ORIGINAL ARTICLE BACK PAIN: AN ASSESSMENT IN BREAST HYPERTROPHY PATIENTS PAULO MAGALHÃES FERNANDES1, MIGUEL SABINO NETO2, DANIELA FRANCESCATO VEIGA3, LUIS EDUARDODUARDO FELIPE ABLABLA4, CARLOS DELANO ARAÚJO MUNDIM 5, YARAARA JULIANOULIANO6,� LYDIAYDIA MASAKOASAKO FERREIRAERREIRA7 SUMMARY used in order to evaluate the magnitude of back pain and Objective – To evaluate the influence of breast hypertrophy on the limitations arising from these symptoms. Results – The the incidence of back pain and how much they can interfere in mean age of the patients in the study group was 32.2 years patients’ daily activities. Methods – This was a cross-sectional and 32.7 for the control group. The scores in the NRS scale analytic study in patients examined at the Outpatient Ortho- and Roland- Morris Questionnaire were higher in the study pedics and Plastic Surgery Departments at Samuel Libânio group when compared to the control group. Conclusion – The University Hospital in Pouso Alegre, MG. 100 women were results achieved showed that back pain is more severe and examined, 50 presenting breast hypertrophy (study group) determined more extensive limitations in the daily activities and 50 with normal breast size (control group). Breasts were for patients presenting breast hypertrophy. classified according to Sacchini’s criteria. The Numerical Ra- ting Scale (NRS) and the Roland-Morris questionnaire were Keywords: Back pain; Quality of life; Neck pain; Breast. Citation: Fernandes PM, Sabino Neto M, Veiga DF, Abla LEF, Mundim CDA, Juliano Y et al. Back pain: an assessment in breast hypertrophy patients. Acta Ortop Bras. [serial on the Internet]. 2007; 15(4): 227-230. Available from URL: http://www.scielo.br/aob. INTRODUCTION This study intends to assess the influence of breast hyper- Back pain is amongst the most frequent complaints of pa- trophy over painful spinal symptoms and also how much the tients at orthopaedic examination, representing a common usual daily activities of the patients can be compromised as cause of work leaves(1). Spinal pain is sometimes difficult a result of the presence of these symptoms. to evaluate, because many factors can be associated to it, and, sometimes, no correlation is found between clinical METHODS (2) and X-ray findings and symptoms reported . In the period of June 2005 to February 2006, 50 women Breast hypertrophy is described as an abnormal augmenta- with breast hypertrophy referred from Orthopaedics and tion of the breasts, and it has been associated to the emer- Plastic Surgery outpatient services of Hospital das Clíni- gence of various symptoms related to musculoskeletal sys- cas Samuel Libânio, in Pouso Alegre (MG) were assessed. tem, with spinal pain being the most frequent ones (Figure 1). This kind of pain may range from a simple discomfort Other 50 women with normal sized breasts and similar so- to functional disability, with frequent indications to surgical ciodemographic characteristics, which were selected from treatment for reducing breasts volume(3-5). The source of the general population of the region, constituted the con- these symptoms may be postural changes resulting from trol group of the study. No restriction was made in terms gravity center changes, a consequence of breast augmenta- of ethnicity, education level or social layer. Women aged tion, which causes exacerbation of the physiological curves between 18 and 59 years with body mass index (BMI) as 2 of the cervical, thoracic and lumbar spine, additionally to low as 30 Kg/m , who had not been previously submitted to keep cervical and thoracic muscles highly tensioned(6). spinal or breast surgeries, were considered as candidates Several methods have been used to measure painful symp- to the study. Women with BMI below 18.5 Kg/m2, presenting toms as well as restraints resulting from these symptoms. with uncontrolled systemic diseases, who had delivered or The use of standardized questionnaires, of which measure- were breastfeeding in the previous one-year period, with hy- ment properties have already been tested, enables us to pomastia or mammary asymmetry were excluded from the evaluate patients’ profiles through their individual perspec- study. Selected women were enrolled only after signing the tives, being thus possible to assess discomfort and disabil- Free and Informed Consent Term. The study was approved ity determined by a disease or treatment(6,7). by the committee on ethics in research of this institution. Study conducted at the University of Vale do Sapucaí -- Hospital das Clínicas Samuel Libânio - Pouso Alegre - MG. Correspondences to: Rua Cássio Carvalho Coutinho, 26 - Bairro Santa Elisa. Pouso Alegre-MG. CEP: 37550000 - Email:[email protected] 1. Master in Health Sciences by Minter - Interinstitutional Mastery Course UNIFESP/UNIVÁS. Orthopaedic Doctor, Department of Orthopaedics and Traumatology, Hospital das Clínicas Samuel Libânio -University of Vale do Sapucaí- UNIVÁS 2. Associate Professor of the Discipline of Plastic Surgery - UNIFESP 3. Doctor, Plastic Surgery Division, Hospital Clínicas Samuel Libânio - University of Vale do Sapucaí- UNIVÁS 4. Associate Professor, Discipline of Plastic Surgery, UNIFESP 5. Orthopaedic Doctor, Department of Orthopaedics and Traumatology, Hospital das Clínicas Samuel Libânio -University of Vale do Sapucaí- UNIVÁS 6. Chairman, Department of Biostatistics, UNIVÁS 7. Chairman, Discipline of Plastic Surgery, UNIFESP Received in: 10/09/06; Approved in: 11/10/06 226 ACTA ORTOP BRAS 15 (4:222-226, 2007) ACTA ORTOP BRAS 15(4:227-230, 2007) 227 Breasts were rated using the Sacchini’s index. In this classi- ues closer to 24 represent the worst results, that is, more fication, a normal breasts are regarded as those presenting restraints. The questionnaire was applied as an interview, measurements between 9 and 11 cm, hypertrophic breasts performed by only one researcher(11). as those with measurements above 11 cm, and hypomas- For statistical analysis of the results, the Mann-Whitney’s tia, those measurements below 9 cm, in which each breast test was used(12), in order to compare any potentially ex- is individually measured(8) (Figure 2). istent differences between data obtained for control and study groups. The test was applied alone in order to as- sess differences regarding age, NRS and Rolland-Morris questionnaire scores. For comparing BMI values for both groups, the Student’s t test was employed(12). Null hypoth- esis rejection level was determined as 0.05 or 5%. On the line below, please check where you believe your back pain represents today. Zero means absence of pain and ten means excruciating pain. Results Among women with breast hypertrophy (study group), the average age was 32.2 years (± 8.2 years) and the average age for control group was 32.7 years (± 11.1 years). Mean BMI for study group was 25.8Kg/m2 (± 2.59 Kg/m2 ) and for Figure 1 - Woman with breast Figure 2 - Sacchini’s index = average control group, 22.3 Kg/m2 (±2.87 Kg/m2). We noticed no hypertrophy: watch for cervical between X and Y distances. muscles’ and shoulder tension in statistically significant difference between assessed groups order to keep an upright posture. regarding age, while there was a statistically significant dif- ference for BMI (p<0.001), with the hypertrophy group pre- senting a higher BMI than control group (Table 1). The Numeric Scale (NRS) was employed to assess spinal (8) pain severity . The scale presents scores ranging from GROUP N Average Median Standard Minimum Maximum p-value zero to ten, where the patient determines the level in which her pain is according to the scale (Figure 3). The scale was Co�rol 50 32.72 30.00 11.10 20.00 56.00 introduced to patients, which informed the number of the AGE Hyperroph 50 32.20 31.50 8.17 19.00 50.00 0.790 scale that best described the level of their pain severity. Re- To�l 100 32.46 30.50 9.70 19.00 56.00 ports of pain on cervical, thoracic and lumbar spine seg- ments were taken into account. Co�rol 50 59.48 58.50 8.31 44.00 80.00 WEIGHT Hyperroph 50 65.33 66.25 7.11 50.00 80.00 < 0.001* To�l 100 62.41 63.25 8.24 44.00 80.00 Neck: Co�rol 50 1.63 1.63 0.07 1.50 1.77 HEIGHT Hyperroph 50 1.59 1.61 0.07 1.41 1.70 0.003* To�l 100 1.61 1.62 0.07 1.41 1.77 Co�rol 50 22.31 22.00 2.98 18.20 29.00 Dorsal (highest region – near to the shoulders): BMI Hyperroph 50 25.88 26.07 2.59 20.55 30.00 < 0.001* To�l 100 24.09 24.42 3.31 18.20 30.00 Table 1 - Comparison of the groups regarding Age, Weight, Height, and BMI When groups were compared for NRS scores, Roland-Mor- ris Questionnaire and pain scale (NRS), a statistically sig- Lumbar (lowest region of the back): nificant difference was found for all scores. In the group of women with breast hypertrophy, only one patient reported absence of pain in all segments of the spine, while, in con- trol group, 12 women (24%) reported none of these symp- toms. For Roland-Morris Questionnaire, the score zero oc- Figure 3 - Numeric scale for pain severity assessment (NRS) curred in 8% of the women with breast hypertrophy, and in 50% of the women in control group. The Roland-Morris Questionnaire(9,10) enables to evaluate The results of NRS pain assessment and the results of physical restraints resulting from reported pain on lumbar the analysis of Roland-Morris questionnaire are shown on spine and has been used to evaluate restraints resulting Table 2. from other spinal segments, as well. The questionnaire is composed of 24 yes/no questions, where each positive an- DISCUSSION swer corresponds to a score.