Objetivos: Determinar el perfil de manejo de dolor musculoesquelético en los profesionales de la salud del Hospital Augusto Hernández de Ica. Métodos: Se realizó un estudio transversal descriptivo en los profesionales de salud del Hospital Augusto Hernández de Ica. El cálculo de muestra fue realizado en Epidat 4.2, resultando en 91 participantes necesarios para el estudio. El muestreo fue por conveniencia y se incluyó a todos los profesionales de la salud del hospital dispuestos y disponibles a participar del estudio entre las fechas de la recolección de datos. No hubo consideraciones de exclusión para este estudio. Se generó una base de datos en Microsoft Excel por doble digitación con control de inconsistencias. El análisis fue realizado en Stata 12 donde las variables cuantitativas fueron presentadas en medias, desviación estándar e intervalos de confianza; y las variables cualitativas, en frecuencias absolutas, porcentajes e intervalos de confianza. El dolor musculoesquelético (DME) y el manejo del dolor musculoesquelético fueron referidos a través del Cuestionario Nórdico y el Cuestionario específico de manejo de dolor musculoesquelético. Resultados: Participaron 107 profesionales: médicos (44,9%), enfermeras (29%), obstetricia (10,3%) y fisioterapeutas (6,5%). Los que tuvieron una media en el índice de masa corporal de 27,1 (±3,7). La prevalencia de DME global fue de 94,4%, donde el 26,2% de los participantes realizaron cambios en sus ambientes y/o actividades laborales. Los principales tratamientos en este estudio fueron: utilización de fármacos 58,9%, realización de cirugías 1,9%, y 36,5% realizaron de terapia física. La adherencia al tratamiento en los fármacos fue del 50,5%, y las terapias físicas del 23,4%. Los participantes refirieron mejoría de sus DME en un 59,8%, y 58,9% de reincidencias. La prescripción de tratamiento farmacológico fue del 31,8%. La medicación consumida fue de: 51,4% de antiinflamatorios no esteroideos (AINES), 18,7% de relajantes musculares, y 4,7% entre opioides y suplementos vitamínicos. Las instituciones de atención de terapia física fueron: EsSalud (23,4%), profesionales independientes a domicilio (9,3%), centros privados de terapia física (4,7%), clínicas privadas (4,7%), y hospitales del ministerio de salud del Perú (1,9%). Conclusiones: El perfil del manejo del DME, en este hospital, fue predominantemente farmacológico automedicado con un alto consumo de AINES, el cual supera al manejo fisioterapéutico de los DME. Asimismo, este perfil presenta una baja adherencia al tratamiento con pocos cambios en los ambientes laborales. / Objectives: To determine the musculoskeletal pain management profile on health care professionals of Augusto Hernández Hospital of Ica – Peru. Methods: A descriptive cross-sectional study was carried out on health care professionals of Augusto Hernández Hospital of Ica – Peru. The sample size calculation was performed in Epidat 4.2, resulting in 91 participants needed for the study. Convenience sampling method was used to include all the hospital’s available health care professionals willing to participate in the study on the assigned data recollection dates. No exclusion criteria were considered for this study. A Microsoft Excel database was generated by double typing for inconsistencies control. Database analysis was carried out on Stata 12 where quantitative variables were presented in means, standard deviation and confidence intervals, and qualitative variables were presented in absolute frequencies, percentages, and confidence intervals. Musculoskeletal pain (MP) and musculoskeletal pain management were referred through the Nordic Questionnaire and the Musculoskeletal Pain Management Specific Questionnaire respectively. Results: 107 professionals participated in the study: doctors (44.9%), nurses (29%), obstetrics (10.3%) and physiotherapists (6.5%). Sample’s mean Body Mass Index was 27.1 (± 3.7). Global MP prevalence was 94.4% where 26.2% of participants made changes in their work environments and/or activities. Main treatments on this study were: Drugs (58.9%), Surgery (1.9%) and Physical Therapy (36.5%). Treatment adherence on “Drugs” were 50.5% and 23.4% on “Physical Therapy”. Participants’ MP improvement was referred as 59.8% and MP relapse as 58.9%. Pharmacological treatment prescription was on 31.8% of the sample. Consumed drugs on this study were: 51.4% of non-steroidal anti-inflammatory drugs (NSAIDs), 18.7% of muscle relaxant drugs, and 4.7% between opioids and vitamin supplements. Physical therapy care institutions usage was: EsSalud (23.4%), independent professionals at home (9.3%), private physical therapy centers (4.7%), and Ministry of Health of Peru’ hospitals (1.9%). Conclusions: Musculoskeletal Pain Management Profile in this hospital was predominantly of self-medicated drug usage of NSAIDs, exceeding physiotherapeutic MP management. In addition, this profile shows low treatment adherence with low work environment changes. / Tesis

Långvarig muskuloskeletal smärta är ett globalt hälsoproblem och är den vanligaste orsaken till funktionnedsättningar hos individer. Individer med långvarig muskuloskeletal smärta har en ökad risk att drabbas av psykisk ohälsa som kan påverka individens välbefinnande och livskvalitet negativt. Individer använder olika strategier (icke farmakologiska och farmakologiska behandlingar) för att hantera smärta. Distriktssköterskan har en avgörande roll vid identifiering av individens smärtproblematik och psykisk ohälsa / Chronic musculoskeletal pain is a global health problem and is the most common cause of disability in individuals. Individuals with long-term musculoskeletal pain have an increased risk of suffering from mental illness, which can negatively affect the individual's well-being and quality of life. Individuals use different strategies (non-pharmacological and pharmacological treatments) to manage pain. The district nurse has a decisive role in identifying the individual's pain problem and mental illness.

High-Performance Marine Craft (HPMC) is a complex system confronted by the stochastic nature of the waves challenging the safety of life at sea. The personnel aboard these craft are vulnerable to detrimental conditions, in fact, limiting the system’s performance evoking the significance of the Human Factors Integration (HFI) in the design and operation of these craft. The risks related to the work environments at sea have inadequately been investigated. A consistently identified fact is that the exposure to work environments containing vibration and repeated shock elevates the risk of adverse effects on human health and performance. In the event that the exposure risk is known, the situation can be managed by the operators and the legislated health and safety demands can be achieved by the employer. Moreover, when quantification of the exposure-effect relationships is potential, human factors, in terms of health and performance, can be integrated into HPMC design and operation. However, the knowledge is limited about the adverse health and performance effects among the High-Performance Marine Craft Personnel (HPMCP), the factors causing theses effects and their relationships. The thesis presents a holistic approach for the integration of human factors, in terms of health and performance, into HPMC design and operation. A research program has been designed branching the design and operational requirements of HPMC concerning HFI. A method is introduced for a real-time crew feedback system, which monitors and characterizes vibration and shock conditions aboard HPMC, enabling determination of the risk of acute injuries due to the high-intensity instantaneous impact exposure and the acquired risk of adverse health and performance effects due to the accumulated vibration exposure. This brings forth the requirement of epidemiological studies in order to strengthen the exposure-effect relationships. Therefore, web-based questionnaire tools are developed, validated and pilot tested for cross-sectional and longitudinal investigation of health and performance in HPMCP. The work exposure is measured aboard HPMC in terms of vibration and investigated in relation to the adverse health and performance event onsets, and the ride perception of the personnel aboard. The introduced method for the real-time crew feedback is capable of informing the exposure risk in terms of human health and performance. The questionnaire tools are feasible for epidemiologically surveying HPMCP and similar populations providing data for investigating adverse health and performance effects, risk factors and their relationships. Promising trends are observed between the quantified work exposure and the health and performance onsets, and the human perception. The work will be continued to identify the exposure-effect relationships facilitating better use of the existing standards, supporting ongoing development of the existing standards and providing information to draw appropriate design and operational limits in rules and regulations. / Högprestandafartyg (HPMC) utgör komplexa tekniska system där sjösäkerheten i den stokastiska vågmiljön är en utmaning. Besättningen ombord utgör många gånger den begränsande faktorn för systemets prestanda vilket betonar betydelsen av att integrera olika aspekter av människan som systemkomponent (Human factors integration, HFI), vid så väl projektering, konstruktion som under driftsfasen. Riskerna vid arbete till sjöss är inte fullt ut kartlagda. Vad som står klart är dock att exponering för vibrationer och upprepade stötar ökar risken för att hälsan såväl som arbetets kvalité påverkas menligt. Om riskerna med exponeringen var kända skulle besättning i sitt handhavande kunna agera så att riskerna hålls på acceptabla nivåer och att arbetsgivaren uppfyller kraven i arbetsmiljö- och säkerhetslagstiftning. Dessutom, om riskrelationen mellan exponering och följder för hälsan och arbetsförmågan kan kvantifieras så öppnas en reell möjlighet att integrera human factors i både konstruktions- och driftsfasen. För närvarande är dock kunskapen begränsad om vilka negativa effekter på hälsa och arbetsförmågan som förekommer hos besättningar till HSMC, vilka faktorer som leder till dessa effekter och hur relationen mellan dessa ser ut.   Avhandlingen presenterar ett holistiskt angreppsätt för att integrera human factors, i termer av hälsa och arbetsförmåga, vid konstruktion och drift av högprestandafartyg. Ett forskningsprogram har utformats för att klargöra konstruktions- och driftskrav för HPMC avseende HFI. En metod för att övervaka och i realtid karaktärisera stöt- och vibrationsförhållandena ombord introduceras för att möjliggöra bedömning av risken för akuta skador till följd av enstaka kraftiga genomslag, risken för nedsatt arbetsförmåga under pågående verksamhet samt risken för negativa hälsoeffekter till följd av ackumulerad stöt- och vibrationsexponering.   Behovet av epidemiologiska studier för att klargöra exponeringens relation till hälsa och arbetsprestation blir i det här sammanhanget tydligt. Därför har nätbaserade enkätverktyg utvecklas, valideras och pilottestas för tvärsnitts- och longitudinella studier av besättningars hälsa och arbetsprestation. Exponeringen mäts med accelerometrar och studeras i relation till besättningarnas hälso- och prestandastatus samt den upplevelse av exponeringen som de rapporterar via enkäterna. Metoden för realtidsåterkoppling av exponeringsnivån kan informera besättningen om hälsorisker och prestationsnedsättning. Enkätverktygen kan användas för datainsamling till epidemiologiska studier i populationer, som t.ex. besättningar till högprestanda fartyg, för att undersöka arbetssituationens inverkan på hälsa och arbetsprestation, riskfaktorer samt relationen dem emellan. Inledande studier påvisar trender mellan kvantitativa mått på exponering och besättningars hälsostatus såväl som mellan uppmätt och upplevd exponering.   Det fortsatta arbetet siktar mot att identifiera och kvantifiera relationerna mellan exponeringen och dess påverkan på hälsa och prestation. Därmed kan man bättre utnyttja befintlig standard, stödja den pågående utvecklingen av befintlig standard och bidra till att sätta relevanta gränser i regelverk och lagstiftning som styr konstruktion och handhavande av högprestandafartyg. / <p>QC 20180305</p>

<p><strong>Purpose:</strong></p> <p>The purpose of this study was to determine what cut-off of the Orebro Musculoskeletal Pain Screening Questionnaire score will best differentiate workers with acute musculoskeletal injuries at-risk for delayed return to work (greater than 3 months), in a population of workers of less than 3 weeks injury duration.</p> <p><strong>Study Design:</strong></p> <p>Retrospective cohort design, using a sample of convenience.</p> <p><strong>Methods:</strong></p> <p>A sample of 259 consecutive WCB patients seeking assessment and treatment at a multidisciplinary rehabilitation facility were reviewed, with 152 meeting the inclusion criteria of having sustained a soft tissue injury within 3 weeks of initial assessment. Descriptive statistics, tests of difference between Time 1 and Time 2 OMPSQ scores and Receiver Operator Characteristic curves were generated. The method of determining predictive ability of the OMPSQ at two points in time was by means of ROC analysis.</p> <p><strong>Results:</strong></p> <p>This study determined that the OMPSQ is moderately predictive of failure to achieve timely return to work (RTW) in a population of injured workers with acute musculoskeletal soft tissue injuries, when assessed two-weeks after treatment is initiated, and less predictive at the initial intake into treatment. Delayed RTW was defined as those workers who had not returned to their pre-injury job full time by 90 days, due to reduced functional ability as it related to their pre-injury occupation.</p> <p><strong>Conclusions:</strong></p> <p>This study demonstrates that there is variability in cut-off scores across studies. Future research should attempt to define cut-off scores as they relate to the population , outcome, condition and time-frame of interest . <strong></strong></p> / Master of Science Rehabilitation Science (MSc)

Résumé : Introduction: À ce jour, notre compréhension des mécanismes neurophysiologiques responsables du développement d'une douleur chronique est encore relativement limitée. Il est proposé que certaines modifications dans l'efficacité des mécanismes endogènes d'inhibition descendante de la douleur pourraient contribuer à ce phénomène. Considérant l'importance de la neurotransmission monoaminergique dans les mécanismes descendants de modulation de la douleur, autant inhibiteur que facilitateur, nous émettons l'hypothèse que la persistance temporelle d'une douleur peut provoquer des modifications dans la fonctionnalité des deux systèmes majeurs (sérotoninergique et noradrénergique) sous-jacents à ces mécanismes de contrôle endogène, participant ainsi à la dynamique de développement et à la progression des états de douleur chronique à travers le temps. Objectif général: En utilisant une approche translationnelle, nous avons exploré l'association entre la fonctionnalité (centrale & périphérique) des systèmes de neurotransmission monoaminergique et l'efficacité des mécanismes descendants d’inhibition pendant le développement et la progression d'une douleur chronique. Résultats cliniques: D'une part, nos résultats répliquent plusieurs observations de la littérature ayant démontré une diminution de l'efficacité des mécanismes descendants d’inhibition de la douleur (à l'aide d'un paradigme de modulation conditionnée de la douleur; MCD) chez des sujets souffrant de douleur musculosquelettique chronique (sujets CP). Chez ces mêmes sujets, nous observons également une diminution des concentrations plasmatiques basales en noradrénaline (NA) et métanéphrine, lorsque comparés à des sujets sains (sujets PF). Pour tous les sujets testés (PF et CP), une association positive est mise en évidence entre l'efficacité de la MCD et les concentrations plasmatiques basales en NA et métanéphrine. Par conséquent, ces concentrations des catécholamines dans le plasma pourraient servir d'indicateurs moléculaires de l'efficacité latente de la MCD. Par ailleurs, aucune différence dans l'activité monoaminergique et aucune association avec l'efficacité de la MCD n'ont été observées au niveau du liquide céphalorachidien (LCR). Résultats précliniques: D'autre part, nous proposons un nouveau modèle de douleur à double atteinte chez le rongeur (i.e., induction initiale d'une douleur persistante [la 1ere atteinte] et activation subséquente des mécanismes descendants de modulation de la douleur à l'aide d'une douleur tonique [la 2e atteinte]). Ce paradigme expérimental nous permet ainsi d'évaluer l'efficacité des mécanismes descendants de modulation de la douleur chez les rongeurs en contexte de douleur chronique. Ainsi, nous mettons en évidence une diminution de la réponse comportementale à une douleur tonique (dans le test à la formaline), 28 jours après l'induction d'une douleur neuropathique (modèle de constriction chronique du nerf sciatique; CCI), lorsque comparés aux rats sham. Bien que cette diminution des comportements nociceptifs soit encore observable 168 jours après le début de la neuropathie, celle-ci semble tout de même s'amenuiser à travers le temps. Parallèlement, en l'absence de stimulation nociceptive tonique, une augmentation des concentrations en sérotonine et noradrénaline est observée au niveau central (i.e., dans le LCR) 12 jours après l'induction de la douleur neuropathique, avant de retourner ensuite à un niveau comparable à celui des rats sham au jour 28. Par ailleurs, la réponse comportementale observée au jour 28 est visible seulement dans un modèle de douleur neuropathique (CCI), et non lorsqu'une douleur inflammatoire est utilisée comme douleur persistante initiale. Conclusions: En contexte de douleur chronique, nos résultats chez l'humain confirment la présence de modifications dans l'efficacité des mécanismes descendants d’inhibition de la douleur, en plus de soutenir le concept émergent qui suggère que les différences dans l'efficacité de ceux-ci pourraient être associées à des différences individuelles dans certains processus périphériques (comme la relâche de catécholamines dans le sang), pouvant ultimement être impliquées dans la régulation cardiovasculaire. Par ailleurs, nos résultats chez le rongeur suggèrent que des changements dynamiques (spécifiques au type de douleur) dans l'efficacité des mécanismes descendants de modulation, ainsi que dans la fonctionnalité centrale des systèmes de neurotransmission monoaminergique, se produisent lors de la progression d'une douleur chronique. Dans son ensemble, cette thèse apporte de nouvelles informations au sujet des changements neurophysiologiques temporels au sein des mécanismes descendants de modulation de la douleur pouvant être impliqués dans le développement et la progression de la douleur chronique. / Abstract : Introduction: Hitherto, our understanding about the neurophysiological mechanisms responsible for the development of chronic pain is still relatively limited. It is suggested that modifications in the efficacy of endogenous pain inhibitory mechanisms could contribute to this phenomenon. Considering the importance of monoaminergic neurotransmission in descending pain modulation, either of inhibitory or facilitatory influence, we hypothesize that temporal persistence of pain can trigger modifications in the functionality of the two major systems (serotoninergic and noradrenergic) underlying these endogenous control mechanisms, thus participating in the development and progression of chronic pain states. General objective: Adopting a translational approach, we explored the association between the functionality (central & peripheral) of monoaminergic neurotransmission and the efficacy of descending inhibitory mechanisms during the development and progression of chronic pain. Clinical results: Our results replicate several observations emanating from the literature demonstrating a diminution in the efficacy of descending pain inhibitory mechanisms (using a conditioned pain modulation paradigm; CPM) in subjects with chronic musculoskeletal pain (CP subjects). In these CP subjects, we also highlight a reduction in basal plasma concentrations of noradrenaline and metanephrine, when compared with pain-free subjects (PF subjects). For all tested subjects (PF and CP subjects), a positive association is observed between CPM efficacy and basal plasma concentrations of noradrenaline and metanephrine. Therefore, basal plasma catecholamines concentrations could be used as molecular indicators of the latent CPM efficacy. Conversely, no difference in monoaminergic activity and no association with CPM efficacy are observed when looking at the molecular content of cerebrospinal fluid. Preclinical results: Here, we expose a new double-hit model of pain in rodents (i.e., initial induction of a persistent pain [the 1st hit] and subsequent activation of descending pain modulatory mechanisms with tonic pain [the 2nd hit]). This experimental paradigm allows us to evaluate the efficacy of decending pain modulation in rodents in the context of chronic pain. Interestingly, we detect a reduction in the behavioral response to tonic pain (in the formalin test), 28 days after the induction of neuropathic pain (chronic constriction injury model; CCI), when compared to sham rats. Even though this reduction in nociceptive behaviors is still present 168 days after neuropathy, the effect seems to wane down over time. Concomitantly, in absence of tonic nociceptive stimulation, an elevation in central concentrations (i.e., cerebrospinal fluid) in serotonin and noradrenaline is observed 12 days after the induction of neuropathic pain, before returning to sham levels on day 28. Moreover, the behavioral response described on day 28 is only observed in a neuropathic pain model (CCI), and absent when inflammatory pain is used as the initial pain. Conclusions: In the context of chronic pain, our results in humans confirm the advent of modifications in the efficacy of descending pain inhibitory mechanisms, while supporting the emerging concept suggesting that individual differences in these mechanisms may be associated with individual differences in peripheral processes (such as the release of catecholamines in plasma), that could ultimately be involved in cardiovascular control. Moreover, our results in rodents suggest that dynamic changes (specific to pain types) in the efficacy of descending pain modulation, as well as in the central functionality of monoaminergic neurotransmission, are present during the progression of chronic pain. Overall, this thesis provides novel information concerning temporal neurophysiological changes in descending pain modulatory mechanisms that may be involved in the development and progression of chronic pain states.

Introdução: Neuromielite óptica (NMO) é uma doença inflamatória desmielinizante do sistema nervoso central associado com auto anticorpo anti-aquaporina 4 (AQP4-Ab) em até 90% dos casos e com anticorpo anti glicoproteína de mielina oligodendrocítica (MOG-IgG) em cerca de 20% dos indivíduos negativos para AQP4-Ab. A apresentação clínica típica do NMO inclui neurite óptica grave (ON), mielite transversa longitudinalmente extensa (MTLE) e lesões do tronco encefálico conhecidas por causar náuseas,vômitos e soluços intratáveis. A dor é um dos sintomas mais frequentes e incapacitantes dessa síndrome. Sabe-se que afeta até 85% dos indivíduos, que é mais intensa e responde menos aos tratamentos usuais quando comparados aos pacientes com esclerose múltipla. O objetivo deste estudo foi caracterizar as síndromes dolorosas em indivíduos na fase crônica livre de recidiva da NMO. A doença também foi considerada um bom modelo para estudar os mecanismos de dor após lesão medular. Métodos: Trata-se de um estudo longitudinal, composto por duas avaliações. A avaliação para entrada no estudo consistiu em um exame neurológico complete padronizado, a fim de determinar as síndromes dolorosas principal e secundária de acordo com seu mecanismo e nível. Os pacientes foram convidados a preencher questionários avaliando a dor (Inventário breve de dor [BPI], Questionário de dor McGill [MPQ], inventário de sintomas de dor neuropática [NPSI]), espasmos tônicos dolorosos, sinal de Lhermitte, incapacidade (EDSS, Barthel ADL), ansiedade e depressão (escala hospitalar de ansiedade e depressão [HADS]), catastrofização (escala de pensamentos catastróficos na dor [PCTS]), disfunção urinária e fecal (questionário de bexiga hiperativa [OABV8], escore de sintomas prostáticos internacionais [IPSS]). Também foram realizados teste quantitativo sensitivo (QST) em área controle (com sensibilidade normal) e área de maior dor e medidas de excitabilidade cortical bilaterais (CE). Imagens prévias de ressonância magnética de encéfalo e medula espinhal foram revistos. Foi realizada uma consulta de acompanhamento entre 6 e 18 meses após a primeira visita, na qual a síndrome dolorosa principal foi reavaliada e os pacientes foram solicitados a preencher questionários (DN-4, BPI, MPQ, BPI, NPSI) sobre a dor. Resultados: Setenta e dois pacientes foram incluídos. Foram identificados 53 (73,6%) indivíduos com dor crônica e 19 (26,3%) sem dor. Quarenta (55,6%) pacientes apresentaram dor neuropática (NP) e 13 (18,1%) dor não neuropática (não-NP). Entre os 53 indivíduos com dor crônica, 38 (71,7%) tinham mais de uma síndrome dolorosa. Dor neuropática no nível sensitivo foi a síndrome dolorosa mais prevalente, sendo observada em 31 doentes (58,5% do total de pacientes com dor). O grupo com dor não-neuropática teve dor lombar como a síndrome mais comum, afetando 8 (61,5%) indivíduos. O grupo com dor neuropática teve um número significativamente maior de dermátomos afetados por alodínea dinâmica (0,8 ± 1,6, comparado a zero dermátomos nos outros 2 grupos, p = 0,004) e estática (0,7 ± 1,3 comparado a 0 no grupo com dor não-neuropática e 0,1 ± 0,5 dermátomos no grupo sem dor). A hiperpatia em nível foi significativamente mais prevalente no grupo com dor neuropática: 39 (97,5%) nesse grupo, contra 10 (76,9%) e 12 (68,4%) nos grupos dor não-neuropática e sem dor (p = 0,013). Os pacientes com dor neuropática apresentaram desempenho significativamente pior quando comparados aos sem dor, no PCS-12 (componente físico do SF-12), (32,5 ± 8 e 43,3 ± 11, respectivamente). O PCS-12 correlacionou-se com a intensidade da dor no BPI nos grupos dor neuropática (r = -0,387, p = 0,014) e não-neuropática (r = -0,734, p = 0,004). Dentro do grupo com dor neuropática, 16 (80%) pacientes relataram prurido na área de dor, enquanto apenas 1 (33,3%) paciente com dor não neuropática relatou o mesmo (p < 0,001). O QST apresentou maiores limiares para a detecção de estímulos quentes dentre aqueles com dor neuropática, quando comparado ao grupo com dor não-neuropática (41,3 ± 5,6 e 36,9 ± 3, respectivamente, p = 0,045). As amplitudes do potencial evocado motor a 120 e 140% foram significativamente menores nos dois grupos com dor quando comparados aos pacientes sem dor. A avaliação de acompanhamento foi realizada em 68 pacientes e 50 (73,5%) relataram dor. A dor neuropática do nível foi novamente a síndrome dolorosa mais prevalente, afetando 29 (58%) indivíduos. Três pacientes inicialmente sem dor relataram na o sintoma na segunda visita. A taxa de incidência de dor foi de 17,7 por 100 pessoas-ano. Onze pacientes que haviam relatado dor na entrada do estudo tinham uma síndrome de dor diferente na segunda avaliação (20,8% da amostra original). O grupo com dor neuropática teve uma diminuição significativa na intensidade do BPI (de 5,6 ± 1,9 para 4,8 ± 2, p = 0,039). O escore total do MPQ diminuiu significativamente em ambos os grupos com dor neuropática (de 9 ± 2,4 para 8 ± 3,1, p = 0,014) e naqueles com dor não-neuropática (9,2 ± 2,5 a 7 ± 4, p = 0,031). Conclusão: A dor é prevalente em pacientes com NMO e a dor neuropática de nível é a síndrome mais comum. A incidência de novas dores e alterações nas síndromes dolorosas não está relacionada à nova atividade inflamatória, mas ao dano estrutural permanente crônico na medula espinhal e tronco cerebral secundário à atividade autoimune prévia. A avaliação das síndromes dolorosas é importante para o tratamento correto desse sintoma e deve ser reavaliada regularmente, mesmo em pacientes sem novas recidivas clínicas / Introduction: Neuromyelitis optica (NMO) is an inflammatory demyelinating disease of the central nervous system. It is associated with anti-aquaporin 4 autoantibody (AQP4-Ab) in up to 90% of cases and with anti-myelin oligodendrocyte glycoprotein (MOG-IgG) in around 20% of subjects negative to AQP4-Ab. The typical clinical presentation of NMOSD includes severe optic neuritis (ON), longitudinally extensive transverse myelitis (LETM) and brainstem lesions known to cause intractable nausea, vomiting and hiccups. Pain is one of the most frequent and disabling symptoms in this syndrome. It is known to affect up to 85% of subjects with NMO which is more intense and less responsive to usual treatments when compared to multiple sclerosis patients. The aim of this study was to fully characterise all pain syndromes in individuals in the chronic relapse-free phase of NMO. The disease was also deemed a good model to study pain mechanisms in spinal cord injuries. Methods: This is a longitudinal study, comprised by 2 evaluations. The Baseline study entry visit consisted of a full standardized neurological examination, in order to determine the main and secondary pain syndrome according to its mechanism and level. Patients were requested to fill questionnaires evaluating pain (Douleur Neuropathique-4 [DN-4], brief pain inventory [BPI], Short-form McGill Pain Questionnaire [MPQ], Neuropathic pain symptoms inventory [NPSI]), painful tonic spasms, Lhermitte sign, hiccups, orthostatic intolerance, persistent nausea, pruritus, fatigue (modified fatigue scale), Uhthoff phaenomenon, quality of life (SF-12), disability (EDSS, Barthel ADL), anxiety and depression (Hospital anxiety and depression scale [HADS]), catastrophizing (PCTS), urinary and faecal dysfunction(OABV8,IPSS). Quantitative sensory test (QST) and measures of cortical excitability (CE) were performed. Previous brain and spinal cord MRIs were reviewed. A follow up visit was done between 6 and 18 months after the first visit, in which the main pain syndrome was reassessed and patients again were requested to fil pain questionnaires (DN-4, BPI, MPQ, BPI, NPSI) and report painful tonic spasms and Lhermitte sign. Results: Seventy-two patients were included. We identified 53 (73.6%) patients with chronic pain and 19 (26.3%) without any chronic pain syndrome. Forty (55.6%) patients had neuropathic pain (NP) and 13 (18.1%) had non-neuropathic pain (non-NP). Amongst those 53 subjects with chronic pain, 38 (71.7%) had more than one pain syndrome. NP at the sensory level was the most prevalent pain syndrome, being observed in 31 patients (58.5% of the total pain patients). Amid the non-NP patients, low back pain was the most common pain syndrome, affecting 8 (61.5%) subjects. NP group had a significantly higher number of dermatomes affected by allodynia to brush (0.8 ± 1.6, compared to zero dermatomes in the other 2 groups, p = 0.004) and to pressure (0.7 ± 1.3 compared to no 0 in the non-NP group and 0.1 ± 0.5 dermatomes in the no pain group). At-level hyperpathia affected a significantly proportion of patients with NP: 39 (97.5%) in this group, versus 10 (76.9%) and 12 (68.4%) in the non-NP and no pain groups (p= 0.013). Patients with NP had significantly worse performance when compared to those without pain, in the PCS-12 (physical component of the SF-12), (32.5 ± 8 and 43.3 ± 11, respectively). PCS-12 correlated with BPI intensity pain amid NP (r= -0.387, p= 0.014) and non-NP (r= -0.734, p= 0.004) groups. Within the group with neuropathic pain, 16 (80%) of patients reported itching on the pain area, whereas only 1 (33.3%) patient with non-neuropathic pain reported the same (p < 0.001). QST showed higher thresholds for warm stimuli detection within NP group, when compared to non-NP (41.3 ± 5.6 and 36.9 ± 3, respectively, p= 0.045) group. Motor evoked potential amplitudes at 120 and 140% were significantly lower in both groups with pain when compared to those without pain. The follow up assessment was done in 68 patients and 50 (73.5%) reported pain. At-level NP was the most prevalent syndrome, affecting 29 (58%) subjects. Three patients initially without pain reported it in the follow up visit. Incidence rate of pain was 17.7per 100 persons-year. Eleven patients who had reported pain upon study entry had a different pain syndrome on the second evaluation (20.8% of the original sample). NP group had a significant decrease in BPI intensity (from 5.6± 1.9 to 4.8±2, p= 0.039). MPQ total score significantly decreased in both groups with NP (from 9±2.4 to 8±3.1, p=0.014) and in those with non-NP (9.2±2.5 to 7±4, p=0.031). Conclusion: Pain is prevalent in patients with NMO and at-level NP is the most common syndrome. The incidence of new pain and changes in its syndromes is not related to new inflammatory activity but to the permanent chronic structural damage in the spinal cord and brainstem secondary to previous autoimmune activity. Assessment of pain syndromes is important for its treatment and they should be re-evaluated regularly even in patients without new clinical relapses

INTRODUÇÃO: O tratamento com ondas de choque (TOC) é utilizado para tratar numerosas afecções musculoesqueléticas, incluindo-se as pseudartroses e as tendinopatias. Há poucos estudos bem estruturados sobre a eficácia do TOC no tratamento da síndrome dolorosa miofascial (SDM) e não há ensaio clínico aleatorizado sobre sua utilização no tratamento das SDMs das regiões lombar e glútea. OBJETIVOS: Avaliar a eficácia do TOC no tratamento das SDMs das regiões lombar e glútea. CASUÍSTICA E MÉTODOS: Foi realizado estudo prospectivo, controlado, com amostra aleatória e duplamente encoberto sobre o tratamento de doentes com dor moderada a intensa decorrente de SDM nas regiões lombar e glútea com duração superior a seis meses, submetidos previamente a tratamento padronizado com antidepressivo, analgésico, terapia física e orientações fisioterápicas durante seis semanas. Foram elegíveis 46 doentes que apresentavam dor com intensidade >= 4 de acordo com a EVA dentre os 121 convocados. Durante seis semanas os doentes elegíveis foram submetidos a tratamento farmacológico e fisioterápico padronizado. Sete doentes usufruíram melhora clínica importante e oito abandonaram o estudo, restando 31 doentes que participaram efetivamente do estudo. Após a randomização, 14 doentes foram submetidos a TOC com cabeçote ativo e 17 a TOC com cabeçote placebo. Foram avaliados os aspectos demográficos, a apresentação clínica, a incapacidade funcional, a intensidade e as características da dor até um ano após a realização dos procedimentos destes 31 doentes. As avaliações foram realizadas com uso da Escala Visual Analógica (EVA), Questionário de Incapacidade de Roland-Morris (RDQ), Índice de Incapacidade de Oswestry (ODI), Versão Reduzida do Questionário de Dor McGill (SF-MPQ) e Inventário Diagnóstico da Dor Neuropática 4 (DN4). RESULTADOS: Não houve diferenças estatisticamente significativas entre os grupos quanto às características sociodemográficas dos doentes. Entretanto, a duração das queixas de dor dos doentes do grupo TOC ativo foi significativamente superior (p < 0,05) a dos do grupo TOC placebo. Em relação aos doentes tratados com TOC placebo, os doentes tratados com TOC ativo usufruíram redução estatisticamente significativa da dor de acordo com a EVA na interação grupo versus tempo a partir do momento \"três meses\"; a melhora manteve-se estatisticamente significativa durante um ano (p < 0,001), achado que sugere que o efeito analgésico instala-se em longo prazo e mantém-se prolongadamente. Não ocorreu modificação estatisticamente significativa na interação grupo versus tempo nas pontuações dos questionários RDQ, ODI e SF-MPQ ao longo do tempo nos doentes de ambos grupos. No momento \"12 meses\" ocorreu redução superior a 50% da incapacidade funcional da dor lombar avaliada de acordo com o RDQ em 70,0% dos doentes do grupo TOC ativo e em apenas 14,3% dos doentes tratados com TOC placebo; diferença percentual estatisticamente significativa (p < 0,05). Ocorreu também redução superior a 50% das pontuações do ODI na avaliação realizada no momento \"12 meses\" em 70,0% dos doentes incluídos no grupo TOC ativo e em apenas 14,3% dos doentes do grupo TOC placebo, diferença percentual estatisticamente significativa (p < 0,05). CONCLUSÕES: O tratamento com o TOC ativo dos doentes com SDM nas regiões lombar e glútea proporcionou melhora significativa da dor a partir do momento \"três meses\" até, pelo menos, o momento \"12 meses\" de acompanhamento, achado que sugere que seu efeito analgésico instala-se tardiamente. Adicionalmente, proporcionou melhora da funcionalidade de acordo com o RDQ e ODI na avaliação realizada no momento \"12 meses\" / INTRODUCTION: Extracorporeal shockwave therapy (ESWT) has been used successfully in different musculoskeletal conditions, including pseudarthrosis and tendinopathies. However, there are very few well-structured studies on the efficacy of ESWT in the treatment of myofascial pain syndromes (MPSs) and no randomized clinical trial about the ESWT in the treatment of lumbar and gluteal myofascial pain. OBJECTIVES: To assess the efficacy of ESWT in the treatment of lumbar and gluteal MPSs. MATERIAL AND METHODS: The study was prospective, randomized, double-blind and placebo-controlled. From 121 patients with moderate or severe pain due to MPS in the lumbar and gluteal regions lasting more than six months were enrolled; a total of 46 patients with pain intensity >= 4 according to the VAS were considered eligible. The elected patients were treated with antidepressant, analgesic and physical therapy as a standard protocol during six weeks. Seven patients had significant clinical improvement with the pharmacological and physical therapies and eight dropped out the study. The remainder 31 patients were randomized and 14 underwent active ESWT and 17 underwent placebo ESWT. The demographic aspects, clinical presentations, functional disabilities, severity and characteristics of pain were evaluated previously to the inclusion in the study until the end of the first year after the treatment with active or placebo ESWT. The evaluations were based on the Visual Analogue Scale (VAS), Roland- Morris Disability Questionnaire (RDQ), Oswestry Disability Index (ODI), Short- Form of the McGill Pain Questionnaire (SF-MPQ), and the Neuropathic Pain Diagnostic Questionnaire 4 (DN4). RESULTS: There were no statistical differences between the groups regarding the baseline characteristics of the patients. However, the duration of pain of the patients treated with active ESWT was significantly higher (p < 0,05) than those treated with placebo ESWT. There was no statistically significant variation over time in the RDQ, ODI and SF-MPQ scores between the patients from each group. Patients treated with active ESWT presented a significant reduction of pain severity according to the VAS from the third until the 12nd month of follow-up (p < 0,001), finding indicative that the analgesic effect of the ESWT starts late but remains over time. At the 12nd month of follow-up, 70,0% of the patients treated with active ESWT and just 14.3% of the patients from de placebo ESWT group had more than 50% improvement of the functional disability of the low back pain according to the RDQ, statistically significant difference (p < 0,05). There was also a reduction of more than 50% of ODI scores in the 12th month of follow-up in 70.0% of the patients treated with active ESWT and in only 14.3% of the patients treated with placebo ESWT (p < 0,05). CONCLUSIONS: The active ESWT provided a significant and lasting reduction in pain intensity from the third until the 12th month of follow-up, finding that suggests that its analgesic effect settles late and has long duration. Additionally, it provided improvement of the functionality according to the RDQ and ODI at the 12th month of follow-up

INTRODUÇÃO: O tratamento com ondas de choque (TOC) é utilizado para tratar numerosas afecções musculoesqueléticas, incluindo-se as pseudartroses e as tendinopatias. Há poucos estudos bem estruturados sobre a eficácia do TOC no tratamento da síndrome dolorosa miofascial (SDM) e não há ensaio clínico aleatorizado sobre sua utilização no tratamento das SDMs das regiões lombar e glútea. OBJETIVOS: Avaliar a eficácia do TOC no tratamento das SDMs das regiões lombar e glútea. CASUÍSTICA E MÉTODOS: Foi realizado estudo prospectivo, controlado, com amostra aleatória e duplamente encoberto sobre o tratamento de doentes com dor moderada a intensa decorrente de SDM nas regiões lombar e glútea com duração superior a seis meses, submetidos previamente a tratamento padronizado com antidepressivo, analgésico, terapia física e orientações fisioterápicas durante seis semanas. Foram elegíveis 46 doentes que apresentavam dor com intensidade >= 4 de acordo com a EVA dentre os 121 convocados. Durante seis semanas os doentes elegíveis foram submetidos a tratamento farmacológico e fisioterápico padronizado. Sete doentes usufruíram melhora clínica importante e oito abandonaram o estudo, restando 31 doentes que participaram efetivamente do estudo. Após a randomização, 14 doentes foram submetidos a TOC com cabeçote ativo e 17 a TOC com cabeçote placebo. Foram avaliados os aspectos demográficos, a apresentação clínica, a incapacidade funcional, a intensidade e as características da dor até um ano após a realização dos procedimentos destes 31 doentes. As avaliações foram realizadas com uso da Escala Visual Analógica (EVA), Questionário de Incapacidade de Roland-Morris (RDQ), Índice de Incapacidade de Oswestry (ODI), Versão Reduzida do Questionário de Dor McGill (SF-MPQ) e Inventário Diagnóstico da Dor Neuropática 4 (DN4). RESULTADOS: Não houve diferenças estatisticamente significativas entre os grupos quanto às características sociodemográficas dos doentes. Entretanto, a duração das queixas de dor dos doentes do grupo TOC ativo foi significativamente superior (p < 0,05) a dos do grupo TOC placebo. Em relação aos doentes tratados com TOC placebo, os doentes tratados com TOC ativo usufruíram redução estatisticamente significativa da dor de acordo com a EVA na interação grupo versus tempo a partir do momento \"três meses\"; a melhora manteve-se estatisticamente significativa durante um ano (p < 0,001), achado que sugere que o efeito analgésico instala-se em longo prazo e mantém-se prolongadamente. Não ocorreu modificação estatisticamente significativa na interação grupo versus tempo nas pontuações dos questionários RDQ, ODI e SF-MPQ ao longo do tempo nos doentes de ambos grupos. No momento \"12 meses\" ocorreu redução superior a 50% da incapacidade funcional da dor lombar avaliada de acordo com o RDQ em 70,0% dos doentes do grupo TOC ativo e em apenas 14,3% dos doentes tratados com TOC placebo; diferença percentual estatisticamente significativa (p < 0,05). Ocorreu também redução superior a 50% das pontuações do ODI na avaliação realizada no momento \"12 meses\" em 70,0% dos doentes incluídos no grupo TOC ativo e em apenas 14,3% dos doentes do grupo TOC placebo, diferença percentual estatisticamente significativa (p < 0,05). CONCLUSÕES: O tratamento com o TOC ativo dos doentes com SDM nas regiões lombar e glútea proporcionou melhora significativa da dor a partir do momento \"três meses\" até, pelo menos, o momento \"12 meses\" de acompanhamento, achado que sugere que seu efeito analgésico instala-se tardiamente. Adicionalmente, proporcionou melhora da funcionalidade de acordo com o RDQ e ODI na avaliação realizada no momento \"12 meses\" / INTRODUCTION: Extracorporeal shockwave therapy (ESWT) has been used successfully in different musculoskeletal conditions, including pseudarthrosis and tendinopathies. However, there are very few well-structured studies on the efficacy of ESWT in the treatment of myofascial pain syndromes (MPSs) and no randomized clinical trial about the ESWT in the treatment of lumbar and gluteal myofascial pain. OBJECTIVES: To assess the efficacy of ESWT in the treatment of lumbar and gluteal MPSs. MATERIAL AND METHODS: The study was prospective, randomized, double-blind and placebo-controlled. From 121 patients with moderate or severe pain due to MPS in the lumbar and gluteal regions lasting more than six months were enrolled; a total of 46 patients with pain intensity >= 4 according to the VAS were considered eligible. The elected patients were treated with antidepressant, analgesic and physical therapy as a standard protocol during six weeks. Seven patients had significant clinical improvement with the pharmacological and physical therapies and eight dropped out the study. The remainder 31 patients were randomized and 14 underwent active ESWT and 17 underwent placebo ESWT. The demographic aspects, clinical presentations, functional disabilities, severity and characteristics of pain were evaluated previously to the inclusion in the study until the end of the first year after the treatment with active or placebo ESWT. The evaluations were based on the Visual Analogue Scale (VAS), Roland- Morris Disability Questionnaire (RDQ), Oswestry Disability Index (ODI), Short- Form of the McGill Pain Questionnaire (SF-MPQ), and the Neuropathic Pain Diagnostic Questionnaire 4 (DN4). RESULTS: There were no statistical differences between the groups regarding the baseline characteristics of the patients. However, the duration of pain of the patients treated with active ESWT was significantly higher (p < 0,05) than those treated with placebo ESWT. There was no statistically significant variation over time in the RDQ, ODI and SF-MPQ scores between the patients from each group. Patients treated with active ESWT presented a significant reduction of pain severity according to the VAS from the third until the 12nd month of follow-up (p < 0,001), finding indicative that the analgesic effect of the ESWT starts late but remains over time. At the 12nd month of follow-up, 70,0% of the patients treated with active ESWT and just 14.3% of the patients from de placebo ESWT group had more than 50% improvement of the functional disability of the low back pain according to the RDQ, statistically significant difference (p < 0,05). There was also a reduction of more than 50% of ODI scores in the 12th month of follow-up in 70.0% of the patients treated with active ESWT and in only 14.3% of the patients treated with placebo ESWT (p < 0,05). CONCLUSIONS: The active ESWT provided a significant and lasting reduction in pain intensity from the third until the 12th month of follow-up, finding that suggests that its analgesic effect settles late and has long duration. Additionally, it provided improvement of the functionality according to the RDQ and ODI at the 12th month of follow-up

This cross-sectional postal survey explores the relationship between musculoskeletal painand level of education in Ullensaker municipality. We used a Standard Nordic Questionnaire(SNQ) to register self-reported musculoskeletal pain in 3325 persons in 2004 (participationrate 55 %). We registered educational level and a series of other demographic and life-stylevariables as well as functional ability and subjective health complaints. We found in thisstudy that educational level and musculoskeletal pain is associated. People with loweducational levels are prone to have more musculoskeletal pain than persons with highereducation. When it comes to musculoskeletal pain that is limiting persons in their daily tasksthe difference is even larger between persons with low educational level and persons withhigher education / I en postal tverrsnittstudie har vi undersøkt forholdet mellom muskelsmerter ogutdanningsnivå i Ullensaker kommune. Vi brukte et standardisert spørreskjema ommuskelsmerter (også kalt Ørebro-skjemaet) og fikk svar fra 3325 personer (svarprosent55%). Vi registrerte utdanningsnivå og en rekke andre demografiske- og livsstilsvariablesamt funksjonsevne og subjektive helseplager. Vi fant i denne studien ensammenheng mellom utdanningsnivå og muskelsmerter. Personer med lavtutdanningsnivå har mer muskelsmerter enn personer med høyere utdanning. Når detgjelder å bli hindret i sine daglige aktiviteter av smertene er forskjellene enda størremellom de med lav utdanning og de med høy utdanning / <p>ISBN 978-91-85721-43-6</p>

A dor crônica musculoesquelética é um importante problema de saúde pública, pois, além de ter alta prevalência, suas consequências são nefastas à condição física, psicológica e comportamental, levando ao afastamento do trabalho e aposentadoria precoce. Considerando que quadros de dor crônica são relacionados a alterações biológicas em importantes sistemas endógenos, a busca de biomarcadores sistêmicos interrelacionados com este processo podeser útil para o entendimento dos possíveis efeitos terapêuticos e adversos de técnicas de neuromodulacão, tanto centrais quanto periféricas. Baseado nisto, o objetivo principal deste estudo foi avaliar o efeito dos tratamentos com estimulação magnética transcraniana repetitiva (rTMS) e eletroestimulação intramuscular (DIMST) na intensidade da dor e em parâmetros bioquímicos e neurofisiológicos em pacientes com dor crônica musculoesquelética,e, secundariamente, buscar possíveis biomarcadores em quadros de dor crônica musculoesquelética. Este estudo foi dividido em dois experimentos. No experimento 1, comparou-se o efeito das técnicas de neuromodulação periférica (DIMST) e central (rTMS) sobre os parâmetros de excitabilidade cortical e níveis séricos de BDNF, S100β, citocinas e parâmetros de estresse oxidativo em pacientes com SDM. Foram recrutadas 46 mulheres, com idade entre 19 e 75 anos e diagnóstico de síndrome dolorosa miofascial (SDM). Trata-se de um ensaio clínico randomizado, cego, em paralelo, controlado com placebo-sham. As pacientes foram randomizadas em 4 grupos: (1) rTMS+DIMST, (2) rTMS +sham-DIMST, (3) sham-rTMS+DIMST e (4) sham-rTMS + sham-DIMST. No experimento 2, avaliou-se parâmetros neurofisiológicos de excitabilidade cortical e níveis séricos de BDNF como marcadores de dor crônica musculoesquelética. Foram recrutadas 72 mulheres, com idade entre 19 e 75 anos e diagnóstico de osteoartrite (OA) e SDM. Os parâmetros mensurados foram: dor pela escala análogo-visual (EAV), limiar de dor por algometria (PPT) e excitabilidade cortical pelo TMS. No experimento 1, as pacientes mostrarem-se iguais entre os grupos no basal. Houve uma redução na dor mensurada pela EAV nos grupos 1, 2 e 3 em relação ao grupo 4. O parâmetro de excitabilidade, potencial evocado motor (MEP), apresentou um aumento de amplitude ao final da intervenção 2. Não foram observadas mudanças nos parâmetros bioquímicos analisados durante e ao final das intervenções, seja entre as intervenções e dentro das intervenções. No experimento 2, observou-se que o PPT apresenta uma correlação positiva com inibição intracortical (ICI) e negativa com a facilitação intracortical (ICF). As pacientes com SDM apresentam o período silente (CSP) mais longo que pacientes com OA. O BDNF e estradiol apresentam relação positiva com PPT; no entanto, quando foi avaliada a interação destes fatores, o efeito sobre o PPT foi em direção oposta. Em resumo, os tratamentos ativos, central e/ou periférico, mostraram-se eficazes no alívio da dor, porém, dentre os parâmetros bioquímicos analisados, não se observouum biomarcador responsivo a estas técnicas. Sugere-se uma relação entre dor crônica musculoesquelética e alterações na excitabilidade cortical do córtex motor. Além disto, é importante ressaltar que estes tratamentos não alteraram nenhum dos parâmetros de avaliação de dano celular, como, por exemplo, o aumento de proteína glial (S100β), sugerindo que são técnicas seguras no que se refere aos parâmetros avaliados nesta tese. Posteriores estudos são necessários buscando novos biomarcadores que permitam um melhor diagnóstico, prognóstico e avaliação da resposta ao tratamento com técnicas de neuromodulação na dor crônica musculoesquelética. / Chronic musculoskeletal pain is a major public health problem with high prevalence, because, besides its high prevalences, its consequences are harmful to the physical, psychological and behavioral condition, leading to absence from work and early retirement. Taking into account that chronic pain processes are related to biological changes in endogenous systems, searching systemic biomarkers interconnected with this process can be useful to understand the potential therapeutic and adverse effects of the neuromodulation techniques, both central and peripheral. Based on that, the aim of this study was to evaluate the effect of treatment with repetitive transcranial magnetic stimulation (rTMS) and intramuscular electrical stimulation (DIMST) on pain intensity, biochemical and neurophysiological parameters in chronic musculoskeletal pain patients. Secondly, the aim was to find possible biomarkers in chronic musculoskeletal pain conditions. This study was divided into two protocols. Protocol 1, it was compared the effect of central (rTMS) and peripheral (DIMST) neuromodulation techniques on pain intensity, cortical excitability parameters and serum levels of BDNF, S100β, cytokines and oxidative stress parameters in patients with myofascial pain syndrome (MPS.) Fourty women, aged between 19 and 75 years, MPS diagnosis were recruited. This is a randomized, blind, parallel, placebo - sham clinical trial. The patients were randomized into four groups: (1) rTMS + DIMST, (2) rTMS + sham-DIMST, (3) sham-rTMS + DIMST, and (4) sham-rTMS + sham-DIMST. Protocol 2, we assessed the neurophysiological parameters of cortical excitability and BDNF serum levels as markers of chronic musculoskeletal pain. Seventy-two women, aged between 19 and 75 years diagnosed with osteoarthritis (OA) and MPS were recruited. The measured parameters were: pain intensity by visual analogue scale (VAS), pain pressure threshold (PPT) and cortical excitability by TMS. In protocol 1, the patients presented similarities in the baseline between the four groups. The patients presented a reduction in painintensity measured by VAS in the groups 1, 2 and 3 in relation to group 4. After rTMS intervention, there was an increase in the MEP amplitude. There were no changes in biochemical parameters analyzed during and after the interventions. In protocol 2, it was observed that PPT has a positive correlation with intracortical inhibition (ICI) and negative correlation with intracortical facilitation (ICF). Patients with MPS exhibit longer silent period (CSP) than OA patients. BDNF and estradiol serum levels presented a positive correlation with PPT; however, when their interaction was assessed, the effect on the PPT was in the opposite direction. In summary, the active, central and/ or peripheral treatments were effective in relieving the pain; however, among the biochemical parameters analyzed, there was no biomarker responsive to these techniques. It is suggested a relationship between chronic musculoskeletal pain and changes in cortical excitability of the motor cortex. Furthermore, it is important to note that these treatments did not alter any of the parameters of cellular damage assessment, such as the increase of glial protein (S100β), suggesting that they are safe as to the parameters evaluated in these techniques. Further studies are needed to find new biomarkers that allow better diagnosis, prognosis and assessment of treatment response with neuromodulation techniques in chronic musculoskeletal pain.