Aspectos Psicológicos do Fenômeno do Membro Fantasma em Pacientes Oncológicos Submetidos à Cirurgia de Amputação: Revisão Integrativa da Literatura / Psychological Aspects of the Phenomenon of the Phantom Limb in Cancer Patients Undergoing Amputation Surgery: Integrative / Literature Review Aspectos Psicológicos del Fenómeno del Miembro Fantasma en Pacientes con Cáncer Sometidos a Cirugía de Amputación: Revisión Integradora de la Literatura

Introdução: Entre os tipos de câncer existentes, estão os tumores ósseos e de tecidos moles. Muitos pacientes acometidos por essas neoplasias são submetidos à cirurgia de amputação e relatam a ocorrência da sensação e/ou dor do membro fantasma. Objetivo: Identificar, sintetizar e discutir estudos realizados acerca dos aspectos psicológicos do fenômeno do membro fantasma em pacientes oncológicos submetidos à cirurgia de amputação. Método: Revisão integrativa da literatura publicada nos últimos 25 anos. Realizou-se a busca de estudos experimentais, ensaios clínicos e revisões de literatura nas bases de dados MEDLINE, LILACS e Embase. Resultados: Foram selecionados sete artigos para compor esta revisão. Três estudos estabeleceram correlações entre os fatores psicológicos e a ocorrência do fenômeno do membro fantasma após a amputação, quatro abordam aspectos psicológicos e emocionais envolvidos na cirurgia de amputação e aspectos psicológicos envolvidos no fenômeno do membro fantasma, entretanto não estabeleceram relações entre eles. Alguns autores defendem a correlação entre os aspectos psicológicos e a ocorrência do fenômeno do membro fantasma em pacientes amputados. Sua explicação neurofisiológica ainda permanece desconhecida pela comunidade científica. Conclusão: O fenômeno do membro fantasma pode sofrer influências de aspectos psicológicos e emocionais provocados pelo adoecimento e seu tratamento. Ressalta-se a necessidade de mais pesquisas sobre o fenômeno em pacientes oncológicos, principalmente, no que refere aos seus aspectos psicológicos, dada a sua relevância no cuidado oncológico

Introduction: Many patients affected by bone and soft tissue tumors, undergo amputation surgery and report the sensation and/or pain of the phantom limb. Objective: Identify, summarize and discuss studies on the psychological aspects of the phantom limb phenomenon in oncological patients who underwent amputation surgery. Method: Integrative review of the literature published in the last 25 years. Experimental studies, clinical trials and literature review were searched in the databases MEDLINE, LILACS and Embase. Results: Seven articles were selected for this review. Three studies established correlations between psychological factors and the occurrence of the phantom limb phenomenon after amputation, four addressed psychological and emotional aspects involved in the amputation surgery and psychological aspects involved in the phantom limb phenomenon, however, they did not establish relationships among them. Some authors defend the correlation between psychological aspects and the occurrence of the phantom limb phenomenon in amputee patients. Its neurophysiological explanation remains unknown to the scientific community. Conclusion: The phantom limb phenomenon can be influenced by psychological and emotional aspects caused by the illness and its treatment. Further studies about the phenomenon in cancer patients are necessary, especially about the psychological aspects, given its relevance in cancer care

Introducción: Entre los tipos de cáncer existentes se encuentran los tumores de huesos y tejidos blandos. Muchos pacientes afectados por estas enfermedades se someten a una cirugía de amputación y notifican la aparición de sensación y/o dolor en el miembro fantasma. Objetivo: Identificar y analizar estudios realizados sobre aspectos psicológicos del fenómeno del miembro fantasma en pacientes oncológicos sometidos a cirugía de amputación. Método: Revisión integradora de la literatura publicada en los últimos 25 años. La búsqueda de artículos se realizó en las bases de datos MEDLINE, LILACS y Embase. Resultados: Se seleccionaron siete artículos para componer esta revisión. Tres estudios establecen correlaciones entre factores psicológicos y la ocurrencia del fenómeno del miembro fantasma después de la amputación, cuatro abordan aspectos psicológicos y emocionales involucrados en la cirugía de amputación y aspectos psicológicos involucrados en el fenómeno del miembro fantasma, sin embargo, no establecen relaciones entre ellos. Algunos autores defienden la correlación entre los aspectos psicológicos y la ocurrencia del fenómeno del miembro fantasma en pacientes amputados. La explicación neurofisiológica sigue siendo desconocida para la comunidad científica. Conclusión: El fenómeno del miembro fantasma puede verse influido por aspectos psicológicos y emocionales provocados por la enfermedad y su tratamiento. Se destaca la necesidad de profundizar en la investigación del fenómeno en pacientes oncológicos, especialmente en sus aspectos psicológicos, dada su relevancia en la atención oncológica

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.

Comportamiento del dolor fantasma en pacientes amputados en Cárdenas. Periodo 2015-2019 / Phantom pain behavior in amputated patients in Cardenas. Period 2015-2019

RESUMEN Introducción: la amputación es un procedimiento quirúrgico y la incapacidad como consecuencia se puede considerar una entidad clínica. Toda respuesta a la amputación es altamente individual. Entre el 40 y 80 % de los amputados manifiestan dolor de la zona amputada o dolor de miembro fantasma. Entre todos los problemas que se pueden presentar tras la cirugía este es uno de los más graves. Objetivo: determinar el comportamiento del dolor fantasma en la población amputada en Cárdenas y la mejoría clínica de los síntomas con los diferentes tratamientos. Periodo comprendido entre 1-1-2015 al 31-12-2019. Materiales y métodos: se realizó un estudio descriptivo de corte transversal en el Hospital General "Julio Miguel Aristegui Villamil" de Cárdenas, en el período comprendido del 1-1-2015 al 31-12-2019. Con el fin de evaluar las variables clínicas y demográficas de pacientes con antecedentes de amputación unilateral de miembro y que acudieron al cuerpo de guardia y/o consultas externas de Ortopedia y Traumatología, de Angiológica y Cirugía Vascular por presentar dolor fantasma. Resultados: con respecto a la mejoría de los síntomas y del propio dolor fantasma, según la escala de evaluación del dolor (EVA), se demostró que hubo alivio muy discreto y en un 96 % de los pacientes se presentó persistencia de los mismos. Conclusiones: los resultados fueron insatisfactorios, a pesar de los tratamientos utilizados en el estudio (AU).

ABSTRACT Introduction: amputation is a surgical procedure and disability as its consequence can be considered a clinical entity. Any response to amputation is highly individual. Between 40 and 80% of amputees refer pain in the amputated area or phantom limb pain, and among all the problems that can occur after surgery, this is one of the most serious. Objective: to determine the behavior of phantom pain in the amputated population in Cárdenas from January 1st 2015 to December 31st 2019 and the clinical improvement of symptoms with the different treatments applied. Materials and methods: a descriptive cross-sectional study was conducted in the General Hospital Julio Miguel Aristegui Villamil of Cárdenas in the period from January 1st 2015 to December 31st 2019, with the aim of evaluating the clinical and demographic variables of patients with antecedents of unilateral limb amputation who attended the emergency department or outpatient Orthopedics and Traumatology, and Angiology and Vascular Surgery consultations for presenting phantom pain. Results: regarding the improvement of the symptoms and the phantom pain itself, according to the pain evaluation scale (VAS), it was shown that there was very discreet relief and its persistence in 96% of the patients. Conclusions: unsatisfactory results are observed instead of the treatments used in the study (AU).

La angustia que no engaña y la que engaña / The anguish that does not deceive and the one that does

El presente texto tiene como propósito interrogar la afirmación lacaniana de la angustia como afecto que no engaña. Para tal propósito, iniciaremos revisando las últimas elaboraciones freudianas sobre la angustia localizables en el texto "Inhibición, síntoma y angustia", para luego ubicar en el seminario La angustia ciertas coordenadas allí desarrolladas por Lacan, como es la de la angustia como señal de lo real, su relación al objeto a, al falo y al fantasma; así como la propuesta de fin de análisis más allá de la angustia de castración. Posteriormente, propondremos que en Lacan podemos ubicar dos modos de presentarse la angustia: una, que engaña, en su articulación al fantasma y a la angustia de castración; otra, que no engaña, en consonancia con el significante de la falta en el Otro en términos de desamparo. Finalmente, ubicamos algunas consecuencias para la práctica analítica, al denotar la articulación del deseo del analista con la angustia vía el acto, y señalando que no distinguir en el análisis las dos manifestaciones de la angustia previamente denotadas, resulta engañoso para el analista al confundir la detención del análisis con su finalización

The purpose of this text is to interrogate the Lacanian affirmation of anguish as an affect that does not deceive. For this purpose, we will begin by reviewing the latest Freudian elaborations on anguish that can be found in the text "Inhibition, Symptom and Anguish", and then locate in the Seminar The anguish certain coordinates developed there by Lacan, such as that of anguish as a sign of what it is real, its relation to object a, phallus and phantasy; as well as the proposal for the end of the analysis beyond castration's anguish. Later, we will propose that in Lacan we can locate two ways of presenting anguish: first one, which deceives in its articulation the phantasy and the anguish of castration; another one, which does not deceive in relation with the signifier of the lack in the Other in terms of helplessness. Finally, we locate some consequences for analytical practice by denoting the articulation of the analyst´s desire with anguish by the means of the act, and pointing out that not distinguishing in the analysis the two previously denoted manifestations of anguish, is misleading for the analyst by confusing the stop of the analysis with its completion

Terapia de oxigenación hiperbárica en el tratamiento del dolor / Hyperbaric oxygenation therapy in pain treatment

El dolor crónico constituye un reto terapéutico especial. Se presenta una revisión narrativa sobre el papel del tratamiento de oxigenación hiperbárica (TOHB) en el tratamiento del dolor neuropático, y sus aplicaciones en dolor crónico, síndromes neurosensitivos disfuncionales y oncodolor. El conocimiento de las indicaciones de TOHB en algiología y su aplicación en la práctica médica puede contribuir a mejorar la calidad de vida del paciente. (AU)

Chronic pain represents a special therapeutic challenge. We present a narrative review on the role of Hyperbaric Oxygen Therapy (HBOT) in the treatment of neuropathic pain, and its applications in chronic pain, dysfunctional neurosensitive syndromes and oncological pain. The knowledge of the indications of HBOT in algiology and its application in medical practice can contribute to improve the quality of life of the patient. (AU)

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)

Dolor fantasma en niños y jóvenes amputados congénitos: prevalencia y características clínicas / Phantom pain in children and youth with congenital amputations: prevalence and clinical characteristics

Introducción: El dolor es una patología discapacitante, que en niños está siendo abordada en los últimos tiempos, siendo el dolor fantasma en amputados congénitos una complicación impensada hace algunos años, considerando teorías que describían que carecían de la madurez biológica suficiente para experimentarlo. Actualmente, existe literatura que reconoce una prevalencia de dolor fantasma de 3,7 a 20% en la población de amputados congénitos. Objetivo general: Evaluar población de amputados congénitos del Instituto Teletón Santiago para determinar incidencia, prevalencia lápsica y características clínicas del dolor fantasma. Pacientes y Métodos: Estudio descriptivo de prevalencia, con revisión de ficha clínica para registro de variables demográficas y clínicas, y aplicación de encuesta telefónica al total de pacientes que asintieran y contaran con el consentimiento de sus padres. Se incluyó a todos los pacientes de 10 o más años; se excluyó a los con hipoacusia asociada o con imposibilidad administrativa para contactarlos. Resultados: 57 pacientes, edad promedio 18,6 años, 59,6% con deficiencia longitudinal. Ningún paciente presentó dolor fantasma en el último mes en la población estudiada. La prevalecia lápsica fue de 7,0%. Un 24,6% refirió además presentar sensación fantasma alguna vez en su vida y un 5,3% haber presentado dolor en el último año. Conclusión: Existe dolor fantasma en la población de pacientes amputados congénitos en los rangos de prevalencia encontrados en la literatura internacional contribuyendo a la evidencia existente. Este es el primer estudio en nuestro país que evalúa dolor en deficiencias congénitas y constituye una línea de base para estudios adicionales.

Introduction: Pain is a crippling pathology, which has been addressed in children only in recent times, and phantom pain in congenital amputees was a complication unthought to exist some years ago, considering theories that described that they lacked biological maturity enough to experience it. Currently, there is literature that recognizes a prevalence of phantom pain of 3.7 to 20% in congenital amputees. Overall objective: To evaluate the in vivo amputee population of Instituto Teletón Santiago, to determine incidence, lapses prevalence and clinical characteristics of phantom pain in these patients. Patients and Methods: A prevalence descriptive study was carried out, with a review of the clinical files to register demographic and clinical variables and application of a telephone survey to the total number of Instituto Teletón Santiago patients who agreed to participate and had the consent of their parents. We included all patients aged 10 years and over; excluding those with associated hearing loss, or inability to contact for administrative reasons. Results: 57 patients, mean age 18,6 years, 59,6% with longitudinal deficiency. No patient refered phantom pain during de last month in the study population. The lapsic prevalence was 7,0%. 24,6% of the population studied reported phantom feeling at som time in their lives and 5,3% had phantom pain during the last year. Conclusion: There is phantom pain in the population of congenital amputees in the prevalence ranges found in the international literature contributing to the existing evidence. This is the first study in our country that evaluates pain in congenital deficiencies and constitutes a baseline for additional studies.

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.

Role of p38MAPK signaling pathway in rats with phantom limb pain / 中南大学学报(医学版)

To investigate the role of p38MAPK signal pathway in spinal cord and dorsal root ganglion (DRG) in rats with phantom limb pain and the effects of specific inhibitors.
 Methods: Healthy adult male SD rats (n=48) were cut off one side of the sciatic under anesthesia to establish a model of phantom limb pain. In addition, the healthy rats were taken as a sham group (group S, n=24). The animals were scored by observing the action of chewing (0=no chewing, 13=the worst chewing) after the operation and were sacrificed on the following day after the operation. The successful model of phantom limb pain were randomly divided into 2 groups: a phantom limb pain group (group P, n=24) and a phantom limb pain plus inhibitor group (group P+I, n=24). SB203580 was given to the rat at 0.8 mg/kg on every Monday until the rats were sacrificed, the rest of the rats received an equal amount of saline. Eight rats from each group were randomly taken for the determination of levels of P-p38MAPK in spinal cord and DRG before administration and on the 4th, 6th, 8th weekend following the administration, respectively.
 Results: In the sham group, no animal developed chewing. Meanwhile, rats in successful model of phantom limb pain group began chewing from the 2nd day after operation with scores at eight to eleven. The chewing scores in the P+I group were reduced after the treatment. Compared with group S, P-p38MAPK levels were elevated in groups of P and P+I (P<0.05 or P<0.01). Compared with group P, P-p38MAPK level was decreased in the group P+I (P<0.05 or P<0.01).
 Conclusion: P38MAPK signal pathway involves in the development of phantom limb pain.

Mirror therapy: A potential intervention for pain management

Summary The consequences of chronic pain and associated disabilities to the patient and to the health care system are well known. Medication is often the first treatment of choice for chronic pain, although side effects and high costs restrict long-term use. Inexpensive, safe and easy to self-administer non-pharmacological therapies, such as mirror therapy, are recommended as adjuncts to pain treatment. The purpose of this review is to describe the principles of use of mirror therapy so it can be incorporated into a health care delivery. The physiological rationale of mirror therapy for the management of pain and the evidence of clinical efficacy based on recent systematic reviews are also discussed. Mirror therapy, whereby a mirror is placed in a position so that the patient can view a reflection of a body part, has been used to treat phantom limb pain, complex regional pain syndrome, neuropathy and low back pain. Research evidence suggests that a course of treatment (four weeks) of mirror therapy may reduce chronic pain. Contraindications and side effects are few. The mechanism of action of mirror therapy remains uncertain, with reintegration of motor and sensory systems, restored body image and control over fear-avoidance likely to influence outcome. The evidence for clinical efficacy of mirror therapy is encouraging, but not yet definitive. Nevertheless, mirror therapy is inexpensive, safe and easy for the patient to self-administer.

Amputación bilateral en paciente diabética con ceguera, el uso de prótesis inadecuadas. Reporte de caso / Bilateral amputation in diabetic patient with blindness, the use of inadequate prosthesis. Case report

Resumen: Las complicaciones más frecuentes asociadas con la diabetes incluyen al pie diabético y al glaucoma, que suelen llevar a la amputación y a la pérdida de la visión, respectivamente. El desarrollo científico y tecnológico actual ha permitido el diseño e implementación de sistemas protésicos óptimos para estos pacientes, asegurando una reincorporación a las actividades de la vida diaria, así como una correcta adaptación al uso de las mismas. La falta de recursos económicos compromete la adquisición de las prótesis ideales, recurriendo al uso de sistemas «artesanales¼ o «rústicos¼ que afectan la adaptación. Se presenta el caso de un paciente femenino de 47 años de edad, ama de casa, quien presenta parestesias bilaterales y sensación de miembro fantasma asociado a neuromas de amputación por diabetes mellitus tipo II de ocho años de evolución. La paciente, con bajos recursos económicos, es evaluada postamputación con diagnóstico de dependencia grave en la ejecución de las actividades de la vida diaria, con desplazamiento en silla de ruedas asistido; esta presentación es una variante frecuente como consecuencia de la pérdida bilateral de miembros inferiores, concomitante a la ausencia total de la visión. Se presenta el tratamiento de rehabilitación en etapa preprotésica y protésica, acompañados por los resultados de las evaluaciones para mostrar la efectividad del proceso terapéutico, sin olvidar la participación del cuidador como ente coterapéutico fundamental en el proceso.

Abstract: The most frequent diabetes-related complications are diabetic foot and glaucoma, which lead to amputation and loss of vision, respectively. Current scientific and technologic developments have permitted the design and implementation of prosthetic systems that are optimal for these patients, as the latter adapt themselves to them and can resume activities of daily living. The lack of economic resources compromises the quality of the prostheses patients can afford, as they resort to «artisanal¼ or «rustic¼ systems that hamper their adaptation process. We present herein the case of a 47 year-old female patient, housewife, with bilateral paresthesias and phantom limb sensation associated with amputation neuromas resulting from type II diabetes mellitus that had affected the patient for eight years. This patient of a low socioeconomic stratum underwent a post-amputation assessment and was diagnosed as being heavily dependent when performing activities of daily living and required assisted wheelchair for ambulation. This is a frequent variant resulting from bilateral loss of lower limbs together with complete loss of vision. We describe the rehabilitation therapy during the pre- and post-prosthetic stages, together with the results of the assessments to show the effectiveness of the treatment process, without forgetting the participation of the caregiver as a fundamental co-therapeutic element in this process.

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.

Extracorporeal Shock Wave Therapy For Treatment of Intractable Stump Pain

Amputation stump pains can be developed in amputation sites after high voltage electrical burn injuries. We experienced one case of these severe stump pains in an upper extremity amputation patient. A 35-year-old man had a 38% total body surface area high voltage electrical burn. The patient underwent skin grafting and left shoulder disarticulation. During the rehabilitation period, he complained about severe stump area pains and phantom pains. We injected 0.5% Bupivacaine and Triamcinolone on the stump neuroma site but the pain sustained. After extracorporeal shock wave therapy (ESWT,) the pain subsided and did not recur. The patient was satisfied with functional and pain outcomes, so we report this case.

Revisión sistemática: cuidados de enfermería en personas portadoras de dolor fantasma de miembro amputado / Systematically review: nursing care in people with phantom pain of amputated limb

Introducción: actualmente, el envejecimiento poblacionaly la tendencia al aumento de las enfermedades crónicas notransmisibles dan cuenta de un contexto epidemiológico dondese espera que exista un aumento sostenido de las enfermedadesque constituyen las principales causas de amputación en adultosmayores de 50 años, dentro de las cuales se encuentra la diabetes.Objetivos: Realizar una revisión respecto de los cuidados yatención de Enfermería dirigida a los pacientes portadores dedolor tipo fantasma, considerando la estrecha relación existenteentre amputación y síndrome del miembro fantasma y suimpacto en la calidad de vida de las personas. Para los pacientesportadores de dolor tipo fantasma, la valoración de Enfermeríacobra relevancia para lograr un correcto abordaje, evaluación ytratamiento del dolor.Material y Método: Revisión sistemática sobre “Cuidados deEnfermería en personas portadoras de dolor tipo fantasma demiembro amputado”. La búsqueda de información fue realizadaen bases de datos Up To Date, Scopus, Pubmed, Proquest.Los descriptores en inglés y en español que se utilizaron enla búsqueda fueron: epidemiology (epidemiología), phantompain (dolor fantasma) y amputation (amputación). Para lacombinación de estos términos se utilizaron los conectoresbooleanos NOT, AND y OR (“pain”[MeSH Terms] OR “pain”[AllFields] OR “dolor”[All Fields]) AND fantasma [All Fields]. Para labúsqueda en español se utilizaron los siguientes descriptores:epidemiología, dolor fantasma y amputación.Resultados: Una vez realizada la búsqueda sistemática, seconfirma la importancia de la revisión de este tema, dado elcontexto epidemiológico actual, que demuestra un aumento dela prevalencia de enfermedades crónicas no transmisibles, comoprincipales causantes de amputación en adultos...

Introduction: currently, population aging and the trend ofincreasing of non transmissible chronic illnesses, accountfor an epidemiology that expects a sustained rising of thediseases as main causes of amputation of older adults agingup 50 years, including diabetes among them.Objectives: We made an appropriate review about thecares and nursing attention services addressed to patientswho carries a phantom pain, considering close relationshipbetween amputation and ghost pain syndrome and its peoplequality life impact. To the patients who carry the phantomtype pain, nursing assesment takes relevance to get a rightapproach, evaluation and pain treatment.Materials and Methods: Bibliographic reviews about“Nursing care in people with phantom pain of amputatedlimb”. The information research was elaborated from databases: Up to Date, Scopus, Medline, Pubmed, Proquest.The English and Spanish descriptors used on this researchwere: epidemiology (epidemiología), phantom pain (dolorfantasma), amputation (amputación). On the combinationof these terms were used Boolean connectors: NOT, AND,OR (“pain”[MeSH Terms] OR “pain”[All Fields] OR “dolor”[AllFields]) AND fantasma [All Fields]. On the Spanish researchwere used the following descriptors: epidemiology, phantompain and amputation.Results: Once the systematic search, the importance ofthe review of this topic given the current epidemiologicalcontext, demonstrating an increased prevalence of chronicnon-transmissible diseases, as the main cause of amputationin adults is confirmed...

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.