Transcranial magnetic stimulation in the treatment of phantom limb pain: a systematic review / Estimulação magnética transcraniana no tratamento da dor do membro fantasma: uma revisão sistemática

Abstract Background Phantom limb pain (PLP) occurs after amputations and can persist in a chronic and debilitating way. Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive neuromodulation method capable of influencing brain function and modulating cortical excitability. Its effectiveness in treating chronic pain is promising. Objective To evaluate the evidence on the efficacy and safety of using rTMS in the treatment of PLP, observing the stimulation parameters used, side effects, and benefits of the therapy. Methods This is a systematic review of scientific articles published in national and international literature using electronic platforms. Results Two hundred and fifty two articles were identified. Two hundred and forty six publications were removed because they were duplicated or met the exclusion criteria. After selection, six studies were reviewed, those being two randomized clinical trials and four case reports. All evaluated studies indicated some degree of benefit of rTMS to relieve painful symptoms, even temporarily. Pain perception was lower at the end of treatment when compared to the period prior to the sessions and remained during patient follow-up. There was no standardization of the stimulation parameters used. There were no reports of serious adverse events. The effects of long-term therapy have not been evaluated. Conclusion There are some benefits, even if temporary, in the use of rTMS to relieve painful symptoms in PLP. High-frequency stimulation at M1 demonstrated a significant analgesic effect. Given the potential that has been demonstrated, but limited by the paucity of high-quality studies, further controlled studies are needed to establish and standardize the clinical use of the method.

Resumo Antecedentes A dor do membro fantasma (DMF) ocorre após amputações e pode persistir de forma crônica e debilitante. A estimulação magnética transcraniana repetitiva (EMTr) é um método de neuromodulação não invasivo capaz de influenciar a função cerebral e modular a excitabilidade cortical. Sua eficácia no tratamento da dor crônica é promissora. Objetivo Avaliar as evidências sobre a eficácia e segurança do uso da EMTr no tratamento da DMF, observando os parâmetros de estimulação utilizados, efeitos colaterais e benefícios da terapia. Métodos Trata-se de uma revisão sistemática de artigos científicos publicados na literatura nacional e internacional utilizando plataformas eletrônicas. Resultados Foram identificados 252 artigos. Duzentas e quarenta e seis publicações foram removidas por estarem duplicadas ou atenderem aos critérios de exclusão. Após a seleção, foram revisados seis estudos, sendo dois ensaios clínicos randomizados e quatro relatos de caso. Todos os estudos avaliados indicaram algum grau de benefício da EMTr no alívio dos sintomas dolorosos, mesmo que temporariamente. A percepção da dor foi menor ao final do tratamento quando comparada ao período anterior às sessões e permaneceu durante o acompanhamento do paciente. Não houve padronização dos parâmetros de estimulação utilizados. Não houve relatos de eventos adversos graves. Os efeitos da terapia a longo prazo não foram avaliados. Conclusão Existem alguns benefícios, mesmo que temporários, no uso da EMTr para alívio dos sintomas dolorosos na DMF. A estimulação de alta frequência em M1 demonstrou um efeito analgésico significativo. Dado o potencial demonstrado, mas limitado pela escassez de estudos de alta qualidade, são necessários mais estudos controlados para estabelecer e padronizar o uso clínico do método.

Prevalence and psychological repercussion of phantom breast syndrome in women undergoing mastectomy: a systematic review

Breast cancer is the most common cancer among women in the world and the leading cause of death among Brazilian women. The presence of phantom breast syndrome (PBS) is one of the possible postoperative complications and may reach prevalences of up to 53% among mastectomized women. This study assessed the scientific evidence regarding the presence of PBS and its psychological repercussions in women undergoing mastectomy. This is a systematic review of observational studies based on the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. The methodological quality of the studies and the level of scientific evidence were assessed using the Newcastle-Ottawa Scale and the Grading of Recommendations Assessment, Development and Evaluation. A total of 95 articles were identified, but only 11 met the eligibility criteria. The outcomes of the presence of PBS and psychological repercussion were evaluated in 2,160 and 1,996 patients, respectively. It was found that the prevalence of PBS varies according to age, being on average 28% and reaching up to 50% in women under 80 years of age. This phenomenon can occur from three months to six years after amputation, tending to regress over time. Anxiety, depression, and sleep disorders are the most prevalent psychological effects (35.8%, 31.5%, and 29.2%, respectively). The studies presented strong scientific evidence of PBS and moderate evidence of psychological repercussions associated with this context.

Phantom sensation and quality of life among patients with lower-limb amputations in the region of Juiz de Fora, Minas Gerais: a cross-sectional study / Qualidade de vida e sensação fantasma em pacientes amputados em membro inferior da região de Juiz de Fora, Minas Gerais: um estudo transversal

ABSTRACT. An amputation is an irreversible event that causes social, psychological, and functional consequences that reduces the quality of life of the amputee. Phantom pain generally is reported by 50 to 80% of amputees. Objective: To describe the pain and phantom sensation and quality of life among lower-limb amputees. Methods: This was a cross-sectional study carried out in the region of Juiz de Fora, state of Minas Gerais, Brazil. Inclusion criteria were being a patient in one of two hospitals in the region at the time of the interview and having at least one lower-limb amputation. A total of 20 amputees were included in the analysis. The interview questionnaire had items adapted from the Groningen Questionnaire Problems After Leg Amputation - describing the frequency and discomfort of phantom pain and sensation, causes and the level of the amputation, as well as the WHOQOL-BREF, for assessing quality of life. Results: Most participants were women (55%) and had a mean age of 55.6 years (SD=14.8). Femoral amputation was the most prevalent (65%), and diabetes (40%) was the main reason for amputation. 29% of amputees classified the phantom pain as moderate or severe, and 15% claimed daily frequency of this phenomenon. As for phantom pain, only 6% stated daily frequency. The mean quality of life was 4.1 (SD=1.1, five score means very satisfied), the physical domain of quality of life had the lowest mean (3.4, SD=0.7). Conclusions: Phantom sensation and pain were prevalent among lower-limb amputees who were, in general, less satisfied with their physical domain of quality of life.

RESUMO. A amputação é um procedimento irreversível que gera consequências sociais, psicológicas e funcionais. A dor do membro fantasma ocorre entre 50 e 80% dos amputados, apresentando implicações na qualidade de vida. Objetivo: Avaliar a sensação, dor fantasma e qualidade de vida entre pacientes amputados. Métodos: Trata-se de um estudo transversal retrospectivo realizado na região de Juiz de Fora, Minas Gerais, Brasil. Os critérios de inclusão foram possuir pelo menos uma amputação de membro inferior e ser paciente de um dos hospitais referência para região. Vinte participantes foram incluídos nas análises. O questionário da pesquisa consistiu em itens, adaptados do Groningen Questionnaire Problems After Leg Amputation, que descrevem frequência e incômodo da sensação fantasma, dor fantasma, causas e nível da amputação, e questões sobre os tratamentos além do questionário qualidade de vida WHOQOL-BREF. Resultados: A maioria dos participantes era do sexo feminino (55%) com idade média de 55,6 (DP=14,8) anos. A maior frequência de amputação foi transfemural (65%), e o principal motivo da amputação foi o diabetes mellitus (40%). Com relação ao incômodo da sensação fantasma, 29% a classificou como moderado ou severa, e 15% alegou frequência diária desse fenômeno. Quanto {a dor fantasma, apenas 6% afirmou frequência diária. A qualidade de vida média dos participantes foi de 4,1 (DP=1,1) em 5 (cinco significa muito satisfeito), de acordo com a primeira questão do WHOQOL-BREF; o domínio físico apresentou a menor média 3,4 (DP=0,7). Conclusão: A sensação e dor fantasmas foram prevalentes nos entrevistados que apresentaram menor satisfação com o domínio físico da qualidade de vida.

Phantom eye syndrome. Case report / Síndrome de ojo fantasma. Reporte de caso

Abstract A frequent complication after limb amputation is the appearance of phantom limb syndrome, a phenomenon that has also been studied in the amputation of different body parts. Cases reported in relation to ophthalmologic surgery are few and evidence is limited in terms of specific management, which makes this a very important study. We report the case of a patient diagnosed with phantom eye syndrome in the post-operative period of an orbital exenteration surgery. A comprehensive approach was taken with multimodal symptom management, including intervention treatment. Significant improvement regarding the pain was achieved; however, non-painful phantom sensations persisted. Upon reviewing the available literature on the subject, its pathophysiology is not fully elucidated. Its incidence is highly variable, as well as the symptoms' appearance. The presence of headache and eye pain prior to surgery seem to be risk factors. Climate and psychological stress are exacerbating factors of the symptomatology. No high-quality evidence was found in terms of management guidelines, with the use of antidepressants, anticonvulsants and opioids being the most recommended. Interventional management is an option according to the characteristics of the pain and associated symptoms.

Resumen Una complicación frecuente luego de la amputación de alguna extremidad es la aparición del síndrome de miembro fantasma, fenómeno que también se ha descrito en la amputación de diferentes partes del cuerpo. Los casos reportados en relación con cirugía oftalmológica son pocos y la evidencia es limitada en cuanto a manejo específico, lo cual justifica la descripción de este caso de interés. Reportamos el caso de una paciente a quien se diagnosticó síndrome de ojo fantasma en el periodo posoperatorio de una cirugía de exenteración orbitaria. Se realizó un enfoque integral con manejo multimodal de los síntomas, incluyendo tratamiento intervencionista. Se logró una notable mejoría del dolor; sin embargo, las sensaciones fantasma no dolorosas persistieron. Al revisar la literatura disponible sobre el tema, la fisiopatología no está totalmente dilucidada. La incidencia es muy variable, así como el tiempo de aparición de los síntomas. La presencia de cefalea y dolor ocular previos a la cirugía parecen ser factores de riesgo. El clima y el estrés psicológico son factores exacerbantes de la sintomatología. No se encontró evidencia de alta calidad en cuanto a pautas de manejo, siendo lo más recomendado el uso de antidepresivos, anticonvulsivantes y opioides. El manejo intervencionista es una opción de acuerdo a las características del dolor y síntomas asociados.

Effect of Myofascial Trigger Points Electric Stimulation on Phantom Limb Pain after Lower Limb Amputation / 中国康复理论与实践

Objective:To explore the clinical efficacy of myofascial trigger point electric stimulation based on mirror therapy on phantom limb pain after lower limb amputation. Methods:From May to November, 2020, 50 patients with phantom limb pain after lower limb amputation were randomly divided into control group (n = 25) and experiment group (n = 25). Both groups accepted mirror therapy, while the experiment group received myofascial trigger point electric stimulation before mirror therapy, for four weeks. They were assessed with short-form of McGill Pain Questionnaire (SF-MPQ), Pittsburgh Sleep Quality Index (PSQI), Hamilton Anxiety Scale (HAMA), Timed 'Up & Go' Test (TUGT) and 6-minute walk test (6MWT) before and after treatment. Results:All the indexes improved in both groups after treatment (|t| > 8.210, P < 0.001), and improved more in the experiment group than in the control group (|t| > 5.103, P < 0.001), except the present pain intensity of SF-MPQ. Conclusion:Mirror therapy is effective on phantom limb pain after lower limb amputation in terms of pain, sleep, anxiety and walking, and the effect could be stronger after myofascial trigger point electric stimulation.

Prevention and control of chronic post-amputation pain of extremities: systematic review / Prevenção e controle da dor crônica pós-amputação de extremidades: revisão sistemática

ABSTRACT BACKGROUND AND OBJECTIVES: Post-amputation pain is very frequent and can become chronic in almost 85% of the cases. The objective of this study was to conduct a systematic review concerning the evidence about the measures for the control or remission of chronic pain in the stump or phantom limb in adults and the elderly after extremity amputation. CONTENTS: The search was conducted in the databases Pubmed, Mendeley, Livivo, and Science Direct. Additional searches were performed at ClinicalTrial.gov, Google Scholar, and in the references of the selected articles. Two independent reviewers performed the screening of the studies as well as the data extraction and synthesis. The Cochrane Collaboration Risk of Bias Tool was used to analyze the risk of bias, and four articles were identified. Two articles on pharmacological prevention strategies and two articles on non-pharmacological treatment. The risk of bias was low for the pharmacological approach, and uncertain or high for the non-pharmacological. CONCLUSION: The findings suggest a protective effect of preventive pharmacological therapies, epidurally, in combination with bupivacaine and fentanyl or added to calcitonin, in the perioperative period. Promising data are also presented for non-pharmacological therapies for pain control, phantom motor execution and gradual motor images. However, caution is necessary due to the risk of bias and considering the number of studies that answer the research question. Additional studies are suggested to strengthen the evidence, especially with quantitative analysis.

RESUMO JUSTIFICATIVA E OBJETIVOS: A dor pós-amputação tem alta prevalência, podendo tornar-se crônica em até 85% dos casos. O objetivo deste estudo foi analisar as evidências acerca de medidas para o controle ou remissão da dor crônica no coto ou membro fantasma em adultos e idosos com amputação de extremidades. CONTEÚDO: Realizaram-se buscas nas bases Pubmed, Mendeley, Livivo e Science Direct. Buscas adicionais foram realizadas na página eletrônica ClinicalTrial.gov, Google Scholar e listas de referências dos artigos selecionados. A triagem dos estudos, bem como a extração e síntese dos dados, foi realizada por dois revisores independentes. A análise do risco de viés foi feita pela Cochrane Collaboration Risk of Bias Tool, sendo identificados quatro estudos. Dois sobre estratégias de prevenção farmacológica, e dois sobre estratégias de tratamento não farmacológico. O risco de viés foi baixo para as abordagens farmacológicas, e incerto ou alto para as abordagens não farmacológicas. CONCLUSÃO: Os achados sugerem efeito protetor das terapias farmacológicas preventivas, por via peridural, em combinação de bupivacaína e fentanil ou somados à calcitonina, no período perioperatório. Dados promissores também são apresentados para as terapias não farmacológicas de controle da dor, execução motora fantasma e imagens motoras gradativas. Porém, é necessário prudência devido ao risco de viés e considerando a quantidade de estudos que respondem a pergunta de pesquisa. Sugerem-se estudos adicionais para fortalecer as evidências, especialmente com análise quantitativa.

Multimodal intrathecal therapy for phantom limb pain: a report of 2 cases / Terapia intratecal multimodal para tratamiento de dolor de miembro fantasma: Reporte de dos casos

Abstract Introduction: Phantom limb pain (PLP) is a chronic debilitating condition, frequently observed in amputees. At present, there is no standard treatment, and its optimal management requires a multidisciplinary approach in which minimally invasive treatment should be considered in more complex cases. Objective: To report successful treatment of 2 cases of PLP treated with ziconotide as part of multimodal intrathecal management. Materials and methods: Descriptive, retrospective case report developed in a multimodal pain treatment unit. Results: A total of 2 cases of patients with diagnosis of PLP refractory to medical therapy, treated with intrathecal multimodal therapy, are presented. Their favorable course, with 50% pain reduction, is described. Conclusion: Implantation of infusion systems for administration of intrathecal analgesia with ziconotide at the cervical and supraspinal level proved to be effective in the described cases; this technique should be evaluated in specific trials for the treatment of PLP refractory to other therapies.

Resumen Introducción: El dolor de miembro fantasma es una condición crónica debilitante, frecuentemente observada en pacientes amputados. En la actualidad carece de un estándar de tratamiento. Su óptimo manejo requiere un abordaje multidisciplinario en el que el tratamiento mínimamente invasivo debe ser considerado en los casos más complejos. Objetivo: Reportar el éxito obtenido en dos casos de dolor de miembro fantasma tratados mediante ziconotida, como parte del manejo multimodal intratecal. Materiales y métodos: Se trata de un reporte de casos, descriptivo y retrospectivo, desarrollado en una unidad de tratamiento integral del dolor. Resultados: Se presentan dos casos de pacientes con diagnóstico de dolor de miembro fantasma refractario a tratamiento médico, tratados con terapia multimodal intratecal; se describe su evolución favorable después del inicio de la terapia, con una reducción de dolor del 50%. Conclusiones: La implantación de sistemas de infusión para administración de analgesia intratecal con ziconotida a nivel cervical y supraespinal demostró ser eficaz en los casos descritos; esta técnica debe ser evaluada en ensayos específicos para el tratamiento del dolor de miembro fantasma en miembros superiores, refractario a otras terapias.

Neuropathic pain and prognosis of a dog submitted to limb amputation after diagnosis of soft tissue sarcoma - case report / Dor neuropática e prognóstico de um cão submetido à amputação de membro após diagnóstico de sarcoma de tecidos moles - relato de caso

Neuropathic pain occurs when there is a lesion or a dysfunction of the nervous system. Humans and veterinary patients may develop neuropathic pain, but in veterinary it is not often reported probably because of its mistaken diagnosis. A canine patient was admitted to the Veterinary Hospital of UNESP-Jaboticabal-SP, Brazil with a nodule on the left thoracic limb. The nodule was surgically removed, and histopathological analysis demonstrated the tumor was a soft tissue sarcoma (STS) and the margins were not clean. Based on the patient's health condition and the lack of suitable equipment, the next procedure was limb amputation. The patient received analgesic medication in the post-surgery period; nevertheless, clinical signs of neuropathic pain were present, such as compulsive licking and other behavioral disorders. Medications were administered for forty days, but clinical signs ceased only when replaced with a tryciclic antidepressant drug, Amitriptyline. Therapeutic management of the patient in this report can be considered effective, since five years after the end of the treatment there was no recurrence or presence of metastasis.(AU)

A dor neuropática ocorre quando há uma lesão ou disfunção do sistema nervoso. Tanto pacientes humanos quanto veterinários podem desenvolver a dor neuropática, mas na medicina veterinária ela é pouco relatada provavelmente por não ser corretamente diagnosticada. Um paciente canino foi atendido no Hospital Veterinário da Unesp-Jaboticabal, SP, Brasil, com um nódulo em membro torácico esquerdo. O nódulo foi removido cirurgicamente, e o exame histopatológico evidenciou a presença de sarcoma de tecidos moles (STM) e de margens comprometidas. Baseando-se nas condições de saúde do paciente e na ausência de equipamentos adequados, o próximo procedimento foi a amputação do membro. No pós-cirúrgico, o animal recebeu medicações analgésicas, todavia, mesmo assim, apresentava sinais de dor neuropática, como lambedura compulsiva e outros distúrbios comportamentais. O tratamento para dor aguda se estendeu por 40 dias; no entanto, os sinais clínicos cessaram apenas quando os analgésicos comuns foram substituídos por um medicamento antidepressivo tricíclico, a amitriptilina. O manejo terapêutico do paciente do presente relato pode ser considerado satisfatório, uma vez que, após cinco anos do término do tratamento, não houve recidiva nem presença de metástase.(AU)

Increased white matter diffusivity associated with phantom limb pain

BACKGROUND: We utilized diffusion tensor imaging (DTI) to evaluate the cerebral white matter changes that are associated with phantom limb pain in patients with unilateral arm amputation. It was anticipated that this would complement previous research in which we had shown that changes in cerebral blood volume were associated with the cerebral pain network. METHODS: Ten patients with phantom limb pain due to unilateral arm amputation and sixteen healthy age-matched controls were enrolled. The intensity of phantom limb pain was measured by the visual analogue scale (VAS) and depressive mood was assessed by the Hamilton depression rating scale. Diffusion tensor-derived parameters, including fractional anisotropy, mean diffusivity, axial diffusivity (AD), and radial diffusivity (RD), were computed from the DTI. RESULTS: Compared with controls, the cases had alterations in the cerebral white matter as a consequence of phantom limb pain, manifesting a higher AD of white matter in both hemispheres symmetrically after adjusting for individual depressive moods. In addition, there were associations between the RD of white matter and VAS scores primarily in the hemispheres related to the missing hand and in the corpus callosum. CONCLUSIONS: The phantom limb pain after unilateral arm amputation induced plasticity in the white matter. We conclude that loss of white matter integrity, particularly in the hemisphere connected with the missing hand, is significantly correlated with phantom limb pain.

Frequencia e fatores determinantes da dor do membro fantasma em pacientes amputados assistidos por um centro de reabilitação situado no centro-oeste do Brasil / Frequency and determining factors of phantom limb pain in amputee patients assisted by a rehabilitation center in the Midwest region of Brazil

Objetivo: Este estudo descritivo, longitudinal e prospectivo busca avaliar a frequência de dor do membro fantasma (DMF) em pacientes amputados que são assistidos por um centro de reabilitação assim como verificar a influência do perfil biopsicossocial, uso de tecnologias assistivas, medicamentos e terapias no caráter da DMF. Método: Foram entrevistados 16 indivíduos em dois momentos com intervalo de seis meses no período de Julho/2016 à Agosto de 2017. Como instrumentos de avaliação foram utilizados: questionário semi-estruturado abordando perfil social e clínico, EVA, SF-36 e Questionário de McGill. Os dados foram analisados descritivamente e com os testes T e Pearson. Resultados: Dos participantes, 8 eram do sexo masculino (50%), com idade média de 55,5 anos (DP:15,7), sendo maior parte procedente de Goiânia (75%) e com amputação transfemural (68,7%) de etiologia traumática (56,2). A frequência de DMF foi de 68,5% na primeira entrevista e 50% na segunda. Entre as duas entrevistas, houve diminuição na intensidade da dor relatada pelos indivíduos assim como no índice da dor e número de descritores do McGill e também acréscimo nos domínios do SF36. Não foi observada correlação positiva entre o uso de próteses, medicamentos ou realização de terapias com o quadro álgico dos amputados. Conclusão: A amostra estudada apresentou alta prevalência de dor do membro fantasma. São necessários mais estudos sobre a DMF e seus determinantes a fim de evidenciar seu impacto na vida do amputado.

Objective: This descriptive, longitudinal and prospective study has the objectives to evaluate the frequency of phantom limb pain (PLP) in amputees who are assisted at a rehabilitation center as well as to verify the influence of biopsychosocial profile, use of assistive technologies, medications and therapies for PLP. Method: Sixteen subjects were interviewed twice with an interval of six months between July / 2016 and August 2017. A semi-structured questionnaire addressing social and clinical profile, Visual Analogue Scale (VAS), SF-36 and McGill Questionnaire were the evaluations used in this study. Data were analyzed descriptively and statistically with the student T-test and Pearson correlation. Results: Of the participants, 8 were male (50%), with 55.5 years of age (SD: 15.7). They were mostly from Goiânia (75%) and had transfemoral amputation (68.7%) of traumatic etiology (56.2%). PLP frequency was 68.5% in the first interview and 50% in the second interview. Between the two interviews, there was a decrease in pain intensity reported by individual, decrease in pain index and number of McGill descriptors, as well as increase in the SF-36 domains. No positive correlation was found between the use of prostheses, use of medications or therapies for pain. Conclusion: The patients studied presented a high prevalence of phantom limb pain. Further studies on PLP and its determinants are needed to evidence the impact of PLP on the amputee's daily life.

Phantom limb pain: A literature review / 中华创伤杂志(英文版)

Since the phantom limb sensation was first described by the French military surgeon Ambroise Pare in the 16th century, the number of studies surrounding phantom limb pain has increased every year. Especially in recent decades, scientists have achieved a better understanding of the mechanism and treatment of phantom limb pain. Although many hypotheses have been agreed and many treatments have been proven effective, scientists still do not have a very systematic understanding of the phantom limbs. The purpose of this review article is to summarize recent researches focusing on phantom limb in order to discuss its definition, mechanisms, and treatments.

Pharmaceutical Care for One Patient with Phantom Limb Pain / 中国药师

The clinical pharmacist involved in the treatment of one case of phantom limb pain from the aspects of doctor's order reorganization,dose adjustment of analgesic drugs,pain score monitoring,ADR monitoring and medication education. And significant effects were shown in the drug use safety and the pain improvement in the patient. Therefore,the participation of clinical pharmacist in pain treatment can optimize analgesic effects,detect adverse drug reactions timely and thus obtain more benefits for patients.

Psychotherapies for the treatment of phantom limb pain / Uso de psicoterapias como tratamiento del dolor de miembro fantasma

Abstract Introduction: The phantom limb pain has been described as a condition in which patients experience a feeling of itching, spasm or pain in a limb or body part that has been previously amputated. Such pain can be induced by a conflict between the representation of the visual and proprioceptive feedback of the previously healthy limb. The phantom limb pain occurs in at least 42-90% of amputees. Regular drug treatment of phantom limb pain is almost never effective. Methods: A systematic review of the literature was conducted in Medline and Cochrane using the MESH terms "phantom limb pain" and "psychotherapy", published in the last 10 years, in English and Spanish, finding 49 items. After reviewing the abstracts, 25 articles were excluded for not being related to the objective of the research. Additionally cross references of included articles and literature were reviewed. Objectives: To describe the psychotherapies used in the management of phantom limb pain, their effectiveness and clinical application reported in the literature. Aims: The mechanisms underlying phantom limb pain were initially explained, as were the published studies on the usefulness of some psychotherapies such as mirror visual feedback and immersive virtual reality, visual imagery, desensitisation and reprocessing eye movements and hypnosis. Conclusions: The phantom limb pain is a complex syndrome that requires pharmacological and psychotherapeutic intervention. The psychotherapies that have been used the most as adjuvants in the treatment of phantom limb pain are mirror visual feedback, desensitisation and reprocessing eye movements, imagery and hypnosis. Studies with more representative samples, specifically randomised trials are required.

Resumen Introducción: El dolor de miembro fantasma ha sido descrito como una condición en la que los pacientes experimentan una sensación de prurito, espasmo o dolor en un miembro o parte del cuerpo previamente amputado. Dicho dolor puede ser inducido por un conflicto entre la representación de la retroalimentación visual y propioceptiva del miembro previamente sano. El dolor de miembro fantasma ocurre en al menos 42 al 90% de los amputados. El tratamiento farmacológico regular del dolor del miembro fantasma casi nunca es efectivo. Método: Se realizó una revisión sistemática en las bases de datos Medline y Cochrane usando palabras MESH "phantom limb pain" y "psychotherapy", publicados en los últimos 10 anos, en español e inglés, encontrando 49 artículos. Al revisar los resúmenes, se excluyeron 25 artículos por no ser afines con el objetivo de la investigación. Adicionalmente se revisaron referencias cruzadas de los artículos incluidos y literatura médica. Objetivos: Describir las psicoterapias usadas en el manejo del dolor de miembro fantasma, su efectividad y aplicación clínica reportada en la literatura. Desarrollo: Se explican inicialmente los mecanismos subyacentes al dolor de miembro fantasma y se describen los estudios publicados sobre la utilidad del uso de algunas psicoterapias como la retroalimentación visual con espejo y con realidad virtual inmersiva, imaginería visual, reprocesamiento y desensibilización por movimientos oculares e hipnoterapia. Conclusiones: El dolor de miembro fantasma es un síndrome complejo que requiere intervención farmacológica y psicoterapéutica. Las psicoterapias que más se han usado como coadyuvantes en el tratamiento del dolor de miembro fantasma son la retroalimentación visual con espejo, la desensibilización y reprocesamiento por movimientos oculares, la imaginería y la hipnosis. Se requieren estudios con muestras más significativas, específicamente estudios clínicos aleatorizados.

Hypnosis with medication on resistant phantom limb pain: A case report / 中国心理卫生杂志

The aim of this study was to evaluate the effect and relative factors of hypnosis combing medication on resistant phantom limb pain (PLP).This study presented one case report involving of the use of visualization,hypnotic imagery,suggestions procedures combing venlafaxine in the alleviation of PLP and depression.Visual analogue score (VAS) and Hamilton Rating Scale for Depression-17 items (HAMD17) were used to assess the severity of PLP and depression,which were evaluated at baseline and the end.Existing literature were reviewed.After hypnosis combing medication,PLP and depression were consistently alleviated.Hypnosis may be a useful adjunct to established strategies for the treatment of PLP.

Effect of Protective Analgesia on Incidence of Phantom Limb Pain after Amputation:A Meta-analysis / 中国康复理论与实践

Objective To systemically evaluate the effect of protective analgesia on preventing phantom limb pain(PLP)after amputa-tion.Methods Published articles from the earliest date available to June,2017 were recalled from Cochrane Library,PubMed,Embase,Web of Science,OVID,and Science Direct to collect prospective studies using protective analgesia in perioperative period to prevent PLP after amputation.Two reviewers screened literatures referring to studies according to the inclusion and exclusion criteria,and assessed the quality of them.Data of general information and incidence of PLP in the follow-up period were extracted and analyzed with RevMan 5.3 software. Results Six studies were included with a total of 256 patients in the one-month follow-up period including 127 cases in the protective anal-gesia group(group P)and 129 cases in the control group(group C),a total of 232 patients in the six-month follow-up period including 114 cases in group P and 118 cases in group C,and a total of 118 patients in the twelve-month follow-up period including 58 cases in group P and 60 cases in group C.The incidence of PLP were lower in group P than those in group C in the one-month follow-up period(RD=-0.21, 95%CI[-0.38,-0.04],Z=2.47,P=0.01)and in the six-month follow-up period(RD=-0.28,95%CI[-0.52,-0.05],Z=2.37,P=0.02),and it was not significant in the twelve-month follow-up period(RD=-0.20,95%CI[-0.48,0.09],Z=1.35,P=0.18).Conclusion Protective analge-sia in perioperative period can prevent against PLP after amputation in the recent time,however,it needs further observation in long-term.

Role of NK-1 Receptor in Fos Protein Expression of Anterior Cingulate Cortex Neurons of Mice Induced by Amputation of the Tail Extremity / 中国医科大学学报

Objective To study whether amputation of the tail extremity could induce change of Fos protein expression in mice ACC neurons , and explore the role of NK?1 receptor in the change. Methods Immunohistochemistry technique was adopted to study Fos protein expression change in mice ACC neurons at 0.25 h,0.5 h,1 h,2 h after amputation of the tail extremity 2.5 cm,and also the effect of NK?1 receptor antagonist GR82334(iv)or GR82334(ith)in the change. Results Fos protein expression in mice ACC neurons was significantly increased at 0.25 h,0.5 h after the amputation,and reached its peak at 1 h after the amputation,then started to decrease at 2 h after the amputation. GR82334(iv)com?pletely antagonized the significant augment in Fos protein expression in mice ACC neurons after the amputation ,but the antagonism of GR82334 (ith)was incomplete. Conclusion Amputation of the tail extremity could significantly increase the Fos protein expression of mice ACC neurons in a time?dependent manner. Both peripheral and central NK?1 receptors were involved in the process. However ,there are also central conduction pathways of other receptors and neurotransmitters involved in the significant augment in Fos protein expression in mice ACC neurons after amputa?tion.

Tratamento da dor Fantasma em Pacientes Submetidos à Amputação: Revisão de Abordagens Clínicas e de Reabilitação / Phantom Pain Treatment in Pacients Submitted to Amputation: A Review of Clinical and Rehabilitation Approaches

A dor do membro fantasma é uma sequela comumapós uma amputação, sendo de difícil tratamento. Comprometea aquisição de habilidades e a qualidade de vida dosamputados, o que justifica a definição de uma terapêuticaeficaz. Objetivo: Identificar e descrever intervenções clínicase/ou de reabilitação para o tratamento da dor fantasma empessoas submetidas à amputação. Material e Métodos:Revisão estruturada da literatura de artigos publicados nasbases de dados eletrônicas Pubmed e Bireme de 2003 a2014 (salvo literaturas clássicas), foram aceitos artigoscompletos, disponíveis na íntegra e nos idiomas português,inglês ou espanhol. Resultados: Identificou-se setemodalidades distintas de tratamento para dor fantasma, sendoque, dos oito artigos inclusos, dois abordavam a mesmaterapia física. Portanto, as modalidades terapêuticas foramclassificadas em medidas invasivas associadas ou não àterapia farmacológica (quatro artigos) e terapia física (quatroartigos). Todas as modalidades terapêuticas identificadasna revisão: infusão venosa de lidocaína seguida de bloqueioda cadeia simpática torácica, substituição de terapiafarmacológica pelo uso de bomba intratecal de zicotinotide,uso bloqueio ciático contínuo, uso da gabapentina no préoperatório,terapia da caixa espelho, prática de exercíciosorientados e aplicação da corrente Transcutaneous electricalnerve stimulation demonstraram ser benéficas paradiminuição da dor fantasma. Conclusão: Foram identificadasas medidas terapêuticas mais relatas e utilizadas na práticaterapêutica, sendo: terapia medicamentosa, terapia invasivae terapia física, entretanto, não houve consenso na literaturaconsultada sobre a melhor opção terapêutica no tratamentoda dor fantasma...

Phantom limb pain is a common sequel ofamputation and difficult-to-treat condition. It compromises theamputees’ acquisition of skills and quality of life, whichjustifies the establishment of an effective treatment.Objective: To identify and describe the clinical and/orrehabilitation interventions to treat phantom limb pain in patientswho underwent amputations. Material and Methods: Thiswas a literature review of articles published in the electronicdatabases Pubmed and Bireme between 2003 and 2014(except classical literature). We selected complete scientificpapers available in full in Portuguese, English or Spanish.Results: Seven different types of treatment for phantom limbpain were identified. Two out of the eight papers includedaddressed the same physical therapy approach. Therefore,the therapeutic modalities were classified as invasivemeasures associated or not to pharmacological (four articles)and physical therapies (four articles). All therapeuticmodalities identified in the review were proved to be beneficialin ameliorating phantom pain, as follows: intravenous infusionof lidocaine followed by thoracic sympathetic chain blockage;replacement of the pharmacological therapy by a ziconotideintrathecal injection pump; continuous sciatic blockage; useof gabapentin preoperatively; mirror box therapy; practiceorientedexercises; and application of transcutaneouselectrical nerve stimulation. Conclusion: The most frequentlyreported and used therapeutic measures were drug therapy,invasive therapy and physical therapy. However, there wasno consensus in the literature about the best therapeuticoption to treat phantom limb pain...

Spinal Cauda Equina Stimulation for Alternative Location of Spinal Cord Stimulation in Intractable Phantom Limb Pain Syndrome: A Case Report

Phantom limb pain is a phenomenon in which patients experience pain in a part of the body that no longer exists. In several treatment modalities, spinal cord stimulation (SCS) has been introduced for the management of intractable post-amputation pain. A 46-year-old male patient complained of severe ankle and foot pain, following above-the-knee amputation surgery on the right side amputation surgery three years earlier. Despite undergoing treatment with multiple modalities for pain management involving numerous oral and intravenous medications, nerve blocks, and pulsed radiofrequency (RF) treatment, the effect duration was temporary and the decreases in the patient's pain score were not acceptable. Even the use of SCS did not provide completely satisfactory pain management. However, the trial lead positioning in the cauda equina was able to stimulate the site of the severe pain, and the patient's pain score was dramatically decreased. We report a case of successful pain management with spinal cauda equina stimulation following the failure of SCS in the treatment of intractable phantom limb pain.

Incompletitud corporal en la persona posamputada portadora de dolor de miembro fantasma: estudio cualitativo / Body incompleteness in person amputated carrier phantom limb pain: a qualitative study

Introducción: En el cuerpo se vivencía el mundo, la alegría, el encuentro, la seguridad, el dolor las reacciones anatomofisiológicas inherentemente al cuerpo; se experimenta la afección por el dolor físico y psíquico, con sensaciones corporales de ansiedad, temor y angustia.Materiales y Métodos: Estudio de abordaje cualitativo-descriptivo, exploratorio; como técnica se empleó la entrevista semiestructurada, de los informantes seleccionados se trataba de personas que fueron atendidas en el Hospital General de Durango, México; participaron 12 personas que al ser amputadas debutaron con dolor de miembro fantasma; el soporte teórico estuvo apoyado por la corporeidad de Le Breton.Resultados y Discusión: En la persona con amputación, la relación de él con el mundo se altera, ya que la amputación cambia no sólo la forma de verse a sí mismo, sino también la forma de interactuar con su entorno, su familia, amigos, compañeros y sociedad en general. Conclusiones: Las enfermeras deben fortalecer la relación enfermera/persona para vivir un encuentro real mostrando actitud de empatía, estar siempre ayudando y apoyando. Igualmente, escuchando, comprendiendo y educando, las personas al sentirse cuidadas contribuirán para que sean tratadas como un ser completo y harán que en su cotidiano la experiencia de vivir con el dolor de miembro fantasma se transforme en una condición aceptable y le permita enfrentar mejor su situación.

Introduction: In the body of the world experience, the joy, the meeting, security, inherently the anatomophysiological pain body reactions; the condition for the physical and mental pain, bodily sensations of anxiety, fear and anxiety is experienced. Materials and Methods: A qualitative descriptive, exploratory approach; as semi-structured interview technique was employed, selected informants were people who were treated at the General Hospital of Durango, Mexico; involving 12 people to be amputated debuted with phantom limb pain theoretical support was supported by the corporeality of Le Breton. Results and Discussion: In the amputee, the relationship with the world is altered, and that amputation not only change the way you look to yourself, but also how to interact with their environment, their family, friends, colleagues and society in general. Conclusions: The nurse must strengthen the nurse / person relationship living a real encounter showing attitude of empathy, always there helping, supporting and listening, understanding and educating, as the person feeling care contribute to be treated as a complete and will in their daily experience of living with phantom limb pain is transformed into an acceptable condition allowing you to better cope with their situation.

Vivir con dolor de miembro fantasma: persona postamputada / Living with member phantom pain: person postamputada

Objetivo: Describir el vivir con dolor de miembro fantasma en la persona posamputada. Método: Estudio de abordaje cualitativo-descriptivo, exploratorio; y como técnica se empleó la entrevista semiestructurada, los sujetos participantes residen en el Estado de Durango, México; participaron 12 personas que al ser amputadas debutaron con Dolor de miembro fantasma, el soporte teórico estuvo apoyado con el dolor de Le Breton (1999)21. Resultados: En los discursos de la persona posamputada se evidencian expresiones de una vida sin objetivos, se de terminan a desempeñar el rol de enfermos al considerar su dolor como una tragedia personal o una desviación social que enluta su vida y la de su familia. Consideraciones Finales: La enfermera debe aprender a escuchar el cuerpo enfermo, seguir con atención sus señales y sus expresiones ya sean de alegría, llanto, tristeza, dolor, desagrado, silencio, etc., interpretando lo que trata de comunicar y solicita. Deberá estar atenta y vigilante procurando que el cuerpo-sujeto alivie el dolor físico y el dolor del alma, que se pueda revertir permanente por el resto de su vida, pues vivir con dolor desde el punto de vista fisiopatológico constituye una crisis circunstancial, eventual y controlable que no sucede igual con la enfermedad del alma.

Objective: To describe the live with phantom limb pain in posamputada person. Method: Qualitative Study-descriptive, exploratory approach; and as a semi-structured interview technique was employed, participating subjects residing in the State of Durango, Mexico; involving 12 people to be amputated debuted with painphantom limb the theoretical support was supported with the pain of Le Breton (1999)21 Results: In the discourses of posamputada individual expressions of life without goals is evident, are determined to play the role of patients to consider their pain as a personal tragedy or social deviance that his life and mourns for his family. Final Thoughts: The nurse must learn to listen to the sick body, carefully follow their signals and whether their expressions of joy, sorrow, sadness, pain, disgust, silence, etc; interpreting what is communicating and requests. You must be alert and vigilant care that the body-subject relieve physical pain and the pain of the soul, which can be reversed permanently for the rest of your life, because living with pain from the physiological point of view is a circumstantial eventual crisis and controllable which does not happen with the disease of the soul.