect- Thus, in addition to databases of indexed scientific publications, ed limb; and type II, previously called “causalgia”. Type II gray literature was explored, which prints unpublished literature CRPS differs from type I in that there is a real nerve injury, as technical documents. It was sought to complement the survey where the pain is not limited to the injured nerve inner- with a manual search in the citations of the identified primary vation territory. Approximately 90% of people with CRPS studies. It was chosen to use the advanced form with the follow- suffer from type I5. ing keywords in their English or Portuguese versions to verify Patients with CRPS develop severe pain associated with ede- the title, abstract or subject, depending on the database: “com- ma, vasomotor instability, joint stiffness, skin lesions, and plex regional pain syndrome”. “pain”, “chronic pain”, “diagnosis” acute bone atrophy. They often add to the picture of allodynia and “treatment”. The Boolean operators adopted in the strategies and hyperalgesia, changes in blood flow and regional sweat- were “and” and “or”. The search was conducted in April 2018. ing; dyscrasia phenomena; changes in the active movement After identification, the primary studies were selected according to pattern of the affected segments, including the accentuation the guiding question and the previously defined inclusion criteria. of physiological tremor; trophic changes of the integument, All studies identified through the search strategy were initially as- musculature and subcutaneous cellular tissue and functional sessed by analyzing the titles and abstracts. In cases where the titles disability of the affected segment6. and abstracts were not sufficient to define the initial selection, the This condition, most often described following acute full publication was read. Therefore, items that did not correspond trauma, surgery, or immobilization of a limb, particular- to scientific research or were duplicated in the different groups of ly after evident peripheral nerve injury (causalgia), is also keywords searched and in the different databases, as well as theses, recognized in association with clinical conditions such as dissertations, and monographs, were removed from the sample. diabetic neuropathy, multiple sclerosis, stroke and acute Figure 1 shows the flowchart of article selection. myocardial infarction (sympathetic reflex dystrophy) and is After exhaustive reading of the selected material and critical anal- a major cause of disability. Its association with repetitive ysis of the data, the captured information was made available strain injuries (RSI) and work-related musculoskeletal dis- in a structured framework to understand and discuss the results orders (WRMSD) is more recent and still little explored7. according to the diagnosis and treatment proposed in the scien- It is noteworthy that CRPS may migrate to another part of tific literature. the body, such as the opposite foot or arm, and emotional During the search in the electronic databases, portal, digital li- stress often aggravates this pain. In some people, the signs braries, and the academic searcher, 416 references were identi- and symptoms of CRPS disappear, while in others, they may fied. Six references were identified by hand searching the cita- continue for months to years4. tions of primary studies. After the initial exclusion of duplicate However, the diagnosis and treatment of CRPS are complex, references, monographs, dissertations, theses, titles and abstracts and probably, for this reason, there are not many studies on that did not apply to the theme, 92 articles were analyzed for these conditions, showing a gap in the scientific literature7,8. eligibility. However, 81 were excluded after reading and register- Considering the importance of knowing the diagnostic meth- ing the full article because it did not address the diagnosis and ods and treatment types of this clinical condition, this study treatment of CRPS, or because it was a literature review. aimed to identify and analyze the diagnosis and treatment So, 11 articles were selected for this study. As gray literature, methods of CRPS. it used the guidelines proposed by the Brazilian Society for 363 BrJP. São Paulo, 2019 oct-dec;2(4):362-7 Bortagaray S, Meulman TF, Rossoni Junior H and Perinetto T

maining articles published from 2015 on are all international, References identified References identified in published in English or Spanish. The predominant language by manual search from databases searched (n=416) of the articles was English, with seven references (63.6%). other sources (n=6) According to the type of study, it was observed that almost half of the articles are case reports (5-45.5%) and two (18.2%) are Duplicate references removed (n=47) case series. Four (36.3%) quantitative studies with descriptive design, case-control, retrospective, and prospective cohort studies were found. Selected references References excluded by In general, the articles present the pathophysiology of the dis- (n=375) title and abstract (n=283) ease, the diagnostic methods, and the treatment methods of CRPS. The main results and conclusions of the articles select- Full articles reviewed Full articles reviewed ed for the study are discussed below, in two thematic catego- for eligibility (n=92) from analysis (n=81) ries, emphasizing the divergences and consonances found in the scientific literature: 1) diagnosis of complex regional pain Articles included in syndrome; and 2) treatment of CRPS. synthesis (n=11) DIAGNOSIS OF COMPLEX REGIONAL PAIN SYNDROME Figure 1. Flowchart of article selection for integrative literature review. Maringá-PR, April 2018 In this study, it was observed in all articles selected for the study, Source: Research Data, 2018. and in other literature reviews1,5 used to support the discussion, that pain is the dominant symptom of CRPS, and trauma is the the Study of Pain10. For better visualization of the results, main etiology of the syndrome. Trauma involves sprains, frac- table 1 was elaborated. tures, dislocations, lacerations, bruises, and strains, as well as Regarding the analysis in the year of publication, it was noted prolonged immobilization, tight cast, and surgical trauma8,15. that the studies were published as of 2004, and most of them Fractures are the most common incitement events for CRPS, (7-63.6%) were published in 2016. The three oldest articles affecting the upper limbs twice as often as the lower limbs. published in the years 2004, 2005, and 2011 are in the Por- This disease has been classified in different ways. Currently, it tuguese language and published in Brazilian journals. The reis divided into three stages: acute, which occurs in the first days

Table 1. Selected studies. Maringá-PR, April 2018

Authors Objectives Types of studies Lauretti, Veloso Report two cases of CRPS in which the application of botulinum toxin A as an adjuvant drug con- Case report and Mattos6 tributed to the functional motor recovery of the affected limb. Azambuja et al.7 Clinically identify and characterize, in a series of RSI and WRMSD cases, patients with FMS and Case series CRPS. Artioli et al.8 Describe the results obtained with the physical therapy treatment alone in one patient. Case report Vas and Pai11 Describe the observational results of ultrasound data of muscles and limbs affected with neuro- Case report pathic pain in 7 patients and to compare with affected muscles with type 1 CRPS in 7 patients. Bullen, Lang Prospectively determine the incidence of CRPS after foot and ankle fractures. Prospective indepen- and Tran12 dent cohort study Salazar13 Assess the effectiveness of sympathetic stellate ganglion block in the treatment of upper extremity Descriptive study type I CRPS. Hayashi et al.14 Report the case of a young woman with type I CRPS who underwent rehabilitation facilitated by Case report continuous epidural block. Christophe et Describe a comprehensive and quantitative case report showing that: (1) not all patients with chro- Case report al.15 nic CRPS exhibit decreased spatial attention to the affected side, and (2) patients may actually have a substantial, broad, and reliable tendency toward attention on the painful side, similar to spatial neglect on the healthy side. Alkosha and Determine predictive factors of long-term sympathectomy outcome in patients with type II upper Retrospective cohort Elkiran16 limb CRPS. Albayrak et al.17 Present 2 cases that suffered from type I CRPS after stroke and were successfully treated with the Case series application of pulsed radiofrequency to the dorsal root ganglia. Kim, Cho and Investigate the effects of frequent long-term ketamine treatment on cognitive function in patients Case-control Lee18 with CRPS. RSI = repetitive strain injury; WRMSD = work-related musculoskeletal disorders; FMS = fibromyalgia syndrome; CRPS = complex regional pain syndrome. Source: Research Data, 2018.

364 Methods of diagnosis and treatment of complex regional BrJP. São Paulo, 2019 oct-dec;2(4):362-7 pain syndrome: an integrative literature review after injury up to three months; dystrophic, three to six months lishing the diagnosis, as there are no precise image indicators after its onset; atrophic, from six months to approximately one or serum markers8, which is one of the most important ele- year from the causal event8. Prevention and early diagnosis are ments to consider. The clinical classification is based on a bet- believed to be important to slow the development of the dis- ter understanding of the pathophysiology of this entity, which ease12. However, signs and symptoms are ignored, causing delays dependent factors coexist, such as changes of the peripheral in the final diagnosis and early initiation of treatment. and central nervous systems, the endocrine system, and psy- Bullen, Lang e Tran12 presented the diagnostic criteria codified chological, environmental, and situational factors13. However, by the International Association for the Study of Pain10, which the expertise of an expert must be of excellence to make the were updated in Budapest in 2007 and have since been statisti- correct diagnosis. But the criterion of higher weight is given cally validated in CRPS populations. For these authors10,12, the by the absence of another diagnosis that better explains the clinical diagnosis should be based on the following criteria: symptoms and signs. 1. Continuous pains that are disproportionate to any instigating In a literature review1, the authors found that, although the diag- event; nosis of CRPS is clinical, other tests may be requested to confirm 2. Reporting at least one symptom in three of the following four or exclude it. A simple radiological test can identify decreased categories: bone calcification, although this change is not specific for CRPS, 2.1 Sensory: reports of hyperesthesia and/or allodynia; as bone demineralization may be caused by limb disuse. Electro- 2.2 Vasomotor: reports of temperature asymmetry and/or chang- neuromyography indicates nerve injury in cases of type II CRPS, es in skin color and/or skin color asymmetry; but it is not useful in the evolutionary control of the disease. 2.3 Sudomotor/edema: reports of edema and/or sweating and or Other laboratory imaging tests may be performed: thermogra- sweating asymmetry; phy determines the temperature difference between the affected 2.4. Motor/trophic: reports of decreased range of motion and/or and normal limbs, and plethysmography highlights the differ- motor dysfunction (weakness, tremor, dystonia) and/or trophic ences in perfusion between the limbs. Therapeutic tests are useful changes (hair, nail, skin). to aid in diagnosis by response to a particular substance1. 3. Must display at least one sign at the time of assessment in two For Vas and Pai11, muscle ultrasonography (MUS) is an import- or more of the following categories: ant research modality used to identify structural lesions of the 3.1 Sensory: evidence of hyperalgesia (sting) and or allodynia myofascial system. The authors conducted case studies where (feeling of light touch and/or temperature and/or deep somatic MUS in patients with type I CRPS showed loss of muscle ar- pressure and/or joint movement); chitecture and volume in the forearm muscles, particularly in 3.2 Vasomotor: evidence of temperature asymmetry (>1°C) and/ the hand extensors. The striking feature of the findings was in- or changes in skin color and/or asymmetry; tramuscular proliferation of fibrous tapes, giving an appearance 3.3 Sudomotor/edema: evidence of changes in edema and/or of hyperechogenicity compared to the normal limb, indicating sweating and/or sweating asymmetry; loss of myoarchitecture. These changes were seen in muscles that 3.4 Motor/trophic: evidence of decreased range of motion and/ caused difficulty in initiating and sustaining movement (usually or motor dysfunction (weakness, tremor, dystonia) and/or tro- flexor digitorum profundus and superficialis of the fingers, but phic changes (hair, nail, skin). also in other flexor muscles, such as the flexor carpi radialis, the 4. There is no other diagnosis that better explains the signs and palmaris longus, and the pronator teres). Muscle edema was vi- symptoms. sualized in a patient with muscle atrophy. However, the marked According to the authors12,19, the criteria updated in Budapest loss of myocardial architecture in CRPS could explain the sever- have been shown to improve the specificity and sensitivity of ity of motor symptoms in this condition. CRPS diagnosis and are the only standardized, internationally Furthermore, it has been found in the literature that several drugs recognized, and validated criteria for CRPS diagnosis. are used to diagnose CRPS, such as guanethidine, phentolamine, Azambuja et al.7 agree with the other authors and emphasize that and lidocaine, by various techniques such as simple venous infu- the diagnosis is eminently clinical, and its primary manifestation sions and regional blocks. These tests are used to prove whether is regional pain. There are currently no “objective” examinations the sympathetic nervous system is involved in pain genesis and with sufficient sensitivity and specificity to be routinely used, thus CRPS signs and symptoms, thus helping to make the diagnosis proposing the following criteria for positive diagnosis of CRPS7: as well as guiding appropriate and effective therapy1. 1. Excruciating diffuse regional pain; It is noteworthy that no examination was considered a “gold 2. At least two of the following signs and symptoms: standard” for diagnosis, although several clinical, radiographic, 2.1 Difference in skin color relative to the other limb; and electrodiagnostic tests have been described. However, from 2.2 Edema; the analysis of these articles, the basis of the diagnosis of this 2.3 Temperature difference in the skin relative to the other limb; syndrome remains clinical. Early identification and treatment are 2.4 Limitation on active range of motion. essential in preventing the progression of CRPS and appear more 3. Additionally: occurrence or exacerbation of the signs/symp- effective when instituted early in the disease. Broader prospective toms described. studies using validated criteria are needed to guide the clinical Despite these criteria, the diagnosis of CRPS presents several management of CRPS and would contribute to consensus on a controversies. It should be remembered the difficulties in estab- gold standard for CRPS diagnosis. 365 BrJP. São Paulo, 2019 oct-dec;2(4):362-7 Bortagaray S, Meulman TF, Rossoni Junior H and Perinetto T

TREATMENT OF COMPLEX REGIONAL PAIN SYN- Ketamine DROME CRPS often does not respond to traditional pharmaceutical treatment and is, therefore, a challenge for healthcare pro- Because it is a complex disease, difficult to diagnose, with fessionals. Ketamine, a non-barbiturate anesthetic drug, has numerous therapeutic proposals and their varied responses, recently been introduced as a new therapeutic intervention there is no standard protocol for the treatment of CRPS. In for pain relief, demonstrating marked reduction in pain and many cases, it is necessary to make associations of techniques improved cognitive function after short-term treatment in pa- for a good result. In this sense, it is believed that patient fol- tients with CRPS. The advantages of using ketamine include a low-up should be multidisciplinary and multiprofessional rapid onset of action, brief cardiorespiratory depressant effects, due to the various components involved in the disease. Thus, and a benign effect on muscle tone and protective airway re- psychological assessment and treatment of its disorders, when flexes. However, given the characteristics of CRPS involving present, ensure better adherence to the treatment instituted. chronic pain, prolonged use may be detrimental. Authors18 In general, the studied literature indicates that the initial have shown that repetitive ketamine use provides analgesic ef- treatment is based on analgesia and intensive and careful fects on CRPS, but its frequent or repetitive use for extended physical therapy to avoid pain exacerbation. In the second periods may impair the cognitive function. This impairment line of treatment is the use of centrally acting analgesics, re- may occur because ketamine is a non-competitive antagonist of gional anesthesia, sympathetic block, desensitization of pe- the glutamate N-methyl-D-aspartate receptor, and its repeated ripheral nerves, among others. Pharmacological therapies are use has been associated with reduced function of the prefrontal varied. In addition, tricyclic antidepressants, gabapentin, opi- dopaminergic system, which plays an essential role in cogni- oids, and topical capsaicin are associated. In refractory cases, tive function. Given these factors, frequent long-term ketamine surgery may be used, but its use is very restricted20. The main treatment may impair cognitive function in CRPS patients by CRPS treatment methods identified in this study will be de- altering dopaminergic function in the prefrontal cortex. tailed below: Epidural anesthesia Stellate ganglion block It is used to promote rehabilitation in CRPS patients who can- The stellate ganglion is a group of nerves in the neck region. A not support physical programs due to severe pain. Authors14 descriptive study13 with 229 patients with type I CRPS in the reported the case of a 15-year-old girl diagnosed with type I upper limbs performed stellate ganglion block according to CRPS who underwent a rehabilitation program facilitating the Nolte-modified Herget technique21. For this, it used 1% epidural block with 0.15% ropivacaine. His rehabilitation lidocaine for the skin papule and 0.25% bupivacaine twice program included physical therapy and cognitive behavioral a week. Once the treatment was performed, the patients re- therapy. The intensity of the exercise was gradually increased mained at least 1h in the post-anesthetic recovery room. All without exacerbation of its symptoms. Finally, she recovered patients were trained to perform physical therapy at home. completely after continuous epidural block for 21 days and At the end of treatment, high efficacy in symptom relief was rehabilitation for 80 days. However, the authors concluded found, although 17.9% of patients returned without finding that there was a combination of continuous epidural block definitive relief for their disease. In this sense, the author13 and intensive rehabilitation and that this association im- proposes that a 50% decrease in pain through stellate gan- proved the patient’s symptoms. glion block should be considered as a satisfactory treatment. Physiotherapy treatment Botulinum toxin A Physiotherapy, previously used in later phases, has its space The reports in the literature on the use of botulinum tox- and importance increased today14. Authors8 state that when in as an adjunct in functional rehabilitation are initial but physiotherapy is mentioned, it is associated with another encouraging. Lauretti, Veloso and Mattos6 used botulinum form of treatment. Therefore, they analyzed the results ob- toxin in two patients with type I CRPS simultaneously during tained with the only physiotherapy in a patient with type I the third stellate ganglion block. A total of 75 IU of bot- CRPS in the acute stage. The patient underwent eight weeks ulinum toxin was equitably administered by muscle to the of treatment, with approximately 40 minutes each session, to- flexor muscles of the affected phalanges and wrist joint of taling 13 physiotherapy sessions, with her reassessment in the each patient. One week after botulinum toxin A application, last session. To assess the effects of physiotherapy on CRPS, it patients presented phalanx and wrist relaxation, reported ease was requested not to give any other form of pharmacological of performing passive physical therapy, and pain was rated 2 treatment or any other kind, just follow-up on CRPS I con- according to the visual analog scale (VAS) for pain in passive ditions. Of the analyzed items, those that showed significant manipulation. After eight months of assessment, the patients improvement were: (1) staining of the skin, (2) decreased ede- presented 70 and 80% of motor and functional recovery of ma; (3) improved neuromuscular control. Despite being the the affected limb. The patients remained under passive physi- rehabilitation of only one individual, the results obtained in cal therapy for the entire period initially, and later active and this study suggest that physiotherapy alone can contribute to were able to integrate again in their routine work. the improvement of this syndrome. 366 Methods of diagnosis and treatment of complex regional BrJP. São Paulo, 2019 oct-dec;2(4):362-7 pain syndrome: an integrative literature review

Sympathectomy cation and treatment are essential in preventing the progression One of the most effective and popular treatment modalities of CRPS and appear to be more effective when initiated early. for type II CRPS is sympathectomy16. However, two types of pain associated with type II CRPS should be considered before REFERENCES sympathectomy: sympathetically maintained and independent 1. Cordon FC, Lemonica L. [Complex regional pain syndrome: epidemiology, patho- pain, depending on whether or not the pain responds to the physiology, clinical manifestations, diagnostic tests and therapeutic proposals]. Rev preoperative stellate ganglion block. Although sympathectomy Bras Anestesiol. 2002;52(5):618-27. Portuguese. is regarded as the treatment of choice for patients with the first 2. Wolff J. Ueber einen Fall von Ellenbogensgelenks-Reaktion. Arch Chir. 1877;20:771. 3. Bonica JJ. The Management of Pain. Philadelphia: Lea & Febiger; 1953. 17 type of pain, it is considered ineffective in the latter. In a study 4. Merskey H, Bogduk N. Classification of Chronic Pain. Seattle: IASP Press; 1994. developed with 53 patients, mean age 47±7 years old and 60% 5. Gaspar AT, Antunes F. [Type I complex regional pain syndrome]. Acta Med Port. 19 2010;24(6):1031-40. Portuguese. women, included according to the Budapest criteria , sympa- 6. Lauretti GR, Veloso Fdos S, Mattos AL. [Functional rehabilitation and analgesia with thectomy proved to be an effective surgical instrument in this botulinum toxin A in upper limb complex regional pain syndrome type I: case reports]. Rev Bras Anestesiol. 2005;55(2):207-11. Portuguese. specific patient population. 7. Azambuja MI, Tschiedel PS, Kolinger MD, Oliveira PA, Mendes JM, Bassanesi SL. Síndrome miofascial e síndrome de dor regional complexa em pacientes com LER/ Pulsed radiofrequency DORT atendidos em ambulatório de saúde do trabalhador do SUS – identificação e caracterização clínica dos casos. Rev Bras Med Trab. 2004;2(4):176-84. It is a therapeutic modality that has been used for years for dis- 8. Artioli DP, Gualberto HD, Freitas DG, Bertolini GR. Tratamento fisioterapêutico eases associated with neuropathic pain. Recently, the application na síndrome complexa de dor regional tipo I. Relato de caso. Rev Bras Clin Med. 2011;9(1):83-6. of pulsed radiofrequency to the dorsal root ganglia has been used 9. Whittemore R, Knafl K. The integrative review: updated methodology. J Adv Nurs. effectively to produce long-term pain relief for neuropathic pain 2005;52(5):546-53. 17 10. Sociedade Brasileira para o Estudo da Dor. Síndrome de Dor Complexa Regional, modalities. One study presented two cases of patients who suf- 2018 [internet]. Disponível em: http://www.sbed.org.br/lermais_materias.php?cd_ fered from type I CRPS after stroke and were successfully treated materias=519. Acesso: 14 jun 2018. 11. Vas P, Pai R. Musculoskeletal ultrasonography to distinguish muscle changes in com- with the application of pulsed radiofrequency current to the cer- plex regional pain syndrome type 1 from those of neuropathic pain: an observational vical ganglia. Both cases suggest that pulsed radiofrequency is an study. Pain Pract. 2016;16(1):E1-E13. 12. Bullen M, Lang C, Tran P. Incidence of complex regional pain syndrome I following option that should be considered for the treatment of therapy-re- foot and ankle fractures using the Budapest criteria. Pain Med. 2016;17(12):2353-9. sistant type I CRPS patients. Moreover, pulsed radiofrequency 13. Salazar CR. Bloqueo del ganglio estrellado para el tratamiento del síndrome doloroso is a safer alternative treatment due to its slightly less invasive regional complejo tipo I en miembros superiores. Rev Cubana Anestesiol Reanim. 2016;15(2):145-54. nature, and the injury produced by the limited and controllable 14. Hayashi K, Nishiwaki K, Kako M, Suzuki K, Hattori K, Sato K, et al. Combination pulsed radiofrequency current. of continuous epidural block and rehabilitation in a case of complex regional pain syndrome. J Nippon Med Sch. 2016;83(6):262-7. 15. Christophe L Delporte L, Revol P, DePaepe A, Rode G, Jacquin-Courtois S, et al. Com- CONCLUSION plex regional pain syndrome associated with hyper attention rather than neglect for the healthy side: a comprehensive case study. Ann Phys Rehabil Med. 2016;59(5-6):294-301. 16. Alkosha HM, Elkiran YM. Predictors of long-term outcome of thoracic sympathec- There was an agreement in the scientific literature regarding the tomy in patients with complex regional pain syndrome type 2. World Neurosurg. diagnosis and the variety of CRPS treatment methods. It has 2016;92:74-82. 17. Albayrak I, Apiliogullari S, Onal O, Gungor C, Saltali A, Levendoglu F. Pulsed ra- been found that the basis of the diagnosis of this syndrome re- diofrequency applied to the dorsal root ganglia for treatment of post-stroke complex mains clinical and there is no “gold standard” to drive the diag- regional pain syndrome: a case series. J Clin Anesth. 2016:33:192-7. 18. Kim M, Cho S, Lee JH. The effects of long-term ketamine treatment on cogniti- nosis as there are no precise image indicators or serum markers. ve function in complex regional pain syndrome: a preliminary study. Pain Med. It is currently believed that patient follow-up should be multidis- 2016;17(8):1447-51. 19. Harden RN, Bruehl S, Stanton-Hicks M, Wilson PR. Proposed new diagnostic crite- ciplinary and multiprofessional due to the various components ria for complex regional pain syndrome. Pain Med. 2007;8(4):326-31. involved in the disease. Therefore, psychological assessment and 20. Álvares JF, Paz NM, Viçoso TM, Abrantes WL. Síndrome dolorosa regional complexa: atualização. Rev Med. 2009;19(3Suppl3):S111-5. treatment of their disorders, when present, ensure better adher- 21. Freire E, Camba MA. Técnicas e indicaciones del bloqueo del ganglio estrellado para ence to the treatment instituted. However, early clinical identifi- el tratamiento del dolor. Rev Soc Esp Dolor. 2002;9(5):328-37.

367 BrJP. São Paulo, 2019 oct-dec;2(4):368-73 REVIEW ARTICLE

Atypical odontalgia: pathophysiology, diagnosis and management Odontalgia atípica: fisiopatologia, diagnóstico e tratamento

André Hayato Saguchi1, Ângela Toshie Araki Yamamoto2, Cristiane de Almeida Baldini Cardoso2, Adriana de Oliveira Lira Ortega2

DOI 10.5935/2595-0118.20190067

ABSTRACT RESUMO

BACKGROUND AND OBJECTIVES: Atypical odontalgia, a JUSTIFICATIVA E OBJETIVOS: A odontalgia atípica, um subti- subtype of persistent idiopathic facial pain, is characterized by po da dor facial idiopática persistente, se caracteriza por dor contínua continuous pain in one tooth or more, or inside the alveolus after em um ou mais dentes, ou no alvéolo, após exodontia sem qualquer exodontia, with no apparent clinical causes. These patients run causa aparente e é um desafio para o dentista. O desconhecimento the risk of going through unnecessary dental/surgical procedures por parte do profissional pode levar a procedimentos odontológicos which would worsen their pain. Since the pathophysiology, di- desnecessários e mutiladores, piorando e/ou cronificando a dor do pa- agnosis, and management of atypical odontalgia are not clear, ciente. Diante desse panorama, o objetivo deste estudo foi apresentar this article aims to present an integrative literature review about informações referentes à fisiopatologia, diagnóstico e tratamento da these aspects. odontalgia atípica através de uma revisão integrativa da literatura. CONTENTS: A review of articles related to the topic was con- CONTEÚDO: A busca na base de dados Pubmed foi realizada ducted on the Pubmed database using the keywords “atypical com os termos: “atypical odontalgia” OR “phantom tooth pain” odontalgia” OR “phantom tooth pain” OR “idiopathic tooth OR “idiopathic tooth pain” OR “odontalgia” OR “odontalgias” pain” OR “odontalgia” OR “odontalgias” OR “atypical tooth- OR “atypical toothache”. Aplicando-se critérios de inclusão ache”. Applying the inclusion criteria (publications in the last (publicações nos últimos 10 anos, de língua inglesa, tipo ensaio ten years, in English, as clinical trials, multicenter studies, case clínico, estudo multicêntrico, relato de caso, revisão, revisão in- reports, reviews, integrative and systematic reviews, 114 articles tegrativa científica e sistemática) foram encontrados 114 artigos, were found, and 39 were selected after the application of the dos quais 39 foram selecionados após aplicação do critério de exclusion criteria (articles with no relation to the topic). exclusão (trabalhos sem relação com o tema). CONCLUSION: Although studies suggest the involvement of CONCLUSÃO: Embora os estudos apontem forte envolvimen- strong neuropathic mechanism, the psychological/psychiatric to de mecanismos neuropáticos, aspectos psicogênicos/psiquiá- aspects might be considered not as a primary cause, but as an tricos devem ser levados em consideração como agravante do es- aggravator of the patient´s pain. Knowledge of other pathologies tado de dor do paciente. Sugere-se conhecimento sobre as outras is recommended in order to determine the differential diagno- doenças existentes para se realizar um diagnóstico diferencial, sis. Also, complementary image tests, qualitative somatosenso- exames complementares de imagem, realização do teste soma- rial test, and reference to an orofacial pain specialist should be tossensorial qualitativo, encaminhamento a um especialista em considered. In case of uncertain diagnosis, it is recommended dor orofacial e neurologista, e em casos de dúvida, não realizar to avoid any dental procedures because the pain can get worse. nenhum procedimento a fim de não piorar a sua dor. Keywords: Atypical odontalgia, Endodontic, Odontalgia. Descritores: Endodontia, Odontalgia, Odontalgia atípica.

INTRODUCTION

Atypical odontalgia (AO) represents a clinical challenge for most André Hayato Saguchi - https://orcid.org/0000-0002-1903-4986; dentists1. Generally, when a patient complains of pain, its origin is Ângela Toshie Araki Yamamoto - https://orcid.org/0000-0003-4402-7531; Cristiane de Almeida Baldini Cardoso - https://orcid.org/0000-0003-3645-5368; odontogenic, and the professional can identify and treat its cause – Adriana de Oliveira Lira Ortega - https://orcid.org/0000-0001-7295-803X. for example, a typical toothache due to pulpitis, caries or periodon- 1. Universidade Cruzeiro do Sul, Programa de Pós-Graduação em Odontologia, São Paulo, tal problem. But in some situations, pain continues in one or more SP, Brasil; Faculdade Anhanguera de Osasco, Osasco, SP, Brasil. teeth or in the socket after extraction without any apparent dental 2. Universidade Cruzeiro do Sul, Programa de Pós-Graduação em Odontologia, São Paulo, 2 SP, Brasil. cause , and the dentist faces the challenge of determining the true non-odontogenic origin of pain and properly diagnosing it1,3-5. Submitted on March 04, 2019. According to the 3rd edition of the International Headache So- Accepted for publication on May 24, 2019. 2 Conflict of interests: none – Sponsoring sources: none. ciety (ICHD-3) , the diagnostic criterion of AO is described by continuous pain in one or more teeth or socket after extraction, Correspondence to: Rua Galvão Bueno, 868 without any apparent dental and neurological causes. Pain lasts 01506-000 São Paulo, SP, Brasil. for more than two hours daily and persists for more than three E-mail: [email protected] months and may or may not be associated with a history of den- © Sociedade Brasileira para o Estudo da Dor tal trauma (Table 1). 368 Atypical odontalgia: pathophysiology, diagnosis and management BrJP. São Paulo, 2019 oct-dec;2(4):368-73

Table 1. Diagnostic criteria of the “International Headache Society 3” Currently, there is insufficient evidence to establish a treatment A. Facial or oral pain that meets criteria B or C. protocol for AO25. Tricyclic antidepressants, antiepileptics, anes- B. Recurrent daily pain for more than 2h/day for more than 3 thetics, and botulinum toxin, although reducing the pain of the months. patient3,22,25, have limited activity and have no proven effective- C. Pain has both characteristics: ness25-27. 1. Poorly located, and does not follow the peripheral nerve path; Generally, the dental surgeon is the first healthcare professional 2. Painful, “boring”, light. with whom the AO patient consults. The lack of knowledge of D. The neurological clinical examination is normal. this situation by the dentist can lead to unnecessary and muti- E. The dental cause is excluded after proper investigation. lating dental procedures, such as endodontic and surgical treat- F. The characteristics do not fall into any other diagnostic criteria ments ranging from apicectomy to extraction28. Knowing the of the ICHD-3. physiopathology and the diagnostic process allows the proper G. Facial or oral pain in the distribution/path of one or both bran- treatment, avoiding further injury to the patient29. ches of the trigeminal nerve that meets criterion I. Given a scenario in which there is no consensus in the literature H. History of an identifiable traumatic trigeminal nerve event, with on the physiopathology, the diagnostic process, and its treat- evidence of positive clinical signs of trigeminal nerve dysfunc- ment, this study aimed to review these aspects, assisting the den- tion (hyperalgesia, allodynia) and/or negative (hypoesthesia, hypoalgesia). tist in his/her professional activity. I. Evidence of cause demonstrated by: 1. Pain is localized in the path of the trigeminal nerve affected by CONTENTS the traumatic event; 2. Pain developed within a period of less than six months from the This is an integrative literature review with a qualitative approach traumatic event. to identify physiopathological, diagnostic, and treatment aspects J. The characteristics do not fall into any other diagnostic criteria of AO. The methodological process was divided into 5 steps, of the ICHD-3. according to Whittemore and Knafl30: 1) problem identification; From A to F when atypical odontalgia falls into a subtype of persistent idiopathic facial pain. G to J: when atypical odontalgia is related to trigeminal 2) literature search; 3) assessment of information; 4) critical anal- nerve trauma. ysis of the information; 5) presentation of results. A search was performed in the Pubmed database. As a search The difficulty in diagnosing AO is because the reported pain is strategy, the following terms were used: “atypical odontalgia” identical to those of odontogenic origin without clinical and ra- OR “phantom tooth pain” OR “idiopathic tooth pain” OR diographic alterations4,6. The patient may have a history of exten- “odontalgia” OR “odontalgias” OR “atypical toothache”. The sive dental treatment without pain relief, which makes the diag- inclusion criteria were articles published in the last 10 years, in nosis more complex7,8. Endodontic treatment, apicectomy and/ English, clinical trial, multicenter study, case report, review, in- or extraction may alleviate pain temporarily, but pain increases tegrative scientific review, and systematic review. After reading in intensity in a few days or weeks7,9. the title and the abstract, those who had no relation to the theme The physiopathology is not well defined, and several mechanisms were excluded. In case of uncertainty of inclusion, the full article have been suggested in the last 50 years3,10. There is great con- was read. troversy regarding AO and psychological factors, with studies A total of 114 articles were found, and after applying the estab- that indicate a large percentage of individuals with depression11 lished inclusion criteria, 48 articles were chosen. Of these, 9 were and others question whether they could be secondary factors to excluded because they were not related to the theme, totaling 39 pain12-16. Vascular origin is a disorder of the pulp and ligament studies. The material was grouped according to the emphasis of blood vessels and is described as a “dental migraine”7,17. the article: physiopathology, diagnosis and treatment. Informa- Neuropathic origin is the most studied, being described in 1971 tion relevant to both steps is summarized in table 2. by Melzack based on Mitchell’s phantom limb pain in 1871 (Apud9 and described by Marbach in 1978 for the first time as PHYSIOPATHOLOGY “phantom tooth pain”). In addition, other neuropathic mechanisms would explain the physiopathological process: deafferen- Current evidence suggests neuropathic mechanisms to explain tation hypersensitivity12,18 and central and/or peripheral sensiti- the physiopathology of AO1,24,41,44,45,50 and the somatosensory zation3,19-21. And, given this scenario, ICHD-3 classifies it as a tests suggest its description in central and peripheral19,23,38,47,52. subtype of persistent idiopathic facial pain (ICHD 13.12). If it One of the tests performed is local anesthesia, which, when ob- is based on a history of trauma, it will be a subtype of posttrau- serving pain reduction, suggests the neuropathic mechanism of matic trigeminal neuropathic pain (ICHD 13.1.2.3). peripheral origin (peripheral sensitization)41. The quantitative so- Although there is a well-defined diagnostic criterion by ICHD-3 matosensory testing (QST) used are based on the pain threshold for AO, there is no protocol on how to perform it22. Detailed using a mechanical stimulus and heat pain threshold tests, for clinical examination, work among various specialists, and listen- example40. Sensory alterations after cold application were iden- ing to the patient about their dental history are proposed23,24. tified in AO patients, also suggesting the involvement of central Some studies have shown that patients with AO have altered re- neuropathic mechanisms52. Qualitative somatosensory testing sponses to qualitative and quantitative somatosensory tests3,19. (QualST) were also used to confirm neuropathic involvement45. 369 BrJP. São Paulo, 2019 oct-dec;2(4):368-73 Saguchi AH, Yamamoto AT, Cardoso CA and Ortega AO

Table 2. Selected studies and relevant information Durham et al.5 The use of a questionnaire to diagnose neuropathic pain (S-LANSS) is desirable because it has sufficient sensitivity and specificity. However, clinical examination and investigation cannot be neglected. García-Sáez et al.25 The use of botulinum neurotoxin type A has been shown to reduce pain in patients with AO. However, randomized controlled trials (RCT) are suggested to prove their effectiveness. Miura et al.16 Attention to psychiatric comorbidity, common in patients with AO. There is no cause-effect relationship. Malacarne et al.1 Persistent dentoalveolar pain is likely to be of neuropathic origin, but physiopathological mechanisms that explain the onset and maintenance of pain are not understood. A correct diagnosis must be established prior to any treatments. Ghurye and The physiopathology of orofacial pain is complex, sometimes associated with psychological comorbidities. Chronic McMillan31 pain has an impact on quality of life. Early diagnosis and referral. Attention to the biopsychosocial approach, which confers a multifactorial etiology to chronic orofacial pain. It should be treated as neuropathy. Tu et al.32 The presence of psychiatric comorbidities aggravated the quality of sleep but had little impact on pain experience. The presence of burning mouth syndrome in patients with AO contributes to more severe pain. Takenoshita et al.33 AO is not purely a sensory problem, but it has psychological involvement. It has a variable response to drug use, and it is necessary to investigate the different pharmacological responses to advance the treatment of AO. Tait, Ferguson and They consider AO, so the diagnosis occurs by exclusion. According to the authors, there is no diagnostic protocol with Herndon34 evidence. Treatments that are considered effective for orofacial pain are disappointing for AO. Kobayashi et al.35 The authors found no relationship between pain relief and duloxetine plasma concentration, which is used to treat AO. Benoliel and Gaul36 Enigmatic physiopathology. Neuropathic mechanisms are more relevant. Interdisciplinarity. Attention to psychiatric comorbidity. Careful interdisciplinary assessment is necessary to institute appropriate treatment. Baad-Hansen and There is no gold standard for diagnosis. A consensus on classification and taxonomy is needed. Prospective studies Benoliel28 are necessary. Education and training for professionals are important to avoid iatrogenies. Careful interdisciplinary assessment is required to institute appropriate treatment. Agbaje et al.37 QualST can be used as a clinical diagnostic tool, as well as to investigate intraoral somatosensory function in patients with AO. QualST is a simple test to verify changes in somatosensory function. Rafael, Sorin and It presents clinical characteristics and physiopathology of painful traumatic trigeminal neuropathy, and what to do to Eli38 prevent it. Toyofuku39 The professional must be aware of the patient’s psychosomatic aspect, which is a priority as well. Cuadrado et al.26 The positive response to the use of botulinum neurotoxin type A suggests that its use is effective and safe in the treatment of neuropathies, but RCT are necessary to prove its effectiveness. Porporatti et al.40 QST can help in the differential diagnosis between pulpitis and AO with substantial accuracy. QST limitations: patient gets tired, it is difficult to examine painful areas Porporatti et al.41 There is central sensitization involvement, and decreased pain with the anesthetic also suggests that there is peripheral involvement. Porporatti et al.10 It reinforces the role of the central nervous system sensitization. The most reliable method would be bilateral QST comparing pain threshold using a mechanical allodynia stimulus or heat pain threshold tests. Baad-Hansen et al.42 QST should be associated with neurophysiological tests or imaging examinations, where possible, to increase test sensitivity and specificity. Forssell et al.24 There is increasing evidence of neuropathic mechanisms for orofacial pain - including AO. The authors suggest that the diagnosis be based on clinical examination, medical history, QST, neurophysiological tests, etc. Pig et al.43 MRI may be of great value as it excludes inflammation processes in the mandibular and maxillary regions. When the diagnosis is uncertain, MRI raises the argument to avoid dental treatments and consider noninvasive treatments. Yatani et al.27 The authors present a guide for the treatment of non-odontogenic origin. The use of tricyclic antidepressants is the most commonly used but has no proven effectiveness. Baad-Hansen et al.44 The QST showed 87.3% abnormality in individuals with AO as an increase in mechanical and thermal stimuli and may be an appropriate tool for scanning patients with neuropathic pain. Tarce, Barbieri and Diagnosis and treatment are challenging. Physiopathology is unclear. They suggest more RCT to prove the effective- Sardella23 ness of drugs used in the treatment of AO. Baad-Hansen et al.45 QualST detect disturbances in individuals with AO, especially sensitivity to cold, touch, and bristle stimulation. Zakrzewska46 It reviews the literature on pain in the lower face and mouth. It addresses classification, epidemiology, and diagnosis. Tınastepe and Oral 47 Neuropathic pain has complex physiopathology and may start after dental treatment such as endodontic treatment, implant surgery, and trauma when anesthetizing. Trigeminal neuralgia, mouth burning syndrome, and postherpetic neuralgia and AO are neuropathic conditions Ciaramella et al.15 Some psychological factors determine predisposition to the development of chronic pain after extraction. Individuals with AO had high levels of resentment and depression. Continue...

370 Atypical odontalgia: pathophysiology, diagnosis and management BrJP. São Paulo, 2019 oct-dec;2(4):368-73

Table 2. Selected studies and relevant information – continuation Nagashima et al.48 Duloxetine relieved the pain of patients with burning mouth syndrome and AO. Patel, Boros and Kumar49 In the absence of an accurate diagnosis, do not perform endodontic and surgical treatment. Abiko et al.22 They present diagnostic criteria and treatment and management protocols. There is insufficient information to establish a diagnosis and treatment protocol for AO. Psychological factors cannot be disregarded as there is a high incidence of related problems. Thorburn e The diagnosis occurs by exclusion. Clinical examination and history are important. With the advances in understan- Polonowita50 ding the mechanisms of chronic neuropathic pain, there will be more focus on the diagnosis and treatment of AO. Bosch-Aranda et al.20 AO is difficult to diagnose because the physiopathological mechanisms are unclear. Still, the evidence is not enough to indicate treatments with analgesics and antidepressants. Pigg et al.51 Cone-beam computed tomography provides the identification of patients without periapical bone destruction, which facilitates the differentiation between symptomatic apical periodontitis and AO. Zagury et al.52 Sensory changes for post-cold sensation were identified in patients, suggesting the involvement of central neuropathic mechanisms. Pain extending to a broader region of the site of origin, and pain occurring on the contralateral side, reinforces the idea of central sensitization. Extraoral QST does not seem to be able to detect change. Takenoshita et al.14 AO patients were most often diagnosed in the stressed F4 neurotic category. Ito et al.53 Milnacipran was effective in reducing pain in AO patients, regardless of the degree of depression. Ram et al.29 If the patient continues to have persistent pain after the treatment, with no apparent clinical and radiographic cause, the professional should consider AO as a differential diagnosis. Dentists should be able to identify this situation and refer to an orofacial pain specialist or neurologist. List, Leijon and Most patients with AO presented somatosensory alteration compared to few in the control group, which reflects in Svensson19 central and peripheral sensitization. AO = atypical odontalgia; QST = quantitative somatosensory testing; MRI = magnetic resonance imaging; RCT = randomized clinical trials; QualST = qualitative somatosensory testing.

In addition to these mechanisms, other neuropathic physio- 2) Importance of the clinical examination: the odontogenic pathological events may be involved: nerve damage and ectopic causes of toothache must be totally ruled out. For this, a thor- activity due to the formation of neuromas, phenotypic changes, ough clinical examination is necessary5,10,24,40. One should not and increased sympathetic activity in times of stress or anxiety38. forget Rees and Harris’s observations7 emphasizing that all Recent studies do not point to psychiatric comorbidity as a de- possibilities of caries, pulp disease and crack/fracture of the termining cause for triggering AO15, but professionals should crown or root should be excluded; be aware of this condition36 and cannot disregard it22. A high 3) Complementary imaging tests: despite the limitations of incidence of AO patients presents these comorbidities22,33, periapical radiographs54,55 they should be used to assess the reaching 50% in another study16. “Neurotic and stressed”16 periapical region. Volumetric computed tomography should be and “resentful and depressed”15 were striking characteristics performed to rule out any possibility of periapical endodontic described in individuals with AO. Moreover, such comorbid- alteration10,51. The use of magnetic resonance imaging (MRI), ities may determine a predisposition to the development of in cases of suspected non-inflammatory dental pain, can be of chronic pain after extraction15. Tu et al.32, however, concluded great value as it excludes inflammation processes in the man- that psychiatric comorbidity in patients with AO and mouth dibular and maxillary region. When the diagnosis is uncertain, burning syndrome had little impact on pain experience. MRI reinforces the importance of noninvasive management43; The vascular cause presented by Rees and Harris7 and Kreis- 4) In order to facilitate and assist the diagnostic process, two berg17 was mentioned in only two studies20,22, thus not being tools should be highlighted: the main physiopathological mechanism of AO. a) Visual analog scale: diagnostic tool for pain measure- ment41,45: DIAGNOSIS b) QST and QualST: are important allies in the diagnosis of AO24,27,40,44,45,52. QST is performed through several stimuli, There is no gold standard diagnostic protocol for AO28,34, and and only mechanical and thermal stimuli are related to AO. existing ones are not sufficiently reliable for diagnosis1. Since Of the patients with AO submitted to these stimuli, 83.7% the physiopathology is not well defined20,23, its diagnosis is had some QST abnormality44. Performing bilateral QST often by exclusion34,50. (pain side versus pain free side) also helps to detect neuro- Even in the face of insufficient information for the elaboration pathic changes10. Despite the indications, QST, when used of a diagnostic protocol22, after analyzing the data extracted outside hospitals and university clinics, is costly and often un- from this study, it was possible to synthesize the main informa- feasible, requiring the calibration and training of examiners45. tion for the professional who may be facing a diagnosis of AO: QualST detects hypersensitivity disorders to touch, cold, and 1) Importance of medical history: patient assessment should bristle stimulation46. begin with its medical history, especially with regard to pain 5) Exclude all hypotheses of non-odontogenic odontalgia. Ac- characteristics23; cording to Yatani et al.27 and ICHD-3, after discarding the 371 BrJP. São Paulo, 2019 oct-dec;2(4):368-73 Saguchi AH, Yamamoto AT, Cardoso CA and Ortega AO hypothesis of dental pain, there are numerous other condi- 2) Knowledge and training by professionals in the diagnos- tions of non-odontogenic origin that should be ruled out; tic process are essential to avoid unnecessary and iatrogenic 6) Refer the patient to other specialists: Given the difficul- procedures28; ty of properly diagnosing and the various physiopathologi- 3) Interdisciplinary work is important not only in the diag- cal mechanisms that could be involved, it is recommended nosis, but also in the institution of the correct treatment36,50; to refer the patient to other specialists23,24,36,57. Interesting to 4) RCTs are necessary to assess the effectiveness of tricyclic note that in 1982, Kreisberg17 already suggested referral to antidepressants, serotonin and norepinephrine reuptake in- the neurologist; hibitors and botulinum neurotoxin type A21,23; 7) Consider psychological aspects: Although psychogenic 5) Minimizing the pain of patients with the lowest drug dose and psychiatric factors have no determining relationship is the main objective and inadvertent use without the need for in the development of AO16, there was a high incidence of several drugs should be avoided20; these patients with psychiatric comorbidities14-16,22,32,36. The 6) And again, a holistic, psychosocial, and not purely me- professional should be aware of these comorbidities, giving chanical approach is important. It is recommended to listen AO a multifactorial etiology31,33. Thus, a biopsychosocial31 carefully to the patient’s complaint and his or her history of and interdisciplinary36 and no less priority39 approach are treatments56. necessary39; After these reflections, it is important to emphasize that this 8) A more holistic, psychosocial, and not purely mechanical study had limitations regarding the choice of database for the se- approach is important. It is recommended to listen carefully lection of studies. However, Pubmed is considered the universal to the patient’s complaint and his/her history of treatments56; English language database with indexed high impact journals. 9) Knowledge and training by professionals are important to avoid unnecessary and iatrogenic procedures28. CONCLUSION

TREATMENT Recent studies use the 3rd edition of the ICHD classification, in which AO falls into the “persistent idiopathic facial pain” Like diagnosis, AO treatment is challenging23,50. Current- category (ICHD-13.12). Since the physiopathological pro- ly, there is insufficient evidence to establish a treatment cess is not defined, the establishment of a protocol to make its protocol25. diagnosis is fundamental. It is suggested knowledge about the Tricyclic antidepressants are the most cited drugs in case re- other existing diseases to make a differential diagnosis, and ports and case-control studies, and for many authors, they are the use of complementary exams such as volumetric comput- considered the first choice in treatment27,35. However, these ed tomography, MRI, and QualST. Tricyclic antidepressants drugs cause adverse effects. Amitriptyline, for example, caus- and serotonin and norepinephrine reuptake inhibitors are the es xerostomia, constipation, urinary retention, and weight drugs of first choice in the treatment of AO. However, cur- gain20 and, depending on the dose and the patient, have var- rently, the use of botulinum neurotoxin type A in pain man- ied responses regarding the effectiveness in pain remission33. agement has been assessed. All these drugs require RCT to Serotonin and norepinephrine reuptake inhibitors, such as have their effectiveness proven. Given the possibility of AO, milnacipran and duloxetine, have also been used in the man- an interdisciplinary approach in the diagnostic process and agement of painful symptoms35,48,53, and although they have definition of its treatment is guided. pain reduction, there is a need for randomized controlled trials (RCT) to prove its real effectiveness20,21,23. REFERENCES As already described, current evidence suggests neuropathic 1,24,41,44,45,50 1. Malacarne A, Spierings EL, Lu C, Maloney GE. Persistent dentoalveolar pain disor- mechanisms to explain the physiopathology of AO . der: a comprehensive review. J Endod. 2018;44(2):206-11. Thus, treating it as a neuropathy sounds coherent31. Howev- 2. Headache Classification Committee of the International Headache Society (IHS) The In- rd er, results with therapies employed for neuropathic orofacial ternational Classification of Headache Disorders, 3 ed. Cephalalgia. 2018;38(1):1-211. 3. Baad-Hansen L. Atypical odontalgia - pathophysiology and clinical management. J 34 pain have been disappointing in AO studies . Oral Rehabil. 2008;35(1):1-11. More recent studies have assessed the action of botulinum 4. Goel R, Kumar S, Panwar A, Singh AB. Pontine infarct presenting with atypical dental pain: a case report. Open Dent J. 2015;9:337-9. neurotoxin type A (Onabotulinum toxin A) in pain control. 5. Durham J, Stone SJ, Robinson LJ, Ohrbach R, Nixdorf DR. Development and pre- The good results regarding pain remission point it as a prom- liminary evaluation of a new screening instrument for atypical odontalgia and persistent dentoalveolar pain disorder. Int Endod J. 2019;52(3):279-87. ising drug in the treatment of AO. However, as with tricyclic 6. Woda A, Tubert-Jeannin S, Bouhassira D, Attal N, Fleiter B, Goulet JP, et al. Towards antidepressants and serotonin and norepinephrine reuptake a new taxonomy of idiopathic orofacial pain. Pain. 2005;116(3):396-406. inhibitors, the use of botulinum neurotoxin type A should be 7. Rees RT, Harris M. Atypical odontalgia. Br J Oral Surg. 1979;16(3):212-8. 8. Koratkar H, Pedersen J. Atypical odontalgia: a review. Northwest Dent. 2008;87(1): 20,25,26 proven to be effective through more RCT . 37-8, 62. Thus, the information obtained from the articles found can 9. Marbach JJ. Phantom tooth pain. J Endod. 1978;4(12):362-72. 10. Porporatti AL, Costa YM, Stuginski-Barbosa J, Bonjardim LR, Duarte MA, Conti be summarized: PC. Diagnostic accuracy of quantitative sensory testing to discriminate inflammatory 1) In cases of doubt, not performing endodontic and surgi- toothache and intraoral neuropathic pain. J Endod. 2015;41(10):1606-13. 11. Graff-Radford SB, Solberg WK. Is atypical odontalgia a psychological problem? Oral cal treatments, as AO would be unnecessary and worsen the Surg Oral Med Oral Pathol. 1993;75(5):579-82. patient’s pain49; 12. Schnurr RF, Brooke RI. Atypical odontalgia. Update and comment on long-term fol- 372 Atypical odontalgia: pathophysiology, diagnosis and management BrJP. São Paulo, 2019 oct-dec;2(4):368-73

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373 BrJP. São Paulo, 2019 oct-dec;2(4):374-80 REVIEW ARTICLE

Pharmacological treatment of pain in pregnancy Tratamento farmacológico da dor na gestante

Fábio Farias de Aragão1, Alexandro Ferraz Tobias2

DOI 10.5935/2595-0118.20190068

ABSTRACT tar a dor, que em alguns casos pode levar à incapacidade. Além disso, a gravidez pode exacerbar condições dolorosas pré-exis- BACKGROUND AND OBJECTIVES: Non-obstetric causes tentes. A escolha de prescrever um fármaco para uma gestante of pain during pregnancy are very common and can be disabling é difícil. As alterações gravídicas no corpo da gestante influem if not treated properly. The objective of this study is to discuss na absorção, distribuição, metabolismo e excreção dos fármacos, the pharmacological treatment of pain during pregnancy with a podendo alterar a resposta esperada. focus on drug classification and pregnancy use, therapy options, CONCLUSÃO: Deve-se considerar os riscos e benefícios do uso teratogenicity, increased fetal malformations and gestational do fármaco para a mãe e filho, pesando-se os riscos de não tratar complications associated with the use of therapy. adequadamente a doença durante a gestação. CONTENTS: During pregnancy, the body goes through several Descritores: Analgésicos, Gestação, Tratamento da dor. anatomical and physiological changes. These changes can precipitate pain, which in some cases can lead to disability. In addition, preg- INTRODUCTION nancy may exacerbate pre-existing painful conditions. The choice to prescribe a drug to a pregnant woman is difficult. The changes in the During pregnancy, non-obstetric causes of pain are very com- body of a pregnant woman influence drug absorption, distribution, mon and can be disabling if not properly treated. A recent study, metabolism, and excretion, and may alter the expected response. with a cohort of over 500,000 pregnant women in the Unit- CONCLUSION: The risks and benefits of the drug for the ed States, found that 14% received an opioid prescription at mother and the child should be considered, weighing the risks of least once during the delivery period, and 6% received opioids not treating the disease adequately during pregnancy. throughout all quarters1. Keywords: Analgesic, Pain treatment, Pregnancy. During pregnancy, many anatomical and physiological changes take place in the body. These changes can precipitate pain, RESUMO which, in some cases, can lead to disability. In addition, pregnancy can boost pre-existing painful conditions. Pain conditions JUSTIFICATIVA E OBJETIVOS: As causas não obstétricas de dor during pregnancy can be bracketed in a system-based classifica- durante a gravidez são muito comuns e podem ser incapacitantes tion, such as musculoskeletal, rheumatological, neuropathic, and se não forem tratadas adequadamente. O objetivo deste estudo foi pelvic-abdominal pain syndromes2. discutir o tratamento farmacológico da dor durante o período gesta- Choosing to prescribe a drug to a pregnant woman is difficult. cional com foco na classificação de fármacos e o uso na gravidez, op- The changes in the body of a pregnant woman influence the ab- ções de terapia, teratogenicidade, aumento de malformações fetais e sorption, distribution, metabolism, and excretion of drugs, and complicações gestacionais associados ao uso da terapia. may change the expected response. Also, it should be consid- CONTEÚDO: Durante a gravidez, várias alterações anatômicas ered the risks and benefits for both the mother and the child e fisiológicas ocorrem no corpo. Essas alterações podem precipi- when using the drug, considering the risks of not treating properly the disease during pregnancy and lactation. Risk assessment can focus not only on structural malformations (teratogenicity), but also on functional changes, changes in gestational dynam- Fábio Farias de Aragão - https://orcid.org/0000-0002-8528-254X; ics (changes in fetal weight, abortion, prematurity, and neonatal Alexandro Ferraz Tobias - https://orcid.org/0000-0001-7710-9547. death), and postpartum complications3-5. 1. Hospital e Maternidade Natus Lumine, Clínica São Marcos, Clínica de Dor, Departa- The goal of this research was to discuss the pharmacological mento de Anestesiologia, São Luís, MA, Brasil. treatment of pain during pregnancy, focusing on drug classifi- 2. Hospital e Maternidade Natus Lumine, Clínica de Dor, Departamento de Anestesiologia, São Luís, MA, Brasil. cation and usage in pregnancy, therapy options, teratogenicity, increase in fetal malformations, and gestational complications Submitted on December 14, 2018. associated with therapy use. Accepted for publication on February 28, 2019. Conflict of interests: none – Sponsoring sources: none. CONTENTS Correspondence to: Av. Grande Oriente, 23 – Renascença 65075-180 São Luís, MA, Brasil. Descriptive summary of available evidence on pharmacological E-mail: [email protected] approaches to pain management during pregnancy. It was con- © Sociedade Brasileira para o Estudo da Dor ducted a search on the medical literature at Pubmed, Cochrane 374 Pharmacological treatment of pain in pregnancy BrJP. São Paulo, 2019 oct-dec;2(4):374-80

Library, Ovid, and Google, using the terms “pain management”, Committee - ADEC) (Table 2) , shared as a characteristic the “pregnancy pain”, “obstetric pain”, “opioid use”, “antiepileptic categorization of drugs into letters. drug pregnancy” and “antidepressant pregnancy” in articles in The US system classifies drugs as A when adequate controlled English, Portuguese and Spanish, in the last 20 years or older, studies in pregnant women showed no risk to the fetus. The Aus- when relevant. The most relevant articles on the topic were se- tralian and Swedish systems do not use controlled studies as a lected and included in the paper. prerequisite to classify a drug as A, and they stratify category B (drugs used by a limited number of pregnant women) as B1, DRUG CLASSIFICATION FOR USE IN PREGNANCY B2, and B3, based on animal data. In the Swedish classification, there is no category X. In order to avoid the administration of drugs with potential However, these systems have been criticized due to: a) catego- risk and to facilitate their prescription during pregnancy, sever- rization in letters is considered too simplistic and does not ade- al classification systems based on animal and human data have quately express adverse effects on the fetus; b) the categorization been developed. Drug use risk classification systems in pregnant in letters gives the false impression that risks increase from A to women in the United States (US Food and Drug Administra- X and that drugs in the same category present the same risk or tion - FDA) (Table 1), the Swedish (Farmaceutiska Specialiteter potential for adverse effects; c) the categories do not discriminate i Sverige - FASS) and the Australian (Australian Drug Evaluation between potential adverse effects based on severity, incidence or

Table 1. Pharmacological risk categories in pregnancy according to the Food and Drug Administration Categories Interpretation A Controlled studies show absent risk. Appropriate well-controlled studies in pregnant women show no risk to the fetus. B No evidence of risk in humans. Findings in animals had shown risk, but not in humans, or if adequate studies with humans have not been conducted, and the findings in animals were negative. C Risk cannot be excluded. There are no positive studies for fetal risk in humans and animals or no studies at all. However, the potential benefits justify the potential risk. D Positive evidence of risk. Data of Investigation or aftermarket release show risk to the fetus. Even though, the potential benefits may outweigh the risk. X Contraindicated in pregnancy. Animal and human studies, or reports on research or aftermarket release, have shown a fetal risk that is greater than the potential benefits. Adapted from IV Brazilian Guidelines for Asthma Management6.

Table 2. Pharmacological risk categories in pregnancy according to the criteria of the Pharmaceutiska Specialiteter i Sverige and Australian Drug Evaluation Committee 7 Categories Farmaceutiska Specialiteter i Sverige Australian Drug Evaluation Committee A Drugs used by many pregnant women without evidence of fetal Drugs used by many pregnant women without evidence of damage. fetal damage. B Data in humans are insufficient and limited; classification is based Data in humans are insufficient and limited; classification on animal data (by allocation in one of three subgroups B1, B2 was based on animal data (by allocation in one of three sub- or B3). groups B1, B2 or B3). B1 Experiments in animals did not provide evidence of an increased Experiments in animals did not provide evidence of an in- incidence of fetal damage. creased incidence of fetal damage. B2 Studies in animals are insufficient. Studies in animals are insufficient. B3 Studies in animals have shown evidence of increased incidence Studies in animals have shown evidence of increased in- of fetal damage, but the significance in humans is uncertain. cidence of fetal damage, but the significance in humans is uncertain. C Drugs that, due to their pharmacological effects, have caused or Drugs that have caused or may be suspected of causing har- are suspected of having caused reproductive disorders that may mful effects on the human or newborn fetus without causing involve risks to the fetus, not being directly teratogenic malformations. These effects may be reversible. D Animal and/or human data indicate an increased incidence of fe- The drugs have caused, are suspected of having caused, or tal malformations or other permanent damages in humans. can be expected to cause an increased incidence of human fetal malformations or irreversible damages. X Does not apply Drugs that have such a high risk of permanent fetal damage that they must not be used during pregnancy.

375 BrJP. São Paulo, 2019 oct-dec;2(4):374-80 Aragão FF and Tobias AF

Table 3. New Food and Drug Administration Standards for the Use of Drugs in Pregnancy, Subsection “Pregnancy”8,9 Pregnancy exposure record If a pregnancy exposure record is available, this subsection should contain a statement of the existence of the record as well as contact information. Risk summary When drug use is contraindicated, this should be stated first. Risk statements shall be presented in the following order: Based on human data, based on animal data, based on pharmacology Human data are available: the risk summary should summarize the specific development of the outcome, its incidence, and the effects of dose, duration of exposure, and gestational exposure time. Animal data are available: labeling should summarize the findings in animals and describe the potential risk of any adverse outcome in humans. Affected species, time, dose, and results should be included. When the drug has a well-understood mechanism of action that may result in the adverse outcome(s) to the development associated with the drug, the risk summary should explain the mechanism of action and potential risks. Clinical considerations Requires titles, as relevant information is available, to: · Maternal and/or embryo/fetal risk associated with the disease · Dose adjustments during pregnancy and the postpartum period · Maternal adverse reactions · Fetal/neonatal adverse reactions · Labor Data . Human data: Labeling should describe adverse outcomes of development, adverse reactions, and other adverse effects and the types of studies or reports, number of individuals and duration of each study, exposure information, and limitation of data. . Animal data: labeling should describe study types, animal species, dose, duration and timing of exposure, presence or absence of maternal toxicity, and limitation of data. type of effect; d) dose, duration, frequency, route and gestational neurological problems (motor development, communica- age for drug exposure are not taken into account7. tion), attention deficit hyperactivity disorder, behavioral In order to facilitate the prescribing process by providing a changes, allergic diseases, among others. Nevertheless, studies consistent and well-structured set of information on drug are inconclusive, and paracetamol is considered a drug with use during pregnancy and lactation, the FDA has published no teratogenic effects and remains the safest analgesic during the Pregnancy and Lactation Labeling Rule (PLLR), on De- pregnancy and lactation11. cember 2014, along with Pregnancy, Lactation, and Repro- Prenatal exposure to paracetamol may be related to the conse- ductive Potential: Labeling for Human Prescription Drug quences of women’s reproductive health as a result of changes and Biological Products - Content and Format. An indus- in ovarian development during intrauterine life12. Concerning try-oriented document that came into force in July 2015 maternal complications, the use of paracetamol may be related (Table 3)8,9. They reformulate the contents and format of to the increased risk of developing pre-eclampsia, deep venous the package inserts by removing references to categories A, thrombosis, and pulmonary thromboembolism13. B, C, D, and X, replacing by a summary of perinatal drug As studies are inconclusive and there is extensive experience in risks, discussion of relevant evidence, and a synthesis of the use of the drug during pregnancy, paracetamol remains the the most relevant data to decide for the drug prescription. analgesic of choice during pregnancy, and the lowest dose should Essential information on pregnancy identification, contra- be used for the shortest possible time. Paracetamol has classifica- ception, and infertility is also included. The information is tion B by the FDA. divided into the subsections “Pregnancy,” “Lactation” and “Reproductive Potential of Men and Women”10. Dipyrone On the other hand, abandoning category-based classifications re- Although this drug has been withdrawn from the market in quires that the professional reviews the available evidence. Thus, some countries, such as the United States, because of its asso- if the review is incomplete or the evidence is inconclusive, the ciation with agranulocytosis and aplastic anemia, it is still being risk of errors increases. Therefore, it is prudent that before pre- used in parts of Europe, Asia, and South American countries, scribing a drug to pregnant or breastfeeding women, to conduct such as Brazil. Its use during pregnancy is not associated with research on different platforms and measure the risks and bene- congenital malformations, intrauterine death, premature birth, fits of the treatment. or low birth weight14. Although widely used in Brazil, two studies have shown a pos- NON-OPIOIDS ANALGESICS sible association between dipyrone use and childhood tumors: Wilms tumor and Leukemia15,16. On the other hand, in in vitro Paracetamol studies in animals, dipyrone showed little mutagenic or carcino- It is the most used analgesic and antipyretic during preg- genic potential and only when administered in high doses17,18. nancy and lactation. However, its use before birth has been Dipyrone is not directly related to major or minor fetal malfor- associated with asthma, shorter anogenital distance in boys mations, but its use should be limited to the lowest possible dose (predictor of low reproductive potential), autistic spectrum, and shortest possible time19. 376 Pharmacological treatment of pain in pregnancy BrJP. São Paulo, 2019 oct-dec;2(4):374-80

Acetylsalicylic acid (ASA) pertension), oligohydramnios (caused by reduced fetal urinary Its use was limited to its analgesic properties during pregnan- output), necrotizing enterocolitis and intracranial hemorrhage. cy. However, the prescription in this population has been in- In the mother, it may be related to prolonged labor period and creasing in recent years. ASA does not increase the incidence of postpartum hemorrhage33. Although short-term administration miscarriages or intrauterine death, nor does it have teratogenic is unlikely to be associated with fetal arterial duct closure, it is effects20. common practice to avoid NSAIDs after 28 to 32 weeks until ASA has been used to treat and prevent pre-eclampsia, espe- the end of pregnancy34. cially in high-risk patients, women with antiphospholipid an- Regarding selective COX-2 inhibitors, it was expected to have tibody syndrome, and a history of recurrent miscarriage (asso- fewer adverse effects than non-selective ones, but the same ciated or not with heparin), and patients who underwent to problems are present, such as oligohydramnios and premature in vitro fertilization20. When used in patients at high risk for closure of the arterial duct35. As there are few studies on the developing pre-eclampsia, ASA reduces the incidence of pre- use of this class of drugs during pregnancy, they are considered mature birth by 14% and restricted intrauterine growth by class C until the second trimester, and D in the third trimester. 20%, probably because of its action by reducing placental isch- Non-selective anti-inflammatory have FDA classification B up emia21,22. ASA interferes with platelet function and may cause to the second trimester, and classification D in the third7. maternal or fetal bleeding23. However, when used at low doses, it has not shown a significant effect on the risk of intraventric- OPIOID ANALGESICS ular hemorrhage and neonatal bleeding24. Low-dose ASA (60-150mg/day), when used in the first quarter, Opioids are important drugs in the treatment of acute pain is not associated with an increased incidence of congenital mal- during pregnancy, especially when associated with NSAIDs. formations, postpartum bleeding, placental rupture, or adverse However, for chronic pain, the risks and benefits of its use effects on anesthesia. When used in the third quarter, it was should be discussed with the woman, and the guidelines of the not associated with an increased incidence of intraventricular American Pain Society recommend minimal use or no use if hemorrhage, neonatal hemorrhage, or premature closure of the possible36. arterial duct25. Opioid use during the first trimester has been associated in When used at low doses, ASA is safe and has positive effects some studies with cardiac abnormalities, spina bifida, and gas- on reproduction. Low-dose aspirin has classification C by the troschisis37,38, while others, to demonstrate these associations FDA, but doses above 150mg per day are considered class D. have failed to relate any malformations to opioid use39,40. Opioids do not seem to have an important teratogenic effect, NON-STEROIDAL ANTI-INFLAMMATORIES but there are doubts about cardiovascular defects, especially with synthetic opioids41. Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most widely used classes of drugs during pregnancy, wheth- Codeine er derived from propionic acid (naproxen, ibuprofen, ketopro- In a study with 67,982 pregnant women, it was observed that fen), phenylacetic acid (diclofenac sodium), salicylates (ace- codeine was used in 2,666 (3.9%) of the cases. No differences tylsalicylic acid), oxicans (meloxicam, piroxicam) or indole in fetal survival rate or incidence of malformations were ob- (indomethacin). Their mechanism of action is the inhibition served between pregnant women who used or not codeine. of prostaglandin production by direct inhibition of the cycloo- On the other hand, its use was associated with a higher in- xygenase (COX) enzyme. Regarding non-selective COX inhib- cidence of elective and emergency cesarean and postpartum itors, it is not clear if there is an association between their use hemorrhage when used at the end of pregnancy. However, and the increased incidence of miscarriage when used in the these changes may be due to the underlying disease rather first trimester or near conception26-28. than drug use39. It is considered Class C by the FDA and On the other hand, a study with more than 65,000 women Class A by ADEC. showed that the use of NSAIDs is not an independent risk factor for abortion29. Studies in humans suggest an association Tramadol between NSAIDs use and reduced female fertility, and it is In a study that evaluated 1,682,846 pregnant women, it was prudent to avoid its use in women trying to conceive30. Re- observed that 1,751 used tramadol at the beginning of preg- garding congenital malformations, the situation of NSAIDs is nancy, with 96 newborns presenting congenital malforma- more complex. In most studies, the risk for any malformation tion, of which 70 were severe (OR 1.33 CI 95% 1.05-1.70). does not increase significantly with its use but maybe increased Among the malformations observed are cardiovascular defects under some conditions, notably heart defects31. On the other (OR 1.56 CI 95% 1.04-2.29) and clubfoot (OR 3.63 CI 95% hand, a study that specifically assessed the risk of interventric- 1.61-6.89)40. In more advanced stages of pregnancy, it does not ular septal defects found no association32. appear to cause major fetal effects, unless used chronically, and The use of NSAIDs in the third trimester of pregnancy may may lead to neonatal abstinence syndrome (NAS). There is no be associated, in the fetus, with the premature closure of the evidence of alterations when used during lactation42. It is con- ductus arteriosus (which may lead to neonatal pulmonary hy- sidered Class C by the FDA and by ADEC. 377 BrJP. São Paulo, 2019 oct-dec;2(4):374-80 Aragão FF and Tobias AF

Morphine associated with an increased incidence of miscarriage, but no When used in the first trimester, there are no reports of mal- malformations. Near delivery, it can lead to respiratory changes formations and must be used with caution. During pregnancy, in the newborn, and during lactation, less than 1% of the drug morphine changes its pharmacokinetics, with increased plasma passes to the milk, suggesting that it may be compatible with clearance, shortening of half-life, decreased distribution volume, lactation. On the other hand, there are few studies to ensure its and increased formation of the 3-glucuronide metabolite. Mor- safety during pregnancy and lactation52. It is Class C by the FDA phine and its metabolite rapidly cross the placenta and establish and B3 by the ADEC. maternal-fetal balance within approximately 5 minutes. New- borns exposed to shorter half-life opioids, such as morphine, are MUSCLE RELAXANTS more likely to have SAN2,43. It is Class B by the FDA and C by the ADEC. Baclofen When taken orally, it is related to fetal malformations such as Fentanyl omphalocele. When used by intrathecal route, it seems to have The use of fentanyl during pregnancy and lactation, when used no harmful effects on the fetus and has a low concentration in as transdermal, may be a good option for the treatment of breast milk53. It is Class B3 by the ADEC. chronic pain. In a case report of a pregnant woman who used the fentanyl patch (125µg/h) throughout pregnancy, it was ob- Cyclobenzaprine served that the newborn had mild symptoms of NAS and did It is considered safe during pregnancy and is one of the most not require pharmacological treatment44. On the other hand, in commonly used analgesics for the treatment of pregnancy-relat- another report of a pregnant woman who used the fentanyl patch ed low back pain. Despite a report of early closure of the ductus (100µg/h), the newborn had prolonged NAS, requiring oral arteriosus, this drug is already widely used in pregnant women54. morphine treatment until the 29th day of life. These differences It is Class B by the FDA. During lactation, about 50% of the may be due to individual drug variation45. It is Class C by the drug passes to breast milk. FDA and ADEC. ANTICONVULSANTS Methadone and buprenorphine Both are safe when used to treat opioid dependence during preg- Anticonvulsants should be used with caution during pregnancy nancy. Prenatal exposure does not seem to alter physical, cogni- because of the risk of major (cardiac, urogenital, central nervous tive, and language development in children followed up to the system, craniofacial) and minor malformations, restricted intra- 36th month of life46. It is Class C by the FDA and ADEC. uterine growth, and cognitive deficits. In addition, monotherapy and the lowest effective dose should be prioritized55. ANTIDEPRESSANTS Gabapentin Tricyclic antidepressants (TCA) There are only a few reports of pregnant women who used gab- Use during pregnancy at therapeutic doses does not appear to apentin, with no evidence of increased incidence of malforma- be associated with an increased incidence of malformations. tions56. May be related to increased risk of fetal loss, restricted Chronic use, or the use of high doses near delivery, may cause intrauterine growth, and premature birth57. It is Class C by the NAS, and the dose must be reduced between 3 and 4 weeks FDA and B3 by the ADEC. before delivery47. Although some studies relate the use of TCA with malformations (eye, ear, face, and digestive system)48, it Pregabalin is noteworthy that despite slight increases in the incidence of In a study evaluating 477 pregnant women who used pregabalin malformations described in some studies, most do not show in the first trimester, RR 1.33 (CI 95% 0.83-2.15) was found any increase. Due to a large number of pregnant women who for major congenital malformations, but when used in mono- used amitriptyline without reporting toxic effects on the fetus, therapy, RR was 1.02 (CI 95% 0.69-1.51). Thus, when used its use seems safe during pregnancy49. Amitriptyline is Class C in monotherapy, it does not seem to increase the incidence of by the FDA and ADEC; nortriptyline is Class C by the ADEC congenital malformations58. It is Class C by the FDA and B3 by and D by the FDA. the ADEC.

Tetracyclic antidepressants Carbamazepine Maprotiline is the most studied drug, and its use is considered It is associated with an increased incidence of malformations be- safe during pregnancy50. It is Class B by the FDA. tween 1 and 8.7%, especially when doses above 1000mg per day are used56. It is Class C by the FDA and B3 by the ADEC. Selective serotonin and norepinephrine uptake inhibitors One population study did not show teratogenic effects related Lamotrigine to venlafaxine use51. It is Class C by the FDA and B2 by the It does not seem to increase the incidence of malformations. ADEC. In general, the use of duloxetine during pregnancy is When used at doses below 300mg per day, the incidence of mal- 378 Pharmacological treatment of pain in pregnancy BrJP. São Paulo, 2019 oct-dec;2(4):374-80 formations is about 2.0%; above this dose it can reach 4.5%56. It tamizole use during first trimester-A prospective observational cohort study on pregnancy outcome. Pharmacoepidemiol Drug Saf. 2017;26(10):1197-204. is Class C by the FDA and D by the ADEC. 20. Bloor M, Paech M. Nonsteroidal anti-inflammatory drugs during pregnancy and the initiation of lactation. Anesth Analg. 2013;116(5):1063-75. CONCLUSION 21. Henderson JT, Whitlock EP, O’Connor E, Senger CA, Thompson JH, Rowland MG. Low-dose aspirin for prevention of morbidity and mortality from preeclampsia: a systematic evidence review from the U.S. Preventative Services Task Force. Ann Intern The increased use of opioid or nonopioid analgesics by preg- Med. 2014;160(10):695-703. 22. van Vliet EO, Askie LA, Mol BW, Oudijk MA. Antiplatelet agents and the prevention nant women may raise doubts about the appropriate treat- of spontaneous preterm birth: a systematic review and meta-analysis. Obstet Gynecol. ment options to offer to this population. Evaluation and ef- 2017;129(2):327-36. 23. Werler MM, Mitchell AA, Moore CA, Honein MA. Is there epidemiologic evidence fective handling are limited by contraindications and risks to to support vascular disruption as a pathogenesis of gastroschisis? Am J Med Genet A. the fetus. 2009;149A(7):1399-406. 24. Askie LM, Duley L, Henderson-Smart DJ, Stewart LA; PARIS Collaborative Group. The decision to use pharmacological therapy should be based Antiplatelet agents for prevention of pre-eclampsia: a meta-analysis of individual pa- on an assessment of the risks and benefits to the mother and tient data. Lancet. 2007;369(9575):1791-8. fetus, taking care to offer all therapeutic options to ensure the 25. Mone F, Mulcahy C, McParland P, McAuliffe FM. Should we recommend universal aspirin for all pregnant women? Am J Obstet Gynecol. 2017;216(2):141.e1-141.e5. well-being of the pregnant woman, minimize fetal teratoge- 26. Nakhai-Pour HR, Broy P, Sheehy O, Bérard A. 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380 BrJP. São Paulo, 2019 oct-dec;2(4):381-5 REVIEW ARTICLE

Instruments that evaluate the functioning in individuals affected with chikungunya and the International Classification of Functioning. A systematic review Instrumentos que avaliam a funcionalidade em indivíduos acometidos com a chikungunya e a Classificação Internacional de Funcionalidade. Revisão sistemática

Marina Carvalho Arruda Barreto1, Bárbara Porfírio Nunes1, Shamyr Sulyvan de Castro2

DOI 10.5935/2595-0118.20190069

ABSTRACT Classification of Functioning, Disability and Health, for the population with chikungunya. BACKGROUND AND OBJECTIVES: Currently, chikungun- Keywords: Chikungunya fever, Disability and health, Interna- ya has become an important health problem due to its painful tional Classification of Functioning. symptomatology and the chronicity of this condition, which may compromise the functioning of individuals. Thus, using RESUMO the International Classification of Functioning, Disability and Health, which focuses on functioning in the biopsychosocial JUSTIFICATIVA E OBJETIVOS: Atualmente a chikungunya vem context, this review sought to detect and assist in the selection of se tornando um importante problema de saúde devido à sua sintoma- the most appropriate tool for measuring functioning in clinical tologia dolorosa e à cronicidade dessa condição, que pode compro- practice and research. The objective of this study was to review meter a funcionalidade dos indivíduos. Assim, através da utilização da the articles that have the functioning of individuals with chiku- Classificação Internacional de Funcionalidade, Incapacidade e Saúde, ngunya as an outcome, analyzing the instruments used for their que tem como foco a funcionalidade no contexto biopsicossocial, esta evaluation and their relationship with the Classification model. revisão buscou detectar e auxiliar na escolha da ferramenta mais ade- CONTENTS: Systematic review of the literature in the Scielo, quada para a medição da funcionalidade na prática clínica e nas pes- Pubmed, Scopus, LILACS, PEDro, and Cochrane databases. Ob- quisas. O objetivo deste estudo foi revisar as publicações que possuem servational or interventional studies were included. For the meth- a funcionalidade de indivíduos com chikungunya como desfecho, ana- odological evaluation of the articles, the Grading of Recommenda- lisando os instrumentos utilizados para sua avaliação, verificando sua tions Assessment, Development and Evaluation system was used. relação com o modelo da Classificação. From a total of 1579 studies found, after applying the inclusion/ CONTEÚDO: Revisão sistemática da literatura, nas bases de exclusion criteria, and reading, five articles remained. The follow- dados Scielo, Pubmed, Scopus, LILACS, PEDro e Cochrane. ing frequencies were analyzed: health condition (3.86%), function Foram incluídos estudos observacionais ou de intervenção. Para (3.86%), body structure (0.86%), activity (67.82%), engagement a avaliação metodológica dos artigos foi utilizado o sistema Gra- (8.15%), environmental factors (8.15%) and personal factors ding of Recommendations Assessment, Development and Evalua- (7.3%). Only one of the five articles covered all the domains of the tion. De um total máximo de 1579 estudos encontrados, após International Classification of Functioning. aplicação de critérios de inclusão/exclusão e leitura, restaram 5 CONCLUSION: There is a lack of tools that approach the func- artigos. Analisando a frequência dos domínios da Classificação tioning according to the model proposed by the International Internacional de Funcionalidade, Incapacidade e Saúde encon- trou-se: condição de saúde (3,86%), função (3,86%), estrutura do corpo (0,86%), atividade (67,82%), participação (8,15%),

Marina Carvalho Arruda Barreto - https://orcid.org/0000-0002-2505-6188; fatores ambientais (8,15%) e fatores pessoais (7,3%). Apenas um Bárbara Porfírio Nunes - https://orcid.org/0000-0001-8274-4203; dos cinco artigos contemplava todos os domínios.  Shamyr Sulyvan de Castro - https://orcid.org/0000-0002-2661-7899. CONCLUSÃO: Há carência de ferramentas que abordem a fun- 1. Universidade Federal do Ceará, Mestranda do Programa de Pós-Graduação em Saúde cionalidade de acordo com o modelo proposto pela Classificação Pública, Fortaleza, CE, Brasil. Internacional de Funcionalidade, Incapacidade e Saúde para a 2. Universidade Federal do Ceará, Fortaleza, CE, Brasil. população com chikungunya. Submitted on February 14, 2019. Descritores: Classificação Internacional de Funcionalidade, Fe- Accepted for publication on June 25, 2019. Conflict of interests: none – Sponsoring sources: none. bre de chikungunya, Incapacidade e saúde.

Correspondence to: Rua Dr. José Lourenço 816 apto 2101 INTRODUCTION 60115-281 Fortaleza, CE, Brasil. E-mail: [email protected] Chikungunya (CHIK) is a painful health condition caused © Sociedade Brasileira para o Estudo da Dor by the Aedes mosquito bite infected with the chikungunya 381 BrJP. São Paulo, 2019 oct-dec;2(4):381-5 Barreto MC, Nunes BP and Castro SS virus (CHIKV)1. After the year 2000, there was a geograph- of the search, and the other did not, creating the difference ical expansion of the CHIKV1-4. The main symptoms are found in the number. polyarthralgia, high fever in the early days, fatigue, edema, First, duplicate studies were excluded. Then, the screening headache, among others5,6. In the acute condition, the pop- by title and abstract was performed. The articles were read ulation reports difficulties in getting around and performing in full, with the selection of the eligible ones. All steps were their activities of daily and working life, adding to the loss- performed individually. In the end, both found the same ar- es in interpersonal relationships7,8. There are reports that the ticles, five in total. Many studies assessed functional capacity limitations remain in chronic stage9. Due to the painful and or quality of life and not functioning, as was the expected disabling symptoms, CHIK has become a major public health outcome, so they excluded. Some articles addressed function- problem10. ing in the microbiological aspects of mosquitoes. Figure 1 de- In the context of a holistic analysis of the person, not having scribes the selection process. the disease as the main focus, the World Health Organiza- The selected studies were assessed according to methodolog- tion (WHO) published the International Classification of ical quality using the Grading of Recommendations Assess- Functioning, Disability, and Health (ICF)11. This instrument ment, Development and Evaluation (GRADE). A system de- promotes an approach to functioning and disability in the signed to achieve unification that is sensitive to grading the biopsychosocial context12. It proposes a new approach that quality of evidence15,16. Publications can be graded into four increases environmental, personal, participation and activity levels of scientific evidence: high, moderate, low, very low. factors in understanding the individual’s situation13. Among the articles found, four had low evidence and one The ICF has seven domains: health condition, body func- moderate (Table 1). tions, and structures, activity, participation, environmental The selected articles assessed the functioning through question- and personal factors. There is a dynamic relationship between naires, with no repetition of instruments. The second stage of these domains, presenting itself as a network of correla- the research consisted of coding these instruments by the ICF tions11,14. The concept of functioning brought by the WHO domains. This process consisted of the extraction of significant is a complex interaction between the health condition and concepts considering the outcomes of the articles. The coding contextual factors through a single and standardized language according to the ICF domains was performed by two indepen- of health11. dent coders taking into account the established and published This study aimed to study the instruments used to measure rules21. The process findings were compared, and discrepancies functioning in individuals affected with CHIK and to com- resolved with the supervision of the third researcher. The cod- pare their consistency with the ICF model, seeking to detect ing data are described in table 2 and figure 2. whether these instruments are related to ICF, helping to make the most appropriate choice to measure functioning in clinical practice and research. Also, to check if the functioning is being All articles found All articles found (n=783) (n=1579) approached according to the model proposed by the ICF.

Duplicate articles Duplicate articles CONTENTS (n=197) (n=395)

A systematic literature review study conducted from May to Excluded after Excluded after July 2018. Scielo, Pubmed, Scopus, LILACS, PEDro and reading the title and reading the title and Cochrane databases were used in English, Portuguese, and abstract (n=563) abstract (n=1124) Spanish. The following descriptors were used: impairment, function- Articles to be read Articles to be read al performance, functionality, functional capacity, disability, in full (n=23) in full (n=60) chikungunya fever, chikungunya virus, in English, Portu- guese, and Spanish. The combination was applied as follows: Excluded after Excluded after Reading in full Reading in full [(“Impairment” OR “Functional Performance” OR “Func- (n=18), (n=55), tionality” OR “Functional Capacity” OR “Disability”)) AND because: because: (“Chikungunya Fever” OR “Chikungunya Virus”)]. Functionality was Functionality was The inclusion criteria for the selection of articles were publi- not the outcome not the outcome (n=10) (n=30) cations as of 2001 (year of publication of the ICF), and that Analyzed cellular Analyzed cellular assessed the functioning in individuals affected with CHIK. or microbiological or microbiological Review articles, theses, and dissertations were excluded. functionality functionality The search and selection of studies were performed by two (n=8) (n=25) researchers independently, with a third researcher for cases of disagreement, which was not necessary. The researchers found Articles selected for the review (n=5) 783 and 1579 articles, respectively. They used the same databases and descriptors, but one used the filters at the time Figure 1. Article selection flow 382 Instruments that evaluate the functioning in individuals BrJP. São Paulo, 2019 oct-dec;2(4):381-5 affected with chikungunya and the International Classification of Functioning. A systematic review

Table 1. General distribution of articles according to the number of participants, objectives, measurement instrument used and methodological quality score Authors No. of Objectives Functioning Quality participants instruments scores Sepúlveda- 10 Assess the association between joint involvement, self-repor- WHO Disability Assess- Low Delgado et al.17 ted disability, and inflammatory biomarkers. ment Schedule 2.0 Rahim et al.18 3869 Investigate the effects of chronic rheumatic and musculos- Health Assessment Ques- Low keletal symptoms on the functional status of people affected tionnaire (Modified - CRD by the chikungunya epidemic in Calicut district, Kerala, sou- pune version). thern India, in 2009. Moro et al.3 250 Describe the clinical course and outcome of long-term chikun- Recent-Onset Arthritis Moderate gunya infection. Disability (ROAD) Bouquillard 307 Analyze the characteristics and progression of rheumatic ma- Health Assessment Ques- Low et al.19 nifestations in patients with post-chikungunya joint pain. tionnaire Heath et al.20 240 Investigate epidemiological, demographic, physical, and Arthritis Impact Low behavioral risks. Measurement Scale Factors associated with the development of chikungunya virus-related chronic arthralgia in Granada

Table 2. Frequency distribution of the domains of the International Classification of Functioning and Health contained in each instrument Article Instruments ICF domains n (%) Sepúlveda-Delgado WHO Disability Assessment Schedule 2.0 Health condition n:9 (11.54%) et al.17 Function n:6 (7.7%) Body structure n:1 (1.28%) Activity n:39 (50%) Participation n:10 (12.88%) Personal factors n:8 (10.25%) Environmental factors n:5 (6.41%) Rahim et al.18 Health Assessment Questionnaire (Modified - CRD pune version). Activity n:46 (86.80%) Environmental factors n:7 (13.20%) Moro et al.3 Recent-Onset Arthritis Disability (ROAD) Function n:3 (13.04%) Body structure n:1 (4.35%) Activity n:18 (78.26%) Participation n:1 (4.35%) Bouquillard et al.19 Health Assessment Questionnaire Activity n:31 (100%) Heath et al.20 Arthritis Impact Measurement Scale Function n:2 (4%) Activity n:2 (48%) Participation n:8 (16%) Personal factors n:9 (18%) Environmental factors n:7 (14%)

80.00%

70.00% 67.82%

60.00%

50.00%

40.00%

Frequency 30.00%

20.00%

10.00% 8.15% 7.30% 8.15% 3.86% 3.86% 0.86% 0.00% Health Function Structure Activity Participation Personal Environmental condition factors factors ICF Domains

Figure 2. Domains of the International Classification of Functioning and Health that encodes the total frequency in the included instruments

383 BrJP. São Paulo, 2019 oct-dec;2(4):381-5 Barreto MC, Nunes BP and Castro SS

The frequency in which the domains appear in the collect- related to activities and environmental factors, showing a dis- ed instruments were: health condition (3.86%), function agreement between what the instrument proposes to assess and (3.86%), body structure (0.86%), activity (67.82%), partic- what is really being considered in its structure, treating func- ipation (8.15%), environmental factors (7.3%) and personal tioning in a limited way. factors (8.15%). All domains were covered by at least one Another instrument used is the Recent-Onset Arthritis Disabil- instrument, and only 1 covered all domains. ity in the validated version adapted for Italian patients with rheumatoid arthritis26. When checking the correspondence DISCUSSION with the ICF, it was noticed that the instrument addresses four domains. In addition, 78.26% of the questionnaire refers to There was a range of articles that aimed to assess the function- the activity, such as WHODAS 2.0, placing the other domains ing of people with CHIK. However, when analyzing the stud- in a lower position and approaching the outcome narrowly. The ies, the final sample consisted of five studies. This small number same was found in the Arthritis Impact Measurement Scale is due to the fact that most had the quality of life and/or func- (AIMS), when related to the ICF, its approach is mainly in the tional capacity as their outcome, not functioning. activity domain. When analyzing the years of publication, there was an in- The study by Bouquillard et al.19 used the Health Assessment crease from 2016 to 2018, a fact that may be correlated with Questionnaire that assessed functional status through 20 ques- the increased geographic distribution of the virus1. The ob- tions27. By correlating with the domains of the ICF, the tool jective of the selected publications is directly related to the addressed only the activity item, revealing the present biomed- confirmation of the profile of the population affected with ical perspective, not addressing important aspects of the ICF. CHIK, having functioning as an outcome, which is with the Only WHODAS 2.0 respects and addresses all the theoretical purpose of this review. concepts presented by the ICF. It was produced by WHO for Regarding the methodological assessment of the studies, most this purpose, as ICF does not assess but classifies it. The WHO publications are of low quality, showing that the methodologi- recommends the use of this instrument to measure function- cal elaboration needs to be more rigorous in execution, accord- ing24. AIMS was the second tool that most covered the doing to the GRADE system guidelines. mains, excluding Health Structure and Condition. Among the selected articles, there was no repetition of in- There was disagreement among the instruments when address- struments for the analysis of functioning, nor a consensus on ing functioning with the predominance of activity. Thus, it which tool to use to assess the given outcome. In contrast, seems that functioning is still understood in a reductionist and Gomes, Buranello and Castro22 found a physical test used in simplified way, placing activity in a higher importance perspec- nine studies, by reviewing the instruments that assess func- tive. However, the ICF seeks to treat its domains equally28. tioning in the elderly. Through the analysis of the research, some relevant data were It was observed that the population affected with CHIK has found: lack of validation of the instruments for people with pain and difficulties in moving one or some joints, mainly: CHIKV (used for the general population or rheumatic con- ankles, wrists, hands, and knees3,18,19, compromising the func- ditions), and one of the studies had a very small sample. Also, tioning of individuals to perform their activities and interper- almost all articles had low methodological quality, according sonal relationships. When analyzing the correlation of the in- to GRADE. struments with the ICF, a deficit in the structure domain was As a limitation of this study, there were a small number of arti- noted, where only one presented questions regarding this out- cles that assessed the outcome in CHIK. It is attributed to the come, present in one question. recent geographical expansion of the virus, resulting in a limit- The WHODAS 2.0 was one of the questionnaires chosen to ed number of studies that seek to determine the consequences perform functioning analysis in individuals with CHIK17. of this health condition. However, functioning is an indicator When analyzing the correlation with the ICF, it was noticed that has been gaining proportion in recent years, both in the that it addressed all domains, being the only one to present this field of science and health. Another limitation is regarding the characteristic, but 50% of its questions were activity-oriented, languages of the publications since the search took place in not homogeneous among the domains. WHO created it in- only three languages. tending to analyze health and disability levels based on ICF23,24. The study has a prominent character since functioning is be- Although not a validated instrument for CHIK, it is generic ing seen as one important indicator to assess the population’s and cross-cultural, providing a standard measurement of func- health29, and it is necessary to have an instrument that can ad- tioning for any health condition24. dress this outcome entirely. CHIK has become a major public Rahim et al.18 used the Health Assessment Questionnaire (Mod- health problem and data from this population need to be ob- ified – CRD Pune version), a version of the Stanford Health tained for better clinical management. Assessment Questionnaire validated and modified for the Indi- an population25. This tool is widely used to assess rheumatic pa- CONCLUSION tients. The questionnaire focuses on the assessment of physical function and quality of life25, addressing only one aspect related The instruments used to measure functioning have shown to be to functioning. The relationship with the ICF reveals questions related to the conceptual framework of the ICF, but most did 384 Instruments that evaluate the functioning in individuals BrJP. São Paulo, 2019 oct-dec;2(4):381-5 affected with chikungunya and the International Classification of Functioning. A systematic review not contemplate the structure in its entirety. WHODAS 2.0 the World Health Organization’s international classification]. Cad Saude Publica. 2009;25(3):475-83. Portuguese. stands out as the most reliable option for the assessment of this 14. Farias N, Buchalla CM. A Classificação Internacional de Funcionalidade, Incapaci- outcome, as it can cover all the concepts proposed by the classi- dade e Saúde da Organização Mundial da Saúde: Conceitos, Usos e Perspectivas. Rev Bras Epidemiol. 2005;8(2):187-93. fication, but it has limitations, lacking validated tools that show 15. GRADE Working Group. GRADE working group. gradeworkinggroup.org/2016. a complete approach to functioning and validated for the CHIK 16. Brasil. Ministério da Saúde. Secretaria de Ciência T e IED de C e T. Diretrizes meto- population. In addition, it is clear that the choice of instruments dológica. Sistema GRADE – manual de graduação da qualidade da evidência e força de recomendação para tomada de decisão em saúde. 2013; 53:1689-99. to measure functioning is not being made considering the rela- 17. Sepúlveda-Delgado J, Vera-Lastra OL, Trujillo-Murillo K, Canseco-Ávila LM, Sán- tionship with the ICF. chez-González RA, Gómez-Cruz O, et al. Inflammatory biomarkers, disease activity index, and self-reported disability may be predictors of chronic arthritis after chikungunya infection: brief report. Clin Rheumatol. 2017;36(3):695-9. REFERENCES 18. Rahim AA, Thekkekara RJ, Bina T, Paul BJ. Disability with persistent pain following an epidemic of chikungunya in rural South India. J Rheumatol. 2016;43(2):440-4. 1. Burt FJ, Chen W, Miner JJ, Lenschow DJ, Merits A, Schnettler E, et al. Chikungunya 19. Bouquillard E, Fianu A, Bangil M, Charlette N, Ribéra A, Michault A, et al. Rheu- virus: an update on the biology and pathogenesis of this emerging pathogen. Lancet matic manifestations associated with Chikungunya virus infection: a study of 307 Infect Dis. 2017;17(4):e107-17. patients with 32-month follow-up (RHUMATOCHIK study). Joint Bone Spine. 2. Leparc-Goffart I, Nougairede A, Cassadou S, Prat C, de Lamballerie X. Chikungunya 2018;85(2):207-10. in the Americas. Lancet. 2014;383(9916):514. 20. Heath CJ, Lowther J, Noël TP, Mark-George I, Boothroyd DB, Mitchell G, et al. 3. Moro ML, Grilli E, Corvetta A, Silvi G, Angelini R, Mascella F, et al. Long-term The identification of risk factors for chronic chikungunya arthralgia in Grenada, West chikungunya infection clinical manifestations after an outbreak in Italy: a prognostic Indies: a cross-sectional cohort study. Open Forum Infect Dis. 2018;5(1):ofx234. cohort study. J Infect. 2012;65(2):165-72. 21. Cieza A, Fayed N, Bickenbach J, Prodinger B. Refinements of the ICF Linking Rules 4. Van Bortel W, Dorleans F, Rosine J, Blateau A, Rousseau D, Matheus S, et al. Chikun- to strengthen their potential for establishing comparability of health information. Di- gunya outbreak in the Caribbean region, December 2013 to March 2014, and the sabil Rehabil. 2019;41(5):574-83. significance for Europe. Euro Surveill. 2014;19(13). pii:20759. 22. Gomes CS, Buranello MC, Castro SS. Assessment instruments of functioning in Bra- 5. van Aalst E, Nelen CM, Goorhuis A, Stijnis C, Grobusch MP. Long-term sequelae of zilian elderly and the ICF: a systematic review. Fisioter. Mov. 2017;30(3):625-37. chikungunya virus disease: a systematic review. Travel Med Infect Dis. 2017;15:8-22. 23. Üstün T, Kostanjsek N, Chatterji S, Rehm J. Measuring Health and Disability: Ma- 6. Vijayan V, Sukumaran S. Chikungunya virus disease an emerging challenge for the nual for WHO Disability Assessment Schedule WHODAS 2.0. World Health Orga- rheumatologist. J Clin Rheumatol, 2016;22(4):203-11. nization. 2010. 7. Couturier E, Guillemin F, Mura M, Léon L, Virion JM, Letort MJ, et al. Impaired 24. Castro SS, Leite CF, Osterbrock C, Santos MT, Adery R. Avaliação de Saúde e Defi- quality of life after chikungunya virus infection: a 2-year follow-up study. Rheumato- ciência: Manual do WHO Disability Assessment Schedule (WHODAS 2.0). Ubera- logy. 2012;51(7):1315-22. ba: Universidade Federal do Triângulo Mineiro - UFTM; 2015. 153p. 8. Weaver SC, Lecuit M. Chikungunya virus and the global spread of a mosquito-borne 25. Chopra A, Saluja M. Validation and usefullness of Indian version (CRD Pune) health disease. N Engl J Med. 2015;372(13):1231-9. assessment questionnaire: Drug trials, community practice and COPCORD Bhigwan 9. Marimoutou C, Ferraro J, Javelle E, Deparis X, Simon F. 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385 BrJP. São Paulo, 2019 oct-dec;2(4):386-9 REVIEW ARTICLE

In vivo methods for the evaluation of anti-inflammatory and antinoceptive potential Métodos in vivo para avaliação do potencial anti-inflamatório e antinociceptivo

Silvio de Almeida Junior1

DOI 10.5935/2595-0118.20190070

ABSTRACT CONTEÚDO: Para a avaliação dessas atividades é necessário um estímulo, sendo que a indução de processo inflamatório ou noci- BACKGROUND AND OBJECTIVES: The constant search ceptivo pode ser por indutores químicos como formol, carrageni- for bioactive compounds with anti-inflammatory and antinoci- na, entre outros, ou ainda, equipamentos eletrônicos como placa ceptive activities are of interest to research centers. For the char- quente. Para todos os ensaios, sempre é realizada a mensuração acterization of these activities, trials on guinea pigs are necessary. basal e posterior à administração do composto que está sendo estu- Therefore, the purpose of this study was to demonstrate some dado em comparação com um grupo controle. O planejamento do methods to evaluate the anti-inflammatory and antinociceptive experimento, assim como toda a condução conforme protocolos já potential of natural products. bem ilustrados, são ferramentas importantes no êxito do trabalho. CONTENTS: A stimulus is required to evaluate these activities, Os testes apresentados avaliaram atividade antinociceptiva e anti- and the induction of inflammatory or nociceptive process can -inflamatória assim como mecanismos envolvidos. be by chemical inducers like formaldehyde, carrageenan, among CONCLUSÃO: Foi possível avaliar que os testes presentes na others, or electronic equipment such as the hot plate. For all literatura hoje, atendem a necessidade do pesquisador na eluci- assays, the baseline and post-dose measurement of the studied dação da atividade anti-inflamatória e atividade antinociceptiva compound is always compared with a control group. The plan- de novos compostos. ning of the experiment, as well as its conduct in accordance with Descritores: Contorção abdominal, Edema de pata, Formalina, well-established protocols, are important tools in the success of Placa quente. the work. The tests presented evaluated the antinociceptive and anti-inflammatory activity as well as the mechanisms involved. INTRODUCTION CONCLUSION: It was possible to evaluate that the tests present in the literature today meet the researcher’s need for the elu- Natural products that carry biological activities are consumed cidation of the anti-inflammatory and antinociceptive activity of daily around the world to help maintain human health, an new compounds. ancient tradition that has been inherited for millennia. From Keywords: Abdominal contortion, Formalin, Hot plate, Paw edema. popular knowledge, scientific investigation of the efficacy of these products is necessary1. Among the diversity of natural RESUMO products found, only a small portion have their phytochem- ical characterizations and biological potential investigated. JUSTIFICATIVA E OBJETIVOS: A busca constante por compos- The steps for clarification, such as isolation, identification, tos bioativos com atividade anti-inflamatória e antinociceptiva são and obtaining structural analogous of the active metabolite, de interesse dos centros de pesquisas. Para a caracterização dessas associated with knowledge of the pharmacological, toxicolog- atividades são necessários ensaios em cobaias. Frente a isso, o objeti- ical potential and mechanism of action of these substances are vo deste estudo foi demonstrar alguns métodos para a avaliação do fundamental to obtain and develop new therapeutic agents2,3. potencial anti-inflamatório e antinociceptivo de produtos naturais. The selection of active compounds present in natural products is a significant challenge faced by researchers, as is the elucidation of the mechanisms of action of these compounds.

Silvio de Almeida Junior - https://orcid.org/0000-0002-7949-4941. Discoveries require biological assays, which should be chosen with caution, since they need to be accurate in detecting the 1. Universidade de Franca, Laboratório de Ciência Animal, Franca, SP, Brasil. specific effect, have sensitivity and reproducibility4. Submitted on March 18, 2019. The amount of research carried out in search of compounds Accepted for publication on June 25, 2019. that are effective for application as an anti-inflammatory Conflict of interests: none – Sponsoring sources: Coordenação de Aperfeiçoamento de Pes- soal de Nível Superior - Brasil (CAPES) - Código de Financiamento 001. agent or with antinociceptive activity and which bring benefits with the fewest possible adverse effects caused by their use Correspondence to: Avenida Dr. Armando Salles de Oliveira, 201 - Parque Universitário is well known. For the good conduct of the experiments, it is 14404-600 Franca, SP, Brasil. necessary the previous study of the methodologies that will E-mail: [email protected] be applied, as well as the tested doses and number of animals. © Sociedade Brasileira para o Estudo da Dor One of the most commonly used tests for antinociceptive 386 In vivo methods for the evaluation of BrJP. São Paulo, 2019 oct-dec;2(4):386-9 anti-inflammatory and antinoceptive potential evaluation is the formalin test. There were 395 articles pub- at two moments: the so-called neurogenic phase and the in- lished, and the anti-inflammatory activity is paw edema, with flammatory phase. The test is performed with mice receiving 244 articles, as evidenced by consulting the Pubmed database, treatment 1h before the beginning of the test, along with neg- in 2018 (until October). ative control (vehicle), and positive control intraperitoneally Therefore, this study aimed to address the topics related to the (usually morphine, 2.5mg/kg b.w., i.p. administered 40 min- main in vivo methods for the evaluation of new compounds utes before the analysis). The test begins with the intraplantar with anti-inflammatory and antinociceptive potential, as well injection of 20µL of formalin at 2.5% in the right posterior as the mechanisms involved. pelvic limb and measuring the time the animal licks, shakes or bites the formalin-injected paw. From zero to five minutes are CONTENTS necessary to evaluate the painful sensitivity in the so-called neurogenic phase, in which the direct activation of nocicep- Due to the rejection rate of drugs available on the market due tors by the chemical agent occurs. Then, 15 to 30 minutes to the adverse effects, it is necessary to study new compounds to determine pain sensitivity in the phase called inflamma- with effective activities. Within ethnobotany, it is necessary tory pain, which involves the spinal cord-reinforced synaptic to evaluate these activities, since the number of publications transmission, as well as the release of local mediators such as is increasing within this area. The selection of promising prostaglandins and histamines13. compounds within anti-inflammatory and analgesic activities begins with the culture of folk medicine followed by the Formalin-induced orofacial pain. Adapted14 chemical evaluation of these natural products. The literature The formalin-induced orofacial pain test is performed to eval- mentions compounds such as alkaloids, essential oils, flavo- uate analgesia in the trigeminal nerve region of action where noids, tannins, saponins, and phenolic compounds as respon- the literature describes several related diseases, leading to a sible for the expected anti-inflammatory and analgesic activ- mild to severe chronic pain. The test can be performed on ity, with greater effect than the drugs found in the market5,6. rats or mice and consists of applying 50µL of the irritant To prove these activities, it is necessary to use animal models substance, in this case, formalin at 2%, in the right cushion according to protocols, always respecting the ethical principles. region of the animal’s vibrissae. The application is subcuta- All procedures must go through their own committee, responsi- neous, and the grooming process is evaluated by scratching ble for the evaluation before the beginning of the experiments. the area where the formalin was applied to the front limbs, Another important observation is the use of the smallest num- evaluating how often the animal performed the self-cleaning ber of animals possible, correct application of the techniques, act, compared to controls15,16. and the minimum suffering caused to the animal7,8. Hot plate test17 Animal selection The assay consists of exposing the animal to a hot surface for Animals such as Mus musculus mice, weighing on average thermal stimulation to evaluate central mechanism-mediated 30±5g, and Rattus norvegicus rats weighing 150±20g on av- analgesic activity. It is a model that assesses the antinocicep- erage are used as a model for in vivo testing. The choice of an tive activity of opioid drugs, but other centrally active drugs, animal model is based on the test performed and the expected such as sedatives and hypnotics, show activity in this exper- result. It is advised to acclimate the animal for seven days, un- imental model18. The motor performance evaluation aims to der controlled temperature conditions (25±3° C) and light/ detect the occurrence of motor incoordination, allowing a dark (12h) cycle with plenty food and water9. more accurate interpretation of the test results to determine the antinociceptive activity. Therefore, drugs that promote Acetic acid-induced writhing tests10 relaxation or sedation alter the motor performance and may The abdominal writhing test in mice is a widely used method interfere with the response, without necessarily being anti- to evaluate the analgesic activity of substances against pain of nociceptive19. For this, a hot plate kept at 55ºC should be inflammatory origin, where the acetic acid (AA) in the con- used, where the animal will be placed during the time limit of centration of 0.6% (0.1mL/10g of the animal) induces lesions 20s or until it flicks its paw to perform the act of licking (la- on the abdomen of the mice, which is enough to cause the tency time). Measurements should be performed at zero, 30, spasms translated as writhing. The compound being tested 60, and 90 minutes after treatment. Along with the treated must be applied at the pre-defined concentrations. After 60 groups, one group with morphine (4.0mg/kg b.w.) should be minutes, apply the peritoneal injection of AA and place the included as the reference compound17. animal in an acrylic box so that it is possible to observe the number of contractions performed for 20 minutes11. Randall-Selitto test20 It is used for nociceptive evaluation that tests the gastroc- Evaluation of analgesic and/or anti-inflammatory activity nemius muscle pressure. Pain measurement requires the use by formalin test12 of an analgesiometer (Ugo-Basile, Stoelting, Chicago, IL). To The formalin test is a test performed to evaluate analgesia, perform the test, animals, usually rats, are allowed to rest in which consists of the evaluation of the inflammatory process a dimly lit room with controlled temperature to reduce the 387 BrJP. São Paulo, 2019 oct-dec;2(4):386-9 Almeida Junior S stress level. After 30 minutes, the animal has the lower pelvic In addition to carrageenan31, which is the most used proinflam- limb placed on the equipment. After placing the animal, the matory mediator, histamine32, dextran33, xylene, and serotonin34, equipment begins to apply pressure in grams, gradually, until bradykinin and prostaglandin can be used35. the animal feels discomfort, flicking the limb or vocalizing. The equipment itself records the pressure supported in grams. Croton oil-induced ear edema in mice36 The test should be performed before the administration of The importance of the test is to evaluate the ability to inhibit the drug tested and within 30 min, 1, 2, 3, and 4 hours, and edema formation in the ear of the animals tested after the topical compared with known analgesic drugs21,22. application of croton oil. To perform this test, the compound of interest should be administered one hour before on the surface of Von Frey test23 the inner ear. It should be decided which ear will receive the in- The von Frey test, or rat paw gradually increase pressure test, conduction of the inflammatory process with croton oil, and which sists of applying pressure in grams to the rat’s hind limbs through will receive acetone in the same quantity as the oil for the nega- electronic equipment. Initially, the described test used manual tive control. Measure the edema formation with the application forms and has been changed to electronic forms for better and of the compound, and in acetone. The test can also be used by more accurate results; however, it is still possible to find work adding a group of animals tested with drugs already known in performed with manual equipment. The animal is positioned the market, such as indomethacin and dexamethasone37. on the equipment, and through von Frey’s rigid-tip monofila- ments, the mechanical pain thresholds are applied and measured Carrageenan-induced peritonitis38 in grams. This test is used to evaluate the antinociceptive activity. It is possible to produce an inflammatory response, using car- The test is performed up to six times so that it is possible to ob- rageenan, in the peritoneal cavity with predominance of many tain a measurement of three close paw flick values after applying polymorphonuclear cells present in the exudate. The treatment a linear pressure. The result is quantified as the change in pres- of the animals should be performed with the group of the vehicle sure (D reaction in grams) obtained by subtracting the average used, a group with NSAID drug and test groups with well-de- of three values expressed in grams (strength) observed before the fined concentrations. Apply carrageenan by intraperitoneal injec- experimental procedure (zero hour) from the average of three tion and wait for 4 hours for the animal to have an anti-inflam- values in grams (strength) after the administration of the stimuli matory action and exudate formation. After the expected period, that vary according to the experiment24. euthanize the animal and wash the peritoneum with heparinized PSB solution for polymorphonuclear cell counting. The number Tail flick test20 of leukocytes should be compared to the test group for analysis39. It is used to evaluate the antinociceptive activity promoted by the central nervous system and is simple to perform. The animal Pleurisy40 (rat) is placed on the equipment, and its tail rested on a spot In the pleurisy test, the systemic anti-inflammatory effect is eval- where a beam of light will be focused that will heat the animal’s uated through the exudate volume, that is, in an inflammatory tail. A baseline test should be performed, and animals with tail process in the pleural region, the number of existing proteins flick time longer than 7.9s should be excluded. After the admin- tends to increase, and the number of defense cells (leukocytes) istration of the evaluated natural product, perform the measure- increases significantly41. In order to perform this study, a ga- ment within 2 hours (30, 60, 90, 120 minutes)19,25. vage treatment must be performed in the animals of the control group, with vehicle solution, a group with a known drug, Carrageenan-induced intraplantar edema26 and test groups with well-defined concentration, and after 60 Intraplantar injection of carrageenan induces an acute and pro- minutes, induce the inflammatory process with carrageenan gressive increase in the volume of the injected paw. This edema, injection into the pleural region. Six hours after the induction which is proportional to the intensity of the inflammatory re- of the inflammatory process, the animals should be euthanized, sponse, is a useful parameter in the evaluation of the anti-inflam- and the pleural cavity opened. Rinse with physiological solution matory activity. Carrageenan triggers the inflammatory process and EDTA (Ethylenediaminetetraacetic acid) and perform cell mediated by prostaglandins, reaching pick levels between 2 and count in a Neubauer chamber, always comparing to the negative 3 hours after application27,28. The inhibition of the edema caused control42. by carrageenan involves the mechanism related to the prostaglandin synthesis, especially PGE2α and PGF2α, and its activity is CONCLUSION compared to non-steroidal anti-inflammatory drugs (NSAIDs)29. Before testing, the volume of the animal’s lower pelvic limb (hind The benefits that are achieved during these studies are undeni- paw) should be evaluated by plethysmometry. The administration able, but ethical principles must be followed in using the number should be in a vehicle control group to assess the solvent used for of animals tested and expected results. The use of animals for ex- solubilization of the tested compound, a control group with an perimental purposes is of paramount importance, and it is up to NSAID, and the test groups with well-defined doses. After 1h of the researcher to know how to choose the best tests that support the application, the volume should be measured at 30, 60, 120, the hypothesis towards the obtention of molecules with analgesic and 180 minutes by the paw injection in the plethysmometer9,30. or anti-inflammatory potential. 388 In vivo methods for the evaluation of BrJP. São Paulo, 2019 oct-dec;2(4):386-9 anti-inflammatory and antinoceptive potential

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389 BrJP. São Paulo, 2019 oct-dec;2(4):390-1 CASE REPORT

Notalgia paresthetica and neuropathic itch. Case report Notalgia parestésica e prurido neuropático. Relato de caso

Thiago Alves Rodrigues1, Eduardo José Silva Gomes de-Oliveira1, João Batista Santos Garcia1

DOI 10.5935/2595-0118.20190071

ABSTRACT RESUMO

BACKGROUND AND OBJECTIVES: Notalgia paresthetica JUSTIFICATIVA E OBJETIVOS: A notalgia parestésica é um is a neuropathic sensory syndrome located in the dorsal region distúrbio neuropático sensitivo que acomete a região dorsal entre between T2-T6 dermatomes and is characterized by a chron- os dermátomos de T2 a T6, caracterizando-se por uma evolução ic evolution with periods of remission and exacerbation. The crônica com períodos de remissão e exacerbação. O objetivo des- objective of this study was to demonstrate a case of notalgia te relato foi descrever um caso de notalgia parestésica, desde a sua paresthetica, from its clinical and laboratory investigation to investigação clínica e laboratorial até a conduta adotada. the treatment adopted. RELATO DO CASO: Paciente do sexo feminino, 77 anos, apo- CASE REPORT: A 77-year-old female patient, retired, attended sentada, compareceu para atendimento no Serviço Ambulato- the Outpatient Pain Service of the University Hospital of the rial de Dor do Hospital Universitário da Universidade Federal Federal University of Maranhão. The main complaint was severe do Maranhão, tendo como queixa principal prurido intenso em pruritus in the right dorsal region with extension to the breasts, região dorsal direita com extensão para as mamas, associada a associated with intermittent pain, burning, shock and tingling, dor intermitente, em queimação, choque e pontadas, piorando worsening with physical effort and movement. Her sleep quality com esforço físico e movimento. Seu sono não era reparador. Ao worsened because of the pain. At the physical examination, no exame físico, não referiu dor à palpação do local, com discreta pain was reported on palpation of the site, with mild hypoes- hipoestesia em dermátomos T5 e T6, não havendo alteração de thesia in T5 and T6 dermatomes, without altering the thermal sensibilidade térmica. Negava histórico de lesões de pele. A pa- sensitivity. She denied a history of skin lesions. The patient re- ciente recebeu tratamento conservador farmacológico, havendo ceived conservative pharmacological treatment, with significant melhora importante do prurido, da dor e da qualidade do sono improvement in pain and sleep quality after six months. após seis meses. CONCLUSION: Notalgia paresthetica is a syndrome of un- CONCLUSÃO: A notalgia parestésica é uma síndrome de etio- known etiology, and the lack of studies makes it difficult to op- logia ainda desconhecida, em que a escassez de estudos dificulta timize the indications and recommendations to direct the treat- uma otimização das recomendações para direcionar o tratamen- ment. This report illustrates the handling of a case of paresthetica to. Este relato ilustrou o manuseio de um caso de notalgia pares- notalgia where gabapentin was used as therapeutic management tésica onde o tratamento com gabapentina foi empregado para o for pain control, for which it proved to be efficient. controle de dor, para o qual se mostrou eficiente. Keywords: Neuralgia, Pain, Pharmacologic treatment, Pruritus. Descritores: Dor, Neuralgia, Prurido, Tratamento farmacológico.

INTRODUCTION

Notalgia paresthetica (NP), first mentioned in 1934 by Astwaza- turow1 derives from the Greek vocabulary, notos (dorsum) and al- gos (pain), and is poorly described in the literature. Nevertheless, it is believed to be a common but underdiagnosed condition2,3. Thiago Alves Rodrigues - https://orcid.org/0000-0003-3086-6844; It is a sensory neuropathic syndrome that affects the dorsal re- Eduardo José Silva Gomes de-Oliveira - https://orcid.org/0000-0003-0883-4774; gion between the T2 to T6 dermatomes and is characterized by João Batista Santos Garcia - https://orcid.org/0000-0002-3597-6471. a chronic evolution with periods of remission and exacerbation. 1. Universidade Federal do Maranhão, Hospital Universitário, Ambulatório de Dor Crônica, The diagnosis is clinical, and the symptoms are localized itching São Luís, MA, Brasil. associated with burning sensation, paresthesia, hyperesthesia and Submitted on April 26, 2019. may present a well-delimited area of hyperpigmentation in the Accepted for publication on September 16, 2019. interscapular region3. Conflict of interests: none – Sponsoring sources: none. The etiology is not well established, but is considered multifac- Correspondence to: torial, including genetic predisposition, increased local skin in- Thiago Alves Rodrigues R. Barão de Itapari, 282 – Centro nervation, chemical agent neurotoxicity, and spinal nerve injury 65070-220 São Luís, MA, Brasil. due to chronic trauma and/or compression by degenerative spi- E-mail: [email protected] nal changes, or adjacent soft tissues 4. Also, females have been © Sociedade Brasileira para o Estudo da Dor described in the literature as the most affected, but there is no 390 Notalgia paresthetica and neuropathic itch. Case report BrJP. São Paulo, 2019 oct-dec;2(4):390-1 preference for race. It is a disease that appears in adulthood, con- hyperpigmented skin in the dorsal region, secondary to chronic sidered benign, but directly affects the quality of life of patients3. scratches and friction of the symptomatic area2,5-9. The objective of this report was to show an NP case, since its The etiology is still unknown, although it is thought to be neu- clinical and laboratory investigation to the adopted approach. ropathic pruritus caused by sensory nerve compression involving the posterior branches of the nerve roots from T2 to T6, and is CASE REPORT mainly associated with degenerative changes in the vertebrae2,5. Eventually, nerve compression can cause very intense dysesthesia Female patient, 77 years old, retired, attended for treatment at and paresthesia, typically located in the region of the skin that the Chronic Pain Outpatient Clinic of the University Hospital is innervated by the injured nerve. This painful sensation occurs of the Federal University of Maranhão (HUUFMA), reporting when the neurons responsible for integrating or transporting the as main complaint intense itching in the right dorsal region, itching perception are injured in any part of the peripheral or extending to the inframammary region, associated with inter- central nervous system, accounting for about 8% of all chronic mittent pain, burning sensation, shock and stinging, worsening pruritus cases6-8. when moving or making efforts. Sleeping was not restful. Among Systemic drugs currently used to treat patients with NP, with her personal history, she reported a diagnosis of osteoporosis and favorable results in relieving pruritus and pain, include gabapen- tuberculosis five years before the appointment, denying diabe- tinoids, tricyclic antidepressants, antihistamines, non-steroidal tes mellitus, hypertension, and allergies. She denied a history of anti-inflammatory drugs, oral muscle relaxants, and anticonvul- dorsal skin lesions. On physical examination, the patient had sants3. In this case, we chose to use gabapentin, achieving satis- no palpable tense muscle band and trigger points in the affected factory results as presented in some studies, with decreased pain region. There was no pain on palpation of the site, with mild hy- intensity and pruritus9,10. poesthesia in T5 and T6 dermatomes, with no change in thermal Other available forms of treatment described are topical cap- sensitivity. The dermoscopy was normal. saicin cream, topical corticosteroids, topical anesthetics (lido- Nuclear magnetic resonance (NMR) of the cervical spine, tho- caine), skin stimulation, paravertebral nerve block, and spinal rax, and pelvis showed no changes. The lumbar NMR showed a nerve decompression surgery. However, there is no treatment degenerative discopathy with mild disc protrusion. Chest com- considered as the standard. The evaluation of its effectiveness in puted tomography (CT) showed bilateral apical pleural thicken- NP is hampered by the lack of papers on the subject2,3. ing and bronchiectasis. The diagnostic hypothesis was NP, based on the main complaint CONCLUSION of severe itching, subjective description of pain, and signs present on physical examination. The patient started the clinical This report corroborated some findings already described in the treatment with gabapentin (300 mg) every 12 hours, orally, and literature, such as the good response to the use of gabapentinoids codeine (30 mg) in case of pain. in patients diagnosed with PN. However, further studies are need- After six months of treatment, the patient reported complete ed to characterize better and understand the pathogenesis of this remission of the pruritus, with only a mild back pain in that disease, as well as to optimize and standardize the chosen therapy. interval, with full recovery using codeine. There was also an improvement in sleep quality. In addition to the pharmacological REFERENCES treatment, respiratory and motor home physical therapy were associated. 1. Astwazaturow M. Über parästhetische Neuralgien und eine besondere form derselben-notalgia paraesthetica. Deutsche Zeitschrift für Nervenheilkunde. 1934;133(3-4):188-96. 2. Shin J, Kim YC. 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Dermatol Ther. 1,5 2013;26(2):104-9. poesthesia, between the dermatomes T2 and T6 . It has no pref- 7. Hachisuka J, Chiang MC, Ross SE. Itch and neuropathic itch. Pain. 2018;159(3):603-9. erence for a race and is described worldwide. It is not considered 8. Misery L, Brenaut E, Le Garrec R, Abasq C, Genestet S, Marcorelles P, et al. Neuro- a severe condition but has a significant impact on the quality of pathic pruritus. Nat Rev Neurol. 2014;10(7):408-16 3 9. Maciel AA, Cunha PR, Laraia IO, Trevisan F. Efficacy of gabapentin in the impro- life . It is clinically characterized by localized itching associated vement of pruritus and quality of life of patients with notalgia paresthetica. An Bras with pain, usually intermittent and paroxysmal, with varying Dermatol. 2014;89(4):570-5. 10. Loosemore MP, Bordeaux JS, Bernhard JD. Gabapentin treatment for notalgia pa- intensity. In addition to a burning or cold sensation, there are resthetica, a common isolated peripheral sensory neuropathy. J Eur Acad Dermatol complaints of paresthesia, hyperesthesia, and well-circumscribed Venereol. 2007;21(10):1440-1.

391 BrJP. São Paulo, 2019 oct-dec;2(4):392-4 CASE REPORT

Sphenopalatine ganglion block for post-dural puncture headache after invasive cerebrospinal fluid pressure monitoring. Case report Bloqueio esfenopalatino para cefaleia pós-punção dural causada por monitorização invasiva de pressão liquórica. Relato de caso

Felipe Chiodini Machado1, Gilson Carone Neto1, Hazem Adel Ashmawi1

DOI 10.5935/2595-0118.20190072

ABSTRACT RESUMO

BACKGROUND AND OBJECTIVES: Post-dural puncture JUSTIFICATIVA E OBJETIVOS: A cefaleia pós-punção pon- headache is a common complication in neuraxial anesthesia and tual é uma complicação comum nos procedimentos de anestesia lumbar puncture diagnostic procedures. The pathogenesis of the neuroaxial e punção lombar diagnóstica. Acredita-se que a pato- headache is thought to be due to a leak of cerebrospinal fluid gênese da cefaleia seja devida a um vazamento de líquido cefalor- from the puncture site that exceeds the rate of cerebrospinal fluid raquidiano do local da punção que excede a taxa de produção de production, causing a downward traction of the meninges and líquido cefalorraquidiano, causando uma tração descendente das vasodilation of the meningeal vessels mediated by the autono- meninges e vasodilatação dos vasos meníngeos mediada pelo sis- mous nervous system. Nowadays, the conservative treatment tema nervoso autônomo. Atualmente, o tratamento conservador involves hydration, and the use of caffeine, analgesics, hydrocor- envolve a hidratação e o uso de cafeína, analgésicos, hidrocortiso- tisone, gabapentin, and theophylline. However, an autologous na, gabapentina, teofilina, porém, o tampão sanguíneo peridural epidural blood patch is considered the definitive treatment for autólogo é considerado o tratamento definitivo para a cefaleia post-dural puncture headache and has an efficacy of up to 75%. pós-punção pontual e tem eficácia de até 75%. Dado que esse Since this procedure comes with intrinsic risks, an alternative is procedimento vem com riscos intrínsecos, uma alternativa é o the sphenopalatine ganglion block. bloqueio ganglionar esfenopalatino. CASE REPORT: We describe a case report using a sphenopal- RELATO DO CASO: O estudo relata um caso utilizando com atine ganglion block to treat post-dural puncture headache in sucesso o bloqueio ganglionar esfenopalatino para tratar cefaleia a patient submitted to cerebrospinal fluid pressure monitoring pós-punção dural em um paciente submetido à monitorização with a subarachnoidal catheter inserted with a low-gauge needle. da pressão liquórica com um cateter subaracnoideo inserido com CONCLUSION: This is the first case report of a post-dural uma agulha de pequeno calibre. puncture headache caused by a subarachnoid monitoring cathe- CONCLUSÃO: Este é o primeiro relato de caso de cefaleia pós- ter successfully treated with sphenopalatine ganglion block. This -punção dural causada por um cateter subaracnoideo de monito- technique can be a non-invasive option in the management of rização de pressão liquórica e tratada com sucesso com o uso de post-dural puncture headache, which requires more study to bloqueio de gânglio esfenopalatino. Esta técnica pode ser uma das evaluate its efficacy and safety. opções não invasivas no manuseio da cefaleia por hipotensão li- Keywords: Headache, Post-dural puncture headache, Spheno- quórica e requer maior estudo para avaliar sua eficácia e segurança. palatine ganglion block. Descritores: Bloqueio do gânglio esfenopalatino, Cefaleia, Cefa- leia pós-punção dural.

INTRODUCTION

Post-dural puncture headache (PDPH) is a common compli- Felipe Chiodini Machado - https://orcid.org/0000-0003-1615-2597; cation in neuraxial anesthesia and lumbar puncture diagnostic Gilson Carone Neto - https://orcid.org/0000-0001-8604-8985; Hazem Adel Ashmawi - https://orcid.org/0000-0003-0957-971X. procedures. The incidence of PDPH is inversely proportional to the gauge of the needle which punctures the dura, thus 1. Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Disciplina de Anestesiologia. São Paulo, SP, Brasil. in anesthesia it is more common for the patient to experience PDPH after accidental dural puncture with 16-gauge Tuohy Submitted on May 02, 2019. needle (70% chance of PDPH) than after dural puncture with Accepted for publication on September 27, 2019. 1 Conflict of interests: none – Sponsoring sources: none. 29-gauge Quincke needle (less than 2%) . The pathogenesis of the headache is thought to be due to a leak of cerebrospinal fluid Correspondence to: Rua Oscar Freire, 1929/404 from the puncture site that exceeds the rate of cerebrospinal fluid 05409-011 São Paulo, SP, Brasil. production, causing a downward traction of the meninges and E-mail: [email protected] vasodilation of the meningeal vessels mediated by the autono- © Sociedade Brasileira para o Estudo da Dor mous nervous system1. 392 Sphenopalatine ganglion block for post-dural puncture headache BrJP. São Paulo, 2019 oct-dec;2(4):392-4 after invasive cerebrospinal fluid pressure monitoring. Case report

Nowadays, the conservative treatment involves hydration and the use of caffeine, analgesics, hydrocortisone, gabapentin, the- ophylline2. Nevertheless, such treatment is not always effective, and an interventional technique is applied. Autologous epidural blood patch (AEBP) is considered the definitive treatment for PDPH and has an efficacy of up to 75%1,3. However, this procedure comes with intrinsic risks, such as difficulty in identifying the epidural space, a new accidental dural puncture, patient discomfort during the procedure, infection, hemorrhagic and neurologic complications4. An alternative between conservative treatment and the AEBP is the sphenopalatine ganglion block (SPGB). The sphenopalatine ganglion is a neural structure located in the pterygopalatine fossa and has both a sympathetic and a parasympathetic component of the autonomous system, as well as somatic sensory roots. It can be accessed through transcutaneous or transnasal approaches. The SPGB has been successfully used in pain clinic practice to treat chronic headaches, atypical facial pain, and even trigeminal neuralgia5,6. The transnasal approach7 is a noninvasive technique that can be easily performed and could be beneficial to PDPH Figure 1. Sphenopalatine ganglion block by blocking the parasympathetic tonus at the cerebral vasculature, returning them to their normal diameter and relieving the After removal, the patient had no pain while sitting or walk- headache with a low cost and low risks procedure8. The related ing (visual analog scale (VAS) score of zero/10). There was a complications reported with the transnasal technique are minor minor discomfort during the gauze insertion, but no bleeding bleeding and temporary nasal discomfort. occurred. The previous clinical treatment was maintained, asso- There are no clinical trials on this hypothesis; only two recent ciated with gabapentin (600mg) per day was. The pain returned case reports showed the use of SPGB to treat PDPH in patients after 12 hours, but with the intensity of 3 using the VAS score who underwent diagnostic lumbar puncture in the emergency and was considered mild and tolerable for about 5 hours sitting 7 9 room or obstetric anesthesia . Both case reports have shown and walking. During this period, the patient refused AEBP, giv- positive results, eventually avoiding the necessity of AEBP in re- en the mildness of the pain and only the clinical treatment was fractory patients to conservative treatments. maintained. After 5h, the patient was pain-free again. At 24h We describe a case report using SPGB to treat PDPH in a patient and 48h post block the patient had no pain. The treatment was submitted to cerebrospinal fluid pressure monitoring with a sub- suspended after 48h, and the patient was discharged. By a phone arachnoidal catheter inserted with a low-gauge needle. contact five days later, there were no reports of headache recur- rence (Table 1). CASE REPORT

Table 1. Relevant data from this episode of care organized as a timeline The patient was a 45-year-old man, 85kg, 165cm, with a history Days of systemic arterial hypertension and hypercholesterolemia who 1 Patient submitted to a thoracic surgery for aorta aneurysm underwent open thoracic surgery for aorta aneurysm correction correction with cerebrospinal fluid pressure monitoring. 3 Catheter withdrawal and PDPH symptoms and beginning Upon the subarachnoid catheter withdraw, the patient devel- of conservative treatment oped PDPH, which was evaluated with the visual numeric scale 3 Pain Team evaluation and treatment (VNS), varying from zero to 10. He rated the intensity as 8 while sitting or standing, and zero while lying down. The surgical team 4 Evaluation 24 hours after the procedure initiated the conservative treatment with caffeine, analgesics, and 5 Evaluation 48 hours after the procedure and discharge hydration, but it was not effective after 12 hours. 10 Evaluation 7 days after the procedure We have confirmed the clinical diagnosis of PDPH, and we of- PDPH = post-dural puncture headache. fered an SPGB as a non-invasive option to relieve the pain. The patient was also offered an AEBP and informed that the latter DISCUSSION was the current definitive therapy. After agreeing on the SPGB, the block was performed with the This is the first case-report of PDPH caused by an invasive mon- patient in the supine position, with the neck flexed and the head itoring anesthetic method, which was refractory to clinical treat- extended. Gauzes soaked in 15g of a 2% lidocaine gel were inserted ment and solved with SPGB without the need for AEBP. carefully into each nostril until it reached the nasopharynx posterior The supratentorial dura mater membrane is supplied by small wall. They were left in place for 10 minutes and removed (Figure 1). meningeal branches of the trigeminal nerve (V1, V2, and V3). 393 BrJP. São Paulo, 2019 oct-dec;2(4):392-4 Machado FC, Carone Neto G and Ashmawi HA

The innervation for the infratentorial dura mater is via upper This is the first case report of a PDPH caused by a subarachnoid cervical nerves. The second division of the trigeminal nerve (V2) monitoring catheter successfully treated with SPGB. This tech- runs through the sphenopalatine ganglion (SPG), which is an- nique can be a non-invasive option in the management of PDPH, atomically accessible to blocking due to its superficial location which requires more study to evaluate its efficacy and safety. in the nasal cavity10. The proposed mechanism is that with the SPGB, the parasympathetic tonus of the cerebral vasculature is REFERENCES reduced, allowing the dilated blood vessels to return to the normal diameter, reducing intracranial volume and thus alleviating 1. Turnbull DK, Shepherd DB. Post-dural puncture headache: pathogenesis, prevention and treatment. Br J Anaesth. 2003;91(5):718-29. PDPH symptoms. In a recent observational study, it was evi- 2. 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Another possibility is that once the tration of local anesthetic (ropivacaine) for sphenopalatine ganglion block, for treatment parasympathetic tonus is reduced with the blockade, it does not of second trigeminal branch neuralgia secondary to maxillary sinus curettage: a case report. Rev Esp Anestesiol Reanim. 2019;5. pii: S0034-9356(19)30067-2. [Epub ahead of print]. increase again. 11. Kim NE, Park B, Moon YR, Lee SY, Gil HY, Kim S, et al. Changes in facial tempe- The SPGB can be performed in ambulatory patients. Non-spe- rature measured by digital infrared thermal imaging in patients after transnasal sphe- cialized medical staff, surgical staff, and even the patient himself nopalatine ganglion block: retrospective observational study. Medicine (Baltimo- re). 2019;98(15):e15084. doi: 10.1097/MD.0000000000015084. can use this simple technique, as it is already used for orofacial 12. Peterson JN, Schames J, Schames M, King E. Sphenopalatine ganglion block: a safe pain, headaches, and trigeminal neuralgia13,14. Despite being a and easy method for the management of orofacial pain. Cranio. 1995;13(3):177-81. 13. Furtado IF, Pinto MM, Amorim P. Sphenopalatine ganglion block may be an effi- simple technique, SPGB requires training to increase its effica- cient treatment of headache after lumboperitoneal shunt placement: a case report. A cy and reduce potential complications14. This technique needs A Pract. 2019;12(11):401-2. 14. Davies JM, Murphy A, Smith M, O’Sullivan G. Subdural haematoma after dural further clinical trials using different anesthetics, dosages and puncture headache treated by epidural blood patch. Br J Anaesth. 2001;86(5):720-3. compared to conservative treatments, and the results achieved 15. Stalis C, Zatochill M, Petersen TR, Falcon RJ, Al Haddadin C, Southwell B, et al. in this case report, and others are concordant and encouraging15. Transnasal sphenopalatine ganglion block for postdural puncture headache in an adolescent: a case report. A A Pract. 2019;30 [Epub ahead of print]. If used in a clinically refractory patient, SPGB has the potential 16. Jespersen MS, Jaeger PT, Aegidius KL, Meyhoff CS. [Sphenopalatine ganglion to relieve PDPH rapidly and may prevent the use of an invasive block for treatment of post-dural puncture headache]. Ugeskr Laeger. 2019;181(19). 16 pii: V12180846. Danish. treatment . The risks of a transnasal SPGB are mainly bleeding, 17. Mehta SP, Keogh BP, Lam AM. An epidural blood patch causing acute neurologic and temporary discomfort6 are significantly lower than the risks dysfunction necessitating a decompressive laminectomy. Reg Anesth Pain Med. 2014;39(1):78-80. of the AEBP, which includes dural puncture, neurologic compli- 18. Tekkök IH, Carter DA, Brinker R. Spinal subdural haematoma as a complication of cations, bleeding, and infection17,18. immediate epidural blood patch. 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