Keywords
repetitive strain injury - chronic pain - surgery - multidisciplinary team
Palavras-chave
lesão por esforço repetitivo - dor crônica - cirurgia - equipe multidisciplinar
Introduction
An individual's perception of his/her own well-being in the areas of work, culture
and values – including personal goals, expectations and personal interests – defines
health-related quality of life.[1] This is a subjective concept inherent to individual perceptions. It encompasses
many dimensions, without focusing only on the worries regarding health.[2]
Pain may produce a negative impact on the quality of life of individuals, affecting
their attention, causing physiological dysfunctions and disorders from an emotional,
social and professional standpoint, as well as sleeping disorders, physical and mental
frailty, social isolation, difficulty to eat, reduction of daily activities and absenteeism.[3]
Chronic pain affects ∼ 10 million individuals around the world. In addition, 14% of
chronic pain is related to the musculoskeletal joints.[4] Musculoskeletal disorders are among the most frequent causes of work disability
in Brazil. Repetitive strain injury (RSI) or work-related osteomuscular disorders
(WRODs) are the ones that affect workers the most.[5] Repetitive strain injury and WRODs are identified by repetitive movements in the
work environment and by the workers' individual characteristics, such as inadequate
posture, genetic predisposition, weight and relationship with work, among others.[6]
Thoracic Outlet Syndrome (TOS) is a type of RSI/WROD characterized by neurogenic symptoms
that involve the upper limbs. It affects young people, mostly women, and, in a few
cases, it may cause disability.[7] It is considered one of the most controversial syndromes among the ones that cause
pain in the upper limbs, and it is at times associated with surgical interventions,
even when there are no clear evidences of a true TOS.[8]
[9]
[10]
Patients diagnosed with TOS must first undergo conservative treatment that involves
strengthening, stretching, and postural correction exercises. And, when possible,
they must reduce the intensity of their manual activities/tasks. Such measures may
help in the recovery and stop the progression of the disorder.[8]
[9]
[10] Surgical treatment, on the other hand, is reserved for those people who remain in
severe and refractory chronic pain for longer than three months, which compromises
the patients' quality of life.[11] Thus, considering chronic pain as a disabling symptom for the neurogenic TOS patient,
the purpose of this study is to evaluate the quality of life of patients who underwent
supraclavicular surgery, and to evaluate whether there was an improvement in the patients'
degree of pain.
Method
Descriptive, quantitative and retrospective studies were conducted with neurogenic
thoracic outlet syndrome patients who underwent a surgical procedure via the supraclavicular
approach in the period between 2008 and 2015. The collection of data was performed
in two steps: firstly, we selected the patients using information from the medical
charts of the neurosurgeon's office (sociodemographic data and preoperative information),
and secondly, we performed and in-person consultation to assess pain and quality of
life after surgery.
The selection criteria were: patients over 18 years of age, who had undergone at least
1 year of a conservative treatment for the syndrome (physiotherapy and painkillers)
without improvement of the clinical condition and with a postoperative period of at
least 6 months of evolution. After that, the selected patients were contacted by email
and/or phone, and those who agreed to participate had to attend an evaluation at the
medical office at a previously scheduled time, according to their availability. In
a reserved room, two medical academics performed the collection of data.
All procedures were standardized, including the collection of data and the strategies
to approach the participants for the research.
This study was approved by the Ethics and Research Committee of our institution (CAE
no. 48351015.6.0000.5368).
Research data
Sociodemographic data such as age, sex and occupation were collected from the patients'
medical charts, as well as data on clinical tests and associated pathologies.
The selected patients were classified according to the type of thoracic duct syndrome
presented. The syndrome was classified as typical and atypical and according to an
adaptation in the classification described by Franklin (2015)[8] due to regional diagnostic difficulties.
Typical neurogenic TOS: the patients present with neurogenic symptoms, at least five positive provocative
maneuvers, and at least one positive neurodiagnostic test (electroneuromyography;
angiography by magnetic resonance of the subclavian vessels with Adson maneuver; or
echo-Doppler of the subclavian vessels with Adson maneuver and magnetic resonance
of the brachial plexus) with lower plexus lesion signs (C8/T1).
Atypical neurogenic TOS: the patients present with neurogenic symptoms, at least five positive provocative
maneuvers, and no positive results in the neurodiagnostic tests mentioned before.
During the evaluation at the physician's office, the medical academics performed the
qualitative and quantitative evaluation of pain, which was based on the patients'
verbal descriptions in the Brazilian short-form version of the McGill pain questionnaire,[12] which is made up of three parts: description of pain, present pain intensity (PPI)
and index of intensity of pain through the visual analog scale for pain (VAS Pain).
In the same occasion, the evaluation of the quality of life regarding health by means
of the 36-item short-form (SF-36) health survey, with a validated adaptation to the
Portuguese language was performed.[13]
Statistical Analysis
Data were analyzed with the Prism (GraphPad, La Jolla, CA, US) software, version 5.0.
The data collected were then submitted to a descriptive statistical analysis (arithmetic
mean and standard deviation) and the differences among the data were identified using
one-way analysis of variance (ANOVA) followed by the Tukey post-hoc test. The differences
were considered statistically significant for values of p ≤ 0.05.
Results
Based on the survey of the medical charts of the patients who had been submitted to
thoracic outlet surgery by the supraclavicular approach between the years of 2008
and 2015, a total of 52 patients were identified and contacted by email and/or phone.
Of these, only 20 patients did not answer the email and/or phone contact, with a total
of 32 patients achieved. However, three among those initially selected were excluded
because they did not meet the research criteria (one did not agree to participate,
and two of them were in a postoperative period lower than six months). Thus, 29 patients
with neurogenic TOS submitted to surgery via the supraclavicular approach participated
in this study.
The average age of the participants was 42 years (25–54 years), and 25 patients were
female. As for professional occupations, eight of them were farmers, nine were housekeepers,
four were production assistants, two were shop owners, two were electricians, one
was an office assistant, one was a clerk, and one was a self-employed professional.
Regarding the period of the surgeries, most of them were performed in the years 2015
(13) and 2013 (6), and the others in 2008 (2), 2009 (2), 2010 (3), 2011 (2) and 2012
(1).
Regarding the classification, three patients had atypical neurogenic TOS that was
positive on the neurologic tests, with five to nine positive provocative maneuvers,
and no positive result in the neurodiagnostic tests; nevertheless, these patients
opted for the surgical procedure.
The other 26 patients had typical neurogenic TOS that was positive on the neurologic
tests, with five to nine positive provocative maneuvers and at least one positive
result in the neurodiagnostic tests. All patients in the study underwent electroneuromyography
and angiography by magnetic resonance of the subclavian vessels (resulting in 25 positive
results), with Adson maneuver tests (resulting in 7 positive results). A total of
16 patients underwent the echo-Doppler of the subclavian vessels with Adson maneuver,
which resulted in 13 positive results. Only two patients underwent magnetic resonance
of the brachial plexus, and both results were positive.
Postoperative complications included two cases of seroma and surgical incision pain,
one thoracic duct lesion, which improved after subcutaneous drainage with Penrose
drains, and two hematomas below the surgical incision area. The other patients did
not present any complications. Only three patients did not undergo physiotherapy after
the surgeries.
Regarding the patients' return to work, 21 out of the sample of 29 failed to resume
their work activities: 18 remained on medical leave, and 3 patients were retired for
length of service.
All participants in the study presented one or more associated pathologies, such as:
contralateral TOS, unilateral or bilateral shoulder cuff syndrome, bilateral or unilateral
carpal tunnel syndrome, cervical disk herniation, epicondylitis, lumbar disc herniation
and/or lumbar spine segmental instability.
Data regarding the intensity of the pain and the quality of life were evaluated with
the Brazilian short-form version of the McGill pain questionnaire. The first part
of the questionnaire refers to the description of pain, which was presented through
the percentage of choice of each word ([Table 1]). It should be noted that 9 out of 15 words that qualify the painful experience
were described by most patients as severe.
Table 1
Percentage of choice of each word in the Brazilian short-form version of the McGill
pain questionnaire for TOS patients submitted to surgery
|
No (%)
|
Weak (%)
|
Mild (%)
|
Severe (%)
|
|
Throbbing
|
20.7
|
10.3
|
20.7
|
48.3
|
|
Shooting
|
20.7
|
10.3
|
27.6
|
41.4
|
|
Stabbing
|
41.4
|
3.4
|
17.2
|
37.9
|
|
Sharp
|
62.1
|
6.9
|
17.2
|
13.8
|
|
Cramping
|
41.4
|
10.3
|
13.8
|
34.5
|
|
Gnawing
|
72.4
|
3.4
|
10.3
|
13.8
|
|
Hot
|
31.0
|
6.9
|
27.6
|
34.5
|
|
Aching
|
24.1
|
10.3
|
31.0
|
34.5
|
|
Heavy
|
30.7
|
6.9
|
27.6
|
44.8
|
|
Tender
|
37.9
|
17.2
|
20.7
|
24.1
|
|
Splitting
|
27.6
|
13.8
|
20.7
|
37.9
|
|
Tiring
|
17.2
|
6.9
|
20.7
|
55.2
|
|
Sickening
|
44.8
|
6.9
|
24.1
|
24.1
|
|
Fearful
|
24.1
|
6.9
|
24.1
|
44.8
|
|
Punishing
|
27.6
|
13.8
|
17.2
|
41.4
|
Abbreviation: TOS, thoracic outlet syndrome.
No differences were found between the median rate of evaluation of pain in the sensory,
affective and total aspects, as all of them were considered severe ([Table 2]).
Table 2
Mean scores for sensory, affective and total aspects of the Brazilian short-form version
of the McGill pain questionnaire filled out by patients with TOS submitted to surgery
(p = 0.95)
|
Rate
|
Mean
|
N
|
|
Sensory
|
2.95 ± 0.96
|
29
|
|
Affective
|
2.97 ± 0.97
|
29
|
|
Total
|
2.90 ± 0.92
|
29
|
Abbreviation: TOS, thoracic outlet syndrome.
In relation to the evaluation of the global PPI, at the time of the application of
the questionnaire, the patients reported severe pain (2.72 ± 1.51, n = 29). On the other hand, pain intensity after the surgical procedure, which was
estimated with the VAS Pain, was of 5.8 ± 2.9.
The analysis of the quality of life scale (QoLS) scores, according to the categories
generated from the application of the instrument, shows a mostly low quality of life
for these patients, who presented a median score below 50.
The median scores of the dimensions evaluated by the SF-36 were presented in [Table 3], where the dimensions with lower values were caused by limitations due to physical
aspects, followed by limitations due to emotional aspects and to pain.
Table 3
Scores for dimensions in the SF-36 questionnaire filled out by patients with TOS submitted
to surgery
|
Mean
|
SD
|
Min.
|
Max.
|
|
Functional capacity
|
47
|
32.6
|
0
|
100
|
|
Limitation due to physical aspects
|
24
|
32.4
|
0
|
100
|
|
Pain
|
34
|
29.1
|
0
|
100
|
|
General health condition
|
40
|
15.9
|
5
|
72
|
|
Vitality
|
38
|
21.8
|
5
|
85
|
|
Social aspects
|
47
|
31.6
|
0
|
100
|
|
Limitation due to emotional aspects
|
26
|
38.2
|
0
|
100
|
|
Mental health
|
42
|
22.8
|
0
|
96
|
Abbreviations: Max., maximum; Min., minimum; SD, standard deviation; SF-36, 36-item
short-form health survey; TOS, thoracic outlet syndrome.
Discussion
Chronic pain may have negative consequences in the quality of life of people.[14] Considering it as an incapacitating symptom for the patient with TOS, this study
evaluated the quality of life of patients who underwent surgery via the supraclavicular
approach. The 29 patients who had undergone surgery more than six months before the
study were evaluated, and they presented low quality of life and persistence of severe
pain. Thoracic Outlet Syndrome is difficult to diagnose,[15] and there is no evidence that the supraclavicular surgery reduces the pain in patients
with this syndrome, who classify it as incapacitating and irritating, with a great
influence over their quality of life.
Most of the participants in the research were females of working age. Such predominance
probably occurs due to women's propensity to seek health care, be it at outpatient
clinics or at hospitals,[16] as well as due to their long working hours, which include housework and work outside
the home.[17] Such long working hours might result in a RSI/WROD, with recurring painful affections
resulting from repetitive movements and, consequently, limitations by physical aspects.
Work performing repetitive movements causes the chronic pain symptoms and reduction
of muscle strength, incapacitating an individual to do his/her job or house chores.
Deconditioned muscles due to any associated pathology are more prone to suffer lesions
during physical activities. Such lesions may cause more pain, further incapacitating
the individual and limiting him/her to a sedentary lifestyle and one of physical immobility.[18]
The patients evaluated had professional occupations such as teachers, cleaners, inventory
controllers, and farmers, which involve repetitive movements of the upper limbs. The
etiology of the syndrome is connected to the patient's occupation, such as those that
involve overload, flexion and abduction positions of the upper limbs above the height
of the shoulders or hyperextension of the shoulders, compression on the shoulder or
of the shoulder against an object, and lateral flexion of the neck.[19] Workers from the most varied fields of activity are submitted to work conditions
that cause and/or aggravate RSI/WROD-related conditions.[20]
The patients in this study attributed the development of their pain to manual labor,
as their jobs involved repetitive movements, always in the same position. They reported
that, at the end of the workday, they felt their arms were numb, and they felt a sensation
of fatigue, but they attributed that to mismanagement of daily tasks. Thus, they postponed
seeking medical attention and made use of over-the-counter painkillers, which helped
improve their condition, but that no longer had any effect over a period of time.
Ergonomics is of the utmost importance, at any company, in order for workers to perform
a certain task. To this end, details such as time, breaks, relaxation exercises, management,
and complexity of task should be observed to allow the workers to sustain the quality
of their work. Ergonomics requires that a task be adapted to the employee within the
limits and skills of this human being, and not the other way around. In this sense,
those employees might be compromised as regards RSI/WRMD.[21]
Most of the patients did not present surgical complications, and only three of them
did not undergo the prescribed postoperative physiotherapy. However, 21 of them did
not return to work. The presence of pain, even after surgery, made it impossible for
them to return to work and perform the movements with their upper limbs. The patients'
return to work depends on the type of surgery and when the rehabilitation process
starts, as most of them are able to return to work with a light workload within 4
to 6 weeks, and to regular work within 10 to 12 weeks after surgery.[8] However, the authors of the present study report that most of the patients on sick
leave do not present good results after a year of surgery, which explains the low
level of return to work among the sample of this study.
An aggravating factor for the patients in this study was that all of them had one
or more associated musculoskeletal pathologies, which may prolong their pain. In addition,
that may be considered an extra factor of confusion in relation to the pain described
by the patient. The neuro-musculoskeletal system is known to be vital for survival,
so we can perform our daily activities and the skilled tasks required at work. The
predisposing or causal factors of osteomuscular disorders have been grouped as biomechanical
and psychosocial factors, and stress is considered one of the means by which psychosocial
factors affect osteomuscular health.[22]
An evaluation of the intensity of the pain after the surgical procedure by means of
the Brazilian short-form version of the McGill pain questionnaire showed that the
pain remained preponderant and debilitating in the life of those individuals, and,
consequently, the result of the SF-36 questionnaire generally showed low quality of
life in these patients. A lower score can be observed for limitations due to physical
aspects, followed by limitations due to emotional aspects and to pain. According to
Ciconelli (1997),[13] the “limitation due to physical aspects” component in the SF-36 questionnaire is
intended to assess the extent to which physical limitations can interfere in the daily
life of an individual. The patients in the present study reported limitations in their
day-to-day tasks, such as hanging clothes on the line, cleaning the house, or even
combing their hair or taking a shower. Such limitations were connected to the feeling
of uselessness by the patients, which may explain the low score in the emotional aspects.
The symptoms of RSI/WRMD affect the life of a worker in an aspect that goes beyond
the work environment, as it affects the personal life of individuals.[23]
Pain might determine changes in sleep, appetite and libido, in addition to causing
irritability, reduction of energy and concentration, difficulty to engage socially,
and low interaction in the work and family environments.[24]
It is suggested that psychological disorders such as anxiety and depression, for example,
should also be investigated in patients with chronic pain, as they may be associated
with the continuity (chronicity) of the symptoms. Chronic pain, mainly when associated
to a high degree of disability, is no longer solely a medical problem.[25] Patients suffering from depression and anxiety often report high levels of physical
symptoms such as pain; on the other hand, many patients with musculoskeletal disorders
complain that their pain caused their depression.[26] The feeling of incapacitation and uselessness reported by many patients may have
interfered with their emotional state.
Therefore, the patient should be examined by a multidisciplinary team including a
surgeon, a neurologist and a physiotherapist, and possibly be sent to a psychologist
or psychiatrist in cases of severe or chronic pain. This may facilitate the return
to work of these patients. In addition, it is necessary to evaluate other factors
such as obesity and postural changes, which are also associated with TOS.[27]
Pain is the fifth vital sign, and it requires a measurement of the symptoms. The International
Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and
emotional experience that is associated with actual or potential tissue damage, or
which is described as such.” Although this definition may be rather succinct, it covers
the complexity of the processing of pain, as it does not regard pain only as a nociceptive
process; it also shows the several psychological influences that are related to pain.[28] Thus, pain may influence negatively people's quality of life, in their emotional
characteristics, in their daily motivation, in behavioral-cognitive aspects, as well
as in their work.
Furthermore, decrease in the quality of life regarding the physical domain may affect
maintenance of the patients' autonomy, which may limit his/her performance in daily
activities, making him/her dependent in his/her social, economic and cultural contexts.[29]
It should be noted how difficult it was to recruit patients to participate in this
study, as 52 medical charts were selected, but only 55.7% of the patients selected
participated in the study, which may be considered a bias inherent to a retrospective
study. The patients who were contacted and participated in the study may represent
those who still had some proximity the doctor's office they were still suffering from
pain.
In conclusion, patients with neurogenic TOS who were submitted to a surgery via the
supraclavicular approach presented low quality of life because of physical, emotional
and pain limitations. Persistence of pain occurred probably due to associated pathologies,
as well as because of the psychosocial context, which may be considered a factor of
confusion in relation to the pain described by a patient. Thus, in order to treat
neurogenic TOS, an intervention of a multidisciplinary team with a holistic view of
the patient is required, as well as adaptations of the working conditions of the people
affected by this syndrome.
