Vol. 04 No 01 Jan/Feb/Mar. 2021

ISSN 2595-3192

BrJPBRAZILIAN JOURNAL OF PAIN Vol. 04 No 01 Jan/Feb/Mar. 2021

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

CONTENTS

Volumen 4 – nº 1 EDITORIAL January to March, 2021 Another step!______1 Trimestral Publication Mais um passo! Irimar de Paula Posso SOCIEDADE BRASILEIRA PARA O ESTUDO DA DOR ORIGINAL ARTICLES DIRECTORY The profile of dexamethasone combined with transcranial direct current stimulation in Biennium 2020-2021 rats submitted to an arthritis model ______2 O perfil da dexametasona combinada com estimulação transcraniana por corrente contínua em ratos President submetidos a um modelo de artrite Paulo Renato Barreiros da Fonseca Gabriela Laste, Bettega Costa Lopes, Liciane Fernandes Medeiros, Felipe Fregni, Wolnei Caumo, http://lattes.cnpq.br/9099397240334208 Iraci L S Torres Vice-President José Oswaldo de Oliveira Junior Impact of sex and environmental conditions on the responses to pain in zebrafish______9

http://lattes.cnpq.br/6744087111028320 Impacto do sexo e das condições ambientais nas respostas do peixe-zebra à dor Scientific Director Gerlânia Oliveira Leite, Sacha Aubrey Alves Rodrigues Santos, Antônia Deyse de Castro Ribeiro, Luci Mara França Correia Francisca Magnólia Diógenes Holanda Bezerra, Adriana Rolim Campos http://lattes.cnpq.br/8878925882317970 Administrative Director Knowledge and use of Integrative and Complementary Health Practices by patients with Dirce Maria Navas Perissinotti orofacial pain______15 http://lattes.cnpq.br/4257309602330961 Treasurer Conhecimento e uso das Práticas Integrativas e Complementares em Saúde por pacientes com dor Josimari Melo de Santana orofacial http://lattes.cnpq.br/9819654988177433 Keila Esterlina Chagas, Clarice do Vale Araújo Melo, Isabela Rodrigues Rocha, Camila Megale Secretary Almeida-Leite, Janice Simpson de Paula Célia Maria de Oliveira http://lattes.cnpq.br/9391711154551929 Prevalence and associated factors with musculoskeletal pain in professionals of the Mobile Emergency Care Service______20 Prevalência e fatores associados à dor musculoesquelética em profissionais do Serviço de Atendimento Sociedade Brasileira para o Estudo da Dor Móvel de Urgência Av. Conselheiro Rodrigues Alves, 937 Roberto Airon Veras dos Santos, Maria Cristina Falcão Raposo, Renato de Souza Melo Cj. 2 – Vila Mariana 04014-012 São Paulo, SP Effect of transcutaneous electrical nerve stimulation and hypnosis on chronic low back Fone: 11 5904-2881/3959 pain______26 www.dor.org.br Efeito da estimulação elétrica nervosa transcutânea e hipnose na dor lombar crônica E-mail: [email protected] Carolina Weizemann, Nathielly Flores Camargo, Taise Vieira Barboza, Alberito Rodrigo de Carvalho, Gladson Ricardo Flor Bertolini Quotations of Brazilian Journal of Pain shall be abbreviated to BrJP. Factors that influence the quality of life in neuropathic, musculoskeletal, and oncological pain______31 BrJP is not responsible Fatores que influenciam a qualidade de vida em dor neuropática, musculoesquelética e oncológica whatosever by opinions. Ana Carolina Rodrigues, Ana Marcia Rodrigues Cunha, José Eduardo Nogueira Forni, Lilian Andreia Chessa Dias, Paulo Rafael Condi, Marielza Regina Ismael Martins Advertisements published in this edition do no generate conflict of interests. Translation and cross-cultural adaptation of six short screening questions on biopsychosocial aspects of chronic pain______37 Tradução e adaptação transcultural de seis perguntas breves de triagem dos aspectos biopsicossociais Indexada na SciELO Indexada na LILACS Indexada na Latindex da dor crônica Gabriela Valentim Cardoso, Anna Paula Campos Sarchis, Paulo Augusto de Almeida Britto Publication edited and produced by MWS Design – Phone: (055) 11 98767-6188 Factors related to self-rated quality of life among women with fibromyalgia according to International Classification of Functioning______43 Journalist In Charge Fatores relacionados a qualidade de vida autorrelatada em mulheres com fibromialgia de acordo com Marcelo Sassine - Mtb 22.869 a Classificação Internacional de Funcionalidade Art Editor Cristiane Vitaliano Graminha, Juliana Martins Pinto, Shamyr Sulyvan de Castro, Maria Anete Salviano Cristina Cortez Carneiro Meirelles, Isabel Aparecida Porcatti de Walsh SCIENTIFIC EDITOR Correlation between muscle strength and the degrees of functionality and kinesiophobia Irimar de Paula Posso reported by patients with chronic hip pain______51 University of São Paulo, São Paulo, SP, Brazil – Correlação entre força muscular e graus de funcionalidade e cinesiofobia relatada por pacientes com [email protected]. dor crônica no quadril http://lattes.cnpq.br/5789900900585872 Gustavo Leporace, Luiz Alberto Batista, Leonardo Metsavaht, Jorge Chahla, Tainá Oliveira, Liszt Palmeira de Oliveira COEDITORS Anita Perpetua Carvalho Rocha de Castro Quality of life in children and adults with Idiopathic juvenile arthritis: cross-sectional Federal University of Bahia, Salvador, BA, Brazil – study in Brazilian patients______58 [email protected] Qualidade de vida em crianças e adultos com artrite idiopática juvenil: estudo transversal em http://lattes.cnpq.br/2863282043928410 pacientes brasileiros Célia Maria de Oliveira Elora Sampaio Lourenço, Cibele Lourenço, Thelma Skare, Paulo Spelling, Renato Nisihara Federal University of Minas Gerais, Belo Horizonte, MG, Brazil – REVIEW ARTICLES [email protected] Instruments that assess functioning in individuals with temporomandibular disorders and http://lattes.cnpq.br/9391711154551929 the International Classification of Functioning: systematic review______63 Dirce Maria Navas Perissinotti Instrumentos que avaliam a funcionalidade em indivíduos com disfunção temporomandibular e a University of São Paulo, São Paulo, SP, Brazil – Classificação Internacional de Funcionalidade: revisão sistemática [email protected] Luana Maria Ramos Mendes, Marina Carvalho Arruda Barreto, Shamyr Sulyvan Castro http://lattes.cnpq.br/4257309602330961 Eduardo Grossmann The effects of acupuncture in fibromyalgia: integrative review______68 Federal University of Rio Grande do Efeitos da acupuntura na fibromialgia: revisão integrativa Sul, Porto Alegre, RS, Brazil – Heloísa Salvador dos Santos Pereira, Mariangela da Silva Nunes, Caíque Jordan Nunes Ribeiro, [email protected] Maria do Carmo de Oliveira Ribeiro http://lattes.cnpq.br/4470378345964718 Josimari Melo de Santana Prevalence of temporomandibular dysfunction in athletes: integrative review______72 Federal University of Sergipe, Aracaju, SE, Brazil – Prevalência da disfunção temporomandibular em atletas: revisão integrativa [email protected] Bruna Prade Medeiros, Eduardo Grossmann, Caren Serra Bavaresco http://lattes.cnpq.br/9819654988177433 Juliana Barcellos de Souza Neuropathic pain screening for diabetes mellitus: a conceptual analysis______77 Federal University of Santa Catari- Rastreamento de dor neuropática para diabetes mellitus: uma análise conceitual na, Florianópolis, SC, Brazil – Daniella Silva Oggiam, Denise Myuki Kusahara, Monica Antar Gamba [email protected] http://lattes.cnpq.br/0009123389533752 CASES REPORTS Lia Rachel Chaves do Amaral Pelloso Epidural needle fragment related low back pain. Case report______87 Federal University of Mato Grosso, Cuiaba, MT, Brazil – Lombalgia incapacitante causada por fragmento retido de agulha peridural. Relato de caso [email protected] Daniela de-Matos, Henrique Cabral, Ricardo Pereira http://lattes.cnpq.br/1267225376308387 Maria Belén Salazar Posso Lumbar erector spinae plane block for total hip arthroplasty analgesia. Case report____91 Christian University Foundation, Pin- Bloqueio do plano eretor da espinha lombar para analgesia de artroplastia total de quadril. Relato damonhangaba, SP, Brazil – de caso [email protected] Artur Salgado de Azevedo, Hermann dos Santos Fernandes, Waldir Cunha Júnior, Adilson Hamaji, http://lattes.cnpq.br/4644641106395490 Hazem Adel Ashmawi Telma Regina Mariotto Zakka University of São Paulo, São Paulo, SP, Brazil – INSTRUCTIONS TO AUTHORS______96 [email protected] Instruções aos Autores http://lattes.cnpq.br/7210747586447129 Mirlane Guimarães de Melo Cardoso Federal University of Amazonas, Manaus, AM, Brazil – [email protected] http://lattes.cnpq.br/1663863759459785 Oscar Cesar Pires University of Taubaté, Taubaté, SP, Brazil – [email protected] http://lattes.cnpq.br/2929971233764932 Thiago Medina Brazoloto University of City São Paulo, São Paulo, SP, Brazil – [email protected] http://lattes.cnpq.br/7245353593408839 Walter Lisboa Oliveira Federal University of Sergipe, Aracaju, SE, Brasil – [email protected] http://lattes.cnpq.br/0512185167681269

EDITORIAL COORDINATION Evanilde Bronholi de Andrade Submitted to articles online: [email protected] https://www.gnpapers.com.br/brjp/default.asp

De 08 a 11/09/2021 Centro de Convenções Frei Caneca São Paulo - SP Programe-se! BrJP. São Paulo, 2021 jan-mar;4(1):1 EDITORIAL

Another step! Mais um passo!

DOI 10.5935/2595-0118.20210020

So that the BrJP may continue improving, both from the ethical and scientific points of view, another adjustment is being introduced at the beginning of this year, aiming at the indexing in other platforms.

The Editorial Board is now composed of the Editor and the Co-Editors, who, starting this year, will assume part of the Editor’s tasks, as they will be responsible for following up the review of the articles and, together with the Editor, accept the article for publication or reject it, not without first informing the authors of the reasons, and encouraging them to produce texts of better quality.

With this adjustment, the Coeditors are free to invite professionals from various areas of healthcare to review the articles, pro- vided that the reviewers have the expertise to perform the arduous task of carefully reading and evaluating the texts submitted by the authors, who are always anxiously awaiting for the positive response, i.e., that their article will be published in BrJP.

The AOP publishing modality introduced last year has contributed greatly to the rapid dissemination of articles published in BrJP, allowing the results to be accessed early by the scientific community and consequently be cited more quickly.

Prof. Dr. Irimar de Paula Posso Editor for the 2020-2021 biennial http://orcid.org/0000-0003-0337-2531. E-mail: [email protected]

1 BrJP. São Paulo, 2021 jan-mar;4(1):2-8 ORIGINAL ARTICLE

The profile of dexamethasone combined with transcranial direct current stimulation in rats submitted to an arthritis model O perfil da dexametasona combinada com estimulação transcraniana por corrente contínua em ratos submetidos a um modelo de artrite

Gabriela Laste1, Bettega Costa Lopes2,3, Liciane Fernandes Medeiros2,4, Felipe Fregni5, Wolnei Caumo6, Iraci L S Torres2,3,6

DOI 10.5935/2595-0118.20210003

ABSTRACT ters were measured with the Open-Field test. ELISA was used to evaluate hippocampal and spinal cord tumor necrosis factor BACKGROUND AND OBJECTIVES: To pursue safer and (TNF-α) levels, cerebral cortex and brainstem BDNF levels. more effective treatments for rheumatoid arthritis, the effect of RESULTS: In pre-treatment measurements, arthritic rats pre- dexamethasone treatment (DEX, 0.25mg/kg) combined with sented an increase in joint swelling and mechanical allodynia transcranial direct current stimulation (tDCS) in the behavior when compared to the control group, confirming chronic pain and neurochemical parameters of arthritic rats was evaluated. establishment. A slight antinociceptive effect of dexamethasone METHODS: Thirty-six Wistar rats were divided into four combined with tDCS in the pain model was observed. The pain groups: control+DEX (CTRL+DEX), arthritis+DEX (RA+- model significantly induced an increase in the grooming beha- DEX), arthritis+DEX+sham-tDCS (RA+DEX+sham-tDCS) vior and a reduction in the spinal cord and hippocampal TNF-α and arthritis+DEX+tDCS (RA+DEX+tDCS). The arthritic levels; these effects were reverted in the sham- and active-tDCS- model (RA) was induced by complete Freund’s adjuvant (CFA) -treated rats. However, no effects of DEX or tDCS were observed paw administration. Paw edema and mechanical allodynia were in the BDNF levels in the cerebral cortex and brainstem. assessed by plethysmometer and von Frey apparatus, respectively. CONCLUSION: Despite the small effect observed, tDCS treat- Fourteen days after the CFA injection, rats received the treatment cannot be discarded as a non-pharmacological adjuvant ment for eight days (DEX and/or tDCS). Behavioral parame- technique for inflammatory chronic pain treatment. Keywords: Cerebral cortex, Hippocampus, Mechanical allodynia, Spinal cord. Gabriela Laste – https://orcid.org/0000-0003-1554-6658; Bettega Costa Lopes – https://orcid.org/0000-0002-8090-0273; RESUMO Liciane Fernandes Medeiros – https://orcid.org/0000-0002-6842-7241; Felipe Fregni – https://orcid.org/0000-0001-9359-8643; Wolnei Caumo – https://orcid.org/0000-0002-5083-4658; JUSTIFICATIVA E OBJETIVOS: Para investigar métodos  Iraci L S Torres – https://orcid.org/0000-0002-3081-115X. mais seguros e eficazes para o manejo da artrite reumatoide, ava- 1. University of Vale do Taquari - Univates, Graduate Program in Medical Sciences, Lajeado, liou-se o efeito do tratamento com dexametasona (DEX, 0,25 RS, Brazil. mg/kg) combinado com estimulação transcraniana por corrente 2. Clinical Hospital of Porto Alegre, Laboratory of Pharmacology of Pain and Neuromodu- lation: Pre-Clinical Investigations. Porto Alegre, RS, Brazil. contínua (ETCC) sobre parâmetros comportamentais e bioquí- 3. Federal University of Rio Grande do Sul, Graduate Program in Biological Sciences: Physi- micos de ratos submetidos a um modelo de artrite reumatoide. ology, Porto Alegre, RS, Brazil. 4. La Salle University, Graduate Program in Health and Human Development. Canoas, MÉTODOS: 36 ratos Wistar foram alocados em 4 gru- RS, Brazil. pos: controle+DEX (CTRL+DEX), artrite+DEX (AR+DEX), 5. Harvard Medical School, Department of Physical Medicine & Rehabilitation, Spaulding Rehabilitation Hospital & Massachusetts General Hospital, Harvard Medical School - Bos- artrite+DEX+sham-ETCC (AR+DEX+sham-ETCC) e artrite+- ton - Massachusetts - USA. DEX+ETCC (AR+DEX+ETCC). O modelo de artrite foi in- 6. Federal University of Rio Grande do Sul, Graduate Program in Medical Sciences, Porto duzido pela administração de complete Freund’s adjuvant (CFA) Alegre, RS, Brazil. na pata. Edema na pata e a alodinia mecânica foram avaliadas Submitted on September 17, 2020. por pletismômetro e teste de von Frey, respectivamente. 14 dias Accepted for publication on December 16, 2020. Conflict of interests: none – Sponsoring sources: This research project was supported by após injeção de CFA, ratos foram tratados por 8 dias (DEX e/ou the following Brazilian funding agencies: National Council for Scientific and Technological ETCC). Atividade locomotora foi avaliada pelo teste do campo Development -CNPq (Dr. I.L.S. Torres and Dr. W. Caumo); Coordination for the Improve- ment of Higher Education Personnel - CAPES (B.C. Lopes, H.R. Medeiros); Graduate Re- aberto. TNF-alfa (hipocampo e medula espinal) e BDNF (córtex search Group - Hospital de Clínicas de Porto Alegre - GPPG-HCPA (Dr. I.L.S. Torres, grant e tronco) foram mensurados por ELISA. FIPE/HCPA No. 20120220); FAPERGS/PRONEM (Dr. I.LS. Torres, grant No. 11/2050); RESULTADOS: Nas medições pré-tratamento, ratos com artrite MCT/FINEP - COENG/2013. exibiram um aumento de o inchaço articular e alodínia mecânica Correspondence to: comparados ao grupo controle, confirmando o estabelecimento Iraci LS Torres Rua Attilio Bilibio, 120, casa 21 - Bairro Jardim Carvalho de modelo de dor crônica. Também se observou discreto efeito an- 91530-008 Porto Alegre, RS, Brazil. tinociceptivo da dexametasona combinada com ETCC no modelo E-mail: [email protected] de artrite. O modelo de dor induziu um aumento no comporta- © Sociedade Brasileira para o Estudo da Dor mento de grooming e reduziu os níveis de TNF-alfa no hipocam- 2 The profile of dexamethasone combined with transcranial direct BrJP. São Paulo, 2021 jan-mar;4(1):2-8 current stimulation in rats submitted to an arthritis model po; estes efeitos foram revertidos nos grupos sham- e ETCC ativo. thic pain9,10, chronic restraint stress-induced hyperalgesia, and allody- Entretanto, não foram observados efeitos da DEX ou ETCC nos nia7,20. tDCS modulates the hyperalgesic response and inflammatory níveis de BDNF no córtex cerebral ou no tronco encefálico. profile in rats subjected to neuropathic pain, changing BDNF, IL-1β, CONCLUSÃO: Apesar dos discretos efeitos observados, não se IL-4, and TNF-α levels in the CNS structures of rats9,10. pode descartar a ETCC como uma abordagem terapêutica não The use of drugs, such as steroid anti-inflammatory, in RA treat- farmacológica para o manejo da dor crônica inflamatória na ar- ment is often associated with several adverse effects that limit their trite reumatoide. usefulness. Thus, the use of no pharmacological tools, like tDCS Descritores: Alodínia, Córtex cerebral, Hipocampo, Medula espinal. associated with anti-inflammatory steroids to reduce the dosage and consequently cause less adverse effects while in synergy with the INTRODUCTION analgesic and anti-inflammatory effects can be an interesting strategy in the treatment of RA. Considering that the use of this com- Rheumatoid arthritis (RA) is associated with chronic pain charac- bination has not been investigated yet, the current study, searching terized by maladaptive plasticity that is regulated by numerous mo- for safer and more effective RA treatments, aimed to evaluate the dulatory mechanisms. These include effects at the nociceptor level, behavior and neurochemical parameters of dexamethasone (DEX, sympathetically mediated pain, the ‘‘wind-up” phenomenon, central 0.25mg/kg) combined with tDCS in arthritic rats. sensitization, and changes in descending and ascending central mo- dulatory mechanisms for the perception of pain1. Pro-inflammatory METHODS cytokines, e.g. tumor necrosis factor-alpha (TNF-α) and interleukin (IL)-1 and IL-6, are increased in the synovium and synovial fluid in Male Wistar rats (n=36; 60 days/old; weighting 280-300g) were al- RA and play a pivotal role in RA’s pathology2,3. located in home cages (49x34x16cm) with the floor covered with Conventional anti-arthritic therapy comprises the use of steroidal sawdust and kept in a controlled environment (22±2°C; 12h/12h and non-steroidal anti-inflammatory drugs (NSAIDs), disease-mo- light-dark cycle), with water and chow ad libitum (Nuvital, Porto difying anti-rheumatic drugs (DMARD), and anti-cytokine drugs4. Alegre/ Brazil). All the experiments and procedures had been pre- The efficacy of steroidal anti-inflammatory drugs in alleviating in- viously approved by the Institutional Committee for Animal Care flammatory disorders results from the pleiotropic effects of the glu- and Use (GPPG-HCPA protocol #20120220) and met ARRIVE cocorticoid receptor on multiple signaling pathways that inhibit the guidelines21. synthesis of cytokines and inflammatory mediators5. Despite the efficacy of steroidal anti-inflammatory drugs, adverse effects such as Experimental design growth retardation in children, immunosuppression, hypertension, Rats were assigned into four groups: control+dexamethasone (CTR- inhibition of wound repair, osteoporosis and metabolic disturbances L+DEX, n=9) (0.25mg/kg); arthritis+dexamethasone (RA+DEX, contraindicate prolonged therapy. n=9) (0.25mg/kg,); arthritis+dexamethasone (0.25mg/kg) + sham- RA treatments that can modulate innate and adaptive immune -tDCS (RA+DEX+sham-tDCS, n=9); and arthritis + dexametha- cells are crucial to avoid pain and chronic inflammatory processes6. sone (0.25mg/kg) + tDCS (RA+DEX+tDCS, n=9). The tDCS or Preclinical and clinical studies have shown that both non-invasive sham and/or dexamethasone treatments were applied 14 days after stimulation7-10 and invasive techniques, such as vagus nerve stimula- the CFA injection. tion (VNS), are associated with an improvement in pain relief and The electronic Von Frey test was performed immediately at the pre- an inflammatory modification profile in11,12 RA . Transcranial direct -treatment (14 days after the CFA injection) and 24 hours after the current stimulation (tDCS) is a non-invasive technique that alters end of treatment (last tDCS session and/or dexamethasone adminis- brain physiology as well as psychological, motor, and behavioral tration). The open field test was conducted 24 hours after the tDCS processes, and clinical symptoms in neurological and psychiatric session and/or dexamethasone administration. The edema measures diseases13. tDCS modulates the motor cortex, which is thought to were performed at pre-treatment, 2, 4, 6 and 8 days after starting the influence pain perception indirectly via neural networks in pain- treatments. The rats were killed by decapitation on day 23 after CFA -modulating areas, probably increasing cortical excitability14. Fur- injection (Figure 1). thermore, tDCS not only changes neuronal activity in the desired cortical areas but also in distant ones, well beyond the sole change of neuronal excitability15. The tDCS effects are based on cortico-cortical interactions with some subcortical components (e.g., thalamic CFA nuclei) in these circuits16. In humans, tDCS has shown significant Days effects on different types of chronic pain17,18. A previous study from the present authors showed long-lasting anti- Legend nociceptive and neuroplastic effects of tDCS in a model of periphe- 8 Paw edema von Frey Open field ral inflammation , supporting the use of the technique in conditions tDCS DEX Death assessment test test involving chronic pain and peripheral inflammation, such as RA. Another study also showed that tDCS in anesthetized rats modulated Figure 1. Experimental design 19 neuro-inflammation . Besides that, it was demonstrated that tDCS CFA = complete Freund’s adjuvant; DEX = dexamethasone treatment; tDCS = has been effective in other pain preclinical models such as neuropa- transcranial Direct Current Stimulation. 3 BrJP. São Paulo, 2021 jan-mar;4(1):2-8 Laste G, Lopes BC, Medeiros LF, Fregni F, Caumo W and Torres IL

Complete Freund’s adjuvant (CFA)-induced arthritis during the 5-minute test sessions in the open field: (1) la- Isoflurane-anesthetized animals received an intradermal CFA in- tency to leave the first quadrant (seconds); (2) total number jection into the right hind paw (1 mg·mL-1; 100 µL; heat-killed of crossings (or number of total crossings) (i.e., horizon- and dried Mycobacterium tuberculosis, each milliliter of the vehi- tal activity in the inner and outer quadrants) (3) grooming cle containing 0.85 mL of paraffin oil and 0.15 mL of mannide behavior (in seconds); (4) number of rearing behaviors (i.e., monooleate), which was suspended in a 1:1 oil/saline emulsion vertical activity); and (5) number of fecal boluses. The num- (in a total volume of 200 µL). This model of arthritis needs ber of line crossings (all paws crossed the boundary into a approximately 14 days to be established22. different marked-out area) was taken as a measure of locomotor activity. The latency to leave the first quadrant asses- Dexamethasone treatment sed anxiety-like behaviors. DEX (Nova Farma, Anápolis, [Goiás], [Brazil]) was dissolved in saline immediately before use and injected intraperitoneally (i.p., Tissue collection 0.25mg/kg) at 1 mL/kg once a day for eight days23. The rats were killed by decapitation 48 hours after the last tDCS session and/or dexamethasone administration and brain Transcranial direct current stimulation (tDCS) structures (hippocampus, spinal cord, cerebral cortex, and After the establishment of arthritis, 14 days after CFA expo- brainstem) were collected. The structures were kept frozen at sure, the animals in the active treatment groups underwent a -80°C until the assays were performed. 20-minute session of bicephalic tDCS every afternoon for eight days, as previously described9,10. A constant direct current of TNF-α and BDNF levels 0.5 mA was delivered from a battery-powered stimulator using Hippocampus and spinal cord TNF-α levels were deter- electrocardiogram electrodes with conductive adhesive hydro- mined via enzyme-linked immunosorbent assay (ELISA) gel. The rats’ heads were shaved for better adherence, electrodes using monoclonal antibodies specific for TNF-α (R&D were trimmed to 1.5 cm2 for a better fit, and a constant current Systems, Minneapolis, United States). The ELISA was intensity of 0.5 mA was applied on their scalp. The electrodes made 48 hours after the last tDCS session and/or dexame- were fixed to the head with adhesive tape (Micropore™) and thasone administration. BDNF analyses were performed covered with a protective mesh to prevent removal. The catho- on the brainstem and cerebral cortex using a commercially de was positioned at the midpoint between the lateral angles available enzyme-linked immunosorbent assay kit for rats of both eyes (supraorbital area). The anode was placed on the (R&D Systems, Minneapolis, MN). All structures were ho- head using neck landmarks and shoulder lines as guidance (the mogenized with a handheld homogenizer using Protease anterior and posterior regions in the midline between the two Inhibitor Cocktail (Sigma® # P8340) in the ratio of 1:100 hemispheres of the parietal cortex). For sham stimulation, the in phosphate-buffered saline (PBS) at pH 7.2. Each of the electrodes were placed and fixed in the same position as for the homogenates was centrifuged for 5 min at 10,000 rpm. actual stimulation. However, the stimulator was off throughout Optical density - wavelength of 450 nm - was measured the procedure. The animals were carefully immobilized with a using an ELISA reader. The values were expressed in pico- cotton towel to prevent their movements without causing dis- grams per milliliter of tissue homogenate (pg/mL). comfort for both the active treatment and the sham. Statistical analysis Paw volume measurement Generalized estimating equations (GEE) were used to analy- The edema was measured using a plethysmometer (UGO Basi- ze the group effects for joint swelling and mechanical allo- le, Italy) and expressed in milliliters (mL). dynia at different assessment time points. One-way ANOVA followed by Student-Newman-Keuls (SNK) post hoc test was Electronic von Frey test performed to compare group differences for behavioral pa- Mechanical allodynia was assessed using an automatic von Frey rameters and biomarkers. Results are expressed as mean ± aesthesiometer (Insight, São Paulo, Brazil). 24 hours before the standard error of the mean (SEM). All statistical analyses test, the rats were habituated to the environment for 15 minutes were performed using SPSS, version 26.0 (SPSS, Chicago, to prevent novelty-induced analgesia24. The test consisted of po- IL, USA). The level of significance was set at p<0.05 for all king the hind paw to provoke a flexion reflex followed by a clear statistical tests. flinch response. Pressure intensity was recorded automatically after paw withdrawal. Three successive von Frey readings were RESULTS then averaged, and the interval between measures was of at least 5 seconds. The averages were used as the final measurements, At baseline, measurements of joint swelling (GEE, p<0.001) and the paw withdrawal threshold was expressed in grams (g). (Figure 2) and hind paw withdrawal latency in the von Frey test (GEE, p<0.05) (Figure 3) were significantly dif- Open field test ferent between the CTRL+DEX group and all three arthri- Behavioral assessments were performed in a varnished wood tis groups, confirming the efficacy of the pain model used cage lined with glass inside. Four measurements were taken (GEE, p=0.001). 4 The profile of dexamethasone combined with transcranial direct BrJP. São Paulo, 2021 jan-mar;4(1):2-8 current stimulation in rats submitted to an arthritis model

Joint swelling ment (one-way ANOVA-SNK, p=0.002). All arthritic groups All immunized rats developed inflammatory monoarthritis. The showed a reduction in the number of crossings in the inner peak incidence occurred on day 14 after immunization (pre-treat- quadrant when compared to CTRL+DEX group (one-way ment) when bicephalic tDCS and DEX treatments started. The ANOVA-SNK, p=0.01). No differences were found between GEE analysis showed significant group effect (p=0.001), time ef- groups regarding latency to leave the first quadrant, rearing fect (p=0.001), and group x time interaction (p=0.001) (Figure 2). behavior, crossings in the outer quadrant, total of quadrants, Compared to baseline values, joint swelling immediately decreased and the number of fecal boluses (one-way ANOVA-SNK, in all three arthritic groups and 24 hours after the end of treatment p>0.05 for all) (Table 1). (last tDCS session and/or DEX administration). On the other hand, there was no difference in joint swelling between arthritis Biomarkers levels groups in any of the assessment time points (p>0.05). Regarding the TNF-α levels, RA rats treated with DEX showed a decrease in spinal cord TNF-α levels (p=0.02) Mechanical allodynia when compared to no pain rats. Immobilization (RA+- Mechanical allodynia was assessed by the von Frey test. The GEE DEX+sham-tDCS group) intensified the reduction, and analysis showed a significant group effect (p=0.001), time effect it was reversed by active tDCS in RA rats up until RA+- (p=0.001) and group x time interaction (p=0.002) (Figure 3). It was DEX levels (one-way ANOVA-SNK, p=0.02, Figure 4, possible to observe immediately and 24 hours after the last bice- panel A). RA rats treated with DEX showed a decrease in phalic tDCS treatment session that pain rats subjected to DEX and the hippocampus TNF-α levels (p=0.02) when compared tDCS slightly increased the paw threshold. m=Mechanical allody- to other groups (one-way ANOVA-SNK, p=0.02, Figure nia was also partially reversed by combined treatments (p>0.05). 4, panel B). Concerning BDNF levels, there was no difference between Behavioral parameters by the open field test groups in the BDNF levels in the cerebral cortex or brainstem A significant increase in grooming behavior was observed in (one-way ANOVA-SNK, p>0.05 for both; Figure 4, panel C arthritic groups, which was reverted by sham-tDCS treat- and D, respectively).

4 80 b a 3.5 b b 70 a a 3 60 ab 2.5 50 b ab b b b b 2 b b b 40 b b b b b b b 1.5 b 30 b b a a a a

Paw edema (mL) 1 a 20 b

0.5 (g) Mechanical threshold 10 0 0 Pre- 2nd day of 4th day of 6th day of 24h after Baseline Immediately 24h after treatment treatment treatment treatment treatment after treatment treatment

CTRL+DEX RA+DEX RA+DEX+ShtDCS RA+DEX+tDCS CTRL+DEX RA+DEX RA+DEX+ShtDCS RA+DEX+tDCS

Figure 2. Paw edema measured at pre-treatment (14 days after CFA injec- Figure 3. Mechanical threshold assessed by von Frey test tion), 2,4 and 6 days of treatment, and 24h after the end of the treatment (CTRL+DEX) = control+DEX; (RA+DEX) = arthritis+DEX; (RA+DEX+sham-tDCS) (CTRL+DEX) = control+DEX; (RA+DEX) = arthritis+DEX; (RA+DEX+sham-tDCS) = arthritis+DEX+sham tDCS; (RA+DEX+tDCS) = arthritis+DEX+tDCS = arthritis+DEX+sham tDCS; (RA+DEX+tDCS) = arthritis+DEX+tDCS Data are expressed as mean ± standard error of the mean (GEE/Bonferroni; p < Data are expressed as mean ± standard error of the mean (GEE/Bonferroni; 0.05). Different letters mean statistical significance. p<0.05). Different letters mean statistical significance.

Table 1. An Open field test was performed 24 hours after the last tDCS session and/or dexamethasone administration Open field test CTRL+DEX RA+DEX RA+DEX+sham-tDCS RA+DEX+tDCS Latency (s) 3.71±1.12 2.83±0.47 4.66±1.30 6.71±1.49 Grooming (s) 2.33±1.56a 35.80±15.04b 1.83±1.22a 53.60±13.77b Rearing (n) 32.42±4.60 22.57±7.59 35.00±5.53 23.14±6.06 Ext quad (n) 96.75±8.74 79.00±7.93 93.85±8.00 77.71±7.82 Int quad (n) 11.71±2.13a 4.83±0.87b 4.33±0.80b 5.28±2.00b Total quad (n) 108.57±7.68 85.14±7.42 97.57±8.00 83.00±7.46 Fecal Bol (n) 2.00±0.87 3.42±1.13 4.00±0.44 2.83±0.60 Groups: CTRL+DEX, RA+DEX, RA+DEX+sham-tDCS, and RA+DEX+tDCS. Data are expressed as mean±standard error of the mean of number (n) or seconds (s). Different letters mean statistical significance (one-way ANOVA/SNK; p< 0.05).

5 BrJP. São Paulo, 2021 jan-mar;4(1):2-8 Laste G, Lopes BC, Medeiros LF, Fregni F, Caumo W and Torres IL

A B 450 6000 400 5000 350 300 4000 250 3000 200 150 2000 (mg/mLof homogenate)

100 (mg/mL of homogenate) Spinal Cord TNF-alfa levels Spinal Cord Hippocampi TNF-alfa levels 1000 50 0 0 CTRL+DEX RA+DEX RA+DEX+ RA+DEX+ CTRL+DEX RA+DEX RA+DEX+ RA+DEX+ ShtDCS tDCS ShtDCS tDCS C D 140 120

120 100 100 80 80 60 60 40 40 Brainstem BDNF levels (mg/mL of homogenate) (mg/mL of homogenate) 20

Cerebral Cortex BDNF levels Cerebral 20

0 0 CTRL+DEX RA+DEX RA+DEX+ RA+DEX+ CTRL+DEX RA+DEX RA+DEX+ RA+DEX+ ShtDCS tDCS ShtDCS tDCS

Figure 4. Biomarkers levels measured in central nervous structures of rats (CTRL+DEX) = control+DEX; (RA+DEX) = arthritis+DEX; (RA+DEX+sham-tDCS) = arthritis+DEX+sham tDCS; (RA+DEX+tDCS) = arthritis+DEX+tDCS Panel A. Spinal cord TNF-α levels. Panel B. Hippocampi TNF-α levels. Panel C. Cerebral cortex BDNF levels. Panel D. Brainstem BDNF levels. Data are expressed as mean ± standard error of the mean (one-way ANOVA/SNK; p < 0.05). Different letters mean statistical significance.

DISCUSSION substance P, adenosine triphosphate, nitric oxide, and prosta- glandins27. The current study demonstrated an immediate and long-lasting Steroidal anti-inflammatory drugs are one of the most com- slight antinociceptive effect of DEX combined with bicephalic monly used for several pathologies. Still, there are several side tDCS treatments in a rat model of arthritis. These effects were effects associated with long-term or high-dose DEX28. Based on not observed after DEX administration alone, suggesting a spe- a previous study using a chronic inflammatory rat model (pan- cific effect of DEX combined with tDCS. Spinal cord TNF-α niculitis) in which pain was completely reversed by DEX23, now levels were reduced in arthritic rats, a result intensified by im- dexamethasone (0.25 mg/kg) was tested. In the current study, a mobilization. tDCS reverted the immobilization effect. DEX discrete analgesic effect using an arthritis rat model was observed associated with the arthritic rat model showed a decrease in the only when combined with bimodal tDCS in the arthritic rat mo- hippocampus TNF-α levels. Active and sham-tDCS were able to del upon mechanical allodynia. Since arthritis is a more aggres- reverse this effect. There was an increase in grooming behavior sive model than panniculitis, it’s interesting to note that the in- in the arthritic rat model, which was reversed by sham-tDCS. flammatory profiles linked to both disorders are different from Also, none of the DEX or tDCS effects were found in the cere- the ones before shown in panniculitis29 and arthritis30. In the bral cortex or brainstem BDNF levels. current study, this analgesic effect was only observed in mecha- For pain and inflammatory assessment, the rats were injected nical allodynia when DEX was combined with tDCS. A result with CFA to develop the arthritic rat model. CFA triggers the that may be explained by the fact that panniculitis is a less severe release of inflammatory mediators, including cytokines and acti- inflammatory process than arthritic rats. It is important to note ve oxygen species25. It also causes hyperalgesia and allodynia25,26, that, in a previous study, an arthritis model30 used, in addition to which may persist for up to 28 days. The present study focused histological changes including periarticular panniculitis in the tion the late phase of inflammation that induces immunological biotarsal joint, also showed inflammatory infiltration containing events. Peripheral afferent fibers synthesize an array of molecu- giant cells, plasmocytes, lymphocytes, and mainly macrophages les that could potentially contribute to hyperalgesia in patients and neutrophils. Furthermore, the rats showed joint damage with chronic inflammatory diseases, such as RA. These include progression, revascularization, and synovial proliferation at day glutamate and other excitatory amino acids, neuropeptides like 14 post-CFA injection. 6 The profile of dexamethasone combined with transcranial direct BrJP. São Paulo, 2021 jan-mar;4(1):2-8 current stimulation in rats submitted to an arthritis model

Previous preclinical studies from the present authors showed CFA-induced arthritis are well described23,37. Similarly, despite immediate and long-lasting effects of repeated sessions of bice- having a sham-tDCS group to compare the therein observed ef- phalic tDCS treatment on chronic inflammation8, hyperalgesia fects to the tDCS effects, a arthritis-saline-tDCS group was not in stress-induced chronic restraint7, neuropathic pain model9, included. 3) It was necessary to restraint the rats during tDCS and neuropathic pain model associated with repeated physical because it was performed without anesthesia. Therefore, res- exercise10. Nonetheless, in the current study, a slight analgesic traint-induced stress could not be avoided. 4) The choice to eu- effect of bimodal tDCS was found only when combined with thanize the rats 48 hours after the last tDCS session was made DEX. The role of central and peripheral levels of cytokines because all behavioral tests were performed in the afternoon 24 and neurotrophins associated with the antinociceptive effect of hours after the last tDCS session, which made euthanasia on tDCS in different chronic pain models was shown. Still, in the the same day after the tests impractical. 5) The findings indi- present study, pain effect upon TNF-α levels without tDCS cate the need to develop a new study using a low dose of DEX and/or DEX effects was found. combined with tDCS. 6) Based on the previous study from this Furthermore, a previous study using mice injected with CFA research group, the dose of DEX (0.25mg/kg) was considered in the footpad and with intrathecally injected TNF-α showed low. However, data from literature diverge about the low and the central role of TNF-α in regulating synaptic plasticity (cen- high dosage range for rats38,39. tral sensitization), and that inflammatory pain was mediated via both TNF-α receptor 1 and TNF-α receptor 231. In dor- CONCLUSION sal root ganglion neurons, TNF-α increases transient receptor potential subtype V1 and induces spontaneous discharge32. It’s In sum, arthritic rats displayed an increase in grooming behavior important to note that glucocorticoid receptors are expressed and anxiety-like behavior indexed by decreased inner crossings; on microglia in vitro and microglia treated with steroidal drugs and decreased central TNF-α level. DEX combined with bi- showed a decrease in the production of TNF-α and IFN-γ in modal tDCS showed a slight analgesic effect upon mechanical response to lipopolysaccharide injection. Additionally, the ad- allodynia, suggesting a possible use of tDCS as an adjuvant te- ministration of methylprednisolone reduces TNF-α expression chnique to reduce the dose of corticoids in the RA management. after spinal cord injury in rats33, corroborating the data of the However, new studies are encouraged to investigate drug–tDCS present study that showed a decrease in central TNF-α levels combinations with the objective of reducing the effective dosage in arthritic rats. and increasing drug efficacy. The present study also observed in the arthritic rats an increase in grooming behavior associated with a decrease in the AUTHORS’ CONTRIBUTIONS time spent in the central part of the open field. Both can be interpreted as anxiogenic-like effects. A previous study has Gabriela Laste shown that the CFA model promoted increased anxiety-like Statistical analysis, Conceptualization, Research, Methodology, behaviors, such as a decrease in time spent and in the num- Writing - Original preparation, Writing - Review and Editing, ber of entries in open arms of the elevated plus-maze and a Supervision, Visualization reduction in the number of central squares visited in the open Bettega Costa Lopes field34. The open field test is a method for measuring locomo- Statistical Analysis, Data Collection, Methodology, Writing - tor and exploratory activities, but it can also indicate some Review and Editing, Visualization anxiety-like behaviors parameters35. Thus, it is possible to Liciane Fernandes Medeiros suggest that the arthritis-induced pain increased anxiety-like Statistical Analysis, Data Collection, Methodology, Writing - behavior and that it was not reversed by DEX and/or repea- Review and Editing, Supervision, Visualization ted bicephalic tDCS treatments. It’s important to note that a Felipe Fregni previous study from the present research group demonstrated Conceptualization, Methodology, Writing - Original prepara- that tDCS reversed chronic neuropathic pain-induced beha- tion, Writing - Review and Editing, Visualization vioral alterations, indexed by changes in locomotor and ex- Wolnei Caumo ploratory activities and anxiety-like behaviors36. However, in Statistical Analysis, Methodology, Writing - Review and Editing, the current study, tDCS was not able to reverse this behavior Visualization in a chronic inflammatory pain model. Iraci LS Torres This study has the following limitations: 1) Non-invasive tDCS Statistical analysis, Funding acquisition, Conceptualization, Re- is not focal in animal models. Given that in humans both elec- source management, Project management, Writing – Original trodes are placed on the head, the attempt was to mimic similar preparation, Writing – Reviewing and editing, Supervision, Vi- electrode positions in the rats. However, it was not possible to sualization avoid bicephalic stimulation because of their relatively small head size. 2) The experimental design did not include a control- REFERENCES -saline, arthritis-saline, and arthritis-saline-tDCS group. Thus, 1. May A. Chronic pain may change the structure of the brain. Pain. 2008;137(1):7-15. the specific DEX effects were not evaluated by comparing them 2. Aletaha D, Smolen JS. Diagnosis and management of rheumatoid arthritis: a review. with potential saline effects. 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8 BrJP. São Paulo, 2021 jan-mar;4(1):9-14 ORIGINAL ARTICLE

Impact of sex and environmental conditions on the responses to pain in zebrafish Impacto do sexo e das condições ambientais nas respostas do peixe-zebra à dor

Gerlânia Oliveira Leite1, Sacha Aubrey Alves Rodrigues Santos1, Antônia Deyse de Castro Ribeiro1, Francisca Magnólia Diógenes Holanda Bezerra1, Adriana Rolim Campos1

DOI 10.5935/2595-0118.20210018

ABSTRACT ce of variation during the nociceptive behavior test of the adult zebrafish. BACKGROUND AND OBJECTIVES: Adult zebrafish (Da- Keywords: Environment, Pain, Nociception, Zebrafish. nio rerio) has been proposed as a low-cost and simple alternative to the use of rodents in laboratory research on novel RESUMO compounds with antinociceptive potential. This study aimed to assess whether there is an influence of animal sex and the JUSTIFICATIVA E OBJETIVOS: O peixe-zebra adulto (Da- test environment on the orofacial nociceptive behavior of the nio rerio) tem sido proposto como uma alternativa simples e de adult zebrafish. baixo custo ao uso de roedores em pesquisas laboratoriais de no- METHODS: First, cinnamaldehyde, menthol, capsaicin, acidic vos compostos com potencial antinociceptivo. Este estudo teve saline, or glutamate was applied into the lips of the adult male como objetivo avaliar se há influência do sexo do animal e do or female zebrafish. Naive groups were included as control. The ambiente de teste no comportamento nociceptivo orofacial do orofacial nociception was quantified in terms of locomotor ac- peixe-zebra adulto. tivity. In other series of experiments, it was evaluated whether MÉTODOS: Inicialmente, cinamaldeído, mentol, capsaicina, the apparatus, acclimatization, period of test, temperature of the solução salina ácida ou glutamato foi aplicada nos lábios do pei- water and color of the open field would alter the nociceptive xe-zebra adulto masculino ou feminino. Grupos naive foram in- response to cinnamaldehyde. cluídos como controle. A nocicepção orofacial foi quantificada RESULTS: The nociceptive behavior did not depend on the sex em termos de atividade locomotora. Em outra série de experi- of the animal, apparatus, time the test was performed or the co- mentos, foi avaliado se o aparato, aclimatação, período de teste, lor of the open field. However, acclimatization promoted noci- temperatura da água e cor do campo aberto alterariam a resposta ceptive behavior in naive animals and did not alter the nocicep- nociceptiva ao cinamaldeído. tive response to cinnamaldehyde (p<0.01 vs acclimatized naive). RESULTADOS: O comportamento nociceptivo não dependeu The nociception behavior was presented only when the test was do sexo do animal, do equipamento de teste, do horário em que performed at a temperature of 26ºC (p<0.01 vs naive). o teste foi realizado ou da cor do campo aberto. No entanto, CONCLUSION: The results suggest the need to control the a aclimatação promoveu comportamento nociceptivo em ani- environment and water temperature as an environmental sour- mais naive e não alterou a resposta nociceptiva ao cinamaldeído (p<0,01 vs naive aclimatado). O comportamento nociceptivo foi verificado apenas quando o teste foi executado a uma temperatura de 26oC (p<0,01 vs naive). CONCLUSÃO: Os resultados sugerem a necessidade de contro- Gerlânia Oliveira Leite – https://orcid.org/0000-0003-1532-6831; Sacha Aubrey Alves Rodrigues Santos – https://orcid.org/0000-0002-4117-2277; lar o ambiente e a temperatura da água como fonte de variação Antônia Deyse de Castro Ribeiro – https://orcid.org/0000-0002-1183-8074; ambiental durante o teste de comportamento nociceptivo do Francisca Magnólia Diógenes Holanda Bezerra – https://orcid.org/0000-0002-7671-3002; Adriana Rolim Campos – https://orcid.org/0000-0002-7355-9310. peixe-zebra adulto. Descritores: Dor, Meio ambiente, Nocicepção, Peixe-Zebra. 1. University of Fortaleza, Center of Experimental Biology, Fortaleza, CE, Brazil.

Submitted on November 09, 2020. INTRODUCTION Accepted for publication on December 28, 2020. Conflict of interests: none – Sponsoring sources: CAPES/FUNCAP, CNPq and Edson Queiroz Foundation. Pain is considered a negative affective state associated with tissue damage and it is important to alleviate pain to improve both hu- Correspondence to: 1,2 Adriana Rolim Campos man condition and animal welfare . Although rodent models are Universidade de Fortaleza widely used in translational pain research3,4, other experimental Núcleo de Biologia Experimental (NUBEX) Av. Washington Soares, 1321 – Edson Queiroz models help to evaluate evolutionarily conserved mechanisms un- 60811-905 Fortaleza, CE, Brasil. derlying nociception and its associated behavioral phenotypes5,6. E-mail: [email protected] It has been already shown that the adult zebrafish (Danio rerio) © Sociedade Brasileira para o Estudo da Dor is a viable alternative to more traditional laboratory models used 9 BrJP. São Paulo, 2021 jan-mar;4(1):9-14 Leite GO, Santos SA, Ribeiro AD, Bezerra FM and Campos AR in the search for new compounds with antinociceptive potential7 ber 8 - agonist; 1.2mM; 5.0μL) injected into the lips of the ani- with the advantages of significant homology to the human geno- mals (male and female; n=8/group) 30 min after pre-treatment me and relatively lower cost compared with rodents7,8. with saline (20.0μL). Naive groups (male and female, n=8/ However, as far as is known, there are no studies that assess each) were included as control. The nociceptive behavior was the relationship between the test environment and nociceptive quantified in terms of locomotor activity (number of crossing behavior of the zebrafish, as well as whether there is interferen- lines) performed during 0 - 10 min. ce of the animal’s sex or not. It’s known, for example, that the water temperature alters the convulsive response of zebrafish to Capsaicin-induced orofacial nociceptive behavior pentylenetetrazole9. Study10 demonstrated that the locomotor Orofacial nociception was induced with capsaicin (TRPV1 activity of zebrafish larvae is sensitive to the time of day and - transient receptor potential cation channel subfamily V light conditions. member 1 - agonist; 40,93μM; 5.0μL), dissolved in ethanol, According to other study11 in zebrafish neurobehavioral, sex is of- PBS (phosphate buffered saline) and distilled water (1:1:8) ten not reported and the use of both rodent and novel (zebrafish) injected into the lips of the animals (male and female; n=8/ models may contribute to the understanding of the mechanisms group) 30 min after pre-treatment with saline (20.0μL). Nai- linking sex to brain and behavior. It has been already shown that ve groups (male and female, n=8/each) were included as con- the corneal nociceptive response induced by hypertonic saline trol. The nociceptive behavior was quantified in terms of lo- in adult zebrafish is independent of the animal’s sex12. Authors13 comotor activity (number of crossing lines) performed during also reported that there was no interference of sex in the nocicep- 10 - 20 min. tive response to acetic acid administered on the lips of zebrafish. However, both hypertonic saline and acetic acid promote noci- Acidic saline-induced orofacial nociceptive behavior ceptive behavior through non-specific mechanisms. Orofacial nociception was induced with acidic saline Therefore, the aim of this study was to assess if there is an in- (ASIC - acid-sensing ion channels - agonist; 0.1%; 5.0μL) fluence of animal sex and the test environment on the orofacial injected into the lips of the animals (male and female; n=8/ nociceptive behavior of the adult zebrafish. group) 30 min after pre-treatment with saline (20.0μL). Naive groups (male and female, n=8/each) were included METHODS as control. The nociceptive behavior was quantified in terms of locomotor activity (number of crossing lines) perfor- Adult wild zebrafish (Danio rerio) of both sexes, short-fin phe- med during 10 - 20 min. notype, aged 60–90 days, similar size (3.5±0.5cm) and weight (0.3±0.2g), obtained from Agroquímica: Comércio de Produtos Glutamate-induced orofacial nociceptive behavior Veterinários LTDA (Fortaleza, Ceará, Brazil). Groups of 50 fish Orofacial nociception was induced with glutamate (NMDA were acclimated for 24 hours in a 10-L glass tank (30x15x- - N-methyl-D-aspartate receptor - agonist; 12.5 mM; 5.0μL) 20cm) containing dechlorinated tap water (ProtecPlus®) and injected into the lips of the animals (male and female; n=8/ air pump with submerged filter at 25°C and pH 7.0, under group) 30 min after pre-treatment with saline (20.0 μL). near-normal circadian rhythm (14:10h of light/dark). The fish Naive groups (male and female, n=8/each) were included as received ad libitum feed 24h prior to the experiments. control. The nociceptive behavior was quantified in terms of locomotor activity (number of crossing lines) performed du- EVALUATION OF THE INFLUENCE OF SEX ON NO- ring 0 - 15 min. CICEPTIVE OROFACIAL BEHAVIOR IN ADULT ZE- BRAFISH EVALUATION OF THE INFLUENCE OF THE TEST EN- VIRONMENT ON NOCICEPTIVE OROFACIAL BEHA- Cinnamaldehyde-induced orofacial nociceptive behavior VIOR IN ADULT ZEBRAFISH Orofacial nociception was induced with cinnamaldehyde (TRPA1 - transient receptor potential cation channel subfa- Cinnamaldehyde-induced orofacial nociceptive behavior mily A member 1 - specific agonist; 0.66μg/mL; 5.0μL) injec- Orofacial nociception was induced with cinnamaldehyde ted into the lips of the animals (male and female; n=8/group), (see above) injected into the lips of the animals (n=8/group), 30 min after pre-treatment with saline (20.0μL). Naive groups 30min after pre-treatment saline (20.0μL). Naive groups (male and female, n=8/each) were included as control. The ani- (n=8/each) were included as control. The nociceptive beha- mals were then placed in a glass Petri dish (10 x 15 cm) divided vior was analyzed as described above during 0-5 min in the into quadrants and the nociceptive response was quantified in following conditions: terms of locomotor activity (number of crossing lines) perfor- • Test performed in Petri dish (10x15 cm) or beaker (250mL); med during 0 - 5 min. in this test, groups (n=8/each); • Test performed in Petri dish with animals acclimated or not Menthol-induced orofacial nociceptive behavior 24 hours before the experiments; Orofacial nociception was induced with menthol (TRPM8 - • Test performed in Petri dish with different schedule of the transient receptor potential cation channel subfamily M mem- experiment (morning or afternoon); 10 Impact of sex and environmental conditions BrJP. São Paulo, 2021 jan-mar;4(1):9-14 on the responses to pain in zebrafish

• Test performed in Petri dish with different temperatures of RESULTS the water: 22, 26 or 30 oC; • Test performed in Petri dish with light or dark floors. Cinnamaldehyde- (p<0.01 - p<0.001 vs naive), menthol- All experimental procedure was approved by the Ethics Com- (p<0.05 vs naive), capsaicin- (p<0.001 - p<0.0001 vs naive), mittee on Animal Research of the State University of Ceará acidic saline- (p<0.0001 vs naive) and glutamate- (p<0.001 - (CEUA-UECE; #7210149/2016). p<0.0001 vs naive) induced nociceptive behavior in adult zebrafish and this effect was not sex-dependent (Figure 1). Statistical analysis Values are expressed as mean±standard error of the mean Influence of the test environment on nociceptive orofacial (S.E.M). The data obtained were evaluated through the one-way behavior of adult zebrafish analysis of variance (ANOVA), followed by Tukey’s test. In all Cinnamaldehyde induced nociceptive orofacial behaviour cases, differences were considered significant if p<0.05. All sta- when the animals were tested in Petri dish (p<0.05 vs naive) tistical analyses were carried out using the GraphPad Prism 6.0 and beaker (p<0.01 vs naive) as described in figure 2. There software (GraphPad Prism Software Inc., San Diego, CA, USA). was nociceptive response when the test was performed in the

A B (n/0-5 min) (n/0-10 min) Crossinglines Crossinglines Crossinglines

CIN M CIN F MNT F Naive M Naive F MNT M Naive M Naive F

C D (n/0-20 min) (n/10-20 min) Crossinglines Crossinglines

AS F CAP F AS M CAP M Naive M Naive F Naive M Naive F

E (n/0-15 min) Linhas de cruzamento

GLU F GLU M Naive M Naive F

Figure 1. Orofacial nociceptive behavior induced by cinnamaldehyde (CIN - A), menthol (MNT - B), capsaicin (CAP - C), acidic saline (AS - D) or glutamate (GLU - E) in adult male (M) and female (F) adult zebrafish. The results are expressed as mean values ± standard error. ANOVA followed by Tukey. **p<0.01, ***p<0.001 and ****p<0.0001 vs the respective Naive group.

11 BrJP. São Paulo, 2021 jan-mar;4(1):9-14 Leite GO, Santos SA, Ribeiro AD, Bezerra FM and Campos AR

morning (p<0.01 vs naive) or afternoon (p<0.05 vs naive) as shown in figure 3B. Whether or not the animals were acclimatized 24h before the test interfered with the nociceptive response, since acclimated naive animals showed nociceptive behavior (p<0.05) like that presented by fish treated with cinnamaldehyde (p<0.01) in (n/0-5 min)

Crossinglines comparison with non-acclimatized naive animals (Figure 3A). The water temperature in which it was possible to verify nociceptive behavior was 26oC (p<0.0001 vs naive – Figure 4A). There was no difference in response when the test was perfor- CIN CIN Naive Naive med on Petri dishes with a white (p<0.001 vs naive) or black (p<0.01 vs naive) background (Figure 4B). Petri dish Beaker

Figure 2. Nociceptive behavior induced by cinnamaldehyde (CIN) in DISCUSSION adult male and female zebrafish for test performed in the Petri dish (A) or beaker (B). The use of adult zebrafish as an animal model of nociception The results are expressed as mean values ± standard error. ANOVA followed by Tukey. **p<0.01, ***p<0.001 and ****p<0.0001 vs the respective has proven to be efficient as a tool for the study of new phar- Naive group. macological targets14-19. The decrease in locomotor activity is

A B (n/0-5 min) (n/0-5 min) Crossinglines Crossinglines

CIN CIN CIN CIN Naive Naive Naive Naive

Acclimatization Noacclimatization Morning Afternoon

Figure 3. Evaluation of the interference of acclimatization (A) and period of the test (B) on the nociceptive behavior induced by cinnamaldehyde (CIN) in adult male and female zebrafish. The results are expressed as mean values ± standard error. ANOVA followed by Tukey. **p<0.01, ***p<0.001 and ****p<0.0001 vs the respective Naive group.

A B (n/0-5 min) Crossinglines (n/0-5 min) Crossinglines

CIN CIN CIN Naive Naive Naive CIN CIN Naive Naive

White floor Black floor Watertemperature (ºC)

Figure 4. Evaluation of the interference of water temperature (A) and color of the open field (B) on the nociceptive behavior induced by cinnamaldehyde (CIN) in adult male and female zebrafish. The results are expressed as mean values ± standard error. ANOVA followed by Tukey. **p<0.01, ***p<0.001 and ****p<0.0001 vs the respective Naive group.

12 Impact of sex and environmental conditions BrJP. São Paulo, 2021 jan-mar;4(1):9-14 on the responses to pain in zebrafish one of the parameters of nociception in zebrafish5 and was no difference in nociceptive response of zebrafish when they used here. To promote accuracy in the translation of research were tested in both black and white open field. findings using zebrafish, several particularities of the zebrafish It was previously showed that adult zebrafish readily (within 5 biology should be considered9. Here, the effect of sex and chan- min) display habituation learning in the open field test34. The ges in the test environment on orofacial nociceptive behavior of acclimatization induced nociceptive behavior in naïve zebrafish adult zebrafish was evaluated. like animals receiving cinnamaldehyde. Non-acclimatized fish There are few confounding factors in the nociceptive behavior presented high locomotor activity, suggesting the existence of of the adult zebrafish, since acclimatization 24h before the test adaptive mechanisms in zebrafish that inhibit nociception in and water temperature were the only parameters that altered situations of threat and release it in situations of novelty or the animals’ response. Thus, as in adult zebrafish, the tempera- expectancy35. ture of the test environment is a key factor in the variation of The nociceptive effect is observed at the water temperature the nociceptive response of rodents20,21. of 26o C, while when the animals are tested at water tempe- It has been reported that there is a difference between the lo- rature of 22o and 30o C there was no nociceptive behavior. comotor activity of male and female zebrafish22,23. Since the This result agrees with previous findings9, confirming the nociception parameter used is locomotor activity, it was inves- need to maintain water temperature as a determining fac- tigated if there would be interference of the animal’s sex on tor for handling zebrafish, since variations in environmental nociceptive behavior. temperature strongly affect fish biology influencing not only The influence of sex on nociceptive behavior in animal models their growth, but also reproduction, spontaneous activity has been widely demonstrated and it appears that females have and metabolism36. hyperresponsiveness, although there is no difference between sexes in some rodent strains24. Here, a relationship between the CONCLUSION animal’s sex and the nociceptive response, as previously reported, was no verified12,13,25. In summary, the results suggest the need to control the envi- The behavioral tests using zebrafish are based on confronting ronment and water temperature during the nociceptive beha- the animal with a new environment, experiencing the conflict vior test of the adult zebrafish. between the urge to explore the unknown area/object, curiosity and the motivation to avoid potential dangers8,25. The nocicep- AUTHORS’ CONTRIBUTIONS tive behavior was not altered by the size of the apparatus, time or color of the Petri dish on which the test was performed. Gerlânia Oliveira Leite Study26 compared the locomotor activity of adult zebrafish in Data Collection, Research, Writing – Preparation of the original two open fields of different sizes and found that locomotor ac- Sacha Aubrey Alves Rodrigues Santos tivity was greater in the larger arena. The animals tested in the Data Collection beaker were expected to show greater locomotor activity than Antônia Deyse de Castro Ribeiro the animals tested in the Petri dish. Both the animals tested in Data Collection the beaker and the animals tested in the Petri dish showed noci- Francisca Magnolia Diogenes Netherlands Bezerra ceptive behavior. Although the nociceptive behavior was more Data Collection significant in the beaker, there was no difference between the Adriana Rolim Campos behaviors presented in the beaker and in the Petri dish. Funding Acquisition, Resource Management, Supervision Several studies have analysed whether the locomotor activity of embryos and zebrafish larvae is altered at different times of REFERENCES the day. Authors27 demonstrated that activity of embryos and larvae was more variable during these periods, while activity 1. Mogil JS, Davis KD, Derbyshire SW. The necessity of animal models in pain research. 10 Pain. 2010;151(1):12-7. was higher and less variable in the afternoon. Study reported 2. Woolf CJ. What is this thing called pain? J Clin Invest. 2010;120(11):3742-4. higher movement of larvae in the morning. However, other 3. Stevenson GW, Bilsky EJ, Negus SS. Targeting pain-suppressed behaviors in preclini- study28 conclude that time of day did not change the activity cal assays of pain and analgesia: effects of morphine on acetic acid-suppressed feeding in C57BL/6J mice. J Pain. 2006;7(6):408-16. of larvae. Although adult zebrafish is known to be more active 4. Meotti FC, Coelho Idos S, Santos, AR. The nociception induced by glutamate in mice in the morning29, no difference was found between the noci- is potentiated by protons released into the solution. J Pain. 2010;11(6):570-8. 5. Sneddon LU, Braithwaite VA, Gentle MJ. Novel object test: examining nociception ceptive response of adult zebrafish tested at morning and at and fear in the rainbow trout. J Pain. 2003;4(8):431-40. afternoon. 6. Du X, Yuan B, Wang J, Zhang X, Tian L, Zhang T, et al. Effect of heat-reinforcing needling on serum metabolite profiles in rheumatoid arthritis rabbits with cold syn- The color of other equipment used in neurobehavioral research, drome. Zhongguo Zhen Jiu. 2017;37(9):977-83. including nets and treatment beakers, is rarely reported in the 7. Magalhães FEA, de Sousa CAPB, Santos SAAR, Meneses RB, Batista FLA, Abreu AO, literature and may play a role30. Zebrafish have color vision31 et al. Adult zebrafish (Danio rerio): an alternative behavioral model of formalin-indu- 32 ced nociception. Zebrafish. 2017;14(5):422-9. and their visual physiology is generally like that of mammals , 8. Crusio WE. Genetic dissection of mouse explaratory behavior. 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14 BrJP. São Paulo, 2021 jan-mar;4(1):15-9 ORIGINAL ARTICLE

Knowledge and use of Integrative and Complementary Health Practices by patients with orofacial pain Conhecimento e uso das Práticas Integrativas e Complementares em Saúde por pacientes com dor orofacial

Keila Esterlina Chagas1, Clarice do Vale Araújo Melo1, Isabela Rodrigues Rocha2, Camila Megale Almeida-Leite3, Janice Simpson de Paula4

DOI 10.5935/2595-0118.20210004

ABSTRACT RESUMO

BACKGROUND AND OBJECTIVES: Use of Integrative and JUSTIFICATIVA E OBJETIVOS: A utilização de Práticas Inte- Complementary Health Practices (ICHP) in pain management grativas e Complementares em Saúde (PICS) no tratamento da has increased, mainly due to the biopsychosocial nature of pain. dor tem aumentado, sobretudo em função da natureza biopsi- The objective of this work is to evaluate the knowledge and use cossocial da dor. O objetivo foi avaliar o conhecimento e uso das of ICHP in patients with orofacial pain and describe the sociode- PICS em pacientes com dor orofacial e conhecer o perfil sociodemographic profile of patients that use these therapies. mográfico dos pacientes que utilizam essas terapias. METHODS: This is a cross-sectional study and data collection MÉTODOS: Estudo do tipo transversal, com pacientes atendi- was performed through a questionnaire about knowledge, use dos de agosto de 2018 a julho de 2019 nas clínicas de dor oro- and interest in ICHP in a sample of patients with orofacial pain. facial. A coleta de dados foi feita por meio de um questionário Adult patients of both sexes under treatment from August 2018 sobre conhecimento, uso e interesse a respeito das PICS. to July 2019 at orofacial pain specialized services were included. RESULTADOS: Dos 66 pacientes, 56 (84,8%) eram mulheres. RESULTS: Fifty-six patients (84.8%) were female and among those Desses, 97% conheciam as práticas integrativas, sendo a acupun- 97% had previous knowledge of complementary practices, with tura a mais conhecida (89,6%). Ademais, 59% dos participantes acupuncture being the most known (89.6%). In addition, 59% of fizeram uso de alguma terapia para dor orofacial, sendo a fitote- participants used therapies for orofacial pain, mainly phytotherapy rapia a mais utilizada (28,8%), e 97% tinham interesse em co- (28.8%). Ninety-seven percent showed interest in knowledge and use nhecer e utilizar as práticas. of complementary therapies. Among users, the majority was female. CONCLUSÃO: Pacientes com dor orofacial conhecem e utili- CONCLUSION: The patients know and use ICHP to relieve oro- zam as PICS para alívio da dor e promoção do bem-estar. Há facial pain and show great interest in the field which justifies inclu- grande interesse pelas práticas, fato que estimula a inclusão no sion of complementary practices for management of orofacial pain. tratamento complementar da dor orofacial. Keywords: Chronic pain, Complementary therapies, Dentistry, Descritores: Dor crônica, Dor facial, Odontologia, Terapias Facial pain. complementares.

INTRODUCTION

Keila Esterlina Chagas – https://orcid.org/0000-0003-0639-2669; Clarice do Vale Araújo Melo – https://orcid.org/0000-0002-4349-9273; Chronic pain (CP) is a public health issue due to high costs as- Isabela Rodrigues Rocha – https://orcid.org/0000-0002-2176-358X; Camila Megale Almeida-Leite – https://orcid.org/0000-0003-2694-8521; sociated with treatment, physical and emotional disabilities, and 1 Janice Simpson de Paula – https://orcid.org/0000-0002-5396-0959. absenteeism . Epidemiological studies report that 33 to 50% of the world population suffers from CP2,3. Among the various 1. Federal University of Minas Gerais, Dentistry Course, Belo Horizonte, MG, Brazil. 2. Federal University of Minas Gerais, Graduate Program in Dentistry, Professional Master types of CP, orofacial pain (OFP), defined as all pain associated of Dental Public Health, Belo Horizonte, MG, Brazil. with soft and mineralized tissues of the head, face and neck, af- 3. Federal University of Minas Gerais, Department of Morphology, Institute of Biological Sciences, Belo Horizonte, MG, Brazil. fects 12 to 22% of the world population and generates great dis- 4. Federal University of Minas Gerais, Department of Social and Preventive Dentistry, comfort and suffering3. School of Dentistry, Belo Horizonte, MG, Brazil. The recommended treatment for OFP, as well as for CP, in gen- Submitted on April 3, 2020. eral, aims at reducing pain and recovering function. For this, one Accepted for publication on December 17, 2020. should consider not only the purely biological diagnosis, but also Conflict of interests: none – Sponsoring sources: none. the wide range of psychological, social and contextual factors in Correspondence to: each individual4,5. Considering, therefore, the biopsychosocial Camila Megale Almeida-Leite Avenida Antônio Carlos, 6627, Pampulha nature of CP, the use of Integrative and Complementary Health 31270-901, Belo Horizonte, MG, Brasil Practices (ICHP) becomes very relevant in the clinical manage- E-mail: [email protected] ment of pain and promotes the therapeutic link between health © Sociedade Brasileira para o Estudo da Dor professionals and patient, generating more effective results6. 15 BrJP. São Paulo, 2021 jan-mar;4(1):15-9 Chagas KE, Melo CV, Rocha IR, Almeida-Leite CM and Paula JS

Although further in-depth studies on the mechanisms, adverse The data collection period was from August 2018 to July 2019. effects and effectiveness of some ICHP are needed, several bene- Prior to the start of data collection, a pilot study was conducted fits for the relief of disease symptoms and CP, among them OFP, with 6 patients, corresponding to 10% of the sample, so that the have already been reported, especially when conventional treat- researchers could train for the interview. ment doesn’t present satisfactory results7-9. Research approved by the Research Ethics Committee In 2006, the Brazilian Ministry of Health approved the Na- (COEP) of the Federal University of Minas Gerais (CAAE tional Policy of Integrative and Complementary Health Prac- 89495618.7.0000.5149). tices (NPICHP), aiming at a humanized and integral attention for the patient, providing multiprofessional care10. Since Statistical analysis then, interest and knowledge on the part of health profes- The data was analyzed by means of descriptive statistics. The as- sionals and patients regarding ICHP have increased in Brazil, sociation of sociodemographic and clinical aspects with the use mainly due to scientific studies that demonstrate their ben- of ICHP was evaluated using the Chi-square test, 5% signifi- efits7,8,11,12. The use of ICHP by patients is related to prior cance level. The IBM® SPSS® Statistics 23.0 software was used. knowledge, access and benefits of combining ICHP with conventional treatment13. However, it’s reported that the use RESULTS is more widespread among individuals with great interest in increasing their knowledge about ICHP, as well as in patients The majority was female (56; 84.8%), with 9 or more years of with chronic health conditions, such as pain14,15. Therefore, education (52; 78.8%), declared religion (55; 83.3%), resid- it’s important to assess the knowledge of patients suffering ing in Belo Horizonte (44, 66.7%) and with familiar income from OFP on ICHP in order to support decision making and from 1 to 4.9 minimum wages (48, 72.7%). As for the marital therapeutic proposals of ICHP integration with traditional status, 30 patients (45.4%) were single and 30 (45.4%) were treatment, which can contribute to pain relief and better married, being the remaining (6; 9.1%) widowers, divorced quality of life. This is particularly important in the context or in stable union. The average age of the participants was of OFP and TMD, since multiprofessional treatment is ad- 42±17 years old. vocated as essential for the management of painful symptoms Twenty-seven (40.9%) patients presented OFP as the only site of and control of perpetuating habits and psychosocial factors pain, with the face and the temporomandibular joint (TMJ) be- associated with these conditions16,17. Moreover, the recogni- ing the most cited regions. Pain duration was 68.4±80.4 months tion of ICHP as a therapeutic modality, both by those who and for symptom relief 17 (25.8%) patients reported using drugs, work in health care and by the general population, will allow 12 (18.2%) non-pharmacological therapies and 28 (42.4%) the its applicability in clinical practice and the development of association of drugs and non-pharmacological treatments. Of new studies, with clear repercussions for science as well as for the 66 (100%) participants, 40 (60.6%) reported using non- the community6. pharmacological therapies, being physiotherapy (13.6%), ICHP The objective was to evaluate the knowledge and usage of ICHP (10.6%) and physical activities (9.1%) the most reported. Only in patients with OFP, as well the sociodemographic profile of 9 (13.6%) participants did not use treatments for pain relief. patients that use these therapies. Regarding knowledge, use, and interest in ICHP, 64 (97%) patients reported previous knowledge, 39 (59%) made use of METHODS it, and 64 (97%) would like to have access to ICHP (Table 1). Acupuncture was the best known practice (89.4%), and phy- A descriptive, analytical and quantitative cross-sectional explor- totherapy the most used (n=19; 28.8%). The patients’ greatest atory study was performed. The sample was chosen by conve- interest was also acupuncture (74.2%). nience, in which all new patients from the Orofacial Pain Ser- The most cited sources of knowledge about ICHP by the partici- vice of the Clinical Hospital and the Orofacial Pain course clinic pants were friends (40.6%), newspaper/television/radio (34.4%) of the School of Dentistry of the Federal University of Minas and family (34.4%). Table 2 details the motivations for using Gerais in Belo Horizonte were invited. Of the total of 88 pa- ICHP by the 39 (100%) patients who reported using it and pain tients who attended the services during the data collection pe- relief was the most cited reason (n=14; 35.9%). riod, 66 (75%), who met the following eligibility criteria, were Table 3 shows the justifications reported by the 64 (97%) par- included in the survey: to be in treatment in one of the described ticipants who would like ICHP to be offered in public health specialized services, to have a minimum age of 18 years old and services. be able to adequately understand the instructions during the ap- When evaluating the sociodemographic characteristics in pa- plication of the questionnaire. The exclusion criterion was the tients who reported using ICHP, the majority was female, with refusal to participate voluntarily and/or to Free Informed Con- statistically significant difference (p=0.012). Most patients who sent Term (FICT). used ICHP had more than 8 years of education, had no declared The data collection was carried out through the application of an religion, were single/widowers/divorced, lived in the capital and adapted questionnaire18, with questions related to sociodemo- had an income higher than 2 minimum wages. Nevertheless, no graphic factors, pain characteristics and treatments performed, statistically significant difference was observed between these va- in addition to questions on use, knowledge and interest in ICHP. riables (p>0.05). 16 Knowledge and use of Integrative and Complementary BrJP. São Paulo, 2021 jan-mar;4(1):15-9 Health Practices by patients with orofacial pain

Table 1. Knowledge, use and interest regarding ICHP by patients seen Table 3. Justifications of patients seen in orofacial pain services for in orofacial pain services offering ICHP for pain treatment ICHP Knowledge Use Interest Justifications n (%) n (%) n (%) n (%) Providing benefits for people’s health and wel- 39 (60.9) Acupuncture 59 (89.4) 11 (16.7) 49 (74.2) l-being Apitherapy 4 (6.1) 1 (1.5) 3 (4.5) To be accessible for the population 7 (10.9) Aromatherapy 19 (28.8) 3 (4.5) 3 (4.5) To be one more treatment option 5 (7.8) Art therapy 12 (18.2) 0 6 (9.1) Decrease the use of drugs 4 (6.2) Auriculotherapy 36 (54.5) 7 (10.6) 17(25.8) Complement traditional treatment methods/ Ayurveda 4 (6.1) 0 2 (3.0) provide benefits for the health and well-being of 1 (1.6) Biodance/circular dance 9 (13.6) 2 (3.0) 7 (10.6) people Bioenergetics 1 (1.5) 0 2 (3.0) To decrease the use of drugs/provide benefits for Family constellation 11 (16.7) 0 2 (3.0) the health and well-being of people 1 (1.6) Crenotherapy 3 (4.5) 1 (1.5) 0 Believe to be a good treatment, based on peo- 1 (1.6) Chromotherapy 11 (16.7) 1 (1.5) 3 (4.5) ple’s report Phytotherapy 45 (68.2) 19 (28.8) 15 (22.7) Pain relief 1 (1.6) Geotherapy 10 (15.1) 0 2 (3.0) Pain relief/to be accessible for the population 1 (1.6) Hypnotherapy 19 (28.8) 0 8 (12.1) To be one more treatment option/provide bene- 1 (1.6) Homeopathy 47 (71.2) 9 (13.6) 13 (19.7) fits for the health and well-being of people Massage 49 (74.2) 18 (27.3) 38 (57.6) Complement traditional treatment methods 1 (1.6) Anthroposophical medicine 3 (4.5) 0 2 (3.0) No information 2 (3.0) Meditation 40 (60.6) 8 (12.1) 11 (16.7) Total 64 (100.0) Music therapy 22 (33.3) 2 (3.0) 7 (10.6) Naturopathy 2 (3.0) 1 (1.5) 0 Osteopathy 2 (3.0) 0 5 (7.6) DISCUSSION Ozoniotherapy 2 (3.0) 0 0 TCM body practices 12 (18.2) 4 (6.1) 7 (10.6) This research highlighted the high prevalence of knowledge Chiropractic 11 (16.7) 2 (3.0) 12 (18.2) and use of ICHP by patients with OFP, demonstrating the Reiki 19 (28.8) 3 (4.5) 5 (7.6) relevance of integrating ICHP to traditional pain treatment Community therapy 3 (4.5) 0 2 (3.0) in dentistry and the need for future studies in this field. It’s also important to highlight the interest of patients in ICHP Bach flower remedies 20 (30.3) 4 (6.1) 7 (10.6) in public health services, especially due to the easier access Yoga 45 (68.2) 6 (9.1) 30 (45.4) and improved quality of life, relevant conditions in the con- Other (laser therapy) 0 7 (10.6) 1 (1.5) text of user satisfaction and the expanded concept of health. TCM = Traditional Chinese Medicine. As for the sociodemographic profile, the studied sample is Table 2. Motivations for which patients in orofacial pain services use similar to the profile of individuals with OFP worldwide. 6,19,20 ICHP Young women are more affected by OFP, especially TMD , 19,20 Motivations n (%) possibly due to the action of the estrogen hormone . In ad- Pain relief 14 (35.9) dition, women are more likely to seek preventive and comple- 15 Pain relief/wellness 5 (12.8) mentary treatments for OFP . Wellness 3 (7.7) It’s possible to observe that most patients with OFP use ICHP Pain relief/anxiety 2 (5.1) concomitantly to the pharmacological treatment, with the Pain relief/anxiety/wellness 2 (5.1) objective of improving pain relief, promoting physical and Pain relief/stress 2 (5.1) emotional well-being and reducing anxiety and stress. These Pain relief/aesthetic 1 (2.6) data reinforce that patients with OFP, in general, seem not Anxiety/cardio-vascular diseases 1 (2.6) satisfied with the biomedical model-based care and seek other 2 Anxiety/wellness 1 (2.6) treatment methods . Given the importance of understand- Anxiety/depression 1 (2.6) ing the multifactorial profile and biopsychosocial model of Anxiety/stress 1 (2.6) CP, the multiprofessional interaction in the diagnosis and Pain relief/anxiety/wellness/depression/ treatment of pain, in order to provide comprehensive care to viral infections/inflammatory diseases 1 (2.6) patients, is necessary22-24. From this perspective, the use of Wellness/aesthetics 1 (2.6) non-pharmacological therapies, as ICHP, in association with Stress 1 (2.6) traditional treatment methods, contributes to the biopsycho- Pain relief/weight loss 1 (2.6) social approach to pain, allows personalized and holistic pa- No information 2 (5.1) tient treatment, in addition to promoting the therapeutic link Total 39 (100.0) between professional and patient, with clear repercussions on 17 BrJP. São Paulo, 2021 jan-mar;4(1):15-9 Chagas KE, Melo CV, Rocha IR, Almeida-Leite CM and Paula JS pain relief and improvement of life quality25. Furthermore, that encourages the inclusion of ICHP in the complementary the adoption of complementary therapies favors the decrease treatment of OFP. in drug use and the prevention of health problems26. In that sense, studies report that the use of ICHP is main- ACKNOWLEDGMENTS ly associated with access, previous knowledge and benefits resulting from their association with conventional treat- To Dr. Gustavo Rodrigues Costa Lages and Dr. Roberto Brígido ment13,15. Moreover, individuals with chronic pain seek to de Nazareth Pedras for access to the patients of the Orofacial Pain know and use complementary treatments to improve their Service of the HC/UFMG linico f Pain and to FAO/UFMG for health condition14. Within this context, the results of the access to the patients of the Orofacial Pain course clinic. present research reveal that participants have previous knowledge and interest, but the use was probably limited AUTHORS’ CONTRIBUTIONS by the difficulty of access to ICHP, whether in the public or private health system. Keila Esterlina Chagas The use of ICHP is primarily related to pain relief in patients Data Collection, Investigation, Writing - Original preparation with OFP, as it happens in other CP2.5 conditions. However, Clarice do Vale Araújo Melo part of the motivation is the promotion of well-being and Data Collection, Research control of anxiety and stress, which has a positive impact on Isabela Rodrigues Rocha quality of life25. Similarly, the interest in offering ICHP oc- Data Collection, Research curs mainly because of the potential health benefits and the Camila M Almeida-Leite possibility of access by the general population, which can Project Management, Writing - Original preparation, Writing - bring numerous benefits to health and quality of life27,28. Review and Editing, Supervision Moreover, it was possible to observe a higher level of educa- Janice Simpson de Paula tion in patients who make use of ICHP, reinforcing that ac- Statistical analysis, Project Management, Writing - Original pre- cess to knowledge about complementary therapies and their paration, Writing - Review and Editing, Supervision benefits is important for their use15. From that perspective, the relevance of the dissemination of knowledge in the field REFERENCES for the population in general and, especially, for the lower socioeconomic classes, becomes clear. 1. Turner JA, Franklin G, Fulton-Kehoe D, Egan K, Wickizer TM, Lymp JF, et al. Pre- diction of chronic disability in work-related musculoskeletal disorders: a prospective, Research shows that interest in the knowledge and use of population-based study. BMC Musculoskelet Disord. 2004;5:14. ICHP by patients and health professionals has increased sig- 2. Gureje O, Von Korff M, Simon GE, Gater R. 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19 BrJP. São Paulo, 2021 jan-mar;4(1):20-5 ORIGINAL ARTICLE

Prevalence and associated factors with musculoskeletal pain in professionals of the Mobile Emergency Care Service Prevalência e fatores associados à dor musculoesquelética em profissionais do Serviço de Atendimento Móvel de Urgência

Roberto Airon Veras dos Santos1, Maria Cristina Falcão Raposo2, Renato de Souza Melo3

DOI 10.5935/2595-0118.20210013

ABSTRACT tor associated with musculoskeletal pain presence in this group of professionals. BACKGROUND AND OBJECTIVES: The professionals who Keywords: Emergency medical services, Knee joint, Low back work in pre-hospital care are exposed to unhealthy environ- pain, Neck pain, Occupational health. ments, which can represent risk factors for the development of musculoskeletal disorders. Thus, the objective of this study was RESUMO to observe the prevalence of musculoskeletal pain in professionals of the Mobile Emergency Care Service (SAMU) and identi- JUSTIFICATIVA E OBJETIVOS: Os profissionais do atendi- fy its associated factors. mento pré-hospitalar estão expostos a ambientes insalubres, que METHODS: Cross-sectional study, carried out at three SAMU podem representar fatores de risco para o desenvolvimento de bases in Pernambuco. Ninety five professionals were evaluated, of distúrbios musculoesqueléticos. Sendo assim, o objetivo des- both sexes and age range between 21-58 years old, being (n=36: te estudo foi observar a prevalência de dor musculoesquelética ambulance drivers, n=38: nursing technicians, n=15: nurses and em profissionais do Serviço de Atendimento Móvel de Urgência n=6: physicians). For the musculoskeletal pain evaluation, the (SAMU) e seus fatores associados. Nordic Questionnaire of Musculoskeletal Symptoms was used. To MÉTODOS: Estudo de corte transversal, realizado em três ba- quantify the intensity of pain, the visual analogue scale was used. ses do SAMU de Pernambuco. Foram avaliados 95 profissionais, RESULTS: Musculoskeletal pain was reported by 71.6% (n=68) de ambos os sexos, com faixa etária entre 21 e 58 anos, sendo of the rescuers; of these, only 18% (n=17) mentioned that they (n=36: condutores socorristas, n=38: técnicos de enfermagem, already had these pains before their SAMU labor activity. Nu- n=15: enfermeiros e n=6: médicos). Para a avaliação da dor mus- rsing technicians were the professionals most affected by the culoesquelética foi utilizado o Nordic Questionnaire of Musculos- musculoskeletal pain (89.5%), followed by nurses (73.3%), am- keletal Symptoms e, para quantificar a intensidade das dores, a bulance drivers (55.6%) and the physicians (50%). The lumbar escala analógica visual. spine (53.5%), knees (32.6%) and cervical spine (30.5%) were RESULTADOS: As dores musculoesqueléticas foram relatadas the body regions most affected by pain and the female sex was por 71,6% (n=68) dos socorristas, desses, apenas 18%(n=17) associated with musculoskeletal pain presence (p=0.024). mencionaram que já apresentavam tais dores antes das suas ati- CONCLUSION: High musculoskeletal pain prevalence was ob- vidades laborais no SAMU. Os técnicos de enfermagem foram served among professionals of SAMU, especially in the nursing os profissionais mais acometidos pelas dores musculoesqueléticas professionals. In addition, the female sex was shown to be a fac- (89,5%), seguidos dos enfermeiros (73,3%), dos condutores socorristas (55,6%) e médicos (50%). A coluna lombar (53,5%), os joelhos (32,6%) e a coluna cervical (30,5%) foram regiões corporais mais acometidas pelas dores e o sexo feminino foi um fator associado à presença das dores musculoesqueléticas (p=0,024). Roberto Airon Veras dos Santos – https://orcid.org/0000-0003-2650-1383; Maria Cristina Falcão Raposo – https://orcid.org/0000-0001-7000-3168; CONCLUSÃO: Foi observada elevada prevalência de dor mus- Renato de Souza Melo – https://orcid.org/0000-0002-6776-3606. culoesquelética nos profissionais do SAMU avaliados, sobretudo 1. University Center of Vale do Ipojuca, Department of Nursing, Caruaru, PE, Brazil. nos profissionais de enfermagem, Além disso, o sexo feminino foi 2. Federal University of Pernambuco, Department of Statistics, Recife, PE, Brazil. um fator associado à presença de dor musculoesquelética nesse 3. Federal University of Pernambuco, Department of Physiotherapy, Recife, PE, Brazil. grupo de profissionais. Submitted on April 13, 2020. Descritores: Articulação do joelho, Cervicalgia, Dor lombar, Accepted for publication on December 18, 2020. Saúde do trabalhador, Serviços médicos de emergência. Conflict of interests: none – Sponsoring sources: none.

Correspondence to: INTRODUCTION Renato de Souza Melo Rua Avelino Cândido, 32, Salgado 55018-070, Caruaru, PE, Brasil. Musculoskeletal disorders (MSD) have been consolidated as one E-mail: [email protected] of the most relevant problems for public health, as they have © Sociedade Brasileira para o Estudo da Dor affected workers in several areas with the appearance of a wide 20 Prevalence and associated factors with musculoskeletal pain BrJP. São Paulo, 2021 jan-mar;4(1):20-5 in professionals of the Mobile Emergency Care Service variety of signs and symptoms such as pain, physical discomfort, with a history of chronic diseases of the osteomyoarticular heaviness sensation, fatigue, paresthesias and limitations of joint system, fractures with plate and/or screw, contusions, recent movements. These signs and symptoms start in an insidious way, distensions, herniated disk and rescuers who were on vacation may be reported to happen simultaneously or not, and evolve or those recently returned from vacation were excluded. rapidly if no changes in working conditions occur1,2. Three instruments were used for the assessments: the evalua- The professionals who work in the pre-hospital care perform tion sheet with personal data and aspects related to work acti- activities that cause great physical wear due to the various vity, the Nordic Questionnaire of Musculoskeletal Symptoms conditions of the patients and their degrees of dependence, (NQMS)15, which was used for the evaluation of musculos- besides the characteristics of the work environment3. These keletal pain, and the visual analog scale (VAS)16, to quantify professionals often face risk situations to provide assistance the intensity of the pain reported. and are exposed to unhealthy environments, places with diffi- Assessments were conducted in a reserved room to avoid pos- cult access, presence of fire, water, mud, uncontrolled electri- sible embarrassments of professionals in exposing musculos- city, often risking their own lives4. keletal pain before their SAMU directors, superiors and work Exposure to these environments is constant and intense due to colleagues. the accelerated pace of demands and the many working hours The evaluation of musculoskeletal pain was performed by that are part of the routine of pre-hospital care, leading to de- the NQMS, an instrument validated for the Brazilian popu- creased productivity and quality of life of the worker5. Moreover, lation15 that consists of dichotomous choices regarding the during pre-hospital care, some techniques for moving victims, presence or absence of osteomuscular symptoms in the cer- such as the use of boards, require an intense body mechanic on vical spine, shoulder, arm, forearm, wrist and hand, thoracic the part of the rescuer and the strategy for transportation of pa- spine, lumbar spine, hip, thigh, knee, leg, ankle and foot, tients may vary according to the situation faced by rescue teams6. providing data on these symptoms at different time periods. The presence of danger on the location, the quantity of profes- In this study, the only osteomuscular symptom evaluated was sionals available to perform the rescue, the diagnosis and the musculoskeletal pain of the last seven days, whose intensity severity of the patient, as well as the rescue scene, all have a di- was quantified by the VAS, which consists of a 100 mm hori- rect influence on the type of transport and when incorrect tech- zontal line, in which zero represents the absence of pain and niques are used the patient may suffer further trauma, just like 10 intense pain17. SAMU6 rescuers. Because of the working conditions, which are The study was approved by the Research Ethics Committee of not always favorable for the rescue of patients, the SAMU pro- the University Center of Vale do Ipojuca (UNIFAVIP), accor- fessionals are prone to develop changes in the musculoskeletal ding to the report number: 1.046.368. system, which can cause more severe pain and MSD. Evidence shows that health professionals, who work in pre- Statistical analysis -hospital care or not, have high prevalence of MSD and ab- Gender, age, body mass index, duration of the weekly wor- senteeism. These disorders have been the main cause of absen- king-hours and the time spent working at SAMU were used ce from the work of these professionals7-11. There is a shortage as possible factors associated with musculoskeletal pain. To of studies on DME in first responders, especially on muscu- test the normality of quantitative variables, the Kolmogorov- loskeletal pain, justifying the present study, whose objective -Smirnov test was used. The Mann-Whitney test was used to was to observe the prevalence of musculoskeletal pain and its compare the means of two groups for cases of non-normality associated factors in the SAMU professionals. of the data and the Student t test, compatible with normal distribution. For the dichotomous variables, Pearson’s Chi- METHODS -square independence tests or Fisher’s Exact were used when necessary. Cross-sectional study, conducted according to the recom- The data was tabulated in Microsoft Office Excel version 2010 mendations of Strengthening the Reporting of Observatio- by two independent researchers (double data entry) to avoid nal Studies in Epidemiology (STROBE) for observational typing errors18, ensuring greater reliability, and was transfer- studies12-14, conducted on three SAMU bases of basic and red to the Statistical Package for the Social Sciences (SPSS) advanced support on the agreste of Pernambuco, including version 20.0, in which all analyses were performed, adopting ambulance drivers, nursing technicians, nurses and physi- the 5% level of statistical significance. cians. It was carried on through a survey on the quantitative of professionals rescuers, totaling 104 professionals, being 36 RESULTS ambulance drivers, 38 nursing technicians, 15 nurses and 15 physicians which were invited to participate in the study. Ninety five professionals were included: 36 ambulance drivers, The inclusion criteria were: to be a SAMU rescuer for at least 38 nursing technicians, 15 nurses and 6 physicians, constitu- one year, to work in the basic/advanced support ambulances ting a sample for convenience (Table 1). Nine physicians were and in the removal of patients and to be 20 to 60 years old. excluded because they didn’t meet the eligibility criteria. All participants signed the Free and Informed Consent Term There was no association between musculoskeletal pain and age (FICT), agreeing to participate in the study. Professionals (p= 0.970 – t Student), BMI (p=0.073 - t Student) and weekly 21 BrJP. São Paulo, 2021 jan-mar;4(1):20-5 Santos RA, Raposo MC and Melo RS

Table 1. Sample features All Drivers Technicians Nurses Physicians (n=95) (n=36) (n=36) (n=15) (n=6) Age (years) 34.4±0.75 34.6±1.29 34.5±1.14 33.5±1.47 35.8±4.68 BMI 26.4±5.19 28.1±4.97 27.2±4.81 21.7±6.45 27.7±2.37 SAMU working months* 48.5±3.70 52.7±6.34 46.4±5.54 50.4±10.6 32.0±9.21 Weekly working hours** 64.6±2.34 40.9±24.5 65.8±23.4 63.0±20.0 70.0±17.6 BMI: Body Mass Index; SAMU = Mobile Emergency Assistance Service; * Months; **Hours.

Table 2. Prevalence of musculoskeletal pain Musculoskeletal pain All (n=95) Drivers Technicians Nurses Physicians (n=36) (n=36) (n=15) (n=6) In the last seven days 68 (71.6) 20 (55.6) 34 (89.5) 11 (73.3) 03 (50.0) Already felt pain before working at SAMU 17 (18.0) 06 (16.7) 09 (23.7) 01 (6.7) 01 (16.7) Almost always feel pain at the end of the working day 16 (16.8) 04 (11.1) 10 (26.3) 02 (13.3) 0 (0) Sometimes feel pain at the end of the working day 37 (39.0) 10 (27.8) 15 (39.5) 09 (60.1) 03 (50.0) Rarely feel pain at the end of the working day 21 (22.1) 09 (25.0) 09 (23.7) 02 (13.3) 01 (16.7) Feel no pain at the end of the working day 21 (22.1) 13 (36.1) 04 (10.5) 02 (13.3) 02 (33.3) Already missed work due to pain 12 (12.6) 05 (13.9) 04 (10.5) 02 (13.3) 01 (16.7) Already rescheduled shift due to the pain 10 (10.5) 04 (11.1) 05 (13.2) 01 (6.7) 0 (0) SAMU = Mobile Emergency Assistance Service. working (p= 0.847 - t Student). The same occurred with the wor- Table 4. Association between musculoskeletal pain and gender king time at SAMU (p=0.362 - Mann-Whitney). Pain (n= 68) No pain (n= 27) A high prevalence of musculoskeletal pain was observed in Male 46 (64.8) 25 (35.2) 71.6% (n=68) of rescuers, and 18% (n=17) reported that they Female 22 (91.7) 02 (8.3) already had the pain before starting the activity in SAMU p=0.024 (Table 2). The lumbar spine, knees and cervical spine were the regions most DISCUSSION affected by musculoskeletal pain and where the pain was most intense (Table 3). A high prevalence of musculoskeletal pain was observed in Table 3. Location and intensity of musculoskeletal pain SAMU professionals. The data showed that young people with significant productive capacity had a high frequency Locations n (%) Mean±SD of musculoskeletal pain, suggesting that the pain is related Cervical spine 29 (30.5) 4.92±0.21 to their work activity characteristics, which can compromise Shoulders 26 (27.4) 3.40±0.16 their performance, harm the assistance to victims and also Arms 16 (16.8) 2.08±0.31 risk the lives of these professionals. Forearm 16 (16.8) 1.52±0.59 The high prevalence of musculoskeletal pain observed may be related to a common feeling of SAMU professionals, as Fist and hand 18 (18.9) 1.73±0.18 evidenced by the study1, which reported that rescuers often Thoracic spine 28 (29.4) 3.76±0.25 ignore their own physical discomfort and pain to guarantee Lumbar spine 51 (53.5) 5.30±0.30 the rescue and survival of the victim receiving assistance. Hips 16 (16.8) 2.22±0.38 In this study, most of the evaluated professionals presented musculoskeletal pain and were in full exercise of their Thigh 15 (15.8) 1.30±0.24 activities, something that, although praiseworthy and al- Knee 31 (32.6) 4.34±0.24 truistic, may contribute to the development of MSD in Leg 22 (23.1) 1.50±0.18 rescuers. Ankle and foot 14 (14.7) 1.07±0.17 Ergonomic risks are also mentioned as causes of MSD in res- SD = Standard deviation. cuers, such as poor posture during care of victims, causing temporary and often permanent withdrawal of SAMU pro- However, there was a significant association between the presen- fessionals. The lack of physical fitness is another factor that ce of musculoskeletal pain and pain in females (p=0.024 - Pear- can compromise health and impair performance, in addition son’s Chi-square) (Table 4). to the extensive working hours to which the professionals 22 Prevalence and associated factors with musculoskeletal pain BrJP. São Paulo, 2021 jan-mar;4(1):20-5 in professionals of the Mobile Emergency Care Service are submitted, which in some cases can reach up to 24 unin- has often been observed in professionals of emergency servi- terrupted hours19. ces and that the lumbar spine has been the area most affected Another possible cause of musculoskeletal pain in SAMU by pain26-28. professionals is the handling of patients in the most varied In this study, the lumbar spine, knees and cervical spine were conditions, such as the removal of victims from inside a vehi- the body regions most affected by musculoskeletal pain and cle and from places of difficult access, with restricted physi- also where the intensity of pain was igher, characterizing mo- cal space, besides the need to contain agitated patients20. A derate pain. These findings are also in line with studies in- study21 observed that 70% of MSD in rescuers were related vestigating the SAMU23-25 professionals’ MSD, demonstrating to the management of patients, however, a limitation of this that spinal pain is a frequent symptom in rescuers. study is that the cause of pain was not pointed out. The main factors associated with back pain are poor posture Besides ergonomic and biomechanical factors, psychosocial during work activities and physical overloads, which generate risks can contribute to musculoskeletal pain in SAMU profes- injury mechanisms in intervertebral discs and compression of sionals, such as insufficient work resources, inadequate phy- the nerve roots29. One of the activities that rescuers perform sical space, reduced staff, organization of task distribution, the most and that requires physical strength is the lifting of intensive control, strict rules, valuation of hierarchies, emo- the victims to the stretcher, when placing them in the am- tional exhaustion and tiredness22. bulance or transporting them from one stretcher to another, The association of these factors and the increase in traumatic already in the intra-hospital care. Repetitive weight lifting has occurrences are the main factors for the appearance of mus- been a cause of MSD, such as lower back and lower limb culoskeletal pain, which is associated with the multifactorial pain30, justifying the spinal and knee pain identified in the aspect of the risks19. sample of this study. Three studies observed the prevalence of pain and MSD in Other studies31-37 also reported that pain in the lumbar spine SAMU professionals, but only one assessed rescuers from ad- was an outcome frequently observed in health professionals, vanced units, including physicians, like the present study. The justifying why MSD and mainly low back pain have been others assessed only professionals from basic units23-25. some of the main causes of absenteeism38-40, of relocation to The study23 evaluated the prevalence of pain in SAMU profes- other functions or withdrawal from the rescuer’s activity due sionals from Porto Alegre, using a questionnaire of work-re- to disorders related to their work activity19. lated habits. This study interviewed 113 ambulance drivers, Although they present high prevalence of musculoskeletal nursing technicians, nurses, physicians and telephonists. Of pain, including back pain, the rescuers included in this study these, 92.9% presented musculoskeletal pain, i.e., very high presented low frequency of absenteeism (12.6%) or changes prevalence of pain, as identified in the present study, where in shifts (10.5%), which may be related to the average age of the highest prevalence of musculoskeletal pain was observed the sample, which was 34.4±0.75 years old, i.e., young pro- in nursing professionals, 89.5% in technicians and 73.3% in fessionals, enthusiastic about their work, even in the face of nurses, values higher than the general prevalence of pain in all apparently unfavorable physical conditions. professionals of SAMU, which was 71.6%. However, this situation brings concern, because rescuers over These results are in line with the study24, which identified os- 39 years old were 6% more likely to develop musculoskeletal teomuscular disorders in 95% of the sample, consisting of 20 pain23,31, despite this study not identifying an association bet- ambulance drivers, nursing technicians and nurses, of both ween age and musculoskeletal pain. sexes, aged between 20 and 60 years old. This study also used In any case, there was a significant association between the NQMS for the evaluation of musculoskeletal disorders, as the presence of musculoskeletal pain and the female gen- in the present research. der, possibly due to their job added to domestic work. Similarly, another study25 evaluated 100 professionals of the Thus, women working in the health field are part of a nursing team of the Recife’s SAMU, being 25 nurses, 57 te- risk group for the development of MSD, since these pro- chnicians and 18 nursing assistants, using a check-list type fessions require greater physical effort and these profes- questionnaire for the mapping of osteomuscular symptoms sionals already accumulate efforts resulting from the ac- in different body regions, identifying a prevalence of 80%, tivities at home41,42. which can be considered high. As this study identified a high prevalence of musculoskeletal However, none of the studies that investigated osteomuscular pain in SAMU professionals, the data may contribute to fos- disorders in SAMU23-25 professionals presented their results in ter health promotion actions and prevent MSD, stimulating a stratified way, demonstrating in which of the analyzed pro- the development of health promotion plans for rescuers by fessions the prevalence of musculoskeletal pain was higher, as the municipal health secretariats and SAMU coordinators, ai- presented in this study, which facilitates the implementation ming at improving quality of life and mental health, as well as of intervention programs in a targeted, precise and indivi- reducing stress and anxiety levels of these professionals. The dualized way according to the real need of each professional results found can also promote periodic training and perma- category. nent interventions, improving the rescuers’ knowledge about The results of this study corroborate the findings of interna- occupational and biomechanical risks, so that they adopt pre- tional investigations, pointing out that musculoskeletal pain ventive behavior on MSD. 23 BrJP. São Paulo, 2021 jan-mar;4(1):20-5 Santos RA, Raposo MC and Melo RS

Implementing labor gymnastics can be a valid alternative, 6. Alexandre NMC, Angerami ELS, Moreira-Filho DC. Back pain and nursing. Rev Esc Enferm USP. 1996;30(2):267-85. since some studies have observed that good posture asso- 7. Fernandes CS, Couto G, Carvalho R, Fernandes D, Ferreira P. Self-reported work-re- ciated with relaxation techniques during the shift intervals lated musculoskeletal disorders among health professionals at a hospital in Portugal. Rev Bras Med Trab. 2018;16(3):353-9. and adequate physical preparation prevent injuries and pain 8. Roberts MH, Sim MR, Black O, Smith P. Occupational injury risk among ambulance caused by labor activities4. Moreover, exercises with music, officers and paramedics compared with other healthcare workers in Victoria, Australia: relaxation, massages and physiotherapeutic exercises are effec- analysis of workers’ compensation claims from 2003 to 2012. Occup Environ Med. 2015;72(7):489-95. 43-47 tive in reducing anxiety, stress and musculoskeletal pain . 9. Senmar M, Pour FZ, Soleimani P, Yamini M, Rafiei H. The prevalence of musculos- These measures can be taken by the authorities responsible for keletal disorders among nurses working in emergency department. J Prev Epidemiol. 2019;4(2):e12. SAMU in order to prevent MSD, providing better working 10. Sedrez JA, Kasten APS, Chaise FO, Candotti CT. Fatores de risco para doenças car- conditions for the rescuers. diovasculares e osteomusculares relacionadas ao trabalho em profissionais do atendimento pré-hospitalar de urgência: uma revisão sistemática. Rev Bras Med Trab. Randomized and controlled clinical trials should be conduc- 2017;15(4):355-63. ted to allow assessment of the impact of periodic training, 11. Vasconcelos DV, Silva LM, Lima LAMS, Pinho MMR, Motta PD, Dantas ST, et al. Absenteísmo em dois hospitais públicos de Minas Gerais: perfil epidemiológico. 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The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Int J Surg. ducing MSD risks for SAMU professionals, so that they can 2014;12(12):1495-9. perform their duties in better conditions and with less occu- 15. Pinheiro FA, Tróccoli BT, Carvalho CV. Validity of the Nordic Musculoskeletal Ques- pational risks. tionnaire as morbidity measurement tool. Rev Saude Publica. 2002;36(3):307-12. 16. Campbell WI, Lewis S. Visual analogue measurement of pain. Ulster Med J. 1990;59(2):149-54. CONCLUSION 17. Ludington E, Dexter F. Statistical analysis of total labor pain using the visual analog scale and application to studies of analgesic effectiveness during childbirth. Anesth Analg. 1998;87(3):723-7. A high prevalence of musculoskeletal pain in SAMU workers, es- 18. Monteiro ET, Albuquerque SP, Melo RS. Organ and tissue donation in a public hospital of Pernambuco. 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25 BrJP. São Paulo, 2021 jan-mar;4(1):26-30 ORIGINAL ARTICLE

Effect of transcutaneous electrical nerve stimulation and hypnosis on chronic low back pain Efeito da estimulação elétrica nervosa transcutânea e hipnose na dor lombar crônica

Carolina Weizemann1, Nathielly Flores Camargo1, Taise Vieira Barboza1, Alberito Rodrigo de Carvalho1, Gladson Ricardo Flor Bertolini1,2

DOI 10.5935/2595-0118.20210005

ABSTRACT Keywords: Hypnosis, Low back pain, Physical therapy modalities, Transcutaneous electrical nerve stimulation. BACKGROUND AND OBJECTIVES: Among the main non-pharmacological analgesic techniques are physical thera- RESUMO pies such as electrotherapy and cognitive-behavioral techniques, such as hypnosis. The objective of this study was to compare JUSTIFICATIVA E OBJETIVOS: Entre as principais técnicas the analgesic effect of transcutaneous electrical nerve stimulation analgésicas não farmacológicas estão as terapias físicas como a (TENS) and hypnosis in the control of chronic low back pain. eletroterapia e técnicas cognitivo-comportamentais, como a hip- METHODS: A crossover study that included 19 young adults nose. O objetivo deste estudo foi comparar o efeito analgésico da of both genders with chronic low back pain who underwent estimulação elétrica nervosa transcutânea (TENS) e hipnose no TENS and hypnosis, and pain education as a control group. The controle da dor lombar crônica. quality of pain was assessed by the McGill’s questionnaire; pain MÉTODOS: Estudo do tipo cruzado que incluiu 19 adultos jo- intensity and threshold were assessed by the visual analog scale. vens de ambos os sexos portadores de dor lombar crônica, subme- The intensity of spontaneous pain, the threshold and intensity of tidos a TENS, hipnose e educação em dor como grupo controle. pain induced by cold and the pressure pain threshold before the A qualidade da dor foi avaliada pelo questionário de McGill, a interventions, immediately after the interventions and 30 minu- intensidade e o limiar da dor pela escala analógica visual. Foi ava- tes after the end of the interventions were evaluated. Statistical liada a intensidade da dor espontânea, o limiar e a intensidade de analysis was performed with Generalized Mixed Linear Models, dor ao frio e o limiar da dor à pressão, imediatamente após as in- with 5% significance, and Cohen’s G effect sizes. tervenções e 30 minutos depois do final das intervenções. A análise RESULTS: There was a statistically significant decrease in the estatística foi realizada com modelos lineares generalizados mistos, intensity of spontaneous and cold induced pain in the hypnosis com 5% de significância, e tamanhos de efeito G de Cohen. and TENS groups compared to the pain education group. The- RESULTADOS: Houve diminuição estatisticamente significati- re was a statistically significant reduction of pain in the sensory va da intensidade da dor espontânea e ao frio nos grupos hipnose and evaluation categories in the intervention groups compared e TENS comparados ao grupo de educação em dor. Ocorreu re- to the control group. There was no significant difference for the dução do quadro álgico estatisticamente significativo nas catego- pressure pain threshold and latency time for cold induced pain. rias sensorial e avaliativa nos grupos intervenção comparados ao CONCLUSION: Hypnosis and TENS decreased the intensity grupo controle. Não houve diferença significativa para o limiar of chronic low back pain with no statistically significant differen- de dor à pressão e o tempo de latência para a dor ao frio. ce between them, but statistically different from the pain educa- CONCLUSÃO: A hipnose e a TENS diminuíram a intensida- tion control group. de da dor lombar crônica sem diferença estatisticamente significativa entre si, porém estatisticamente diferentes em relação ao grupo controle. Carolina Weizemann – https://orcid.org/0000-0003-0061-8479; Descritores: Dor lombar, Estimulação elétrica nervosa trans- Nathielly Flores Camargo – https://orcid.org/0000-0001-8068-2299; Taise Vieira Barboza – https://orcid.org/0000-0002-9567-8732; cutânea, Hipnose, Modalidades de fisioterapia. Alberito Rodrigo Carvalho – https://orcid.org/0000-0002-5520-441X;  Gladson Ricardo Flor Bertolini – https://orcid.org/0000-0003-0565-2019. INTRODUCTION 1. State University of Western Paraná, Physiotherapy, Cascavel, PR, Brazil. 2. State University of Western Paraná, Biosciences and Health Program, Cascavel, PR, Brazil. Chronic low back pain (CLBP) is characterized by pain, discomfort or muscle fatigue in the lower third of the spine1-4 and is Submitted on May 3, 2020. considered a public health problem, constituting a heavy burden Accepted for publication on January 4, 2021. 5 Conflict of interests: none – Sponsoring sources: none. for health and social security systems . The treatment of lumbar dysfunctions involves non-pharmaco- Correspondence to: Rua Universitária, 2069 – Jardim Universitário logical drugs and analgesic techniques with physical therapies 85819-110 Cascavel, PR, Brasil. such as electrotherapy, which activates the sensitive-discrimina- E-mail: [email protected] tive system and stimulates the pain suppressor system6; and with © Sociedade Brasileira para o Estudo da Dor cognitive-behavioral techniques, such as hypnosis, which pro- 26 Effect of transcutaneous electrical nerve stimulation BrJP. São Paulo, 2021 jan-mar;4(1):26-30 and hypnosis on chronic low back pain motes muscle relaxation, attention distraction and suggestion, All participants went through three interventions, one each interfering in the stimulation of pain7. week. The sample was randomly divided at https://www.gra- Transcutaneous electrical nerve stimulation (TENS) is an anal- phpad.com/quickcalcs/randomize1/, and each individual recei- gesic technique for the relief of acute and chronic pain, including ved the interventions alternately once a week, for a total of three low back pain (LBP), applied with different frequencies, inten- weeks, so that all were submitted to TENS, hypnosis and pain sities and durations of stimulation pulses, aiming at activating education (PE). ascending or descending antinociceptive pathways. Some studies The McGill Pain Questionnaire is organized into four categories, point out that the effectiveness of TENS may depend on the fre- with variable numbering for the words in each subclass. Volunteers quency and neural accommodation, a process that occurs when were asked to choose one word from each subcategory, also being a physiological response is continuously decreased, which can be allowed to choose none. For the evaluation score the sum of the an important factor for the perception of analgesic stimulus8-11. word values of each subclass was considered for each category score. Hypnotic techniques have presented evidence in brain activities in The VAS consists of a 10cm line, with the phrases “no pain” locations related to pain. The “hypnotic trance”, the basis of hyp- and “unbearable pain” at the extremes corresponding to “zero” nosis, defined as a voluntary state in which the individual is more and “10”. Each individual chose a position on the line that best willing to accept suggestions without critical evaluation of infor- quantified their pain. mation can produce a facilitating state of analgesia in the upper For the evaluation of the threshold and intensity of pain indu- nervous centers12,13 and can be useful as therapy for CLBP14,15. ced by cold, the temperature of an ice cube was measured with The hypothesis is that both techniques induce analgesia, but an infrared thermometer, which was positioned over the spinous TENS may have superior results when the quality of pain per- process of the fifth lumbar vertebra (L5). The time from the place- ception presents a predominant sensory aspect and, conversely, ment of the cube to the moment the individual reported pain was hypnosis would present superior effects when the quality of pain measured and then the intensity of pain was evaluated by the VAS. is affective. This study aimed primarily to compare the effect of The pressure pain threshold was measured though the DDK-50 analgesic techniques, TENS and hypnosis in patients with CLBP, (Kratos®, São Paulo, Brazil) algometer, capable of exerting pressure in a single application. The secondary objective was to evaluate of up to 50kgf. The volunteers were positioned in ventral decubitus whether the analgesic effect of the techniques occurs through position, palpation of the lumbar vertebrae was performed to iden- different qualifications of pain perception. tify the one with the greater discomfort, pressure was exerted by the algometer with a circular end of 1.2cm in diameter positioned 1cm METHODS beside the vertebra. Pressure was increased until the volunteer reported the onset of pain, and the pressure was recorded in gram-force. Quantitative and crossover study, with a sample consisting of 19 vo- For the TENS application, volunteers were positioned in ven- lunteers, of both genders (12 women and 7 men), with a mean age tral decubitus position on a treatment stretcher, and electrical of 21.36±2.75 years old, height 1.71±0.09m, weight 75.24±17.81kg stimulation was applied through the TENS device (Ibramed®, and body mass index (BMI) 25.56±4.24kg/m2, that presented diag- Amparo, Brazil), with phase duration of 250µs and frequency nosis of CLBP and that accepted to participate in the research, signing of 100Hz, by pairs of electrodes placed bilaterally, 1cm from the the Free and Informed Consent Term (FICT). For this sample size, spinous processes of the lumbar vertebrae, from L1 to L5, for 30 based on the visual analog scale (VAS), difference of 1.5cm, standard minutes, at the patient›s tolerance level17. Each individual was deviation of 1.4, the power of the test was calculated at 80%. warned that they would feel a tingling sensation from moderate Inclusion factors were: age between 18 and 30 years old, LBP to strong, but not pain, and when they felt the intensity of the for more than three months and readiness to participate in the current accommodating, they should tell the therapist, so that study. The exclusion factors were: doing physiotherapeutic treat- the intensity is increased. ment by electroanalgesia, regardless of the used current, to have The hypnosis was performed in an individual therapist/patient a cardiac pacemaker, to be pregnant, to have undergone surgical session lasting 30 minutes. The sessions took place in a room procedures in the spine, to have used analgesic drugs 24 hours with light, temperature and reduction of external noise suitable before the interventions, to have contraindication against cold for relaxation. After the trance was deepening, the patients were and to have red flags related to LBP16. given suggestions for pain relief18. The volunteer was suggested Data collection and interventions were performed at the Physi- to identify each painful point in the body and attribute to them cal Rehabilitation Center (CRF - Centro de Reabilitação Física) shape, color and mass. of UNIOESTE, by trained therapists, being only one therapist The subjects were slowly and calmly suggested that, for each res- responsible for the application of each therapeutic method and piratory movement, these points were becoming smaller, more the evaluations made by the same evaluator. The McGill pain transparent and light. The changes in shape, color and mass were questionnaire was applied for the qualification of painful per- becoming so intense that these points got loose like soap bubbles ception and the VAS for quantification of pain. Evaluation of being carried far away until they blew up and disappeared, allu- pain threshold and intensity of pain induced by cold, as well ding to the pain that moved away and disappeared. At the end of as evaluation of pressure pain threshold was also performed. All the trance, the idea that the feeling of well-being and pain relief evaluations were performed sequentially before (AV1), just after produced would be maintained indefinitely after the end of the (AV2) and 30 minutes after interventions (AV3). session was reinforced. 27 BrJP. São Paulo, 2021 jan-mar;4(1):26-30 Weizemann C, Camargo NF, Barboza TV, Carvalho AR and Bertolini GR

The PE method was carried out by lectures addressed to the partici- In the affective category there were differences between groups pants in order to provide information and clarify doubts regarding (p<0.001) and moments (p=0.016). In the evaluation category LBP. Support material was distributed at the end. The PE served as there were differences between groups, moments and interaction control, being performed only once for each individual. Evidence (p<0.001), showing that at the PE moment there was no reduc- shows discrete results of isolated PE in individuals with CLBP19. tion of scores, but there was for the other moments. In the mis- This study was approved by the Research Ethics Committee of cellaneous category these results were repeated with differences the State University of Western Paraná (2.681.234) (Brazilian between groups (p<0.001), moments (p=0.003) and interaction Registry of Clinical Trials: RBR-7528X4). (p=0.019), and the evaluations within each moment showed that only after the TENS there was reduction of values (Table 1). Statistical analysis As for the effect size observed when comparing the subsequent The SPSS 20 software was used. The adopted significance level evaluations with the first, it was possible to observe that for PE was 5% (α=0.05). The analyses were made through the Genera- the effect size was trivial; for TENS they were moderate or large; lized Linear Mixed-effects Models (GLMMs) with Bonferroni and for hypnosis they varied from trivial to large (Table 2). post-hoc. In the tables, the significant differences between groups The pain intensity values, for both spontaneous and cold indu- were pointed out by different capital letters and differences wi- ced pain, showed that there were differences in groups (p<0.001 thin the intervention groups by lowercase letters. Cohen’s effect and p<0.001), moments (p<0.001 and p=0.002), as well as in- size analysis was performed according to the following classifica- teraction (p=0.002 and p=0.036), indicating that there were no tion: <0.2: trivial; 0.2-0.5: small; 0.5-0.8: moderate; >0.8: large. reductions only for PE. The pain thresholds, both at cold and pressure, did not present significant differences in comparisons RESULTS between and within groups (p>0.05) (Table 3). The size of the effect of PE, regardless of the analyzed variab- The McGill questionnaire showed a decrease in scores in the le, was trivial; however, for TENS and hypnosis, regarding the four categories, with some differences between them, indicating intensity measured by the VAS, they were large. Regarding the a reduction in the pain scenario of the intervention groups. In intensity of pain induced by cold measured by the VAS, TENS the sensory category there were differences between the groups showed moderate and high results and hypnosis showed modera- (p<0.001), moments (p<0.001) and interaction (p=0.017), for te; for the threshold of cold induced pain, the modalities varied the PE moment there was no change in values, but reduction for from trivial to small and for the pressure pain threshold they the other two moments. were small and moderate for TENS in AV1-AV2 (Table 4).

Table 1. Mean and standard deviation for the sensory, affective, evaluation and miscellaneous variables, by the McGill’s pain questionnaire, with comparisons between and within groups Sensory Affective*# Evaluation Miscellaneous PE# AV1 17±7Aa 4.4±3.9 3±1Aa 7±4Aa AV2 17±7Aa 4±4 2.6±1.2Aa 7±4Aa AV3 17±7Aa 4±4 3±1Aa 6.8±3.9Aa TENS AV1 13.1±7.5Ba 2.5±3 2.2±1Aa 4.7±4.5Ba AV2 7.9±7.1Bb 1±1.7 1.2±1.7Bb 2.2±3Bb AV3 7.5±5.6Bb 0.8±1.4 0.9±0.7Bb 1.6±1.9Bb Hypnosis AV1 11.7±6.8Ba 1.7±2.3 2±0.8Aa 2.7±2.5Ca AV2 5.7±4.6Bb 0.7±1.5 0.9±0.9Bb 1.9±2Ba AV3 8.4±5.4Ba 0.5±1.4 1.1±0.9Bb 1.9±2.1Ba PE = pain education; TENS = transcutaneous electrical nerve stimulation. Similar capital letters demonstrate statistical similarity between the groups for the same evaluation. Similar lower case letters demonstrate statistical similarity within the group for the different evaluations. *Significant difference between AV1 and AV3, regardless of the group.# Significant difference between PE and interventions, regardless of the moment.

Table 2. Observed effect size values for McGill’s pain questionnaire items. Evaluations within subgroups, compared to the first evaluation (AV1) Sensory Affective Evaluation Miscellaneous PE AV1 – AV2 0.0 0.0 0.0 0.0 AV1 – AV3 0.0 0.0 0.0 0.0 TENS AV1 – AV2 -0.70 0.58 -0.73 -0.66 AV1 – AV3 -0.83 -0.72 -1.48 -0.90 Hypnosis AV1 – AV2 -1.04 -0.53 -1.31 -0.35 AV1 – AV3 -0.55 -0.62 -1.06 -0.31 PE = pain education; TENS = transcutaneous electric nerve stimulation.

28 Effect of transcutaneous electrical nerve stimulation BrJP. São Paulo, 2021 jan-mar;4(1):26-30 and hypnosis on chronic low back pain

Table 3. Mean and standard deviation for the variables of pain intensity, threshold in seconds and pain intensity induced by cold, as well as pressure pain threshold, with their respective comparisons between and within groups VAS Threshold for cold VAS for cold Pressure pain threshold PE AV1 4.8±2Aa 8.4±11Aa 6±1Aa 5734±1890 Aa AV2 5±2Aa 8.5± 11Aa 6±1Aa 5744±1862 Aa AV3 5±2Ba 8.5±11 Aa 6±1Aa 5717±1812 Aa TENS AV1 4.9±2.2Aa 6.7±10.1 Aa 5.3±2ACa 5207±1628 Aa AV2 2±2.3Bb 10±12 Aa 4.2±1.1Bb 6004±1507 Aa AV3 2.1±1.5Bb 8.3±12.4 Aa 3.5±1.4Bb 5835±1670 Aa Hypnosis AV1 4.6±2.5Aa 7±11.3 Aa 4.7±1.9BCa 5584±1853 Aa AV2 2.5±2.5Bb 8.5±10.3 Aa 3.6±1.5Bb 6296±1884 Aa AV3 2.5±1.8Ba 9.2±12.5 Aa 3.9±1.4Bab 6273±2301 Aa VAS = visual analog scale; PE = pain education; TENS = transcutaneous electrical nerve stimulation. Similar capital letters demonstrate statistical similarity between the groups for the same evaluation. Similar lower case letters demonstrate statistical similarity within the group for the different evaluations.

Table 4. Values of observed effect sizes for pain intensities and thresholds. Evaluations within subgroups, compared to the first evaluation (AV1) VAS Threshold for cold VAS for cold Pressure pain threshold PE AV1 – AV2 -0.03 0.01 0.04 0.01 AV1 – AV3 -0.06 0.01 0.04 -0.01 TENS AV1 – AV2 -1.27 0.29 -0.65 0.51 AV1 – AV3 -1.43 0.14 -0.99 0.38 Hypnosis AV1 – AV2 -0.84 0.14 -0.66 0.38 AV1 – AV3 -0.94 0.19 -0.51 0.33 VAS = visual analog scale; PE = pain education; TENS = transcutaneous electrical nerve stimulation.

DISCUSSION system presents an altered threshold of response to pain, which generates pain scenarios as a response to stimuli considered to A comparison of the immediate effect of two analgesic techni- be non or mildly painful, therefore, the pain is maintained23,24. ques with different characteristics was evaluated in young adults Neuroimaging studies related to pain modulation show changes in with CLBP. The evidence was that both were effective, with ad- the activity of specific areas of the brain responsible for pain modu- vantages for TENS in pain induced by cold. lation when individuals receive stimuli of distraction through cogni- CLBP may not present well defined causes, so its etiology is mul- tive tasks during cold induced pain25. This study showed reduction tifactorial. Some etiological factors are more frequent, such as in general pain scores and in the cold and hypnosis intervention, degenerative and inflammatory processes, as well as congenital although for the latter the use of TENS showed better results. or mechanical postural changes. The hypnotic technique can, besides shaping pain perception, The imbalance between the effort required for a determined ac- influence sensory and affective aspects of pain perception26,27. tivity and the potential to develop it can generate pain3,20. The In experimental studies, hypnotic analgesia has been shown to etiology of CLBP may be anatomical or physiological, however, be associated with changes in pain thresholds, including brain psychosocial factors have a direct impact on the perception of activity, potentials related to somatosensory events and spinal pain, because emotional problems such as stress, depression, an- reflexes. The more susceptible to hypnosis individuals are, the xiety and fear interfere with neurological processes of pain mo- better the result obtained in relation to analgesia25, something dulation21. that was observed in this study, since the scores of the McGill Knowledge of the pain pathways, as well as their basic mechanis- questionnaire, which assessed the subjective character of pain, ms of action, is essential for understanding the pain scenario and changed after the interventions. On the opposite, a study that for understanding the methods of intervention for pain relief22. evaluated the pain threshold in healthy individuals did not show Pain starts with activation of nociceptors in the periphery gene- alterations after hypnosis28. In addition to that, hypnosis was not rating stimuli that are conducted to the central nervous system advantageous compared to TENS in the evaluation of affective where they will be processed, generating the sensation of pain. modality and presented similar results in the sensory modality. Specific regions of the encephalus, such as the periaqueductal The application of TENS reduced pain intensity, probably through gray substance, the nucleus raphe magnus, the insular cortex and ascending analgesic pathways, as in the Gate Control Theory9,10. A the medial prefrontal cortex play an important role in modula- retrospective cohort study evaluated pain changes after 60 days of ting nociceptive spinal activity and can contribute to cognitive high frequency TENS use, suggesting that this therapy is an op- and affective aspects. In chronic pain syndromes, the nociceptive tion for the treatment of chronic pain because it reduces pain in- 29 BrJP. São Paulo, 2021 jan-mar;4(1):26-30 Weizemann C, Camargo NF, Barboza TV, Carvalho AR and Bertolini GR tensity, improving sleep and mood changes due to analgesic effects 2019;14(5):e0216482. 29 5. Furtado RN, Ribeiro LH, Abdo Bde A, Descio FJ, Martucci CE Jr CE, Serruya DC. probably resulting from the activation of central pain inhibition , Nonspecific low back pain in young adults: associated risk factors. Rev Bras Reumatol. as demonstrated in this study, where there was a reduction in the 2014;54(5):371-7. 6. Piccoliori G, Engl A, Gatterer D, Sessa E, in der Schmitten J, Abholz HH. Mana- intensity of spontaneous and cold induced pain. gement of low back pain in general practice – is it of acceptable quality: an obser- No difference in the pressure pain threshold was observed in the vational study among 25 general practices in South Tyrol (Italy). BMC Fam Pract. present study, regardless of the technique used, unlike a study 2013;14:148. 7. Wellington J. Noninvasive and alternative management of chronic low back pain (ef- that showed significant increase in the pressure pain threshold ficacy and outcomes). Neuromodulation. 2014;17(Suppl 2):24-30. with the use of TENS for 15 minutes at 120Hz and pulse du- 8. Yurdakul OV, Beydoğan E, Yalçınkaya EY. Effects of physical therapy agents on pain, 30 disability, quality of life, and lumbar paravertebral muscle stiffness via elastography in ration of 100µs . The authors evaluated the point of greatest patients with chronic low back pain. Turkish J Phys Med Rehabil. 2019;65(1):30-9. pain and two more adjacent points, different from this study, 9. Garaud T, Gervais C, Szekely B, Michel-Cherqui M, Fischler M. Randomized study of the impact of a therapeutic education program on patients suffering from chronic which evaluated only one point lateral to the spinous process low-back pain who are treated with transcutaneous electrical nerve stimulation. Medi- most painful on palpation. cine. 2018;97(52):e13782. New studies with different methods need to be developed in order 10. Wu LC, Weng PW, Chen CH, Huang YY, Tsuang YH, Chiang CJ. Literature review and meta-analysis of transcutaneous electrical nerve stimulation in treating chronic to assess pressure pain, with longer therapy times, to evaluate the back pain. Reg Anesth Pain Med. 2018;43(4):425-33. effects in longer terms. Another limitation of this study is that the 11. Facci LM, Nowotny JP, Tormem F, Trevisani FVM. Effects of transcutaneous electrical nerve stimulation (TENS) and interferential currents (IFC) in patients with nonspecific control group received health education techniques, which may chronic low back pain : randomized clinical trial. São Paulo Med J. 2011;129(4):206-16. have influenced results31. However, when isolatedly applied, health 12. Jensen M, Patterson DR. Hypnotic treatment of chronic pain. J Behav Med. 19,32 2006;29(1):95-124. education produces small effects on pain reduction . 13. Azizmohammadi S, Azizmohammadi S. Hypnotherapy in management of delivery pain: a review. Eur J Transl Myol. 2019;29(3):210-7. CONCLUSION 14. Tan G, Fukui T, Jensen MP, Thornby J, Waldman KL. Hypnosis treatment for chronic low back pain. Int J Clin Exp Hypn. 2010;58(1):53-68. 15. Noergaard MW, Hakonsen SJ, Bjerrum M, Pedersen PU. The effectiveness of hypno- Hypnosis and TENS techniques have reduced pain in patients tic analgesia in the management of procedural pain in minimally invasive procedures: a systematic review and meta ‐ analysis. J Clin Nurs. 2019;28(23-24):4207-24. with CLBP. There was no significant difference between the two 16. Verhagen AP, Downie A, Popal N, Maher C, Koes BW. Red flags presented in current techniques. low back pain guidelines: a review. Eur Spine J. 2016;25(9):2788-802. 17. Verruch CM, Fréz AR, Bertolini GR. Comparative analysis between three forms of application of transcutaneous electrical nerve stimulation and its effect in college stu- AUTHORS’ CONTRIBUTIONS dents with non-specific low back pain. BrJP. 2019;2(2):132-6. 18. Dillworth T, Jensen MP. The role of suggestions in hypnosis for chronic pain: a review of the literature. Open Pain J. 2010;8(1):39-51. Carolina Weizemann 19. Clarke CL, Ryan CG, Martin DJ. Pain neurophysiology education for the manage- Funding acquisition, Data Collection, Research, Methodology, ment of individuals with chronic low back pain: A systematic review and meta-analysis. Man Ther. 2011;16(6):544-9. Writing - Preparation of the original 20. Vlaeyen JWS, Maher CG, Wiech K, Zundert J Van, Meloto CB, Diatchenko L, et al. Nathielly Flores Camargo Low back pain. Nat Rev Dis Primers. 2018;4(1):52. 21. Cao S, Song G, Zhang Y, Xie P, Tu Y, Li Y, Yu T, Yu B. Abnormal local brain activity Funding aquisition, Data Collection, Research, Methodology, beyond the pain matrix in postherpetic neuralgia patients: A resting-state functional Writing - Preparation of the original MRI study. Pain Physician. 2017;20(2):E303-14. Taise Vieira Barboza 22. Gosling AP. Physical therapy action mechanisms and effects on pain management. Rev Dor. 2013;13(1):65-70. Data Collection, Conceptualization, Research, Methodology, 23. Marchand S. The physiology of pain mechanisms: From the periphery to the brain. Writing - Preparation of the original Rheum Dis Clin N Am. 2008;34(2):285-409. 24. Ossipov MH, Dussor GO, Porreca F. Central modulation of pain. J Clin Invest. Alberito Rodrigo Carvalho 2010;120(11)3779-87. Funding aquisition, Data Collection, Conceptualization, Re- 25. Knudsen L, Petersen GL, Nørskov KN, Vase L, Finnerup N, Jensen TS, et al. Review of neuroimaging studies related to pain modulation. Scand J Pain. 2011;2(3):108-20. source Management, Project Management, Methodology, Su- 26. Brugnoli MP, Pesce G, Pasin E, Basile MF, Tamburin S, Polati E. The role of clinical pervision hypnosis and self-hypnosis to relief pain and anxiety in severe chronic diseases in Gladson Ricardo Flor Bertolini palliative care: a 2-year long-term follow-up of treatment in a nonrandomized clinical trial. Ann Palliat Med. 2018;7(1):17-31. Statistical analysis, Funding aquisition, Conceptualization, Re- 27. Castañeda E, Krikorian A. Clinical hypnosis in Latin America: systematic review of source management, Project management, Research, Methodo- the literature. Av Psicol Latinoam. 2018;36(2):269-83. 28. Kramer S, Zims R, Simang M, Rüger L, Irnich D. Hypnotic relaxation results in logy, Writing - Review and Editing, Supervision elevated thresholds of sensory detection but not of pain detection. BMC Complement Altern Med. 2014;14:496. REFERENCES 29. Kong X, Gozani SN. 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30 BrJP. São Paulo, 2021 jan-mar;4(1):31-6 ORIGINAL ARTICLE

Factors that influence the quality of life in neuropathic, musculoskeletal, and oncological pain Fatores que influenciam a qualidade de vida em dor neuropática, musculoesquelética e oncológica

Ana Carolina Rodrigues1, Ana Marcia Rodrigues Cunha2, José Eduardo Nogueira Forni3, Lilian Andreia Chessa Dias4, Paulo Rafael Condi3, Marielza Regina Ismael Martins5

DOI 10.5935/2595-0118.20210011

ABSTRACT serious for patients with neuropathic pain. The association between quality of life and the analyzed factors was statis- BACKGROUND AND OBJECTIVES: The clinical practice of tically significant in terms of adherence to treatment, pain analgesia in chronic pain is often deficient or ineffective, either levels, sleepiness, anxiety and depression. Individuals with due to the subjectivity or presence of potentiating factors. The neuropathic pain were more affected, except for kinesiopho- most common chronic pains are musculoskeletal, neuropathic, bia, which had more incidence in individuals with muscu- and oncological. This research aimed at understanding the as- loskeletal pain. pects that intersperse the process of pain and how they interfere CONCLUSION: Data revealed that all types of pain considera- in quality of life. bly decrease quality of life, and it’s more evident in individuals METHODS: Descriptive, cross-sectional, exploratory study with neuropathic pain. with a sample of 44 patients,15 with musculoskeletal pain, 15 Keywords: Cancer pain, Chronic pain, Musculoskeletal pain, with oncological pain and 14 with neuropathic pain, belonging Pain, Quality of life. to the Base Hospital Pain Clinic in São José do Rio Preto/SP. Data were collected through specific semi-structured interviews, RESUMO self-assessment and application of instruments: Visual Analog Scale, Health-Related Quality of Life Questionnaire, Morisky JUSTIFICATIVA E OBJETIVOS: A prática clínica no trata- and Green Drug Treatment Adherence Test, Questionnaire for mento da dor crônica é frequentemente deficiente ou ineficaz, Diagnosis of Neuropathic Pain, Epworth Sleepiness Scale, Tam- seja pela subjetividade ou pela presença de fatores potencializa- pa Kinesiophobia Scale, Beck Anxiety Inventory, and Beck De- dores. As dores crônicas mais comuns são a musculoesquelética, pression Inventory. a neuropática e a oncológica. Este estudo teve como objetivo co- RESULTS: The data analysis revealed poor quality of life nhecer os aspectos que entremeiam o processo de dor e como tal in 61.36% of the patients, and this situation was even more condição interfere na qualidade de vida. MÉTODOS: Estudo descritivo, transversal e exploratório que incluiu 44 pacientes, sendo 15 com dor musculoesque- lética, 15 com dor oncológica e 14 com dor neuropática. Os dados foram coletados por meio de entrevista específica semiestruturada, autoavaliação e aplicação dos instrumen- Ana Carolina Rodrigues – https://orcid.org/0000-0002-0883-5948; Ana Marcia Rodrigues Cunha – https://orcid.org/0000-0001-9503-6337; tos: Escala Analógica Visual, Health-related Quality of Life José Eduardo Nogueira Forni – https://orcid.org/0000-0003-1269-003X; Questionnaire, Morisky and Green Drug Treatment Adherence  Lilian Andreia Chessa Dias – https://orcid.org/0000-0003-0250-9647; Test Questionnaire for Diagnosis of Neuropathic Pain Epworth Paulo Rafael Condi – https://orcid.org/0000-0002-2693-5387; , , Marielza Regina Ismael Martins – https://orcid.org/0000-0002-1140-7581. Sleepiness Scale, Tampa Kinesiophobia Scale, Beck Anxiety In- ventory e Beck Depression Inventory. 1. São José do Rio Preto Medical Faculty, São José do Rio Preto, SP, Brazil. 2. São José do Rio Preto Base Hospital, Anesthesiology Department, São José do Rio Preto, RESULTADOS: A análise dos dados revelou baixa qualidade de SP, Brazil. vida para 61,36% dos pacientes, sendo mais grave para os por- 3. São José do Rio Preto Base Hospital, Orthopedics Department, São José do Rio Preto, SP, Brazil. tadores de dor neuropática. A associação da qualidade de vida 4. São José do Rio Preto Base Hospital, Social Service, São José do Rio Preto, SP, Brazil. com os fatores analisados foi estatisticamente significante quan- 5. São José do Rio Preto Medical Faculty, Neurological Sciences Department, São José do Rio Preto, SP, Brazil. to à adesão ao tratamento, nível de dor, sonolência, ansiedade e depressão. Os indivíduos com dor neuropática foram os mais Submitted on July 13, 2020. afetados, exceto pela cinesiofobia, que teve maior ocorrência nos Accepted for publication January 11, 2021 Conflict of interests: none – Sponsoring sources: PIBIC/CNPq Scientific Initiation indivíduos com dor musculoesquelética. Scholarship CONCLUSÃO: Os três tipos de dor diminuem consideravel- Correspondence to: mente a qualidade de vida dos pacientes, sendo a redução mais Avenida Brigadeiro Faria Lima, 5416 evidente nos portadores de dor neuropática. Neurological Sciences Department 15090-000 São Jose do Rio Preto, SP, Brasil. Descritores: Dor, Dor crônica, Dor do câncer, Dor musculoes- E-mail: [email protected] quelética, Qualidade de vida. 31 BrJP. São Paulo, 2021 jan-mar;4(1):31-6 Rodrigues AC, Cunha AM, Forni JE, Dias LA, Condi PR and Martins MR

INTRODUCTION Adherence Test (MGDTAT), Questionnaire for Diagnosis of Neuropathic Pain (DN4), Epworth Sleepiness Scale (ESS), Tam- Chronic pain (CP) is defined by the International Association pa Kinesiophobia Scale (TSK), Beck Anxiety Inventory (BAI) for the Study of Pain (IASP) as the persistence of pain for more and Beck Depression Inventory (BDI). than three months, with absent biological factors, associated The research project was approved by the Research Ethics Com- with the combination of multiple aggregating and potentia- mittee of FAMERP (opinion nº 2.024.585) and performed in ting events1. Due to the subjective and individualistic aspect, the Pain Outpatient Clinic, São José do Rio Preto Base Hospital. it results in ineffective clinical practice of analgesia2. The most (FUNFARME/FAMERP). common types of CP are musculoskeletal, neuropathic and oncological pain2,3. Statistical analysis The estimation is that one in five people in the world popula- The data were organized in spreadsheets using Microsoft Office tion experiences some form of CP and its limitations in daily Excel 2019. In order to perform the correlations of the quanti- and work activities throughout their lives3, in addition to chan- tative variables, the Mann-Whitney test was used, with the help ges in sleep, self-esteem, mood, and depreciation of longevity2,3. of the BioEstat 5.0 software, because the data are not conside- Therefore, pain impacts the entire environment of an individual, red parametric. A significance level of 5% was used. Descriptive becoming a public health problem. analyses of qualitative variables were performed, with median A study4 conducted in Brazil from 1990 to 2016 established a and frequency. correlation between the morbidity profile and the impact on life expectancy of patients and demonstrated that chronic non-trans- RESULTS missible diseases are the main causes for the increase in lost years in the population. Pain was incorporated into virtually all disea- The sample’s sociodemographic and clinical profile presented a ses with morbidity and mortality at some point of the process. mean age of 53±11.31 years old, with a level of schooling below Chronic musculoskeletal pain results from primary or secondary high school 59.08%, female 61.36% (n=27), married 70.46% structural alteration to somatic lesions, an inflammatory process (n=31), active work status 31.81% (n=14) and median pain inten- or biomechanical alterations5. Oncological pain, in turn, is re- sity measured by the VAS of 7 points, being 54.54% (n=24) with lated to both cancer and its treatment and, despite therapeutic CP and 25% (n=11) with painful post-Laminectomy syndrome. advances6,7, to relieve pain in these patients remains a challenge. Regarding the emotional impact caused by pain, 88.63% (n=39) Neuropathic pain is a consequence of somatosensory nervous described it as an unpleasant or disapproving feeling. Regarding system dysfunction or injury8 and is closely related to other types the functional impact caused by pain, 90.90% (n=40) reported of pain, such as musculoskeletal and oncological pain. Such asso- inability to perform work activities. ciation contributes to inadequate pain treatment8,9. When asked about the existence of a support network or su- The present study’s objective was to expand the knowledge on pport for pain treatment, 45.45% (n=20) denied the existence the aspects that intersperse the process of pain, understanding of either. The supports listed were rehabilitation services, clinic which factors can me modified and what is the best treatment support groups, psychiatric and psychological care. Of these, option, providing a better quality of life (QoL) for these patients. 83.33% (n=20) considered the services relevant for pain treatment, however, only 37.50% (n=9) were active during the period METHODS of the interview. As for treatment expectations and goals, 79.54% (n=35) were Descriptive, cross-sectional and exploratory study, including 44 maintaining follow-up to improve pain, while 11.36% (n=5) de- patients from a pain clinic (PC) with three fronts of treatment: sired intervention or surgery and 9.09% (n=4) stated they had neuropathic, oncological and musculoskeletal pain. The patients no expectations of improvement. were subdivided according to the type of pain and best ability of The majority, 61.37% (n=27), had poor adherence to treatment, the clinical body. reporting delays and/or forgetfulness in administration, adverse The sample calculation was based on the number of patients seen effects, lack of understanding of treatment or self-medication. The monthly in the PC, being composed of 15 patients with muscu- drugs in use for pain varied in quantity, from zero to six types, with loskeletal pain, 15 with oncological pain and 14 with neuropa- a median of three. The most prescribed in descending order were thic pain, which were included regardless of age or sex, screened gabapentin, methadone, amitriptyline, dipyrone and codeine. by the Mini-Mental State Exam (MMSE) and that agreed with The DN4 was positive in 65.90% (n=29) of the patients, being the Free and Informed Consent Term (FICT). The data were 44.82% (n=13) with musculoskeletal, 37.93% (n=11) neuropa- collected through a specific semi-structured interview composed thic and 17.29% (n=5) oncological pain. of questions such as name, age, marital status, schooling, work The QoL aspect was evaluated in the physical and mental do- status, diagnosis, drugs in use and self-assessment of Emotional mains. The physical aspect evaluated health in general, functio- Impact, Functional Impact, Quality of Sleep, Treatment Expec- nal capacity for average activities, difficulties in performing such tation and Resource Capacity. The following instruments were activities and how much pain interfered in the process, being 25 also used: visual analog scale (VAS), Health-related Quality of points below the average, in 77.27% (n=34). The mental do- Life Questionnaire (SF12), Morisky and Green Drug Treatment main, in turn, evaluated how emotional aspects, mental health, 32 Factors that influence the quality of life in neuropathic, BrJP. São Paulo, 2021 jan-mar;4(1):31-6 musculoskeletal, and oncological pain vitality and social aspects interfered in the performance of acti- 60.00 vities, revealing that 31.81% (n=14) were 25 points below the average. Figure 1 presents the comparison between the averages 50.00 of each aspect for each type of pain. Regarding the overall results for QoL, 61.36% (n=27) were 40.00 50 points below the mean with a standard deviation of 19.72. Values lower than 50 points refer to worse QoL. In musculos- 30.00 keletal pain the mean was 40 points, in oncological 50 points and in neuropathic 37 points. Figure 2 shows the average scores 20.00 of each domain and the general score for each specialty. 10.00 Abnormal sleepiness levels, according to ESS, were observed in 38.63% (n=17), being 41.1% (n=7) suffering from musculos- 0.00 keletal, 35.29% (n=6) oncological and 23.52% (n=4) neuro- Physical Mental Total QoL aspect aspect pathic pain. When asked about self-assessment of sleep quality, Musculoskeletal Oncological Neuropathic 77.27% (n=34) reported poor quality of sleep, and the following expression was common: “I don’t sleep well even taking drugs”. Figure 2. Types of pain according to domains related to QoL by Evaluation through the TSK showed that 40.90% (n=18) had SF-12 average levels of kinesiophobia. Of these, 44.44% (n=8) were suffering from musculoskeletal, 16.66% (n=3) oncological and (p<0.0001), QoL and anxiety level (p<0.0001) and QoL and de- 38.88% (n=7) neuropathic pain. There were no high levels of pression (p<0.0001) were statistically significant. However, the kinesiophobia. relation between anxiety and depression (p= 0.7042), and QoL Data related to anxiety and depression obtained by the means of and kinesiophobia (p=0.8511) was not significant. The p-values the BAI and BDI questionnaire were analyzed by a psychologist. obtained by associating the QoL variable and the other related The results showed that 31.81% (n=14) presented moderate to factors are presented in Table 1. intense anxiety; of these, 14.28% (n=2) correspond to patients In an individualized way, there were some singularities in each with musculoskeletal pain; 28.57% (n=4) oncological pain; and type of pain. There was a prevalence of musculoskeletal pain in 57.14% (n=8) neuropathic pain. As for depression, 15.90% males (53%), patients suffering from painful syndrome after la- (n=7) presented moderate to severe depression, of which 28.57% minectomy (73%), positive DN4 (87%), abnormal sleepiness (n=2) belonged to the group of musculoskeletal, 28.57% (n=2) (47%) and kinesiophobia (53%). Patients with neuropathic oncological and 42.85% (n=3) neuropathic pain. pain presented more depression and anxiety (86%). There was Through the Mann-Whitney test, factors were analyzed in pairs a prevalence of CP (93%), higher availability of resource and and considered statistically significant when p<0.05. Relations effectiveness (60%), higher percentage of active patients (56%), between pain intensity and treatment adherence (p<0.0001), complete high school (47%) and average intensity of 4.4 of pain QoL and pain intensity (p<0.0001), QoL and drug adherence assessed by VAS in patients with oncological pain.

4.50

4.00

3.50

3.00

2.50

2.00

1.50

1.00

0.50

0.00 General Functional Physical Pain Emotional Mental Vitality Social health capacity aspect aspect health aspect Musculoskeletal Oncological Neuropathic

Figure 1. Types of pain according to the domains of influence of QoL by the SF-12

33 BrJP. São Paulo, 2021 jan-mar;4(1):31-6 Rodrigues AC, Cunha AM, Forni JE, Dias LA, Condi PR and Martins MR

Table 1. Comparative analysis between factors and quality of life Association with QoL Musculoskeletal Oncological Neuropathic General P-values* Pain intensity <0.0001 <0.0001 <0.0001 <0.0001 Adherence to treatment <0.0001 <0.0001 <0.0001 <0.0001 Anxiety 0.0001 <0.0001 0.0596 <0.0001 Depression <0.0001 <0.0001 0.0004 <0.0001 Sleepiness <0.0001 <0.0001 <0.0001 <0.0001 Kinesiophobia 0.7089 0.0890 0.0596 0.8511 *p<0.05 = statistically significant difference.

DISCUSSION ment has also been approached and criticized in other studies, considering that, for better results, the active role of the patient The studies that analyzed the sociodemographic data of CP pain the therapeutic plan is essential22. tients in general present results similar to those obtained in this In a similar manner, although 83.33% considered non-pharma- investigation, with prevalence of the female sex (61.36%), age cological treatment important and significant in pain control, range from 51 to 60 years old (36.36%), married individuals 62.50% were not adherent. For inactivity, the most reported (70.46%), level of schooling below high school (59.08%), inac- factors were lack of financial resources and distance between re- tive work situation (68.19%) and median score of 7 for pain sidence and place of activity. For those who are active with non- intensity3,10,11. These characteristics12 make patients more prone -pharmacological treatments, pain was less intense, adherence to to inadequate pain treatment. The prevalence of CP diagno- pharmacological treatment was higher23,24 and there was better sis (54.54%) was higher than the national13. It’s important to QoL. Such result reinforces the value and effectiveness of phar- highlight that the sample came from CP, however, other studies macological therapy associated with the multiprofessional19,25. are needed to fully evaluate all epidemiological aspects of CP in The prevalence of abnormal sleepiness was higher in subjects Brazil14. with musculoskeletal pain, however, contrary to what was pro- The emotional impact of pain was reported by 88.63% of pa- posed by the study26, the association of hypersomnia with this tients as demotivational and saddening. Such phenomena is type of pain did not result in mood worsening. In contrast to related mainly to the functional impact reported as disabling another study24, although 77.27% of patients self-reported bad for 90.90% of patients. The dysfunctional process increases the quality of sleep, it did not correlate with the intensity of pain emotional impact3,15, reflected in the self-reported desire of the mentioned by the patient. Sleep was considered unrepairing or patients for ‘’improvement of pain’’ and/or ‘’going back to work’’. insufficient, which suggests greater susceptibility and less control When one analyzes the expectation regarding treatment, the de- of the process of pain27,28. sire manifested by the majority is the improvement of pain. The- The impact of the physical domain was significantly negative in se patients, due to long periods of inefficient and stressful treat- the evaluation of QoL29, being more relevant in musculoskeletal ments, only wish for an improvement in pain intensity so that and neuropathic pain. In both, kinesiophobia, even at a medium they can return to their daily activities. The process of accepting level, was also predominant and independent of pain intensity. CP, evidenced by the review16, contributes to treatment, because This intersection of factors explains the lower levels of physical the alignment between perspective and possibility is fundamen- activity, low adherence to non-pharmacological therapies, higher tal for efficient therapeutic planning. amount of drugs and, consequently, lower QoL30,31. The complexity of patients with CP goes beyond the traditional According to obtained results, patients presented mild signs of biomedical model, also encompassing the central sensitization anxiety in 68.19% and of depression in 84.10%. The study32 (CS) process generated by constant exposure to pain. When trea- showed that the persistence of these negative emotions, even ting CS in a single or short-term manner, the therapeutic failure at mild levels, is associated with the chronification of pain as rate is high, as can be observed in practice. The most commonly a consequence of neuroanatomical alterations and modulation used drugs for analgesia were gabapentin, methadone, amitripty- of the corticolimbic pathways. This result correlates with ano- line, dipyrone and codeine17,18, which act centrally on the modu- ther study33 that investigated how this predisposition is inten- lation of CS in response to pain. Although the medications used sified by the organism’s poor evolutionary adaptation to the assist in the clinical treatment of these patients, the neuropsychic stress factors of daily life. Although the association between interaction of CS requires multiprofessional treatment capable anxiety and depression was not significant for the impact of of desensitizing the individual19. Moreover, the adverse effects QoL in patients with CP, the need for emotional monitoring, of drugs, especially when several are used simultaneously, due even at mild levels, is consolidated by the study34, whose results to other associated comorbidities, worsen treatment adherence20 reinforced the interrelationship of these factors with CP. These which, intentionally or unintentionally, triggers attitudes such are components of great importance, not only for those who as changing the timing, dosage or totally abdicating prescribed worsen pain, but especially for those who interfere with the drugs21. The lack of active participation of patients in their treat- tolerable limits of pain35. 34 Factors that influence the quality of life in neuropathic, BrJP. São Paulo, 2021 jan-mar;4(1):31-6 musculoskeletal, and oncological pain

The neuropathic pain patients presented the lowest QoL values. Ana Marcia Rodrigues Cunha This is due to the process of somatization of comorbidities10,36. Research, Methodology Such association corroborates the difficulty in treating these pa- José Eduardo Nogueira Forni tients, making them more susceptible to invasive pain control Research, Methodology procedures, although they present a low success rate37. These in- Lilian Andreia Chessa Dias dividuals also present a higher prevalence of anxiety and depres- Research, Methodology sion when compared to other patients. Paulo Rafael Condi Individuals that suffer from oncological pain presented higher Research, Methodology level of education, availability of resources and effectiveness, Marielza Regina Ismael Martins higher adherence to non-pharmacologic treatment12,23 and lower Funding Acquisition, Conceptualization, Resource Manage- pain intensity. Thus, with fewer factors that potentialize pain, ment, Project Management, Research, Methodology, Writing they obtained a higher QoL score than the others. The study12 – Preparation of the original, Writing – Review and Editing, Su- also showed female prevalence, however, the analysis of data pervision, Validation, Visualization from the present study revealed lower frequency and intensity of neuropathic pain than the results obtained in that study. This REFERENCES difference may be due to the fact that those patients are active in cancer treatment, which may intensify the process of pain. 1. Slattery BW, O’Connor LL, Haugh S, Barrett K, Francis K, Dwyeret CP, et al. 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36 BrJP. São Paulo, 2021 jan-mar;4(1):37-42 ORIGINAL ARTICLE

Translation and cross-cultural adaptation of six short screening questions on biopsychosocial aspects of chronic pain Tradução e adaptação transcultural de seis perguntas breves de triagem dos aspectos biopsicossociais da dor crônica

Gabriela Valentim Cardoso1, Anna Paula Campos Sarchis1, Paulo Augusto de Almeida Britto1

DOI 10.5935/2595-0118.20210009

ABSTRACT RESUMO

BACKGROUND AND OBJECTIVES: It is now recognized JUSTIFICATIVA E OBJETIVOS: Para que a avaliação de pa- that psychosocial factors influence the patient’s painful experien- cientes com dor crônica se torne mais ampla e focada nas reais ce. For the assessment of patients with chronic pain to become necessidades do paciente, é necessário levar em consideração os broader and focused on the real needs of the patient, it’s necessary fatores psicossociais que influenciam na experiência dolorosa. O to be aware of the existence or not of these factors. The objective objetivo deste estudo foi realizar a tradução e adaptação transcul- of this study was to perform the translation and cross-cultural tural para o contexto brasileiro de seis perguntas breves de tria- adaptation of six brief screening questions for biopsychosocial gem dos aspectos biopsicossociais em pacientes com dor crônica. aspects in patients with chronic pain for the Brazilian context. MÉTODOS: Após o consentimento do autor do instrumento, o METHODS: After the consent of the author of the instrument, the estudo seguiu o protocolo de tradução e adaptação transcultural study followed the protocol of translation and cross-cultural adap- de acordo com as diretrizes internacionais, dividido nas etapas: tation according to international guidelines22, divided into 6 stages: tradução inicial, síntese das traduções, retrotradução, comitê de initial translation, synthesis of translations, back-translation, expert especialistas, pré-teste e análise do conteúdo e aparência. committee, pre-test and analysis of content and appearance. RESULTADOS: O pré-teste foi aplicado em 40 pacientes com RESULTS: The pre-test was applied to 40 patients with chronic dor crônica, com idade acima de 18 anos. A idade média foi de pain, aged over 18 years. The mean age was 57±10 years, most of 57±10 anos, grande parte tinha ensino fundamental incompleto them had incomplete elementary education and were away from e estava afastada da atividade laboral. Não houve dificuldade de work. No difficulty in comprehension when answering the ques- compreensão para responder as perguntas. O teste de legibilidade tions was perceived by the examiner or reported by the patients. foi de 100 pontos e o tempo de aplicação das perguntas foi de 4 The readability test score was of 100 points and the average time a 5 minutos. to apply the questions was 4 to 5 minutes. CONCLUSÃO: Os resultados permitem afirmar que as seis per- CONCLUSION: The results allow us to affirm that the six short guntas curtas podem ser utilizadas para avaliação de fatores psi- questions can be used to assess psychosocial factors related to an- cossociais relacionados à ansiedade, estresse, depressão, medo do xiety, stress, depression, fear of movement and catastrophization movimento e catastrofização em pacientes com dor crônica por in patients with chronic pain because it’s easy to understand and ser de fácil entendimento e rápida aplicação. quick to apply. Descritores: Depressão, Dor crônica, Inquéritos e questionários, Keywords: Chronic pain, Depression, Surveys and questionnai- Tradução. res, Translating. INTRODUCTION

Chronic pain (CP) is a worldwide public health concern and is a burden both to individuals and society1,2. Considered as pain Gabriela Valentim Cardoso – https://orcid.org/0000-0002-3866-8933;  that persists for 3 to 6 months or more, its prevalence has been Anna Paula Campos Sarchis – https://orcid.org/0000-0003-0357-6462; 3,4 Paulo Augusto de Almeida Britto – https://orcid.org/0000-0002-8762-2229. increasing according to age . Recently, the International Asso- ciation for the Study of Pain (IASP) revised the concept of pain, 1. Federal University of Juiz de Fora, University Hospital, Juiz de Fora, MG, Brazil. which was defined as “An unpleasant sensory and emotional Submitted on August 21, 2020. experience associated with, or resembling that associated with, Accepted for publication on December 28, 2020. actual or potential tissue damage’’. In addition to revising the Conflict of interests: none – Sponsoring sources: none. concept, explanatory notes were added, including: “Pain is al- Correspondence to: ways a personal experience that is influenced, to varying degrees, Paulo Augusto de Almeida Britto 5 Rua Carlos Monteiro 28 – Bairro São Mateus by biological, psychological and social factors” . 36016-510 Juiz de Fora, MG, Brasil. The social and economic costs of CP are immense6,7, with an esti- E-mail: [email protected] mated annual prevalence between 15 and 45% in the general po- © Sociedade Brasileira para o Estudo da Dor pulation, associated with greater disability2,8, early retirement3,4,9 37 BrJP. São Paulo, 2021 jan-mar;4(1):37-42 Cardoso GV, Sarchis AP and Britto PA and decline in quality of life7,10, being considered more prevalent med Consent Term (FICT). Factors for exclusion were: being than heart disease, diabetes and cancer combined1,2. illiterate or not speaking the Brazilian Portuguese language. Besides the complex pathophysiological processes involved, it’s After the consent of the original questionnaire’s author18, the accepted that psychosocial factors influence the patient’s expe- study followed the cross-cultural translation and adaptation pro- rience and treatment of pain11. Evidence shows a very strong tocol22 divided into six stages: initial translation, synthesis of the relationship between CP, cognition and emotional variables. translations, back-translation, experts committee, pre-test and Cognitive factors include beliefs related to pain, such as low analysis of content and appearance. self-efficacy, catastrophization and kinesiophobia as well as, for The initial translation was performed by two bilingual indepen- emotional variables, anxiety, depression and stress12-16. dent translators from the original language, English, to the target Knowledge about the presence or absence of these factors related language, Brazilian Portuguese. One of the translators was from to CP can help both therapist and patient to better understand the health field and each one reproduced an independent version the process and condition of pain4,7,17-19. A review on current is- named T1 and T2. sues involving the treatment of CP has shown that it’s still focu- The T1 and T2 versions were submitted to the evaluation and sed on the biomedical model of pain, not focusing on biopsycho- comparison of the translators with the authors of the present social aspects8. McGill’s pain questionnaire, validated in Brazil20, study. Together they produced a consensual version in Portugue- evaluates pain in sensory, affective and evaluative dimensions, se, named T3. but focuses almost exclusively on the description of pain21. The T3 synthesis version was back-translated from Portuguese to Due to the need of a more complete evaluation, several psycho- the original language, English, by two other bilingual indepen- social screening questionnaires with better accuracy in relation dent translators who did not know the original instrument and to the informal judgment of health professionals were developed. did not participate in the previous phase. Each back-translator The questionnaires, however, are extensive, sometimes complex produced a new version, named RT1 and RT2, giving rise to a and require more time to be applied, many times being difficult new consensual back-translated version, named RT3, which had for both the evaluator and the patient, which means that these the purpose of evaluating whether the content of the synthesis instruments are not used routinely in clinical practice and, thus, version was similar to the original instrument. many psychosocial comorbidities do not receive support and ne- After the RT3 back-translation, a committee of experts, formed cessary treatment9,18. Routine screening of these factors could be by a psychologist and four physiotherapists with knowledge facilitated with brief validated screening questions18. about CP met in order to produce the pre-final version of the The study18 compared six short screening questions for biop- questions, also evaluating the semantic, idiomatic, experimental sychosocial aspects of chronic low back pain with scores from and conceptual equivalence of the translated version. already validated full questionnaires, finding good sensitivity and In case any item was identified as unsuitable by one of the com- specificity. The aspects evaluated were: depression, anxiety, stress, mittee specialists, that item was reviewed and discussed until a catastrophization and kinesiophobia. For anxiety and depres- culturally adapted version for the Brazilian population, named sion, the study showed a correlation of 0.62 to 0.83, diagnostic T4 or final version, was reached and applied to the 40 patients, accuracy of 78 to 91%, sensitivity of 70 to 82% and specificity who were encouraged to suggest improvements and report any of 75 to 95%, while for catastrophization and kinesiophobia, difficulty in understanding. the correlation was of 0.89 to 0.95, diagnostic accuracy of 88 Finally, an audit of the entire process was carried out, analyzing all to 93%, sensitivity of 78 to 88% and specificity of 91 to 96%. phases step by step, certifying that proper translation and adaptation Another study9 used the same questions under different CP con- were performed. An assessment was also made on the readability of ditions. Anxiety, stress and depression demonstrated sensitivity of the instrument using the Flesch–Kincaid readability index (F–K) 71.2 to 80.8% and specificity of 70.6 to 73.1%, kinesiophobia which, besides the reading level, evaluates whether the instrument is and catastrophization demonstrated sensitivity of 75.7 to 90.7% suitable for the target population, with a score index ranging from and specificity of 60.9 to 74.4%. Such results indicate, therefore, zero to 100. The lower the score, the more difficult is the text20. The that short questions could help the early detection of biopsychoso- reading level was calculated by the equation 206.835 - [(1.015 x cial disorders in a simpler, faster and more reliable manner. average length of sentence) + 84.6 x (average number of syllables)]. This study’s objective was to make a cross-cultural translation A score of 60 or higher is considered appropriate for the adult and adaptation to Brazilian Portuguese of the six brief screening population. Table 1 shows the interpretation of the F–K index. questions on the biopsychosocial aspects, anxiety, depression, stress, kinesiophobia and catastrophization in patients with CP, Table 1. Interpretation of the Flesch–Kincaid readability Index providing a simple tool that can be quickly applied. F–K Index Readability level 0 – 29 Very difficult METHODS 30 – 49 Difficult 50 – 59 Fairly difficult The sample consisted of 40 patients with CP, aged over 18 years 60 – 69 Normal old and with pain for at least 3 months, accompanied by the Pain 70 – 79 Fairly easy Outpatient Clinic of the University Hospital of Juiz de Fora. All 80 – 89 Easy agreed to participate in the study by signing the Free and Infor- 90 – 100 Very easy 38 Translation and cross-cultural adaptation of six short screening BrJP. São Paulo, 2021 jan-mar;4(1):37-42 questions on biopsychosocial aspects of chronic pain

Patients were selected while waiting for their routine appoint- The average income of 77.5% of the sample was 1 to 3 mi- ment at the pain outpatient clinic during 2019’s second se- nimum wages, 55% were white, 7.5% were tobacco smokers, mester. Before the questions were applied, the patients answe- 52.5% practiced physical activities and 77.5% were hyperten- red an initial evaluation sheet, providing data for the sample sive (Table3). characterization. The study’s questions comprised 5 domains: The original version and the final version of the translated short anxiety, fear of movement, stress, catastrophization and depres- questions are in table 4. The resulting versions of the translation sion. The scores ranged from zero to 10, the closer to 10, the (T1 and T2) and the back-translation (RT1 and RT2) presented higher the probability of some alteration in the evaluation field identical or very similar results, showing good agreement between of the question. the versions, and only small grammatical adjustments for better un- This study was approved by the HU UFJF/EBSERH Ethics and derstanding and applicability of the questions were necessary. The Research Committee, opinion No. 13525619.0.0000.5133. necessary changes were made by the committee of experts. In order to evaluate anxiety and stress, the following questions were RESULTS chosen respectively “Do you feel anxious?” with the answer ranging from “zero: not at all’’ to “10: Quite anxious” and “Do you Forty patients with CP participated in the study, 87.5% women, feel stressed?” with the answer from “zero: Not at all stressed’’ to 42.5% married, 37.5% with incomplete elementary education. “10: Very stressed”. No chantes were necessary, since the transla- The majority were either dismissed from work (25%) or retired tions were identical and there was no alteration in meaning after the due to disability (27.5%). Tables 2 and 3 characterize the sample. back-translation. As for fear of movement, the chosen question was “Physical activity Table 2. Clinic characteristics of the sample might damage me” which was translated by the second translator Variables Results (mean±SD) (T2), because it was concluded that this version would contribute Age (year) 57.95 ± 10 more to a better understanding of the patient compared to the ver- N° of comorbidities 3.22 ± 2.21 sion translated by T1 “Physical activities can cause me injury” due Self-evaluation of health status 5.62 ± 2.09 to the term “injury”. The answer to the question did not require any changes, being “zero: Completely disagree’’ to “10: Completely Intensity of pain (VNS) 8.25 ± 1.95 agree”. Moreover, for the title of the question’s domain, the T2 trans- Duration of pain (years) 7.77 ± 7.58 lation was chosen, since the term used “Fear of movement” is closer VNS = visual numeric scale; SD = standard deviation. to the term used in the original question than “Kinesophobia” used by T1, it’s also a term that can be better understood by the popula- The average pain level on the numerical pain scale19 was 8.25 ± tion that presents different educational levels. 1.95, being the spine (55%) and lower limbs (42.5%) the most The question chosen to evaluate catastrophization was “When I feel affected areas. Regarding the time the patients had CP, the lowest pain, it is terrible and I feel that it will never get better” with the ans- was 1 year and the highest 38 years. wers: “zero: Never do that’’ to “10: Always do that”, with identical Table 3. Characteristics of the sample translations and no change in meaning after the back-translation. The only change made was to the title of the question’s domain, Variables Categories n° % opting for the T1 translation, because the T2 translation brings the Education Complete elementary 5 12.50 Incomplete elementary 15 37.50 title “Catatrosphize’’ and T1 brings “Catastrophization’’, a term clo- Complete middle 14 35 ser to that used in other studies when evaluating the same domain, Incomplete middle 2 5 as well as closer to the title given by the original author. 3 7.50 For the evaluation of depression, two questions were used: “During 1 2.50 the past month, have you often felt sad, depressed or had a sense of Work Active 6 15 hopelessness”? and “During the past month, have you felt bothered Dismissed 10 25 Retired 24 60 by little interest or pleasure in to do something”? both with answers ranging from “Zero: never’’ to “10: All the time’’. Each question SAH Yes 31 77.50 No 9 22.50 evaluates a dimension of depression, the first one is related to the Tobacco Yes 3 7.50 depressed mood and the second one to the lack of interest or anhe- No 37 92.50 donia. Regarding the changes made, in the T1 version the words Physical activity Yes 21 52.50 “despair” in the first question and “bothered” in the second distan- No 19 47.50 ced the translated versions from the original version. Therefore, the Location of pain Head and neck 4 10 option was to use the T2 version in both questions, because the Superior limbs 9 22.50 experts decided that the terms were more related to the evaluated Trunk 1 2.50 dimensions. Hip 3 7.50 Lower limbs 17 42.50 The time spent on the FICT presentation, filling out of the initial Spinal column 22 55 evaluation sheet and the six screening questions was 4 to 5 minutes. "Generalized pain" 10 25 The degree of reading facility was 100, highlighting the facility of SAH = systemic arterial hypertension. the instrument. 39 BrJP. São Paulo, 2021 jan-mar;4(1):37-42 Cardoso GV, Sarchis AP and Britto PA

Table 4. Comparison of original and final versions The process of translation and cross-cultural adaptation was Original version Synthesis version done by two translations and two back-translators. The use of Anxiety Ansiedade two independent translators in each of the phases was of utmost “Do you feel anxious?’ “Você se sente ansioso?” importance, as the versions produced by them could be compa- Not at all: zero De modo algum: zero red and discussed extensively when discrepancies were identified, Quite anxious: 10 Muito ansioso: 10 so that a final version with the best possible resolution could be Fear of movement Medo do movimento reached. Although the translators had no previous knowledge of “Physical activity might damage “Atividades físicas podem me me’ machucar” the questions and worked independently, their language expe- Completely Disagree: zero Discordo completamente: zero rience was essential for determining the semantic equivalence of Completely agree: 10 Concordo completamente: 10 the terms. Often some problems can be found in the translation Stress Estresse of instruments due to lack of familiarity with the research area. “Do you feel stressed?’ “Você se sente estressado?” In order to solve these problems, the committee formed by spe- Not at all stressed: zero Nenhum estresse: zero Very stressed: 10 Muito estressado: 10 cialists analyzed the questions with the authors of the study, who contributed with some suggestions and modifications in order to Catastrophization Catastrofização “When I feel the pain, it is terri- “Quando sinto dor, é terrível e ensure clarity and conceptual equivalence. ble, and I feel that it will never sinto que nunca vai melhorar” The recommendations for the transcultural translation and adap- get better’ Nunca acontece: zero tation process22 were followed, in which the focus should be on Never do that: zero Sempre acontece: 10 semantic equivalence and not literal translation, with the objec- Always do that: 10 tive of expressing the original content in a way that makes sense Depression Depressão “During the past month, have “Durante o último mês com que to the new target population. Therefore, whenever possible, the you often felt sad, depressed or frequência você se sentiu triste, central meaning was kept as close as possible to the original ver- had a sense of hopelessness?’ deprimido ou teve uma sensa- sion, without jeopardizing the comprehension of the questions. Never: zero ção de desesperança?” The sample included 40 patients with CP in different areas and All the time: 10 Nunca: zero O tempo todo: 10 intensities, with different ages, sex, education level and income in order to encompass as much personal characteristics as possi- Depression Depressão “During the past month, have “Durante o último mês, você se ble that would reflect a wide variation of answers. you felt bothered by little interest sentiu incomodado por estar The prevalence of CP increases steadily with age1,3, a fact confir- or pleasure in to do something?’ tendo pouco interesse ou prazer med in this study. In the elderly population, the control of CP is Never: zero em fazer alguma coisa?” more difficult due to the presence of pain in multiple locations, All the time: 10 Nunca: zero O tempo todo: 10 the higher number of comorbidities and the limitation in pharmacological management3,4. Over 85% of the study’s population DISCUSSION was composed of women, which is in accordance with most studies on the subject1,2,15. In addition to the higher prevalence in women, there is also a higher prevalence in married adults15,26, According to data from the IASP, the annual prevalence estimates corresponding to the findings of the present study. that between 15 and 45% of the general population has CP1,2. In Regarding the level of education and income, the study showed Brazil, although there are not many epidemiological studies, some that CP affected more those who had incomplete elementary studies show that CP is the main demand in outpatient care25,26. education and income between R$ 998.00 and R$ 2,994.00, Aspects such as mood, beliefs, expectations, previous experien- which corroborates with the study2. Indicators of socioeconomic ces, attitudes, knowledge and the symbolic meaning attributed level, such as poverty, education and health services coverage are to pain can modulate the painful sensation. Thus, comorbidities associated with the general state of health2. The reason is that or psychological symptoms are highly prevalent in patients with people with low income and less education have less knowledge 27 CP , being those associated with increased pain and greater disa- about evaluation and treatment adequate for CP, often self-medi- 1,2 bility, with an important role in the consequence of pain . Due cate and have less access to health services6,25. It’s also important to the need for a more complete and practical evaluation, as well to highlight that a large part of the sample is away from work as the lack of adequate tools, the translation and cross-cultural or already retired due to disability, in addition to having higher adaptation of the six short screening questions on the biopsycho- intensity of pain measured by the VNS. social aspects of CP emerges as an option for implementing a Studies show that pain affects work productivity, social life and simple and fast evaluation in clinical practice. leads to disability29. A systematic review and meta-analysis con- However, before applying an instrument for evaluation in a dif- ducted in the United Kingdom showed that CP is still associated ferent culture, it must be submitted to the process of translation with higher levels of pain and is quite disabling in many cases1. and cross-cultural adaptation, which is not just a literal transla- One study showed that CP was more prevalent in low back pain tion, but also the maintenance of semantic, conceptual, opera- (21.1%), followed by lower limb pain (15.8%), with many patients tional and measurement equivalence of the items that compose reporting generalized pain25, and another article30 also showed a it28. The objective is to maintain the similarity of concepts in the higher prevalence of CP in women, with low back pain and lower translated and adapted version despite the cultural differences. limb pain being the most frequent, results also found in this study. 40 Translation and cross-cultural adaptation of six short screening BrJP. São Paulo, 2021 jan-mar;4(1):37-42 questions on biopsychosocial aspects of chronic pain

Research12 involving 4.859 participants found that CP is usually Anna Paula Campos Sarchis associated with comorbidities, sleep disorders and psychological Resource Management, Project Management, Methodology, disorders. The present study also showed a higher prevalence re- Writing – Review and Editing, Supervision garding the number of comorbidities, with hypertension being Paulo Augusto de Almeida Britto the most frequent, similarly to the study15. Statistical Analysis, Project Management, Methodology, Writing In order to achieve a balance between the original version and – Review and Editing, Supervision the one adapted by this study, not many modifications were necessary aiming at the better comprehension by the Brazilian REFERENCES population. The fact that the questions were short, straightfor- ward and showed a good level of readability did not present 1. Fayaz A, Croft P, Langford RM, Donaldson LJ, Jones GT. 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42 BrJP. São Paulo, 2021 jan-mar;4(1):43-50 ORIGINAL ARTICLE

Factors related to self-rated quality of life among women with fibromyalgia according to International Classification of Functioning Fatores relacionados a qualidade de vida autorrelatada em mulheres com fibromialgia de acordo com a Classificação Internacional de Funcionalidade

Cristiane Vitaliano Graminha1, Juliana Martins Pinto1, Shamyr Sulyvan de Castro2, Maria Cristina Cortez Carneiro Meirelles1, Isabel Aparecida Porcatti de Walsh1

DOI 10.5935/2595-0118.20210006

ABSTRACT cioeconomic, environment and health status. However, other aspects may mediate or moderate that outcome, deserving atten- BACKGROUND AND OBJECTIVES: Fibromyalgia is cha- tion in a biopsychosocial approach. The results highlighted the racterized by diffuse pain, which may compromise the self-rated relevance of biopsychosocial aspects on quality of life of women quality of life (SRQoL). Little is known about the influence of with fibromyalgia, addressing factors that could be approached psychosocial and environmental factors on SRQoL in women in clinical practice to promote health and well-being. with fibromyalgia. The objective was to investigate factors related Keywords: Chronic pain, Depression, Health surveys, Muscu- to SRQol among women with fibromyalgia, according to Inter- loskeletal diseases, Public health. national Classification of Functioning domain. METHODS: A cross-sectional population-based study was RESUMO performed with 1,557 women. Those who self-reported fibromyalgia answered the Fibromyalgia Impact Index. SRQoL JUSTIFICATIVA E OBJETIVOS: Fibromialgia é caracterizada was evaluated by questions ranging from 1 (unsatisfied) to 3 por dor difusa, que pode comprometer a qualidade de vida au- (very satisfied). Exposures included personal and environmen- torrelatada (QVAR). Sabe-se pouco sobre a influência de fatores tal factors distributed in four blocks according to hypothesized psicossociais e ambientais na QVAR em mulheres com fibromial- influence on outcome. Multiple linear regression was perfor- gia. O objetivo deste estudo foi investigar fatores relacionados à med, considering 95% of confidence interval, using IBM SPSS QVAR entre mulheres com fibromialgia, segundo o domínio da version 24. Classificação Internacional de Funcionalidade. RESULTS: Income sufficiency was related to higher SRQoL in MÉTODOS: Estudo transversal de base populacional realiza- model 1. Physical environment was related to SRQoL in model do com 1.557 mulheres. Aquelas que se autorrelataram com fi- 2, 3 and 4. Functional capacity measurement was related to SR- bromialgia responderam ao Índice de Impacto da Fibromialgia QoL in model 4. In the final model, only depressive symptoms (n=115). A QVAR foi avaliada por questões que variavam de 1 (ß:-0.374; CI: -0.037/ -0.004) and number of painful body areas (insatisfeita) a 3 (muito satisfeita). As exposições incluíram fato- (ß: 0.204; CI: -0.102/-0.001) remained significantly related to res pessoais e ambientais distribuídos em quatro blocos de acordo SRQoL, explaining 27% of the variance. com a influência hipotética no desfecho. Foi realizada regressão CONCLUSION: SRQoL was related to depressive symptoms linear múltipla, considerando 95% do intervalo de confiança, and number of painful body areas even after controlled by so- utilizando-se a versão 24 do IBM SPSS. RESULTADOS: Suficiência de renda foi relacionada à maior

Cristiane Vitaliano Graminha – https://orcid.org/0000-0002-7013-2688; QVAR no modelo 1. Ambiente físico estava relacionado à QVAR Juliana Martins Pinto – https://orcid.org/0000-0003-2617-3308; nos modelos 2, 3 e 4. Medição da capacidade funcional esteve Shamyr Sulyvan de Castro – https://orcid.org/0000-0002-2661-7899; relacionada à QVAR no modelo 4. Apenas sintomas depressi- Maria Cristina Cortez Carneiro Meirelles – https://orcid.org/0000-0002-4427-9563; Isabel Aparecida Porcatti de Walsh – https://orcid.org/0000-0002-2317-1326. vos (ß:-0,374; IC: -0,037/ -0,004) e número de áreas corporais dolorosas (ß: 0,204; IC: -0,102/-0,001) mantiveram-se signifi- 1. Federal University of the Triângulo Mineiro, Department of Applied Physiotherapy, Uberaba, MG, Brazil. cativamente relacionado à QVAR, explicando 27% da variância. 2. Federal University of Ceará, Department of Physiotherapy, Fortaleza, CE, Brazil. CONCLUSÃO: QVAR esteve relacionada a sintomas depressi-

Submitted on August 26, 2020. vos e número de áreas corporais dolorosas mesmo depois de con- Accepted for publication on December 17, 2020. trolada por condição socioeconômica, ambiental e saúde. Ou- Conflict of interests: none – Sponsoring sources: This work was supported by Research Sup- tros aspectos podem mediar esse desfecho, merecendo atenção na port Foundation of State of Minas Gerais (FAPEMIG) APQ – 01825 - 12 abordagem biopsicossocial. Os resultados destacaram relevância Correspondence to: dos aspectos biopsicossociais na qualidade de vida das mulheres Cristiane Vitaliano Graminha Rua Santa Beatriz da Silva Ave, 111, Ap. 102 com fibromialgia, recorrendo a fatores que poderiam ser aborda- 38020-233 Uberaba, MG, Brasil. dos na prática clínica para promover saúde e bem-estar. E-mail: [email protected]/[email protected] Descritores: Depressão, Doenças musculoesqueléticas, Dor crô- © Sociedade Brasileira para o Estudo da Dor nica, Inquéritos epidemiológicos, Saúde pública. 43 BrJP. São Paulo, 2021 jan-mar;4(1):43-50 Graminha CV, Pinto JM, Castro SS, Meirelles MC and Walsh IA

INTRODUCTION understood the content of the survey and signed the Free and Informed Consent Term (FICT), was interviewed at their home. Fibromyalgia (FM) is a complex rheumatic syndrome, which af- Participants who failed to understand the research objective or fects predominantly women, characterized by chronic and diffuse did not agree to commit to the research protocol were excluded. pain, presence of points sensible to palpation (tender points) at The sampling process was stratified by clusters to be represen- predetermined anatomical sites, and associated symptoms such tative for the study population. The probabilistic sampling was as anxiety, depression, sleep and mood issues, fatigue, paresthesia carried out in two stages, firstly by census tracts and then by and cognitive problems1,2. Worldwide prevalence ranges between houses, according to recommendations of the Brazilian Institute 0.2 and 6.6%3, estimated in Brazil in 2.5%4. of Geography and Statistics (IBGE). For the final calculation of The syndrome involves physical and psychological symptoms the sample, a 50% prevalence estimate, a 95% confidence level, and is frequently associated with multimorbidity, leading to a maximum error of 0.10 and a drawing effect of approximately restriction of social activities and relations5,6. Depression is the 2 were considered. The minimum sample size for the study was main mental condition that affects people with FM, contribu- approximately 400 participants. However, in order to maximize ting to worsen pain symptoms. Authors6 showed that 50% of the representativeness of sample, 1,557 women were randomly people with FM have depressive symptoms, 33% with mode- selected and interviewed. rate to severe symptoms. People with FM who have severe de- Home interviews were conducted by female interviewers, spe- pressive symptoms report increased pain and fatigue intensity, cially trained for this study and coordinated by the technical su- poorer sleep quality, greater overall severity of the disease and pport team. a greater impairment of the emotional aspects of health-related Data collection was arranged in structured questionnaires ela- quality of life (HRQL) than people with FM with mild depres- borated by the researchers who coordinate this project and ins- sive symptoms7,8. truments translated and validated for the Brazilian population. Recent studies have found relationships between physical en- The first part of the research protocol evaluated sociodemogra- vironment and disability9-13. Socioeconomic condition and phic and economic conditions, chronic self-reported diseases, neighborhood characteristics seemed to impact functioning and QoL, eating habits, musculoskeletal symptoms, physical acti- quality of life (QoL) regardless of individual characteristics9,10. As vity, depressive symptoms and common mental disorder. From for the physical environment, characteristics such as social con- the answers obtained, the participants were invited to respond nectivity, sidewalk and street quality and house accessibility were to specific instruments according to their reported conditions, negatively associated with disability11,12. Therefore, the worse the for example, QoL in urinary incontinence, climacteric women’s environmental conditions, the greater the level of disabilities13. health, work capacity and impact of FM. QoL is recognized as a construct that summarizes the personal In order to answer research questions built for this study, a sub- satisfaction with several life domains reflecting the impact of -sample composed by 115 participants who self-reported FM objective conditions on perceived functioning14,15. This self-per- and answered the Fibromyalgia Impact Questionnaire (FIQ) was ception is influenced by individual and social expectations, as selected. Variables and instruments selected to analyses are des- well as cultural and socioeconomic aspects15. Such body of evi- cribed below. dence calls for the need of a biopsychosocial approach of people Self-rated quality of life (SRQoL) was evaluated through one with FM, investigating a broader range of aspects that may in- question adapted from The World Health Organization Quality form physicians and positively impact QoL of those people. The of Life (WHOQOL-brief), an instrument validated to Brazilian World Health Organization proposed in The International Clas- people15: “how do you evaluate your quality of life?”, to which sification of Functioning, Disability and Health (ICF) that hu- participants answered: very badly or bad (zero), neither bad nor man functioning is a multicausal phenomena determined by the good (1), good or very good (2). Scores ranged from zero to 2, interaction between aspects comprising the following domains: the greater, the better QoL. body function, activity limitation, participation restriction, Personal aspects included age, partnership, schooling, and suffi- personal factors and environment. To provide a comprehensive ciency of income. All variables were obtained by self-report. Age understanding of SRQoL, the present study operationalized the and schooling were considered as quantitative variables, both in independent variables (exposure) according to the respective do- years; partnership was derived from marital status report which main of ICF. was grouped in “having a partner” and “not having a partner”; The objective of this study was to investigate factors related to sufficiency of income was evaluated through the question “do self-rated QoL among women with FM, according to the ICF you have enough money to meet your needs?’’ Participants’ ans- domain. wers were categorized in ‘’nothing or very little’’, ‘’average’’ and ‘’very or completely’’. METHODS Environment aspects were indicated by satisfaction with social support and satisfaction with physical environment, both ques- The Women’s Health Survey is a cross-sectional population-ba- tions from The WHOQOL-brief15. The questions were: “How sed study performed in 2014 and 2015 to investigate health con- satisfied are you with the support you get from people?” and ditions among women living in Uberaba, Minas Gerais, Brazil. “How satisfied are you with the conditions of the place where A representative sample of 1.557 women aged 18 or over, who you live?” Answers were categorized in ‘’very unsatisfied or unsa- 44 Factors related to self-rated quality of life among women with BrJP. São Paulo, 2021 jan-mar;4(1):43-50 fibromyalgia according to International Classification of Functioning tisfied’’, ‘’neither satisfied nor unsatisfied’’ and ‘’satisfied or very body height, expressed in units of kg/m2. Number of drugs taken satisfied’’. was obtained by self-report. Participation restriction was indicated by satisfaction with social The research project was approved by the Research Ethics Com- relations and satisfaction with leisure opportunities, which were mittee of the Federal University of the Triângulo Mineiro, under evaluated by the questions: “how satisfied are you with your so- the number 1826. cial relationships?”, being the answer options ‘’very unsatisfied or unsatisfied’’, ‘’neither satisfied nor unsatisfied’’ and ‘’satisfied Statistical analysis or very satisfied’’; and “to what extent do you have opportunities Means, median and percentages were calculated to describe for leisure activities?”, to which answer options were ‘’nothing or the characteristics of the sample. Given the data distribution, a very little’’, ‘’average’’ and ‘’very or completely’’. non-parametric test was performed to verify bivariate associa- Limitations for daily activities were evaluated by the FIQ16 tions and correlations of independent variables with SRQoL. which comprises questions about disability to perform To compare the median of life quality between groups the daily activities such as shopping, laundering, cooking, hou- Mann-Whitney and Kruskal-Wallis tests were used; for quan- sekeeping, walking for many blocks, visiting relatives and titative variables the Spearman’s Correlation test was used. The friends, gardening and transportation. Furthermore, the ins- multivariate model was tested through linear regression in five trument contains other questions about how pain, fatigue, blocks based on ICF domains. They were: model 1 – personal sadness and stress have impacted their work and daily life. factors; model 2 – personal factors and environment factors, Scoring was performed according to the recommendations social, support and physical environment; model 3 – perso- of American Association of Rheumatology17. The FIQ score nal factors, environment factors and participation restrictions, shows a maximum of 100 that represents the greatest possible social relations and leisure opportunities; model 4 – personal impact of the disease on the participant’s QoL, but attention factors, environment factors, participation restrictions and should be directed to the calculation of this value, since each activity limitation, fibromyalgia impact; model 5 – personal item of the questionnaire should be analyzed separately. The factors, environment factors, participation restrictions, activity first item, which corresponds to functional capacity, consists limitations and body dysfunctions. Significance level adopted of the 10 questions, whose answers vary from zero to 3, and, was 5% and confidence interval 95%. Data were analyzed in by summing the answers, a maximum score of 30 can be ob- the IBM SPSS 24 for Windows. tained (R1). Item 2, related to feeling good, presents a score (R2) inversely proportional to the result marked, that is, if RESULTS the patient indicated answer 7, their score would be zero or if they indicated zero, they would receive a score of 7. Item Mean age was 56.45±11.45 years, and schooling 8.72±4.98 3 presents a question about absences to work and was noted years; 62.3% had a partner and approximately half (47%) of (R3) directly related to the response indicated, that is, 7 = 7 the participants stated that income was insufficient to meet the and zero = zero. Items 4 to 10 present visual scales that were needs. Regarding environmental factors, 30.5% reported low scored according to distance in centimeters displayed between satisfaction with social support and 42.6% reported low satis- the icons from left to right, and can display values (R4 – R10) faction with physical environment. Regarding the indicators of from zero to 10 cm. To calculate the final score, the values restriction of social participation, 72.1% presented low satisfac- obtained with the previous calculations in the following for- tion with leisure opportunities and 29.5% with social relations. mula: (R1/3) + (R2x1.43) + (R3x1.43) + (£ R4-R10) were The mean score of the FM impact in daily life activities was substituted16. This formula was used to compute the indivi- 59.12±23.10. dual scores of the subjects from the study. Regarding the body dysfunctions indicators, the sample was cha- Body dysfunctions included number of painful body areas, racterized by consuming, on average, approximately three drugs, depressive symptoms, satisfaction with sleep, body mass index with a high average of depressive symptoms 21.16±13.67), BMI (BMI) and number of drugs taken. Number of painful areas was of 29.32±5.4 and a mean of painful body areas of 4.31±3.09. In evaluated asking them whether they feel pain in the neck, shoul- addition, more than half of the sample was classified as having ders, thoracic spine, elbows, lumbar spine, wrists and hands, hips low sleep satisfaction (57.4%) (Table 1). and thighs, knees, ankles and feet. Then, the number of painful Table 2 shows results from the associations and correlations tests areas was calculated for each participant. Depressive symptoms used to bivariate comparisons of exposure and SRQoL, whi- were assessed by the Center for Epidemiologic Studies Depres- ch showed significant and low correlation between QoL and sion Scale (CES-D), adapted and validated for Brazilian people, schooling (p=0.002), FM impact (p<0.001), number of drugs with 20 items regarding frequency of negative feelings, ranging (p=0.042) and number of painful body areas (p<0.001) while from ‘’rarely’’ (zero) to ‘’mostly’’ (3). The greater score means moderate correlation was observed for depressive symptoms the more depressive symptoms18,19. Satisfaction with sleep was (p<0.001). Further associations were with income (p=0.005), evaluated by the question “How satisfied are you with sleep?”, social support (p<0.001), physical environment (p=0.002), lei- being the answers very unsatisfied or unsatisfied (zero), neither sure opportunities (p=0.047) and sleep satisfaction (p=0.036). satisfied nor unsatisfied (1) and satisfied or very satisfied (2). The The mean of QoL was lower among those classified with dissatis- BMI was defined as the body mass divided by the square of the faction with income, social support, physical environment, lei- 45 BrJP. São Paulo, 2021 jan-mar;4(1):43-50 Graminha CV, Pinto JM, Castro SS, Meirelles MC and Walsh IA

Table 1. Characteristics of the sample F (%) M (SD) Md (IR) Personal factors Age (n=115) 56.45 (11.45) 56 (16) Partnership (n=114) Not having a partner 43 (37.7) Having a partner 71 (62.3) Schooling (n=109) 8.72 (4.98) 8 (8) Sufficiency of income (n=115) Nothing 54 (47) Average 39 (33.9) Very 22 (19.1) Environment factors Satisfaction with social support (n=115) Unsatisfied 11 (9.6) Neither satisfied nor dissatisfied 24 (20.9) Satisfied 80 (69.6) Satisfaction with physical environment (n=115) Unsatisfied 19 (16.5) Neither satisfied nor dissatisfied 30 (26.1) Satisfied 66 (57.4) Participation restriction Satisfaction with leisure opportunities (n=115) Unsatisfied 55 (47.8) Neither satisfied nor dissatisfied 28 (24.3) Satisfied 49 (42.6) Satisfaction with social relations (n=115) Unsatisfied 12 (10.4) Neither satisfied nor dissatisfied 22 (19.1) Satisfied 81 (70.4) Activity limitation FIQ (n=115) 59.12 (23.10) 65.12 (34) Body dysfunction Number of painful body areas (n=107) 4.31 (3.09) 4 (5) Depressive symptoms (n=113) 21.16 (13.67) 20 (21) Satisfaction with sleep (n=112) Unsatisfied 42 (36.5) Neither satisfied nor dissatisfied 24 (20.9) Satisfied 49 (42.6) BMI (n=112) 29.32 (5.74) 28.94 (24.75) Number of drugs (n=115) 2.92 (2.12) 3 (4) How do you evaluate your quality of life? (n=115) 1.32 (0.76) 1.50 (1) F = Frequency; M = mean; SD = standard deviation; Md = median; IQR = interquartile range; FIQ = Fibromyalgia Impact Questionnaire; BMI = Body Mass Index.

sure opportunities and sleep. Likewise, the lower the mean of life environment was an important predictor of SRQoL, a relation quality, the greater were the means of FM impact, the number which was maintained in model 3, when variables of the partici- of drugs, the depressive symptoms, and the number of painful pation domain were included. In model 4, the functional capa- body areas. The higher the years of schooling, the greater was city measurement was included, which proved to be a predictor QoL (Table 2). of SRQoL, together with satisfaction with the physical environ- The multivariate analysis allowed understanding the influence of ment. However, in the final model (model 5), after inclusion of the exposures on SRQoL, according to the functioning domains indicators of body dysfunctions, only depressive symptoms and (ICF). According to the results, income sufficiency was related number of painful body areas remained significant related to SR- to higher SRQoL among the personal factors (model 1). After QoL in women with FM (Table 3). the inclusion of the environmental domain (model 2), physical The final model explained 27% of the variance of SRQoL. 46 Factors related to self-rated quality of life among women with BrJP. São Paulo, 2021 jan-mar;4(1):43-50 fibromyalgia according to International Classification of Functioning

Table 2. Distribution of means, median and Spearman’s Correlation Coefficient of quality of life evaluation, according to independent variables SCC M (SD) Md (IQR) p-value Age 0.033 0.729 Partnership 0.382 Not having a partner 1.23 (0.78) 1 (2) Having a partner 1.37 (0.72) 2 (2) Schooling (years) 0.292 0.002 Sufficiency of income 0.005 Insufficient 1.11 (0.71) 1 (2) Average 1.44 (0.75) 2 (2) Sufficient 1.64 (0.65) 2 (2) Satisfaction with social support 0.001 Dissatisfied 0.91 (0.94) 1 (2) Neither satisfied nor dissatisfied 0.96 (0.62) 1 (2) Satisfied 1.49 (0.69) 2 (2) Satisfaction with physical environment 0.002 Dissatisfied 0.95 (0.78) 1 (2) Neither satisfied nor dissatisfied 1.10 (0.75) 1 (2) Satisfied 1.53 (0.66) 2 (2) Satisfaction with social relations <0.001 Dissatisfied 0.67 (0.77) 0.5 (2) Neither satisfied nor dissatisfied 1.05 (0.72) 1 (2) Satisfied 1.49 (0.67) 2 (2) Satisfaction with leisure opportunities 0.047 Dissatisfied 1.16 (0.73) 1 (2) Neither satisfied nor dissatisfied 1.39 (0.73) 2 (2) Satisfied 1.53 (0.71) 2 (2) FIQ -0.366 <0.001 Number of drugs -0.190 0.042 Depressive symptoms -0.531 <0.001 BMI -0.025 0.792 Number of painful body areas -0.394 <0.001 Satisfaction with sleep 0.036 Dissatisfied 1.17 (0.82) 1 (2) Neither satisfied nor dissatisfied 1.17 (0.70) 1 (2) Satisfied 1.53 (0.64) 2 (2) SCC = Spearman’s Correlation Coefficient; M = mean; SD = standard deviation; Md = median; IQR = interquartile range; FIQ = Fibromyalgia Impact Questionnaire; BMI = Body Mass Index.

Table 3. Linear regression using enter method Model 1 Model 2 Model 3 Model 4 Model 5 β (CI) β (CI) β (CI) β (CI) β (CI) Age 0.112 0.077 0.060 0.050 0.035 (-0.008-0.023) (-0.010-0.021) (-0.011-0.019) (-0.012-0.018) (-0.013-0.018) Partnership 0.073 0.000 -0.008 -0.023 -0.004 (-0.206-0.437) (-0.311-0.312) (-0.329-0.303) (-0.346-0.274) (-0.309-0.297) Schooling 0.166 0.105 0.086 0.096 0.055 (-0.058-0.331) (-0.108-0.280) (-0.125-0.267) (-0.113-0.270) (-0.144-0.235) Sufficiency of income 0.217 0.136 0.106 0.064 -0.026 (0.004-0.425) * (-0.070-0.340) (-0.116-0.326) (-0.156-0.282) (-0.242-0.190) Continue...

47 BrJP. São Paulo, 2021 jan-mar;4(1):43-50 Graminha CV, Pinto JM, Castro SS, Meirelles MC and Walsh IA

Table 3. Linear regression using enter method – continuation Model 1 Model 2 Model 3 Model 4 Model 5 β (CI) β (CI) β (CI) β (CI) β (CI) S. social support 0.168 0.095 0.058 0.034 (-0.040-0.423) (-0.149-0.365) (-0.187-0.320) (-0.211-0.288) S. physical environment 0.292 0.251 0.237 0.148 (0.096-0.486) * (0.050-0.451)* (0.039-0.433) * (-0.059-0.353) S. social relations 0.174 0.143 0.050 (-0.059-0.458) (-0.091-0.419) (-0.205-0.320) S. leisure opportunities 0.055 -0.018 -0.024 (-0.142-0.240) (-0.211-0.180) (-0.218-0.176) FIQ -0.242 -0.078 (-0.015-0.001) * (-0.010-0.005) Number of drugs 0.052 (-0.062-0.100) Depressive symptoms -0.374 (-0.037—0.004) * BMI 0.008 (-0.024-0.026) Number of painful body area -0.204 (-0.102—0.001) * Satisfaction with sleep -0.049 (-0.255-0.141) BMI = Body Mass Index; FIQ = Fibromyalgia Impact Questionnaire. β = Standardized coefficient; CI = Confidence interval. Model 1 – personal factors; model 2 – personal factors and environment factors; model 3 – personal factors, environment factors and participation restrictions; model 4 – personal factors, environment factors, participation restrictions and activity limitation; model 5 – personal factors, environment factors, participation restrictions, activity limitations and body dysfunctions.

DISCUSSION are entered together. Also, it’s possible to observe the changes in significance when variables are being entered in the mo- The study aimed at identifying factors related to SRQoL of del. From this analysis was possible to identify the stronger women with FM based on ICF domain which allowed an predictor and the potential mediators or moderators. In the overview of aspects that determine well-being in this popu- present study, the final model showed depressive symptoms lation beyond physical health problems and symptoms. This and number of painful body areas as the stronger predictors approach contributes to an integrative health management of SRQol, however, in the previous models, physical environ- addressed to prevent functional decline and promote health ment and functional capacity were related to SRQoL. This and QoL among people with FM. may suggest that these aspects have a mediator or moderator The literature characterizes FM as a multidimensional and role on the relationships between depressive symptoms, pain multifactorial condition requiring a broader approach given and SRQoL. its associations with sleepiness, pain, drugs, depressive symp- Some sample characteristics deserve attention and discussion. toms, lack of social support, lower schooling level and social The mean age of 56.4 years was higher compared to others vulnerability7,20-22. The present study’s findings support those studies whose mean age ranged from 47 to 52 years22. Schoo- data and add some insights and further contributions. ling level was 8.7 years, which is lower than of the findings of Using ICF domain to group different exposures according to study22, which found a mean of around 11 years. BMI mean their level of influence on SRQoL allowed maximizing the was 29.3, higher than other findings which range from 22 understanding of the role of several aspects beyond body dys- to 276,22. FIQ mean score agreed with findings of the stu- function which are strongly investigated and have well known dy22, which was 59, however, it differed from other authors influence. This strategy meets the recent movement of resear- who found a mean around 647,20. The depressive symptoms chers who have been studying chronic pain from a multidi- mean score was 21.16 points which is higher than means fou- mensional perspective. They are embodying and approaching nd among people with other rheumatic diseases, for instance, emotional, cognitive, behavioral and social aspects in their systemic lupus erythematosus (mean 18.3)23. research and clinical practice. In this context, the present re- Although bivariate results showed all exposure related to SR- sults include FM as a health condition that has potential to be QoL except age, partnership and BMI, such variables were managed whether those aspects were considered. kept in the model in the multivariate analysis in order to Other strength of this study was analyzing exposure varia- control the effect of other predictors. Income sufficiency is bles in blocks. This strategy allowed to identify significant a relevant aspect related to SRQoL among other personal as- relationships that are covered when all independent variables pects such as age, schooling level and partnership. Indeed, 48 Factors related to self-rated quality of life among women with BrJP. São Paulo, 2021 jan-mar;4(1):43-50 fibromyalgia according to International Classification of Functioning economic and social status are closely related to health status, was 11.2 per 1000 person-year against 5.1 in people without functionality and, consequently, QoL, because it allows grea- rheumatoid arthritis30. Besides, the impact of FM in daily life ter health services and information access and use of commu- activities was related to depressive symptoms in findings from nity resources that support healthier behaviors. Authors13 study22, which suggests that limitations in daily activities can performed a systematic review of literature and discussed the be a mediator of impact between body dysfunctions and QoL influence of physical/built and socioeconomic neighborhood in people with FM. Additionally, age differences may play aspects on disability. The influence of the socioeconomic cha- a role in the incidence and prevalence of depression among racteristics of the neighborhood is explained by the fact that people with rheumatic diseases30, which requires more inves- they are restricted to house, with fewer amenities and servi- tigations. ces options that provide interaction and social support, and The present findings should be interpreted considering some this contributes to the loss of functional autonomy. In addi- limitations. The Women’s Health Survey was not designed to tion, areas with greater social deprivation also reflect a smal- study FM specifically, but to be a secondary source of data ler social network, contributing to greater social restriction. for its investigation. FM was indicated by self-report from Conditions of poverty and social vulnerability can be precur- the participants, not by physical evaluation as recommended sors to precarious working conditions, such as low levels of to its diagnosis. Probably, the prevalence of FM was overes- schooling, which limit the access and information needed to timated because participants tend to associate body pain to perform more complex activities and maintain health. This this condition. Nevertheless, the proportion of women with context is recognized to increase the vulnerability to chronic FM in the sample study was like the population, which is and disabling diseases24. around 6%. Secondly, self-rated conditions regarding to en- The literature dedicated to studying the influence of physi- vironment and leisure opportunities may be underestimated cal environment on health status is re-emergent. According because people tend to be satisfied even when there are real to study25, human functioning is a result of the personal limitations and restrictions in the environment. In this sense, competence and environment press; therefore, as people future studies should approach environment characteristics grow older and become less physically able, the environment objectively in order to better estimate its impact on SRQoL. implies more barriers to the functioning. People living with These findings highlighted the relevance of depression and pain, fatigue and depression may be more sensitive to the pain approach in women with FM in order to promote better environment barriers than others. They tend to avoid chal- QoL. In addition, the potential impact of socioeconomic and lenging environments and are more physically and socially environmental aspects was noted, highlighting the necessity restrict to their homes which contributes to health and func- of a biopsychosocial approach of people with FM. tional decline. Better street characteristics, such as greater connectivity between them and even sidewalks, tend to in- CONCLUSION fluence the mobility and level of physical activity contributing to health promotion and postponement of disabilities26. SRQoL of women with FM is influenced by depressive symp- In addition, the lack of accessibility in public places affects toms and the number of painful body areas. However, atten- individuals directly with reduced mobility which can aggra- tion should also be drawn to income, physical environment vate the levels of limitations and restrictions on social par- and the impact of FM in daily activities. These are modifiable ticipation27. Healthy environments tend to offer common aspects to be approached by physicians in clinical practice and spaces and greater social interaction among residents of the public health managers aiming to promote health and quality same place28. Evidence suggests that paved streets increase of life for this population. the sense of security in the place, avoiding the isolation, and consequently, its negative impacts on functionality29. Those ACKNOWLEDGMENTS assertions probably explain the relevance of physical and social environment aspects in SRQoL of people with chronic To thank the participants and students involved in the data col- pain condition, such as FM. lection, without which this study would not have been possible This study allowed identifying that environment conditions and activities limitations have influence on SRQoL when AUTHORS’ CONTRIBUTIONS body functions were not entered. When body dysfunctions were included, the final model shows that the better predic- Cristiane Vitaliano Graminha tors of QoL were depressive symptoms and number of pain- Conceptualization, Writing - Preparation of the original, Wri- ful body areas. Those findings corroborate the literature who- ting - Review and Editing. se data have shown the prevalence and the impact of these Juliana Martins Pinto symptoms in people’s life. 71% of people with FM reported Statistical analysis, Writing - Preparation of the original, Writing moderate and severe depressive symptoms. Furthermore, de- - Reviewing and Editing. pressed people reported greater pain intensity than those not Shamyr Sulyvan de Castro depressed7. Corroborating these findings, the incidence rate Funding aquisition, Resource management, Project manage- of depressive disorders in patients with rheumatoid arthritis ment, Methodology, Writing - Review and Editing. 49 BrJP. São Paulo, 2021 jan-mar;4(1):43-50 Graminha CV, Pinto JM, Castro SS, Meirelles MC and Walsh IA

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50 BrJP. São Paulo, 2021 jan-mar;4(1):51-7 ORIGINAL ARTICLE

Correlation between muscle strength and the degrees of functionality and kinesiophobia reported by patients with chronic hip pain Correlação entre força muscular e graus de funcionalidade e cinesiofobia relatada por pacientes com dor crônica no quadril

Gustavo Leporace1,2, Luiz Alberto Batista3,4, Leonardo Metsavaht1,2, Jorge Chahla5, Tainá Oliveira3,4, Liszt Palmeira de Oliveira6

DOI 10.5935/2595-0118.20210015

ABSTRACT CONCLUSION: The reduction in peak strength of the hip extensors, abductors and external rotators was associated with a re- BACKGROUND AND OBJECTIVES: This study aimed to duction in the level of hip functionality but did not correlate with identify the association between hip muscle strength and the neither the level of overall functionality of the lower limbs nor the scores from subjective functional and psychological evaluation degree of kinesiophobia. Also, a reduction of hip external rotators questionnaires in patients with chronic hip pain. strength was related to an increase in the intensity of pain. METHODS: Fifty-five patients with painful hip injuries (30 Keywords: Hip joint, Muscle strength, Muscle strength dyna- males) performed isometric peak strength tests of the abductors, mometer, Pain measurement, Quality of life. extensors, and internal and external rotators of the hips with a hand-held dynamometer. The degree of functionality was mea- RESUMO sured by the Hip Outcome Score (HOS) and Lower Extremity Functional Score (LEFS), pain was estimated by the Visual Ana- JUSTIFICATIVA E OBJETIVOS: Este estudo teve como ob- log Scale (VAS) and kinesiophobia was calculated using the Tam- jetivo identificar a associação entre a força muscular do quadril pa questionnaire. The Pearson correlation coefficient was used e os escores de questionários subjetivos de avaliação funcional e (alfa=5%) to test the associations between the muscle strength psicológica em pacientes com dor crônica no quadril. and the scores from the questionnaires. MÉTODOS: Cinquenta e cinco pacientes com lesões dolorosas RESULTS: There were significant correlations between the no quadril (30 homens) realizaram testes isométricos do pico de strength of all four hip muscles and the HOS (r>0.29). Only força de abdutores, extensores e rotadores internos e externos do the hip external rotators showed a significant correlation with quadril com um dinamômetro portátil. O grau de funcionalida- pain (r=-0.30). No significant correlations were found for LEFS de foi medido pelo Hip Outcome Score (HOS) e Lower Extremity (r<0.24) and Tampa questionnaires (r←0.15). Functional Score (LEFS), a dor foi avaliada pela escala analógi- ca visual (EAV) e a cinesiofobia foi calculada pelo questionário de Tampa. O coeficiente de correlação de Pearson foi utilizado (alfa=5%) para testar as associações entre a força muscular e os Gustavo Leporace – https://orcid.org/0000-0002-7265-4658; escores dos questionários. Luiz Alberto Batista – https://orcid.org/0000-0002-4609-4095; Leonardo Metsavaht – https://orcid.org/0000-0001-9263-1309; RESULTADOS: Houve correlações significativas entre a força de Jorge Chahla – https://orcid.org/0000-0002-9194-1150; todos os quatro músculos do quadril e o HOS (r>0,29). Apenas Tainá Oliveira – https://orcid.org/0000-0002-9726-5528; Liszt Palmeira de Oliveira – https://orcid.org/0000-0002-9051-937X. os rotadores externos do quadril apresentaram correlação significativa com a intensidade da dor (r=-0,30). Nenhuma correlação 1. Brazil Institute of Health Technologies, Research Department, Rio de Janeiro, RJ, Brazil. 2. Federal University of São Paulo, São Paulo School of Medicine, Diagnostic Imaging De- significativa foi encontrada para LEFS (r<0,24) e questionário de partment, São Paulo, SP, Brazil. Tampa (r←0,15). 3. State University of Rio de Janeiro, Laboratory of Biomechanics and Motor Behavior, Rio CONCLUSÃO: A redução no pico de força dos extensores, ab- de Janeiro, RJ, Brazil. 4. State University of Rio de Janeiro, Post-Graduation Program in Sport and Exercise Sci- dutores e rotadores externos do quadril foi associada à redução ence, Rio de Janeiro, RJ, Brazil. no nível de funcionalidade do quadril, mas não se correlacionou 5. Rush University Medical Center, Midwest Orthopaedics at RUSH, Chicago, Illinois, USA. com o nível de funcionalidade geral dos membros inferiores ou 6. State University of Rio de Janeiro, Medical Sciences Post-Graduation Program, Rio de com o grau de cinesiofobia. Além disso, uma redução da força Janeiro, RJ, Brazil. dos rotadores externos do quadril foi relacionada a aumento na Submitted on September 07, 2020. intensidade da dor. Accepted for publication on January 06, 2021. Descritores: Articulação do quadril, Dinamômetro de força Conflict of interests: none – Sponsoring sources: none muscular, Força muscular, Medição da dor, Qualidade de vida. Correspondence to: Gustavo Leporace Instituto Brasil de Tecnologias da Saúde, Departamento de Pesquisa INTRODUCTION 22410-003 Rio de Janeiro, RJ, Brasil. E-mail: [email protected] Chronic hip pain is a frequent cause of dysfunction in young © Sociedade Brasileira para o Estudo da Dor adults1 and may lead to limitations in daily living and sporting 51 BrJP. São Paulo, 2021 jan-mar;4(1):51-7 Leporace G, Batista LA, Metsavaht L, Chahla J, Oliveira T and Oliveira LP activities2. Subjective evaluation questionnaires related to the lower limb questionnaires; (ii) peak muscle strength values are degrees of functionality and hip pain are the primary outco- associated with scores on the visual analog scale (VAS) for pain; mes used to identify the impact of hip diseases on patients’ and (iii) peak muscle strength values are associated with the de- quality of life, as they establish a quantitative interpretation gree of kinesiophobia. of the patient regarding their level of functionality3. Although these questionnaires are routinely used in longitudinal studies, METHODS they have limited applicability in selecting objective interventions for improving lower limb functionality. Decreased muscle Data from this cross-sectional study were collected from consecu- strength has been reported to be a frequent objective physical tive clinical and biomechanical evaluations of patients with painful finding4,5. Study5 suggested that patients with chronic hip pain hip injuries performed consecutively in a private biomechanics’ tend to have reductions in internal rotator, external rotator and laboratory from January to August 2016. Fifty-five patients (30 hip abductor peak strength in both the affected and contrala- male) were classified according to the classification of hip joint teral limbs when compared with healthy subjects. These fin- involvement (Table 1)9. All the diagnoses were made by the same dings have been corroborated by authors6,7 in individuals with orthopedic physician (initials blinded for review). osteoarthrosis (OA). The degree of functionality was measured by applying the valida- Periarticular muscles are important dynamic stabilizers of the ted version of the questionnaires Hip Outcome Score (HOS)10 hip joint and may be responsible for movement dysfunctions and Lower Extremity Functional Score (LEFS)11, pain was esti- of the hip and lumbopelvic region when they are limited in mated by the VAS and kinesiophobia was estimated using the their capacity to generate force or when there are neuromus- Tampa questionnaire12. cular control deficits8 because they tend to generate a biomechanical overload in the intra-articular structures8. Although Streng measurement a good capacity to generate muscle strength and good motor The maximum isometric peak strength levels of the abductors, control are paramount for functionality and maintaining the extensors, and internal and external rotators of the hips were quality of life of patients with chronic hip pain4,5, no studies measured with a manual dynamometer (Lafayette Manual have sought to establish a possible association between the abi- Muscle Tester Model 01163; Lafayette Instrument Company, lity to generate hip muscle strength and the level of functional Lafayette, IN, USA). Make tests were performed because they capacity reported by patients with chronic hip pain. Such data had better reliability than break tests13. Intra- and inter-rater could aid the optimization of muscle strengthening exercises in reliability of these devices has been previously reported to be programs aimed at improving the motor function of patients excellent, with values above 0.8014-16. In cases of patients with with chronic hip pain. unilateral pain, the tests were performed on the limb indicated For the above-mentioned reasons, the purpose of this study was in the complaint of pain. In cases of bilateral pain, the tests to identify the association between hip muscle strength and the were performed on the limb with greater pain and functional scores from subjective functional and psychological evaluation limitation. All patients underwent two attempts to familiarize questionnaires in patients with chronic hip pain. The hypotheses themselves with the procedures and two more attempts to col- of the study were that: (i) peak muscle strength values are asso- lect peak strength. The maximum value of the two test attempts ciated with the subjective assessment questionnaire scores and for each muscle in each participant was used in the analysis. are higher for hip-specific questionnaires than for generalized The participants were instructed to push the dynamometer

Table 1. Charnley9 classification of hip joint involvements that have a negative influence on walking capacity

Classification Sample Diagnosis

A - Unilateral disease 9 - Gluteal enthesopathy (n = 4) - Femoroacetabular impact (n = 3) - Femoral head osteonecrosis (n = 1) - Acetabular dysplasia (n = 1)

B - Bilateral disease 25 - Gluteal enthesopathy (n = 1) - Femoroacetabular impact (n = 19) - Coxarthrosis (n = 3) - Femoral head osteonecrosis (n = 2)

C -Some factor besides the hip impairing 21 - Gluteal enthesopathy (n = 10) function* - Coxarthrosis (n = 9) - Pubalgia (n = 2).

Class A refers to unilateral hip disease; Class B refers to bilateral hip involvement; and Class C refers to some factor besides the hip negatively influencing walking capacity. * The other impaired body segment in group C was mainly the lumbar spine (n = 19), in addition to one case of bilateral knee osteoarthrosis and one case of iatrogenic sciatic nerve injury.

52 Correlation between muscle strength and the degrees of functionality BrJP. São Paulo, 2021 jan-mar;4(1):51-7 and kinesiophobia reported by patients with chronic hip pain with the greatest possible effort while avoiding sudden move- determination of 0.15 between variables and a moderate effect ments so that the force was gradually increased over a period size of α=0.05, using a bivariate normal model, defined a priori of 5 seconds17. using GPower software. The Pearson correlation coefficient was The hip abductor muscles were tested with the patient in lateral used at a significance level of 5% in order to test the associations decubitus with the hip in a neutral position. The manual dynamo- between the absolute peak muscle strength of the four muscle meter was positioned 5cm proximal to the lateral epicondyle of the groups in Newtons and the LEFS questionnaire, the two sub-s- femur in a direction perpendicular to the thigh. The subjects were cales of the HOS, the VAS and the Tampa kinesiophobia ques- instructed to press their leg toward the ceiling without rotating the tionnaire. MATLAB software (Mathworks, version 8.6.0, USA) pelvis or limbs. For hip extensors, the patient assumed a ventral de- was used in data processing and statistical testing. cubitus position, and the manual dynamometer was positioned 5cm proximal to the posterior articular line of the knee in a direction per- RESULTS pendicular to the thigh. The patient was instructed to press their leg up toward the ceiling, without rotating their pelvis or limb. For the The mean age of the patients was 48.5±16.7 years old, ranging hip rotator evaluation, the patients remained seated with 90° of hip from 18 to 84 years; the mean height was 167.5±10.9cm, ran- and knee flexion. For the internal rotator examination, the dynamo- ging between 146 and 192.5cm and the mean body weight was meter was positioned 5cm proximal to the lateral malleolus, and the 74.1±18.9 kg, ranging between 49.5 and 114.4kg. patient was instructed to exert force to rotate the leg laterally. For There were significant correlations between the peak muscle the external rotators, the dynamometer was positioned 5 cm above strength levels of the extensors, abductors and external and inter- the medial malleolus, and the patient was instructed to exert force to nal hip rotators and the HOS in the domains activities of daily rotate his/her leg in the medial direction. living (ADL) (r>0.42, p<0.002) and sports (S) (r>0.29, p<0.04) The study project was approved by the Institutional Ethics Com- (Figures 1 and 2, respectively). mittee (number 039.3.2010). All participants signed the Free For the pain scale score, there was a significant and inversely and Informed Consent Term (FICT) proportional correlation only for the external rotators (r=-0.30; p=0.03) (Figure 3). No significant correlations were found bet- Statistical analysis ween peak muscle strength and the LEFS questionnaire (r<0.24; Sample size was determined as the number of participants ne- p>0.05) (Figure 4) and between the peak muscle strength and cessary to reach a statistical power of 80%, with a coefficient of the degree of kinesiophobia (r<-0.15, p>0.05) (Figure 5).

Hip extensors Hip abductors r=0.48, p=0.0001 r=0.42, p=0.0002 HOS ADL HOS ADL

Peak isometric strength (N) Peak isometric strength (N) Hip external rotators Hip internal rotators r=0.52, p<0,0001 r=0.53, p<0,0001 HOS ADL HOS ADL