Vol. 44 No.

2 August 2012 Journal of Pain and Symptom Management 239

Original Article

Prevalence, Characteristics, and Factors

Associated With Chronic Pain With and
Without Neuropathic Characteristics in S~ao
Luı́s, Brazil
Erica Brand~ao de Moraes Vieira, RN, MSc, Jo~ao Batista Santos Garcia, MD, PhD,
Ant^onio Augusto Moura da Silva, MD, PhD,
Rayanne Luı́za Tajra Mualem Ara ujo, RN, and Ricardo Clayton Silva Jansen, RN

Pain Research Group (E.B.d.M.V.), Department of Anesthesiology, Pain and Palliative Care
(J.B.S.G.), Department of Public Health (A.A.M.d.S.), and Department of Nursing (R.L.T.M.A.,
R.C.S.J.), Federal University of Maranh~a o, and Academic League of Pain (R.L.T.M.A.), S~ a o Luı́s,
Brazil

Abstract
Context. Chronic pain (CP) with and without neuropathic characteristics is
a public health problem. This is the first population-based study in South
America, and the third in the world, to use the Douleur Neuropathique
4 Questions (DN4) tool in epidemiologic studies.
Objectives. The objectives were to estimate the prevalence and associated
factors of CP with and without neuropathic characteristics in S~ao Luı́s, Brazil.
Methods. We surveyed 1597 people. The DN4 questionnaire was applied.
Poisson regression was used to analyze the risk factors.
Results. The prevalence of CP was 42%, and 10% had CP with neuropathic
characteristics (CPNC). The results showed that female sex and age $30 years
were associated with an increased prevalence of CP (P < 0.001) and education
$12 years with a reduction in the prevalence of CP. The sensations listed in the
DN4 were more common in people with CPNC and most frequent were pins and
needles (87.9%). The cephalic region (36%) and limbs (51%) were the locations
most affected. Most respondents felt pain between six months and four years
(51.6%), with daily frequency (45%). Pain intensity, the impediments caused by
pain, and sadness were more prevalent in people who had CPNC (P < 0.001).
Health status was regular for most, 50.9% did not know the cause of their pain,
64.1% used drugs, and only 7% had consulted with a pain specialist.
Dissatisfaction with treatment was reported by 55%.
Conclusion. CP with and without neuropathic characteristics is a public health
problem in Brazil, with high prevalence and great influence on people’s daily
lives. J Pain Symptom Manage 2012;44:239e251. Ó 2012 U.S. Cancer Pain Relief
Committee. Published by Elsevier Inc. All rights reserved.


Address correspondence to: Erica Brand~ao de Moraes
Vieira, RN, MSc, Av. Bahia, Condomı́nio Gran Vi-
lage Turu III, casa 28, Chacara Brazil, Tur
u, S~ao
Luı́s 65077-310, Brazil. E-mail: enfermeira_erica@
yahoo.com.br
Accepted for publication: September 1, 2011.

Ó 2012 U.S. Cancer Pain Relief Committee. 0885-3924/$ - see front matter
Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpainsymman.2011.08.014
240 de Moraes Vieira et al. Vol. 44 No. 2 August 2012

Key Words
Epidemiology, prevalence, neuralgia, neuropathic pain, pain, chronic pain

Introduction Recently, a group of French researchers de-

veloped a questionnaire for the diagnosis of
Chronic pain (CP) is a serious public health
CPNC, called the Douleur Neuropathique
problem not only in terms of human suffering
4 Questions (DN4).17 In practice, few studies
but also because of its great socioeconomic
have used the DN4. Population studies in
implications.1e3 The prevalence of CP can
France and Canada have used the DN4 inter-
range from 12% to 55% of the population.4
view,12,16 and another group used the tool for
These variations are attributed to the different
patients in an emergency room.18 Since then,
definitions of CP, the type of population stud-
the DN4 has been internationally validated19
ied, and the methodology used in research.5
and translated into several languages.20e23 A
The need to plan improvements in the
recent study conducted in Brazil validated
health system, including prevention and treat-
the DN4 in the Portuguese language and con-
ment, provided for the development of several
cluded that the use of this instrument would
searches for the risk factors related to CP. Stud-
be viable in research.24
ies have shown that some of the factors associ-
Despite the importance of major published
ated with CP are female sex, increasing age,
international studies, few studies in Brazil
being divorced, lower socioeconomic status,
have been conducted on the prevalence of
and a lower educational level.2,5e9 A few stud-
CP. One study was conducted in 2007, but
ies have shown associations with obesity,2,9
the population was restricted to the elderly.25
alcoholism,3,9 and smoking.3,10
Another study was done within the general
Within the category of CP, neuropathic pain
population, but the main focuses of the study
tends to arise as a result of injury or disease
were cardiovascular disease and diabetes. CP
affecting the somatosensory system.11 Neuro-
was assessed in a superficial manner, resulting
pathic pain is one of the most disabling types
only in the analysis of associated factors.9
of pain,12 and it affects 7%e8% of the
Moreover, these studies only included sociode-
population.12,13
mographic questions and questions on pain
A recent guideline proposed a classification
site and pain intensity but did not assess the in-
system dividing neuropathic pain into possible,
fluence of CP on daily life, the use of pain
probable, and definite categories. Neuropathic
medication, or the demand for medical atten-
pain is possible if pain distribution is neuroana-
tion, information which is crucial for imple-
tomically plausible and the history suggests
mentation of health policies. Furthermore,
a relevant lesion or disease. The designation
an epidemiologic study of CPNC has never
of probable neuropathic pain requires signs of
been done before in South America.
sensory dysfunction confined to territory inner-
The objectives of this study were to estimate
vated by an injured nerve structure. For definite
the prevalence of CP with and without neuro-
neuropathic pain, sensory signs and diagnostic
pathic characteristics in the population of
tests confirming a lesion or disease explaining
S~ao Luı́s, Brazil; identify factors associated
the neuropathic pain are necessary. This pro-
with CP; assess the differences between CP
posed classification system has been used for
with and without neuropathic characteristics;
clinical purposes and research.11,14
and assess CP’s influence on daily life and on
Some epidemiologic studies dealing with pos-
the use of medication and health services.
sible or probable neuropathic pain also have
used the term CP with neuropathic characteris-
tics (CPNC) or of neuropathic origin,12,13,15,16
but there are no population data on this form Methods
of CP from Brazil. The lack of an easy instru- Study Design
ment to use in large surveys partly explains the We conducted a cross-sectional and population-
paucity of epidemiologic studies on the based interview study in the municipality of S~ao
subject.12 Luı́s (Brazil) during 2009 and 2010.
Vol. 44 No. 2 August 2012 Chronic Pain in S~
a o Luı́s, Brazil 241

Data Collection Instruments delineated subsectors, called ‘‘blocks.’’ In the

We used two questionnaires. The first had 31
questions involving socioeconomic aspects,
lifestyle, and central obesity, as well as issues re-
lated to CP.
The second questionnaire was specific to neu-
ropathic pain, the DN4, which has been shown
to demonstrate 100% sensitivity and 91.3%
specificity in the Portuguese language (Bra-
zil).24 It consists of a scale with 10 items and is di-
vided into four sections. Two sections rely on an
interview with the patient, and two are based on
the clinical examination. A score of one was
given for each positive item and zero for each
negative item, and the total was calculated as
the sum of the 10 items. A total score of four
or more indicated CPNC.17
A team of nurses was trained in the adminis-
tration of the questionnaires, and all proce-
dures were performed in a standardized way.
The local Ethics and Research Committee ap-
proved the project, and the participants signed
consent forms.
second stage, individuals were drawn randomly
from the blocks and corners, using maps of cen-
sus tracts. We chose the corner drawn on each
map for the collection starting point. From
that point, the collections proceeded clockwise
around the block until we reached 54 people.
This sample was obtained in each of the 30 cen-
sus tracts, totaling 1620 people. The interviews
were conducted face-to-face at the subjects’
homes (Fig. 1).
Definitions for the Study
Sociodemographic Data. Age was categorized in
groups, and educational level was measured in
years. Marital status was divided into categories
of married/consensual union, single, divorced,
and widowed. Skin color was self-reported and
classified as it is officially used in population
censuses in Brazil. Monthly income was

Sample Size
The estimated prevalence of CP was 25%, the
same percentage used in the previous study con-
ducted in Brazil.4,9 We considered a 95% CI and
estimated relative accuracy of approximately
3%. The calculation of sample size resulted in
800 individuals. Considering also that the study
would address factors associated with the preva-
lence of CP, the sample was increased to 1620
adults. This sample size had 80% power for de-
tecting differences in the 6% prevalence of CP,
assuming a Type I error probability of 5% and
an estimated prevalence of CP in about 20%
of the reference categories.

Study Population and Sampling

S~ao Luı́s is a city in northeastern Brazil with an
estimated population of one million inhabi-
tants. The target population for the study com-
prised persons aged 18 years and older, of
both genders, residing in S~ao Luı́s. Excluded
were individuals with cognitive impairment,
any psychosis, or who were pregnant. The sub-
jects were selected by conglomerate random
sampling in two stages. In the first stage, from
the numerical ratio of 979 census tracts in the
city of S~ao Luı́s, 30 census tracts were randomly
selected. We mapped each census tract and Fig. 1. Flowchart of the data collection process.
242 de Moraes Vieira et al.
classified into categories as low (up to $320), av-
erage ($321 to $1024), or high (above $1024).
Occupational status was divided into categories
of active (people who were working), unem-
ployed, retired, and licensed (for medical
treatment).
Lifestyle and Central Obesity. For the smoking
criterion, respondents who regularly smoked
any amount of tobacco were considered smokers
and those who had quit were considered former
smokers. With respect to alcohol consumption,
those who drank three or more shots of distilled
beverages or three bottles of fermented bever-
ages per week were considered alcoholic.26
People who engaged in physical activity at
least three times a week for 30 minutes were
considered active. Waist circumference was as-
sessed with a tape measure, taking as a parame-
ter the narrowest part of the trunk between the
thorax and hip. The classification used for cen-
tral obesity was increased waist circumference
($102 cm for men and $88 cm for women).27
CP With and Without Neuropathic Characteristics.
The criterion for CP was persistent pain for
more than six months.7,9 We assessed pain inten-
sity using a visual analogue scale, which ranges
from 0 to 10 (0, ‘‘no pain;’’ 1e4, ‘‘mild pain;’’
5e7, ‘‘moderate pain;’’ and 8e10, ‘‘severe
pain’’).28
To identify neuropathic pain sensations, we
used the DN4 questionnaire in all patients
who had CP. The criterion for defining
CPNC was a DN4 score of four or greater.17
For issues related to the DN4 questionnaire
and based on the physical examination, we in-
vestigated hypesthesia to touch by sliding the
tip of the index finger bilaterally into the
area affected. For the evaluation of hypesthesia
to a pinprick, we used a blunt needle, which
was pushed down slightly at the site of pain.
Pain sensitivity to brushing was assessed using
disposable brushes.
Statistical Analysis
We performed all tests using Stata 10.0 (Stata-
Corp LP, College Station, TX). Poisson regres-
sion with a robust variance estimate is the best
alternative for analysis in cross-sectional studies
with binary outcomes, particularly compared
with logistic regression, in which there is a high
prevalence outcome. The prevalence ratio (PR)
Vol. 44 No. 2 August 2012
provided by Poisson regression is interpreted in
the same way as the odds ratio in logistic regres-
sion models.29,30 This method has been used in
a population-based study in CP.31
The dependent variable was the presence of
CP. The independent variables were sex, age,
skin color, educational level, income, marital
status, occupational status, smoking, alcohol-
ism, physical activity, and central obesity.
We conducted a descriptive analysis and per-
formed a Poisson regression to assess the associ-
ation between explanatory variables and CP. We
included variables with P < 0.20 in the adjusted
model and proceeded with stepwise and back-
ward elimination. P < 0.10 was required to
keep the variables in the final regression model.
Considering the complex sampling design, esti-
mates were corrected with the Stata 10.0 ‘‘svy’’
command.
On specific questions regarding pain, we ap-
plied a Chi-square test to verify a difference in
prevalence between the groups who had CP
with and without neuropathic characteristics.
P < 0.05 was considered statistically significant.
Results
From the initial sample of 1620 subjects, we
interviewed 1597 people. The losses were the
result of access difficulties. The average age of
participants was 39.5
16.6 years, with a plural-
ity between 18 and 29 years (35.8%). Most re-
spondents were female (66.4%), had brown
skin (50.3%), and had a marital status classified
as married or living in a consensual union
(50.7%). The most common level of education
was nine to 11 years of schooling (50.6%). Most
of the population (60.3%) had low incomes.
Regarding occupational status, active status pre-
dominated (49.2%), despite the large number
of unemployed workers (36.2%). Regarding
lifestyle, there was a predominance of non-
smokers (72.2%), and 25.5% said they had in-
gested some type of alcoholic beverage. Only
25.4% were considered active, and most had
central obesity (62.8%).
The prevalence of CP in the population,
considering the minimum duration of six
months, was 42% (n ¼ 676), and 23% of these
respondents had CPNC (n ¼ 157), which rep-
resented 10% of the total sample (N ¼ 1597).
The average score on the DN4 questionnaire
Vol. 44 No. 2 August 2012 Chronic Pain in S~
a o Luı́s, Brazil 243

in the population with CP was 2.2
2.3, and
the score increased to 5.6
1.6 in the popula-
tion with CPNC.
Table 1 shows the unadjusted analysis of
factors associated with CP. Being female and
older than 30 years of age were associated
with a higher prevalence of CP (P < 0.001).
There was a lower prevalence of CP in people
who had an education of more than 12 years
(P < 0.001).
Single subjects were less affected by CP than
those who were married, divorced, or widowed
(P < 0.001). Retirees and licensees had a high-
er prevalence of CP (P < 0.001). Former
smokers had a higher prevalence of CP com-
pared with nonsmokers (P ¼ 0.006).
Alcohol consumption was associated with
a lower prevalence of CP (P ¼ 0.001). Sedentary
respondents had a higher prevalence of CP
than did those considered active (P ¼ 0.037).
Central obesity was shown as being associated
with CP (P < 0.001). There was no association
observed regarding income and skin color
variables.

Table 1
Unadjusted Regression Analysis of Factors Associated With CP (N ¼ 1597)
Variables CP, n (%) PR 95% CI Pa

Sex <0.001
Male 152 (28.4) 1.00
Female 524 (49.4) 1.74 1.46e2.07
Age (years) <0.001
18e29 154 (26.9) 1.00
30e39 132 (39.4) 1.46 1.17e1.82
40e49 130 (50.4) 1.87 1.47e2.37
$50 260 (60.2) 2.23 1.78e2.80
Skin color 0.285
Brown 346 (43.1) 1.00
White 168 (38.9) 0.90 0.78e1.03
Black 162 (44.7) 1.03 0.87e1.22
Educational level (years) <0.001
#8 276 (53.4) 1.00
9e11 325 (40.2) 0.75 0.66e0.84
$12 75 (27.6) 0.51 0.39e0.67
Income 0.293
Low 429 (44.5) 1.00
Average 178 (39.5) 0.88 0.74e1.05
High 69 (37.7) 0.84 0.62e1.15
Marital status <0.001
Married/consensual union 372 (46.0) 1.00
Single 170 (30.4) 0.66 0.57e0.78
Divorced/widowed 134 (58.8) 1.27 1.08e1.50
Occupational status <0.001
Active 303 (38.5) 1.00
Retired/license 131 (56.2) 1.45 1.23e1.71
Unemployed 242 (41.9) 1.08 0.93e1.26
Smoking 0.006
Smoker 85 (42.3) 1.00
Former smoker 127 (52.3) 1.23 1.01e1.51
Nonsmokers 464 (40.2) 0.95 0.75e1.19
Alcohol consumption 0.001
No 542 (45.6) 1.00
Yes 134 (32.8) 0.72 0.61e0.84
Physical activity 0.037
Active 147 (36.3) 1.00
Sedentary 529 (44.4) 1.22 1.01e1.47
Central obesity <0.001
No 199 (33.5) 1.00
Yes 477 (47.6) 1.41 1.18e1.70
CP ¼ chronic pain; PR ¼ prevalence ratio.
a
Poisson regression with robust variance estimate.
244 de Moraes Vieira et al. Vol. 44 No. 2 August 2012

After adjusted analysis, female sex remained CPNC. The same result occurred with the pres-
a factor linked to CP (PR 1.71; 95% CI ence of pain in relation to brushing (Question
1.43e2.04; P < 0.001). The prevalence of CP 4), which was reported by more than half of
was associated with age $30 years (P < 0.001). this group (51.6%).
Education of more than 12 years of schooling The predominant pain sites among those
remained a factor associated with a lower prev- who had CPNC were the lower limbs (51%).
alence of CP (PR 0.66; 95% CI 0.51e0.85; The cephalic region was more frequently af-
P ¼ 0.010). Single respondents had a lower fected in subjects who had CP without neuro-
prevalence of CP than those who were married, pathic characteristics (36%). The second site
divorced, or widowed (PR 0.79; 95% CI most frequently mentioned in the two groups
0.68e0.93; P ¼ 0.024) (Table 2). was the lumbar region, representing 36% of
The distribution of painful sensations ac- the total population with CP.
cording to the DN4 questionnaire is presented Most individuals interviewed reported experi-
in Table 3. All 10 items on the questionnaire encing pain for a period of six months to four
had higher prevalences in individuals with years (51.6%). Pain duration for more than
CPNC compared with the group with CP with- 10 years was significantly higher among those
out neuropathic characteristics (P < 0.001). who had CPNC (P ¼ 0.013). The frequency of
Question 1 of the DN4 addresses pain charac- pain was reported as daily in most people, and
teristics. A burning sensation was the most re- in individuals with neuropathic CP, the preva-
ported characteristic, affecting 26.8% of the lence was more than 50% (P < 0.001) (Table 4).
total population with CP. Regarding the symp- A small proportion of the population reported
toms listed in Question 2, itching had the lowest continuous pain, but among people who had
prevalence among groups. Tingling, pins and CP with neuropathic pain, the prevalence of con-
needles, and numbness were the most frequent tinuous pain reached 27.4% (P ¼ 0.001). When
characteristics among all items covered in this the pain was intermittent, most respondents
questionnaire, representing 80.2%, 87.9%, felt the pain for a period longer than six hours
and 80.2%, respectively, of the individuals who (37.8%).
had CPNC. Hypesthesia to touch and hypesthe- At the time of the interview, 38.9% of the pop-
sia to pinprick, addressed in Question 3, were ulation with CP was feeling mild-to-intense pain,
more frequent only in individuals who had and they represented more than half of the
CPNC group (P < 0.001). In a general context,
Table 2 pain was moderate (57.7%), but 64.8% of people
Adjusted Regression Analysis of Factors reported the worst moment of their pain as
Associated With CP severe.
Variables PR 95% CI Pa The influence of CP in daily life is displayed in
Sex <0.001 Table 5. Most people thought that they could tol-
Male 1.00 erate most of their pain episodes (59.6%). More
Female 1.71 1.43e2.04
than half the population with CP (51.3%) re-
Age (years) <0.001 ported impediments caused by pain. Among
18e29 1.00
30e39 1.39 1.11e1.74 them, inability to go to work was the most re-
40e49 1.69 1.35e2.12 ported difficulty in the group, affecting 29.3%
$50 1.96 1.55e2.48 of people who had CPNC (P < 0.001).
Educational level (years) 0.010 A feeling of sadness was present in more than
#8 1.00
9e11 0.96 0.85e1.08
half of those respondents who had CPNC
$12 0.66 0.51e0.85 (65.6%), and they represented 47.2% of the
Marital status 0.024 total population with CP (P < 0.001). Most fam-
Married/consensual union 1.00 ily members believed in the pain reported by
Single 0.79 0.68e0.93 the patients (93.8%), and there was no statistical
Divorced/widowed 0.95 0.82e1.09
difference between groups. The health-status
CP ¼ chronic pain; PR ¼ prevalence ratio.
a
Poisson regression with stepwise and backward elimination. The
perception reported by most people was regular
variables sex, age, educational level, marital status, occupational sta- (44.7%). Among those who had CPNC, 17.2%
tus, smoking, alcohol consumption, and central obesity had P < 0.20
and were entered into the adjusted analysis. We considered P < 0.10
thought that their health status was poor
necessary to keep the variables in the final regression model. (P < 0.001).
Vol. 44 No. 2 August 2012 Chronic Pain in S~
a o Luı́s, Brazil 245

Table 3
Distribution of Painful Sensations According to the DN4 Questionnaire in Patients With CP
n (%)

CP Without Neuropathic Characteristics Total Population With CP

DN4 Questionnaire CPNC (n ¼ 157) (n ¼ 519) (n ¼ 676)

Question 1: Does the pain have one or more of the following characteristics?
Burning 104 (66.2)a 77 (14.8) 181 (26.8)
Painful cold 96 (61.1)a 40 (7.7) 136 (20.1)
Electric shocks 99 (63.1)a 43 (8.3) 142 (21.0)
Question 2: Is the pain associated with one or more of the following symptoms in the same area?
Tingling 126 (80.2)a 128 (24.7) 254 (37.6)
Pins and needles 138 (87.9)a 212 (40.8) 350 (51.8)
Numbness 126 (80.2)a 130 (25.0) 256 (37.9)
a
Itching 56 (35.7) 17 (3.3) 73 (10.8)
Question 3: Is the pain located in an area where the physical examination may reveal one or more of the following
characteristics?
Hypesthesia to touch 89 (56.7)a 22 (4.2) 111 (16.4)
Hypesthesia to prick 98 (62.4)a 22 (4.2) 120 (17.7)
Question 4: In the painful area, can the pain be caused or increased by
Brushing 81 (51.6)a 10 (1.9) 91 (13.5)
CP ¼ chronic pain; CPNC ¼ CP with neuropathic characteristics.
Chi-square test to verify a difference in prevalence between the groups who had CP with and without neuropathic characteristics.
a
P < 0.001.

The vast majority of respondents (65.1%) a recent study of CP found a prevalence of

used some type of pain medication. The most
frequently used were nonsteroidal anti-
inflammatory drugs (NSAIDs) and analgesics.
The duration of use was quite varied, but the
group that had CPNC used more medications
(79.0%) and had more time of use compared
with the other group (P ¼ 0.003). Regarding
the daily dose used, most respondents used
medication only when they were feeling pain
(41.3%) (Table 6).
We found no differences between the CP
groups with and without neuropathic charac-
teristics regarding the demand for medical
care. We noted that much of the population
still did not know the cause of their pain
(50.9%), although most had sought some ser-
vice for treatment (86.8%). Because of pain,
33.6% of people consulted with a doctor every
six months. A minority of respondents had
consulted with a doctor specializing in pain
(7.0%), and only 5.0% had knowledge of
some specialized clinic for the treatment of
pain. Satisfaction with the treatment received
for pain was present in only 31.8% of the pop-
ulation with CP (Table 7).
Discussion
The prevalence of CP measured was high
compared with other study results. In the U.S.,
34.5%.5 In South Australia, 17.9% of respon-
dents reported CP.8 Another large study in
Europe found that the prevalence ranged
from 12% to 30%.7 However, a study conducted
in Salvador, Brazil, also found a high prevalence
(41.4%).9 The high prevalence of CP found in
this study can be justified because the research
was conducted in a poor region of northeastern
Brazil with high rates of unemployment and
a preponderance of low income, factors that
are associated with CP.
This study was pioneering in CPNC research
in Brazil, the third in the world that used the
DN4 questionnaire in population studies. Lit-
tle is known about the epidemiology of this
type of CP. A study conducted in the U.K.
found a CPNC prevalence of 8% in the popu-
lation.13 In France, the prevalence of CPNC
was 6.9%.12 An important aspect to be taken
into account is that in previous studies, the
DN4 questionnaire was used only as the
DN4-interview version, which is self-reported.
This comprises only seven items. The last
three items, completed with a physical exam,
have not been used in epidemiologic studies
before. The use of the DN4-interview in epide-
miologic studies should be discussed because
the clinical examination is a crucial part of
the diagnostic process for neuropathic pain
and should be included to reduce false-
positive results.
246 de Moraes Vieira et al. Vol. 44 No. 2 August 2012

Table 4
Characterization of CP in the Population
n (%)

CP Without Neuropathic
Variables CPNC Characteristics Total Population With CP P

Time since pain onset 0.013

6 months to 4 years 72 (45.8) 277 (53.4) 349 (51.6)
4e10 years 37 (23.6) 140 (26.0) 177 (26.2)
Above 10 years 48 (30.6) 102 (19.6) 150 (22.2)
Frequency of pain <0.001
Daily 95 (60.5) 209 (40.3) 304 (45.0)
Weekly 26 (16.6) 99 (19.1) 125 (18.5)
Monthly 10 (6.3) 39 (7.5) 49 (7.2)
Variable 26 (16.6) 172 (33.1) 198 (29.3)
Duration of pain 0.001
Intermittenta 114 (72.6) 431 (83.0) 545 (80.6)
Up to 1 hour 21 (18.4) 131 (30.4) 152 (27.9)
1e6 hours 37 (32.5) 150 (34.8) 187 (34.3)
More than 6 hours 56 (49.1) 150 (34.8) 206 (37.8)
Continuous 43 (27.4) 88 (16.0) 131 (19.4)
Pain intensity during the interview <0.001
Mild 38 (24.2) 103 (19.8) 141 (20.8)
Moderate 32 (20.4) 54 (10.4) 86 (12.7)
Intense 13 (8.3) 23 (4.4) 36 (5.4)
Absent 74 (47.1) 339 (65.3) 413 (61.1)
Intensity at the worst moment of pain <0.001
Mild 6 (3.8) 56 (10.8) 62 (9.2)
Moderate 28 (17.8) 148 (28.5) 176 (26.0)
Intense 123 (78.4) 315 (60.7) 438 (64.8)
Pain intensity in the general context <0.001
Mild 21 (13.4) 119 (22.9) 140 (20.7)
Moderate 81 (51.6) 309 (59.6) 390 (57.7)
Intense 55 (35.0) 91 (17.5) 146 (21.6)
Total 157 (100.0) 519 (100.0) 676 (100.0)
CP ¼ chronic pain; CPNC ¼ CP with neuropathic characteristics.
Chi-square test to verify a difference in prevalence between the groups who had CP with and without neuropathic characteristics.
a
This variable was subdivided according to the time of referred pain.

The lack of studies concerning CPNC is
mainly the result of the difficulty in diagnosing
CPNC. From a research perspective, recruiting
large enough patient populations with definite
neuropathic pain may present a problem.
Additionally, the need to recruit only ‘‘pure
patients’’ may necessitate the use of tests that
are not readily available in many poor coun-
tries, such as Brazil.32,33 The emergence of
the DN4, a questionnaire that is easy to under-
stand for people with low educational levels,
facilitated the development of neuropathic
pain research in Brazil.
Factors associated with the prevalence of CP
were similar to those seen in studies in several
countries. In the U.S., the prevalence of CP
was higher in women (34.3%) than in men
(26.7%).5 In Hong Kong, about 40% of
women reported CP.34 In Canada, CP affected
31% of women.35 Aside from social and
psychological factors, women also have the
influence of biological mechanisms, mainly
hormonal, predisposing them to CP.36
Increase in age was a factor strongly associ-
ated with CP; prevalence increased in older in-
dividuals. Several studies have found similar
results.6,9,35,37 However, a study conducted in
Hong Kong found a higher prevalence of CP
in those aged 40e49 years.34 In Denmark,
the prevalence in women increased until the
age of 65 years and then declined.2 It is known
that increasing age is associated with the emer-
gence of noncommunicable diseases and in-
juries, a fact that causes an increase in CP.38
An education of more than 12 years has been
associated with a lower prevalence of CP, as de-
scribed by some authors.2,8,39 However, other
studies have found no such association.5,9 In
Vol. 44 No. 2 August 2012 Chronic Pain in S~
a o Luı́s, Brazil 247

Table 5
Influence of CP on Daily Life
n (%)

CP Without Neuropathic
Variables CPNC Characteristics Total Population With CP P

How do you tolerate the pain? 0.012

Very much 76 (48.4) 327 (63.0) 403 (59.6)
A little 53 (33.8) 142 (27.4) 195 (28.9)
Cannot tolerate further 28 (17.8) 50 (9.6) 78 (11.5)
Impediments caused by pain <0.001
Fun 17 (10.8) 24 (4.6) 41 (6.1)
Work 46 (29.3) 113 (21.8) 159 (23.5)
Daily activities 43 (27.4) 104 (20.0) 147 (21.7)
Does not disturb 51 (32.5) 278 (53.6) 329 (48.7)
Feeling sad because of pain? <0.001
Yes 103 (65.6) 216 (41.6) 319 (47.2)
No 54 (34.4) 303 (58.4) 357 (52.8)
The family believes the pain you 0.637
feel?
Yes 146 (93.0) 488 (94.0) 634 (93.8)
No 11 (7.0) 31 (6.0) 42 (6.2)
Perception of health status <0.001
Excellent 4 (2.5) 16 (3.1) 20 (2.9)
Very good 4 (2.5) 33 (6.4) 37 (5.5)
Good 36 (22.9) 203 (39.1) 239 (35.4)
Regular 86 (54.9) 216 (41.6) 302 (44.7)
Bad 27 (17.2) 51 (9.8) 78 (11.5)
Total 157 (100.0) 519 (100.0) 676 (100.0)
CP ¼ chronic pain; CPNC ¼ CP with neuropathic characteristics.
Chi-square test to verify a difference in prevalence between the groups who had CP with and without neuropathic characteristics.

Brazil, the lower prevalence of CP in people with
a higher education is probably related to the
fact that people with more education have
greater access to health services and informa-
tion on the prevention and treatment of
diseases.
The single subjects in this study were less af-
fected by CP than married, divorced/separated,
and widowed respondents. Similar results also
have been observed in several studies.2,5,9,34
However, other authors have found no associa-
tion between marital status and CP.8,25 Perhaps
the unmarried subjects have taken greater care
with their health. However, the lack of consen-
sus among studies shows that the relationship
of this variable to CP must be better understood.
According to the DN4, painful sensations were
more common in people who had CPNC. Simi-
larly, in another study, painful sensations were
significantly more frequent in the group with
CPNC.12 The signs and symptoms most fre-
quently reported across studies are burning,
electric shock, numbness, tingling, and pins
and needles.12,18 The complexity and heteroge-
neity of the appearance of unpleasant sensations
experienced by these individuals are worth
noting.
Several studies have found similar results in
related pain sites.34,35,39 In Europe, nearly half
of the population had back pain, and one in
five people had pain in the head and lower
limbs.7 The predominance of CPNC in periph-
eral areas, such as the upper and lower limbs,
also was found in the U.K.13 These sites are
possibly associated with diseases such as diabe-
tes and radicular compression, among others.
The higher pain intensity and longer duration
of pain in people who had CPNC were found in
a U.K. study.13 In Norway, most respondents had
a pain duration of three months to five years.40 In
Europe, only 12% suffered from CP for less than
two years, and 34% reported severe pain.7 People
with CPNC have greater pain intensity and suffer
longer, and their treatment is poorly responsive
to conventional analgesics.33
It is very difficult to tolerate pain and its influ-
ence on daily life. In Europe, only 18% of re-
spondents thought they tolerated pain, and
one in four people said that pain influenced
their work situations.7 In Hong Kong, 12% of
248 de Moraes Vieira et al. Vol. 44 No. 2 August 2012

Table 6
Characterization of the Population With CP on Use of Medicines
n (%)

CP Without Neuropathic
Variables CPNC Characteristics Total Population With CP P

Type of medication used for pain 0.002

NSAIDs 54 (34.4) 108 (20.8) 162 (24.0)
Analgesics 55 (35.0) 167 (32.2) 222 (32.9)
Corticosteroids 2 (1.3) 7 (1.4) 9 (1.3)
Psychotropic 4 (2.6) 11 (2.1) 15 (2.2)
Other 9 (5.7) 23 (4.4) 32 (4.7)
Do not use 33 (21.0) 203 (39.1) 236 (34.9)
Time of medication use (years) 0.003
<1 27 (17.2) 78 (15.0) 105 (15.5)
1e4 45 (28.7) 128 (24.7) 173 (25.6)
4e10 25 (15.9) 65 (12.5) 90 (13.3)
>10 27 (17.2) 45 (8.7) 72 (10.7)
Do not use 33 (21.0) 203 (39.1) 236 (34.9)
Daily dose used 0.004
Only when there is pain/once 73 (46.5) 206 (39.7) 279 (41.3)
a day
Twice a day 32 (20.4) 73 (14.1) 105 (15.5)
Three times a day 14 (8.9) 24 (4.6) 38 (5.7)
Four times a day 3 (1.9) 6 (1.2) 9 (1.3)
Other 2 (1.3) 7 (1.3) 9 (1.3)
Do not use 33 (21.0) 203 (39.1) 236 (34.9)
Total 157 (100.0) 519 (100.0) 676 (100.0)
CP ¼ chronic pain; CPNC ¼ CP with neuropathic characteristics.
Chi-square test to verify a difference in prevalence between the groups who had CP with and without neuropathic characteristics.

the population experienced interference with
their work caused by pain.34 CP limits the per-
formance of usual activities. At work, it leads
to decreased productivity and increased absen-
teeism. In addition, leisure time is no longer ex-
perienced, causing great emotional distress.41
A feeling of sadness and depression is fre-
quent in people with CP. In several European
countries, pain also had great emotional im-
pact, and 21% of respondents had a diagnosis
of depression because of pain.7 We were un-
able to diagnose depression in this study. How-
ever, it is known that feelings of sadness can be
associated with depression. The perception of
health status has been described in people
with CP. In Denmark, 79.4% thought that their
health was poor.2 Other authors have observed
that a poor state of health was 10 times more
prevalent in the group of people with CP.6
Physical and emotional suffering decreases
the self-esteem of people with CP, which leads
to a worse perception of their health status.
The most widely used drugs for the treatment
of CP in this study were analgesics and NSAIDs.
Likewise, in Europe and Canada, the most used
medications for pain were analgesics and
NSAIDs.7,35 In Spain, 61% of respondents
used pain medications, of which 93.2% used
analgesics.37 The use of analgesics and NSAIDs
brought to light the high use of these drugs,
which are easily sold in Brazil without
prescriptions.
The demand for medical care and the dissat-
isfaction with treatment is found in many re-
search studies. In the U.S., a population study
showed that one-third of the population with
CP did not yet know the cause of their pain.5
In Europe, only 25% had gone to a pain special-
ist, and 40% were dissatisfied with the treatment
received.7 The reality found in northeastern
Brazil reinforces the need for specialized ser-
vices. Overcrowded services also hinder proper
monitoring. Therefore, CP is often misdiag-
nosed, causing dissatisfaction among patients.
We faced some limitations in this study. The
DN4 questionnaire analyzed only the sensory
tests, and neuropathic pain was classified as
probable. Accurate diagnosis of neuropathic
pain was not possible because of the difficulty
in performing detailed examinations. Another
limitation was that people needed to remember
moments of pain experienced, and these mo-
ments may have been underestimated as a result
of recall bias. At the same time, this study had an
Vol. 44 No. 2 August 2012 Chronic Pain in S~
a o Luı́s, Brazil 249

Table 7
Characteristics of the Demand for Medical Care in the Population With CP
n (%)

CP Without Neuropathic
Variables CPNC Characteristics Total Population With CP P

Know the cause of pain 0.294

Yes 70 (44.6) 262 (50.5) 332 (49.1)
No 87 (55.4) 257 (49.5) 344 (50.9)
Searched for any medical service 0.362
to treat pain
Yes 139 (88.5) 448 (86.3) 587 (86.8)
No 18 (11.5) 71 (13.7) 89 (13.2)
Frequency of visits because of pain 0.615
Weekly 6 (3.9) 19 (3.7) 25 (3.7)
Once a month 28 (17.8) 71 (13.7) 99 (14.6)
Every 6 months 54 (34.4) 173 (33.3) 227 (33.6)
Not consulted 41 (26.1) 160 (30.8) 201 (29.7)
Other 28 (17.8) 96 (18.5) 124 (18.4)
Consultation with a pain specialist 0.161
Yes 7 (4.5) 40 (7.7) 47 (7.0)
No 150 (95.5) 479 (92.3) 629 (93.0)
Know any pain clinic 0.241
Yes 11 (7.0) 23 (4.0) 34 (5.0)
No 146 (93.0) 496 (96.0) 642 (95.0)
Satisfaction with the treatment 0.583
received for pain
Yes 47 (29.9) 168 (32.4) 215 (31.8)
No 92 (58.6) 280 (53.9) 372 (55.0)
Untreated 18 (11.5) 71 (13.7) 89 (13.2)
Total 157 (100.0) 519 (100.0) 676 (100.0)
CP ¼ chronic pain; CPNC ¼ CP with neuropathic characteristics.
Chi-square test to verify a difference in prevalence between the groups who had CP with and without neuropathic characteristics.

appropriate methodological approach, being CPNC. CP had a negative influence on people’s

the first population study in Brazil and the third
in the world to deal with chronic neuropathic
pain using the DN4 questionnaire. This study
brought knowledge of CPNC to a place never
studied before and contributed to the epidemi-
ology of CPNC internationally. In Brazil, we can
implement more specialized services. Strategies
in health policy also can be undertaken to train
health professionals and improve patient care.
Further studies are needed to advance our
understanding of the epidemiology of CP with
and without neuropathic characteristics in
Brazil.
In summary, this study showed a high preva-
lence of CP with and without neuropathic char-
acteristics in the population of S~ao Luı́s, Brazil,
compared with other studies. Female sex and
age $30 years were associated with an increased
prevalence of CP, and education $12 years with
a reduction in the prevalence of CP. The lower
limbs and the cephalic region were the pain
sites most frequently cited. Pain intensity and
duration of pain were greater in people with
daily lives, especially regarding work. A feeling
of sadness because of pain was present in
much of the population. Most respondents
did not know the cause of their pain, despite
their demand for medical care. Few people
had consulted with a pain specialist. Dissatisfac-
tion with the treatment they received was re-
ported in more than half the population.
Disclosures and Acknowledgments
This work had financial support from
FAPEMA (Foundation for Research and Techno-
logical Development of the State of Maranh~ao)
and CNPq (National Council for Scientific
and Technological Development). The authors
declare no conflicts of interest.
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