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Ferreira et al. used in planned interventions for managing pain in children with PIMD. MARIELY LIMA, PhD,* KARINE SILVA, PhD,† ISABEL AMARAL, PhD,‡ ANA MAGALHÃES, PhD,§ and LILIANA de SOUSA, PhD† *Escola Superior de Educação Paula Frassinetti; † Departamento de Ciências do Comportamento, Instituto de Ciências Biomédicas Abel Salazar; § Instituto de Biologia Molecular e Celular, Universidade do Porto, Porto; ‡ Escola Superior de Saúde, Campus do Instituto Politécnico de Setúbal, Setúbal, Portugal References 1 Nakken H, Vlaskamp C. A need for a taxonomy for profound intellectual and multiple disabilities. J Policy Pract Intellect Disabil 2007;4:83–7. 2 Breau LM, Camfield CS, McGrath PJ, et al. Risk factors for pain in children with severe cognitive impairments. Dev Med Child Neurol 2004;46:364– 71. 3 van der Putten A, Vlaskamp C. Pain assessment in people with profound intellectual and multiple disabilities; a pilot study in to the use of the Pain Behavior Checklist in every day practice. Res Develop Dis 2007;32:1677–84. 4 Marcus DA. The science behind animal-assisted therapy. Curr Pain Headache Rep 2013;17:1– 7.
5 Green CW, Reid DH. Defining, validating, and increasing indices of happiness among people with profound multiple disabilities. J Appl Behav Anal 1996;293:67– 78. 6 Corff KE, Seideman R, Venkataraman PS, et al. Facilitated tucking: A nonpharmacologic comfort measure for pain in preterm neonates. J Obstet Gynecol Neonatal Nurs 1995;24:143–8. 7 Gray L, Watt L, Blass EM. Skin-to-skin contact is analgesic in healthy newborns. J Pediatr 2000; 105:14–22. 8 Chermont AG, Falcão LFM, de Souza Silva EHL, et al. Term newborn infants skin-to-skin contact and/or oral 25% dextrose for procedural pain relief. J Pediatr 2009;124:1101–7. 9 Lima M, Silva K, Magalhães A, et al. Beyond behavioral observations: A deeper view through the sensory reactions of children with profound intellectual and multiple disabilities. J Child Care Health Dev 2013;39:422–43. 10 Cohen J. Statistical Power Analysis for the Behavioral Sciences, 2nd edition. New Jersey: Lawrence Erlbaum Associates; 1988. 11 Cignacco E, Hamers JPH, Stoffel L, et al. The efficacy of non-pharmacological interventions in the management of procedural pain in preterm and term neonates. A systemic literature review. Europ J Pain 2007;11:139–52.
A Pain Unit in a Developing Country: Epidemiology of Chronic Pain in Maputo, Mozambique Disclosure: We did not have financial support for this research. All the expenses were funded by the researchers. We did not have conflict of interest related to this manuscript. Dear Editor, Chronic pain has been an important health problem in the entire world, leading to emotional, social, and financial disability. The literature about chronic pain is scarce in developing countries, and there is a lack of studies conducted at pain units [1,2]. Another important consequence of chronic pain is the damage caused by physical disability due to pain. Approximately 560 to 635 billion dollars are spent each 1986
year in the United States for the treatment of pain and for workers’ compensation resulting from physical disability [3]. In Mozambique, a pain unit in the Central Hospital of Maputo was implanted in 1996 with the help of a French nongovernmental organization with humanitarian objectives called “Douleur sans Frontières,” created by French doctors in order to export knowledge about pain to underprivileged world locations [4]. The objective of the present study was to describe and analyze the epidemiological data of patients with chronic pain who were treated at the pain unit: the characteristics of their pain, treatment, comorbidities, emotional aspects, quality of life, and work absenteeism.
Letters to the Editor During 9 months, a survey was carried out to identify and interview people with chronic pain at the pain unit, older than 18 years. Those who were not fluent in Portuguese, who did not agree to participate, and who did not have chronic pain according to the criteria of the International Association for the Study of Pain were excluded. The Ethics National Committee for Health of Mozambique approved the study (247-CNBS/10). The following information was obtained: demographic data, pain diagnosis, clinical characteristics (based on the Brief Pain Questionnaire) [5] and severity (Visual Numeric Scale [VNS]), comorbidities, treatment used including abortive medication for pain, adjuvant medication, and nerve blocks. Quality of life and work absenteeism were measured by simple questions: “Does your pain disturb your work activities?”; “Does your pain disturb your home activities?”; and “Are you away from your job due to pain?” Data were entered and analyzed using SAS, version 8 (SAS/STAT® User’s Guide, Version 8 (1999), SAS Institute Inc., Cary, NC, USA). A total of 123 patients with pain were interviewed. Five people were excluded (one patient did not have chronic pain, three did not speak portuguese and another one refused to be studied). Of the 118 patients included, 79 (66.9%) were women. Mean age was 52.4 years (standard deviation 13.7). One-hundred and seven patients (90.7%) were black. Thirty-six (17.8%) had up to 4 years of schooling. Forty patients (33.9%) had a diagnosis of musculoskeletal pain, 40 (33.9%) had neuropathic pain, 17 (14.4%) oncologic pain, 8 (6.8%) pain related to HIV/AIDS, 6 (5.1%) myofascial pain, 6 (5.1%) visceral pain, and 1 (0.8%) had headache. There was no significant correlation between diagnosis of pain and ethnic group (P = 0.44) or pain intensity (P = 0.26). At the time of evaluation, the mean duration of pain was 41.7 months. The mean VNS score was 8.37 at first consultation and 4.75 after the treatment received. There was no correlation between pain intensity and gender (P = 0.69) or ethnic group (P = 0.55). Lumbar pain was the most frequent site of pain (36.4%), including radiculopathic pain (23.7%) (lumbar disc herniation, degenerative disc disease, lumbar stenosis) and mechanical pain (12.7%) (muscle spasm). Among the abortive medications for pain, paracetamol (33.9%) was the most widely used, followed by codeine (24.6%), tramadol (18.6%), morphine (10.2%), and ibuprofen (6.8%). Among adjuvant medications for pain, amitriptyline (44.1%) was the most widely used, followed by imipramine (8.5%), carbamazepine (1.7%), gabapentin (1.7%), and pregabalin (0.8%). Forty-eight patients (40.7%) had nerve blocks or injections to treat their pain (epidural block, medial lumbar branch block, intercostal block, supra-scapular block, and myofascial trigger point injection). Patients with
neuropathic pain received more nerve blocks than others (P = 0.0018). Regarding the comorbidities, 16 patients (13.6%) had AIDS, 17 (14.4%) had cancer, 39 (33.1%) patients had depressive symptoms fulfilling the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) criteria for depressive disorder, and 15 (12.7%) patients fulfilled the DSM-IV criteria for generalized anxiety disorder. Ninety-three (78%) patients reported that pain interfered with their jobs, 93 (78%) reported that pain interfered with their home activities, but only 11 (9.3%) were not working because of pain. The present data also agree with data from previously published studies for patients with chronic pain, with a predominance among women and prevalence in the mean age range of 52 years [1,2]. There were no correlations between gender or ethnic group and pain intensity, although prior studies have suggested that AfroAmericans exhibit less tolerance to an experimental pain stimulus than Hispanics [6]. The predominate types of pain corresponded to musculoskeletal and neuropathic diagnoses, with an emphasis on back pain, also in agreement with previous studies [1,2]. In general, study patients had been experiencing pain for a long time before being treated in the pain unit, likely due to the many social and structural obstacles in Mozambique for patients who need specialized medicine. The prevalence of depressive disorder was below the expected level for patients with chronic pain [1,2]. We do not know for sure if the impact of a chronic disease may be lower in this population or if these people are simply more likely to “numb” their feelings or underreport them. A remarkable fact in our sample was the low rate of work absenteeism. A previous study showed that up to 59% of cases of sick leaves are related to pain. In a country where labor rights are not well defined and most of the population works without regulation by the government, there is no support for medical absence [7]. In conclusion, we believe that it is important to report these findings as the literature about chronic pain in Africa is sparse. Despite all the difficulties existing in Mozambique, our impression regarding the data collected in our research was optimistic. The approach to pain in Maputo gained ground in recent years, with the construction of the pain unit and the commitment of local professionals to providing good quality of care. KAREN DOS SANTOS FERREIRA, PhD,* MARIA TERESA SCHWALBACH, MD,† JOÃO SCHWALBACH, MD,† and JOSÉ GERALDO SPECIALI, PhD* *Department of Neurosciences and Behavioral Sciences, Division of Neurology, School of Medicine at Ribeirao 1987
Ferreira et al. Preto, University of Sao Paulo, Sao Paulo, Brazil; † Pain Unit, Central Hospital of Maputo, Maputo, Mozambique References 1 Tsang A, Von Korff M, Lee S, et al. Common chronic pain conditions in developed and developing countries: Gender and age differences and comorbidity with depression-anxiety disorders. J Pain 2008;9(10):883– 91. 2 Gureje O, Von Korff M, Simon G, Gater R. Persistent pain and well-being. A World Health Organization study in primary care. JAMA 2008;280(2):147–51. 3 Gaskin DJ, Richard P. The economic costs of pain in the United States. J Pain 2012;13(8):715–24.
1988
4 Schwalbach T. Archives of Pain Unit of the Central Hospital of Maputo, Mozambique, 2009. 5 Toledo FO, Barros PS, Herdman M, et al. Cross-cultural adaptation and validation of the Brazilian version of the Wisconsin Brief Pain Questionnaire. J Pain Symptom Manage 2012;46(1):121–30. pii: S0885-3924(12) 00459. 6 Rahim-Williams FB, Riley JL, Herrera D, et al. Ethnic identity predicts experimental pain sensitivity in African Americans and Hispanics. Pain 2007;(1–2):177– 84. 7 Walsh IAP, Corral S, Franco RN, et al. Work ability of subjects with chronic musculoskeletal disorders. Rev Saúde Pública 2004;38(2):149–56.
Copyright of Pain Medicine is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Ferreira et al. used in planned interventions for managing pain in children with PIMD. MARIELY LIMA, PhD,* KARINE SILVA, PhD,† ISABEL AMARAL, PhD,‡ ANA MAGALHÃES, PhD,§ and LILIANA de SOUSA, PhD† *Escola Superior de Educação Paula Frassinetti; † Departamento de Ciências do Comportamento, Instituto de Ciências Biomédicas Abel Salazar; § Instituto de Biologia Molecular e Celular, Universidade do Porto, Porto; ‡ Escola Superior de Saúde, Campus do Instituto Politécnico de Setúbal, Setúbal, Portugal References 1 Nakken H, Vlaskamp C. A need for a taxonomy for profound intellectual and multiple disabilities. J Policy Pract Intellect Disabil 2007;4:83–7. 2 Breau LM, Camfield CS, McGrath PJ, et al. Risk factors for pain in children with severe cognitive impairments. Dev Med Child Neurol 2004;46:364– 71. 3 van der Putten A, Vlaskamp C. Pain assessment in people with profound intellectual and multiple disabilities; a pilot study in to the use of the Pain Behavior Checklist in every day practice. Res Develop Dis 2007;32:1677–84. 4 Marcus DA. The science behind animal-assisted therapy. Curr Pain Headache Rep 2013;17:1– 7.
5 Green CW, Reid DH. Defining, validating, and increasing indices of happiness among people with profound multiple disabilities. J Appl Behav Anal 1996;293:67– 78. 6 Corff KE, Seideman R, Venkataraman PS, et al. Facilitated tucking: A nonpharmacologic comfort measure for pain in preterm neonates. J Obstet Gynecol Neonatal Nurs 1995;24:143–8. 7 Gray L, Watt L, Blass EM. Skin-to-skin contact is analgesic in healthy newborns. J Pediatr 2000; 105:14–22. 8 Chermont AG, Falcão LFM, de Souza Silva EHL, et al. Term newborn infants skin-to-skin contact and/or oral 25% dextrose for procedural pain relief. J Pediatr 2009;124:1101–7. 9 Lima M, Silva K, Magalhães A, et al. Beyond behavioral observations: A deeper view through the sensory reactions of children with profound intellectual and multiple disabilities. J Child Care Health Dev 2013;39:422–43. 10 Cohen J. Statistical Power Analysis for the Behavioral Sciences, 2nd edition. New Jersey: Lawrence Erlbaum Associates; 1988. 11 Cignacco E, Hamers JPH, Stoffel L, et al. The efficacy of non-pharmacological interventions in the management of procedural pain in preterm and term neonates. A systemic literature review. Europ J Pain 2007;11:139–52.
A Pain Unit in a Developing Country: Epidemiology of Chronic Pain in Maputo, Mozambique Disclosure: We did not have financial support for this research. All the expenses were funded by the researchers. We did not have conflict of interest related to this manuscript. Dear Editor, Chronic pain has been an important health problem in the entire world, leading to emotional, social, and financial disability. The literature about chronic pain is scarce in developing countries, and there is a lack of studies conducted at pain units [1,2]. Another important consequence of chronic pain is the damage caused by physical disability due to pain. Approximately 560 to 635 billion dollars are spent each 1986
year in the United States for the treatment of pain and for workers’ compensation resulting from physical disability [3]. In Mozambique, a pain unit in the Central Hospital of Maputo was implanted in 1996 with the help of a French nongovernmental organization with humanitarian objectives called “Douleur sans Frontières,” created by French doctors in order to export knowledge about pain to underprivileged world locations [4]. The objective of the present study was to describe and analyze the epidemiological data of patients with chronic pain who were treated at the pain unit: the characteristics of their pain, treatment, comorbidities, emotional aspects, quality of life, and work absenteeism.
Letters to the Editor During 9 months, a survey was carried out to identify and interview people with chronic pain at the pain unit, older than 18 years. Those who were not fluent in Portuguese, who did not agree to participate, and who did not have chronic pain according to the criteria of the International Association for the Study of Pain were excluded. The Ethics National Committee for Health of Mozambique approved the study (247-CNBS/10). The following information was obtained: demographic data, pain diagnosis, clinical characteristics (based on the Brief Pain Questionnaire) [5] and severity (Visual Numeric Scale [VNS]), comorbidities, treatment used including abortive medication for pain, adjuvant medication, and nerve blocks. Quality of life and work absenteeism were measured by simple questions: “Does your pain disturb your work activities?”; “Does your pain disturb your home activities?”; and “Are you away from your job due to pain?” Data were entered and analyzed using SAS, version 8 (SAS/STAT® User’s Guide, Version 8 (1999), SAS Institute Inc., Cary, NC, USA). A total of 123 patients with pain were interviewed. Five people were excluded (one patient did not have chronic pain, three did not speak portuguese and another one refused to be studied). Of the 118 patients included, 79 (66.9%) were women. Mean age was 52.4 years (standard deviation 13.7). One-hundred and seven patients (90.7%) were black. Thirty-six (17.8%) had up to 4 years of schooling. Forty patients (33.9%) had a diagnosis of musculoskeletal pain, 40 (33.9%) had neuropathic pain, 17 (14.4%) oncologic pain, 8 (6.8%) pain related to HIV/AIDS, 6 (5.1%) myofascial pain, 6 (5.1%) visceral pain, and 1 (0.8%) had headache. There was no significant correlation between diagnosis of pain and ethnic group (P = 0.44) or pain intensity (P = 0.26). At the time of evaluation, the mean duration of pain was 41.7 months. The mean VNS score was 8.37 at first consultation and 4.75 after the treatment received. There was no correlation between pain intensity and gender (P = 0.69) or ethnic group (P = 0.55). Lumbar pain was the most frequent site of pain (36.4%), including radiculopathic pain (23.7%) (lumbar disc herniation, degenerative disc disease, lumbar stenosis) and mechanical pain (12.7%) (muscle spasm). Among the abortive medications for pain, paracetamol (33.9%) was the most widely used, followed by codeine (24.6%), tramadol (18.6%), morphine (10.2%), and ibuprofen (6.8%). Among adjuvant medications for pain, amitriptyline (44.1%) was the most widely used, followed by imipramine (8.5%), carbamazepine (1.7%), gabapentin (1.7%), and pregabalin (0.8%). Forty-eight patients (40.7%) had nerve blocks or injections to treat their pain (epidural block, medial lumbar branch block, intercostal block, supra-scapular block, and myofascial trigger point injection). Patients with
neuropathic pain received more nerve blocks than others (P = 0.0018). Regarding the comorbidities, 16 patients (13.6%) had AIDS, 17 (14.4%) had cancer, 39 (33.1%) patients had depressive symptoms fulfilling the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) criteria for depressive disorder, and 15 (12.7%) patients fulfilled the DSM-IV criteria for generalized anxiety disorder. Ninety-three (78%) patients reported that pain interfered with their jobs, 93 (78%) reported that pain interfered with their home activities, but only 11 (9.3%) were not working because of pain. The present data also agree with data from previously published studies for patients with chronic pain, with a predominance among women and prevalence in the mean age range of 52 years [1,2]. There were no correlations between gender or ethnic group and pain intensity, although prior studies have suggested that AfroAmericans exhibit less tolerance to an experimental pain stimulus than Hispanics [6]. The predominate types of pain corresponded to musculoskeletal and neuropathic diagnoses, with an emphasis on back pain, also in agreement with previous studies [1,2]. In general, study patients had been experiencing pain for a long time before being treated in the pain unit, likely due to the many social and structural obstacles in Mozambique for patients who need specialized medicine. The prevalence of depressive disorder was below the expected level for patients with chronic pain [1,2]. We do not know for sure if the impact of a chronic disease may be lower in this population or if these people are simply more likely to “numb” their feelings or underreport them. A remarkable fact in our sample was the low rate of work absenteeism. A previous study showed that up to 59% of cases of sick leaves are related to pain. In a country where labor rights are not well defined and most of the population works without regulation by the government, there is no support for medical absence [7]. In conclusion, we believe that it is important to report these findings as the literature about chronic pain in Africa is sparse. Despite all the difficulties existing in Mozambique, our impression regarding the data collected in our research was optimistic. The approach to pain in Maputo gained ground in recent years, with the construction of the pain unit and the commitment of local professionals to providing good quality of care. KAREN DOS SANTOS FERREIRA, PhD,* MARIA TERESA SCHWALBACH, MD,† JOÃO SCHWALBACH, MD,† and JOSÉ GERALDO SPECIALI, PhD* *Department of Neurosciences and Behavioral Sciences, Division of Neurology, School of Medicine at Ribeirao 1987
Ferreira et al. Preto, University of Sao Paulo, Sao Paulo, Brazil; † Pain Unit, Central Hospital of Maputo, Maputo, Mozambique References 1 Tsang A, Von Korff M, Lee S, et al. Common chronic pain conditions in developed and developing countries: Gender and age differences and comorbidity with depression-anxiety disorders. J Pain 2008;9(10):883– 91. 2 Gureje O, Von Korff M, Simon G, Gater R. Persistent pain and well-being. A World Health Organization study in primary care. JAMA 2008;280(2):147–51. 3 Gaskin DJ, Richard P. The economic costs of pain in the United States. J Pain 2012;13(8):715–24.
1988
4 Schwalbach T. Archives of Pain Unit of the Central Hospital of Maputo, Mozambique, 2009. 5 Toledo FO, Barros PS, Herdman M, et al. Cross-cultural adaptation and validation of the Brazilian version of the Wisconsin Brief Pain Questionnaire. J Pain Symptom Manage 2012;46(1):121–30. pii: S0885-3924(12) 00459. 6 Rahim-Williams FB, Riley JL, Herrera D, et al. Ethnic identity predicts experimental pain sensitivity in African Americans and Hispanics. Pain 2007;(1–2):177– 84. 7 Walsh IAP, Corral S, Franco RN, et al. Work ability of subjects with chronic musculoskeletal disorders. Rev Saúde Pública 2004;38(2):149–56.
Copyright of Pain Medicine is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
