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Original article
Relationship between sleep quality and pain intensity in patients with chronic low back pain
Andi Kurnia Bintang
Corresponding author
, Ivan Santosa, Yudy Goysal, Muhammad Akbar, Susi Aulina
Department of Neurology, Faculty of Medicine, Hasanuddin University, Makassar, Indonesia
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Relationship between Sleep Quality &#40;PSQI score&#41; and Pain Intensity &#40;VAS score&#41; in Chronic LBP patients&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Sleep is defined by the Sleep Disorders Management Guide &#40;2017&#41; by the Sleep Disorders Study Group of the Indonesian Neurologist Specialist Association &#40;PERDOSSI&#41;&#46; Sleep is defined by the Sleep Disorders Management Guide &#40;2017&#41;&#44; the Sleep Disorders Study Group of the Indonesian Neurologist Specialist Association &#40;PERDOSSI&#41; is a reversible decrease in consciousness that is a physiological and recurrent form&#44; usually&#44; a decline in cognitive function globally&#44; so the brain does not respond to surrounding stimuli&#46; The function of sleep can be seen by the fact that people spend about a third of their lives sleeping&#46; Sleep quality has several components that involve a variety of domains&#44; including assessments of sleep duration&#44; sleep latency&#44; sleep efficiency&#44; sleep dysfunction&#44; and the use of sleeping pills&#44; if one or more of the disrupted domains will result in decreased sleep quality&#46; Poor sleep quality has been associated with increasing age&#44; low socioeconomic status&#44; poor general health&#44; poor lifestyle behavior&#46; Changes in terms of quality&#44; quantity&#44; and sleep patterns cause sleep disturbance&#46; Sleep disorders that occur continuously and repeatedly are important predisposing factors for the development of chronic diseases&#44; such as heart disease&#44; diabetes mellitus&#44; obesity&#44; depression&#44; cancer&#44; stroke&#44; chronic back pain&#44; and decreased quality of life&#46; Sleep disturbance is proven to increase the stress response so that it can delay the healing process&#44; causing sequelae that are detrimental to the cardiovascular system&#44; metabolism&#44; and endocrine&#46; Moreover&#44; it can cause hyperalgesia and contribute to the dysregulation of emotional reactivity&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">1&#8211;6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In the United States&#44; there are 50&#8211;70 million adults who have sleep disorders with the proportion of insomnia of 6&#8211;10&#37; and sleep apnea of 10&#8211;25&#37;&#46; The Center on Sleep Disorders Research estimates that 38&#44;000 deaths occur per year for cardiovascular cases due to sleep disorders&#46; Another study conducted in the Netherlands with a total of 20&#44;000 patients aged 12 years or older showed an alarming prevalence&#44; with 21&#46;2&#37; of men and 33&#46;2&#37; of women having some type of sleep disorder&#46; <a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">3&#44;7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Based on the Alsaadi et al&#46; study&#44; data for 1936 patients were taken from 13 other author studies between 2001 and 2009&#44; found the prevalence of sleep disorders in patients with low back pain by 58&#46;9&#37;&#46; Another study conducted by Franca et al&#46;&#44; in 51 patients with chronic low back pain found 82&#46;35&#37; of patients with sleep disorders&#46; According to research conducted by Donoghue et al&#46;&#44; Mentioned that patients with chronic low back pain &#40;chronic NPB&#41; have significantly poor sleep quality&#44; both subjectively and objectively&#46; This study also showed a statistically significant relationship between low back pain with disability levels and subjective sleep quality&#46; <a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Sleep disturbance has a considerable economic impact&#46; The economic impact of the annual cost of treating moderate-severe sleep disorders in the United States is 165 billion US dollars&#44; far higher than other non-communicable diseases such as heart failure&#44; stroke&#44; hypertension&#44; asthma &#40;20&#8211;80 billion US dollars&#41;&#46; <a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Chronic pain and sleep disorders have a reciprocal relationship and are often found together&#46; Sleep deprivation of eight hours each night is considered to be of reduced sleep duration and can cause long-term disruption in sleep patterns&#46; Reduced sleep duration and poor sleep quality can reduce pain threshold in subjects experiencing pain and mental capacity to cope with pain&#44; and vice versa i&#46;e&#46;&#44; chronic pain can cause a decrease in sleep quality&#46; Sleep disturbance is a common problem that is often found as much as 50&#8211;70&#37; in patients with chronic non-malignant pain&#46; Sleep disorders in patients with chronic pain such as chronic LBP cases&#44; include a variety of factors and are characterized by reduced sleep efficiency&#44; sleep duration&#44; increased sleep latency&#44; daytime sleepiness&#46; Difficulty in starting and maintaining sleep is a symptom that is often found in the general population&#46; Difficulty in going to sleep&#44; maintaining sleep&#44; waking up earlier has been found in chronic pain patients&#46; Chronic LBP is one of the most common symptoms of chronic pain&#46; Decreased slow-wave sleep appears to be responsible for increased sensitivity to pain&#46; <a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">9&#44;10</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Based on several studies that show a relatively high prevalence and sizable economic impact for cases of chronic low back pain with sleep disorders&#44; the researchers aim to study there is a relationship between sleep quality with pain intensity in chronic low back pain patients&#46; Subjective sleep quality was assessed by the Pittsburgh Sleep Quality Index &#40;PSQI&#41;&#46; PSQI is an effective instrument for measuring sleep quality and patterns in adults&#44; which can distinguish between &#8220;poor&#8221; and &#8220;good&#8221; sleep quality through 7 components&#46; Pain intensity assessed by visual analog scale &#40;VAS&#41; score&#44; VAS is an instrument for valid and reliable pain assessment&#46; <a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">11&#44;12</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Method</span><p id="par0035" class="elsevierStylePara elsevierViewall">This study is a type of observational analytic study using cross-sectional studies&#46; The study was conducted at the Neurology Polyclinic of the Wahidin Sudirohusodo Education General Hospital and the Network Hospital&#44; in April&#8211;May 2019&#46; The study population was all patients with chronic low back pain who sought treatment at the Poly Neurology of Wahidin Sudirohusodo Education Hospital and the Network Hospital&#44; in the month of April&#8211;May2019&#46; The sample of this study was chronic low back pain sufferers who met the inclusion and exclusion criteria&#46; The sample obtained by a consecutive sampling method&#46; The inclusion criteria used &#40;1&#41; Patients aged 18&#8211;65 years&#44; both male and female with significant complaints of low back pain that have been experienced for more than 12 weeks &#40;3 months&#41; and visited the Neurology Wahidin Sudirohusodo General Hospital and Network Hospital in April&#8211;May 2019&#46; &#40;2&#41; Samples are willing to be included in this study by giving signatures for informed consent and filling out research questionnaires&#46; Subjects were excluded from the study if&#58; &#40;1&#41; Patients who have other musculoskeletal disorders&#44; &#40;2&#41; Patients with low back pain due to disorders of the visceral organs such as infection and kidney stones&#44; &#40;3&#41; Patients who get serious illnesses&#44; such as malignancy or other complications&#44; &#40;4&#41; Patients who get other intracranial disorders&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Result</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Characteristics of subjects with chronic low back pain</span><p id="par0040" class="elsevierStylePara elsevierViewall">This study was conducted at Wahidin Sudirohusodo General Hospital and Network Hospital in April&#8211;May 2019&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows&#44; a total sample of 29 people was obtained with a higher number of women&#44; 19 of them &#40;65&#46;5&#37;&#41;&#44; and as many as men ten people &#40;34&#46;5&#37;&#41;&#46; Based on education and employment&#44; patients with chronic low back pain who received elementary school education were three people &#40;10&#46;3&#37;&#41;&#44; junior high school as many as three people &#40;10&#46;3&#37;&#41;&#44; high school as many as 11 people &#40;37&#46;9&#37;&#41;&#44; and Diploma-there were 12 scholars &#40;41&#46;3&#37;&#41;&#46; While in terms of work divided into high-risk work and low risk of chronic low back pain&#46; Heavy and rough work is considered as a job with a high risk of 2 people &#40;6&#46;9&#37;&#41;&#44; and low-risk jobs of 27 people &#40;93&#46;1&#37;&#41;&#46; Based on the data&#44; diplomas-scholars have the most chronic low back pain&#44; while many low-risk jobs experience chronic low back pain &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Baseline data of the subjects showed the distribution of the age group&#44; the group of patients aged 21&#8211;40 years as many as eight people &#40;27&#46;6&#37;&#41;&#44; the group of patients aged 41&#8211;60 years as many as 18 people &#40;62&#46;1&#37;&#41;&#44; the group of patients with age &#62;60 years amounted to 3 people &#40;10&#46;3&#37;&#41;&#46; While the duration of pain three months &#8211; 1 year has the most subjects experiencing chronic low back pain as many as 16 people &#40;55&#46;2&#37;&#41;&#44; duration of 1 year-2 year by three people &#40;10&#46;3&#37;&#41;&#44; and duration &#62; 2 years of 10 people &#40;34&#46;5&#37;&#41;&#46; Obese patients with chronic low back pain were 13 people &#40;44&#46;8&#37;&#41;&#44; and not obese as many as 16 people &#40;55&#46;2&#37;&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Based on the Visual Analog Scale &#40;VAS&#41; score&#44; the number of chronic low back pain patients who had mild pain intensity was ten people &#40;34&#46;5&#37;&#41;&#44; the most intensity was moderate pain by 12 people &#40;41&#46;4&#37;&#41;&#44; and severe pain as much as seven people &#40;24&#46;1&#37;&#41;&#46; The PSQI questionnaire assessed the sleep quality of chronic low back pain patients&#46; Chronic low back pain subjects with good sleep quality were six people &#40;20&#46;7&#37;&#41;&#44; while poor sleep quality were 23 people &#40;79&#46;3&#37;&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">The relationship between sleep quality and pain intensity</span><p id="par0055" class="elsevierStylePara elsevierViewall">In <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the number of subject groups of good and poor sleep quality on pain intensity&#46; In subjects with good sleep quality&#44; they have mild pain intensity as many as five people &#40;83&#46;3&#37;&#41;&#44; moderate pain one person &#40;16&#46;7&#37;&#41;&#44; and there were no subjects with severe pain intensity&#46; Whereas the subjects with poor sleep quality have mild pain intensity as many as five people &#40;21&#46;7&#37;&#41;&#44; moderate pain as many as 11 people &#40;47&#46;8&#37;&#41;&#44; and severe pain as many as seven people &#40;30&#46;4&#37;&#41;&#44; with a <span class="elsevierStyleItalic">P</span>-value<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;017&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">Chronic pain that is most often complained of by people is chronic low back pain&#46; The effects of chronic LBP include considerable clinical&#44; social&#44; and economic aspects throughout the world&#46; Chronic LBP has multifactorial causes such as work or physical activity&#44; body mass index associated with obesity&#44; socioeconomic level&#44; and education&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In this study&#44; there was a total sample of 29 people with chronic low back pain&#44; and women had a higher population than men at 65&#46;5&#37; and 34&#46;5&#37;&#46; Chronic LBP consistently has a higher proportion of women than men&#46; One reason for this is that women are shown to have lower pain perception thresholds&#44; and menstrual cycle fluctuations affect pain sensitivity&#44; but if chronic LBP is related to work&#44; the proportion of men is higher&#46; The number of chronic LBP subjects with high-risk work in this study was only two people&#44; and both were male&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Based on the age of patients who experience chronic low back pain&#44; they obtained the age with the largest population between 41 and 60 years that is as many as 18 people&#44; with an average age of 44 years&#46; According to the National Institute of Neurological Disorders and Stroke&#44; the first attack of low back pain occurs at the age of 30&#8211;50 years&#44; and lower back pain becomes more common with age because increasing age is associated with decreased bone density&#44; reduced elasticity and muscle tone&#44; flexibility intervertebral discs are reduced&#46; Chronic LBP subjects were 13 people obese&#44; and 16 people were not obese&#46; Chronic LBP is strongly influenced by obesity because obesity causes an emphasis on the intervertebral discs&#44; the greater cartilage&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">In this study&#44; more subjects were not obese&#44; chronic LBP occurred due to multifactorial influence&#44; so it is possible that the cause of chronic LBP is by other factors&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Based on pain intensity assessed using a visual analog scale &#40;VAS&#41; score&#44; it was found that the most subjects experienced moderate pain intensity as many as 12 people&#46; In contrast&#44; the intensity of mild pain was ten people&#44; and severe pain was seven people&#44; then subjects were also subjected to subjective sleep quality using the PSQI questionnaire&#46; Poor sleep quality with more prevalence than good sleep quality&#44; as many as 23 people and six people&#46; In this study&#44; the prevalence of poor sleep quality was higher than good sleep quality&#46; This number is following several studies that showed a higher prevalence of sleep disorders in patients with chronic low back pain&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The relationship between sleep quality and pain intensity was tested using chi-square and statistically significant&#44; which is <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;017&#46; In the group that had poor sleep quality tended to have moderate and severe pain intensity with a moderate pain population of 47&#46;8&#37;&#44; severe pain 30&#46;4&#37;&#44; and mild pain 21&#46;7&#37;&#46; While the group with good sleep quality tends to have mild and moderate pain intensity with a population of mild pain 83&#46;3&#37; and moderate pain 16&#46;7&#37;&#46; The effect of sleep quality on pain intensity is strengthened by the absence of subjects with good sleep quality who have severe pain intensity&#46; These results are consistent with the study of Marin et al&#46; &#40;2006&#41;&#44; which states that sleep disturbance is a common finding in cases of chronic low back pain&#44; an increase in pain intensity in patients with chronic low back pain influenced by poor sleep quality&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">There is increasing evidence that poor sleep quality affects increasing mortality in certain diseases and susceptibility to infections&#46; Acute and chronic reduction in the duration and quality of sleep has been shown to induce excessive expenditure from proinflammatory cytokines&#46; IL-6 is one of the most critical cytokines that mediate the rapid interaction between the immune system and the central nervous system function&#46; Poor sleep quality causes a significant increase and peak of IL-6 levels the next day&#46; This level can be reduced if the patient sleeps during the day&#46; Exogenous administration of IL-6 has been shown to have a somnogenic effect in studies conducted on experimental animals&#44; besides activating hypothalamic&#8211;pituitary&#8211;adrenal &#40;HPA&#41;&#44; which causes nonphysiological hypercortisolemia during the first hour during sleep which explains the decline in sleep quality&#46; Whereas IL-6 increases pain intensity in neuropathic pain&#46; In this study&#44; subjects with poor sleep quality had moderate to severe pain intensity&#44; while subjects with good sleep quality had mild to moderate pain intensity&#46; Statistically has a significant relationship between sleep quality and pain intensity in chronic LBP cases&#44; with a <span class="elsevierStyleItalic">p</span>-value<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05 &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;017&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">This study is a preliminary study to see the relationship between sleep quality and pain intensity in chronic LBP cases&#46; The limited number of samples and subjective sleep quality measurement tools in the form of PSQI questionnaires are the weaknesses of this study&#46; Subsequent studies can use direct IL-6 serum levels&#44; which influence pain intensity and sleep quality&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conclusion</span><p id="par0100" class="elsevierStylePara elsevierViewall">There is a relationship between sleep quality and pain intensity in chronic low back pain patients&#46; Poor sleep quality is associated with an increase in pain intensity in chronic low back pain patients&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflict of interest</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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        1 => array:2 [
          "identificador" => "xpalclavsec1365122"
          "titulo" => "Keywords"
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        2 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
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        3 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Method"
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          "identificador" => "sec0015"
          "titulo" => "Result"
          "secciones" => array:2 [
            0 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Characteristics of subjects with chronic low back pain"
            ]
            1 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "The relationship between sleep quality and pain intensity"
            ]
          ]
        ]
        5 => array:2 [
          "identificador" => "sec0030"
          "titulo" => "Discussion"
        ]
        6 => array:2 [
          "identificador" => "sec0035"
          "titulo" => "Conclusion"
        ]
        7 => array:2 [
          "identificador" => "sec0040"
          "titulo" => "Conflict of interest"
        ]
        8 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2020-09-24"
    "fechaAceptado" => "2020-10-15"
    "PalabrasClave" => array:1 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1365122"
          "palabras" => array:3 [
            0 => "Sleep quality"
            1 => "PSQI"
            2 => "Pain intensity"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:1 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The general objective of this study was to determine the relationship between sleep quality and pain intensity in chronic low back pain patients&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Method</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Cross-sectional analytic study with consecutive sampling&#46; Chronic patients who met the inclusion criteria at clinic neurology Wahidin Sudirohusodo Makassar&#46; Independent variable&#58; sleep quality&#44; measured by the Pittsburgh Sleep Quality Index &#40;PSQI&#41;score&#46; Dependent variable&#58; pain intensity&#44; measured by the Visual Analog Scale &#40;VAS&#41;score&#46; Data analysis using a Chi-Square test&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Result</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A total of 29 samples met our inclusion criteria and divided into two groups&#44; 23 samples of poor sleep quality&#44; and six samples of good sleep quality&#46; Within the poor sleep quality group&#44; five patients &#40;21&#46;7&#37;&#41; had mild pain intensity&#44; 11 patients &#40;47&#46;8&#37;&#41; had moderate pain intensity&#44; and seven patients &#40;30&#46;4&#37;&#41; had severe pain intensity&#46; In good sleep quality&#44; five patients &#40;83&#46;3&#37;&#41; had mild pain intensity&#44; one patient &#40;16&#46;7&#37;&#41; had moderate pain intensity&#44; and no samples with severe pain intensity&#46; A significant relationship found between sleep quality and pain intensity &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;017&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">There is a relationship between sleep quality and pain intensity&#46; Poor sleep quality is associated with increased pain intensity in patients with chronic low back pain&#46;</p></span>"
        "secciones" => array:4 [
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            "identificador" => "abst0005"
            "titulo" => "Objective"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Method"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Result"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusion"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Peer-review under responsibility of the scientific committee of the Technology Enhanced Medical Education International Conference &#40;THEME 2019&#41;&#46; Full-text and the content of it is under responsibility of authors of the article&#46;</p>"
      ]
    ]
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        "etiqueta" => "Fig&#46; 1"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Relationship between Sleep Quality &#40;PSQI score&#41; and Pain Intensity &#40;VAS score&#41; in Chronic LBP patients&#46;</p>"
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                  <table border="0" frame="\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total sample &#40;<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>29&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Frequence &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Gender</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">65&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Age</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>21&#8211;40 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>41&#8211;60 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#62;60 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Education</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Elementary school&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Junior high school&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Senior high school&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diploma-bachelor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Occupation</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Low risk&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">93&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>High risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Duration</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Three months&#8211;1 year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">55&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#62;1 year&#8211;2 year&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#62;2 year&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No obesity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Good&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">20&#46;7&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">PSQI&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-head\n
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos