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OBJECTIVE: To explore the relationship between sociodemographic, clinical, and neurophysiological variables and health-related quality of life (HR-QOL) of patients with phantom limb pain (PLP). METHODS: This is a cross-sectional analysis of a previous clinical trial. Univariate and multivariate linear and logistic regression analyses were used to model the predictors of HR-QOL. We utilized a sequential modeling approach with increasing adjustment levels, controlling for age and sex, and other relevant clinical variables (time since amputation, level of amputation, and pain). HR-QOL was assessed by the SF-36 Health Survey and its 8 subdomains. RESULTS: We analyzed baseline data from 92 patients with lower-limb amputations. They were mostly male (63%), 45.2 ± 15.6 years, with a mean time since amputation of 82.7 ± 122.4 months, and an overall SF-36 score of 55.9 ± 21.5. We found an association between intracortical facilitation (ICF) in the affected hemisphere, gabapentin usage, and HR-QOL. ICF is a predictor of better HRQOL, whereas gabapentin usage was associated with a poorer HR-QOL, with the main model explaining 13.4% of the variance in the outcome. For the SF-36 subdomains, ICF was also a positive predictor for social functioning, bodily pain, and vitality, while medication usage was associated with lower scores in mental health, general health perception, bodily pain, and vitality. CONCLUSION: We found firsthand 2 new independent predictors of HR-QOL in individuals with PLP, namely, the neurophysiological metric ICF and gabapentin usage. These results highlight the role of the motor cortex excitability in the HR-QOL and stress the need for treatments that favor the neuroplastic adaptation after amputation, for which ICF may be used as a possible marker.

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Postamputation pain is currently managed unsatisfactorily with neuron-targeted pharmacological and interventional therapies. Non-neuronal pain mechanisms have emerged as crucial factors in the development and persistence of postamputation pain. Consequently, these mechanisms offer exciting prospects as innovative therapeutic targets. We examined the hypothesis that engaging mesenchymal stem cells (MSCs) would foster local neuroimmune interactions, leading to a potential reduction in postamputation pain. We utilized an ex vivo neuroma model from a phantom limb pain patient to uncover that the oligodeoxynucleotide IMT504 engaged human primary MSCs to promote an anti-inflammatory microenvironment. Reverse translation experiments recapitulated these effects. Thus, in an in vivo rat model, IMT504 exhibited strong efficacy in preventing autotomy (self-mutilation) behaviors. This effect was linked to a substantial accumulation of MSCs in the neuroma and associated dorsal root ganglia and the establishment of an anti-inflammatory phenotype in these compartments. Centrally, this intervention reduced glial reactivity in the dorsal horn spinal cord, demonstrating diminished nociceptive activity. Accordingly, the exogenous systemic administration of MSCs phenocopied the behavioral effects of IMT504. Our findings underscore the mechanistic relevance of MSCs and the translational therapeutic potential of IMT504 to engage non-neuronal cells for the prevention of postamputation pain. PERSPECTIVE: The present study suggests that IMT504-dependent recruitment of endogenous MSCs within severely injured nerves may prevent post-amputation pain by modifying the inflammatory scenario at relevant sites in the pain pathway. Reinforcing data in rat and human tissues supports the potential therapeutic value of IMT504 in patients suffering postamputation pain.

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BACKGROUND: Phantom pain limb (PLP) has gained more attention due to the large number of people with amputations around the world and growing knowledge of the pain process, although its mechanisms are not completely understood. OBJECTIVES: The aim of this study was to understand, in patients with amputations, the association between PLP and residual limb pain (RLP), and the brain metabolic response in cortical motor circuits, using functional near-infrared spectroscopy (fNIRS). METHODS: Sixty participants were recruited from the rehabilitation program in São Paulo, Brazil. Included patients were aged over 18 years, with traumatic unilateral lower-limb amputation, with PLP for at least 3 months after full recovery from amputation surgery. PLP and RLP levels were measured using visual analogue scales. fNIRS was performed during motor execution and motor mirror tasks for 20 s. In order to highlight possible variables related to variation in pain measures, univariate linear regression analyses were performed for both experimental conditions, resulting in four fNIRS variables (two hemispheres x two experimental conditions). Later, in order to test the topographic specificity of the models, eight multivariate regression analyses were performed (two pain scales x two experimental conditions x two hemispheres), including the primary motor cortex (PMC) related channel as an independent variable as well as five other channels related to the premotor area, supplementary area, and somatosensory cortex. All models were controlled for age, sex, ethnicity, and education. RESULTS: We found that: i) there is an asymmetric metabolic activation during motor execution and mirror task between hemispheres (with a predominance that is ipsilateral to the amputated limb), ii) increased metabolic response in the PMC ipsilateral to the amputation is associated with increased PLP (during both experimental tasks), while increased metabolic response in the contralateral PMC is associated with increased RLP (during the mirror motor task only); ii) increased metabolic activity of the ipsilateral premotor region is associated with increased PLP during the motor mirror task; iii) RLP was only associated with higher metabolic activity in the contralateral PMC and lower metabolic activity in the ipsilateral inferior frontal region during motor mirror task, but PLP was associated with higher metabolic activity during both tasks. CONCLUSION: These results suggest there is both task and region specificity for the association between the brain metabolic response and the two different types of post-amputation pain. The metabolic predominance that is ipsilateral to the amputated limb during both tasks was associated with higher levels of PLP, suggesting a cortical motor network activity imbalance due to potential interhemispheric compensatory mechanisms. The present work contributes to the understanding of the underlying topographical patterns in the motor-related circuits associated with pain after amputations.

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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.

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.

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BACKGROUND: Pain in the postoperative period of amputation surgeries, when not managed correctly, can have consequences for the patient. PURPOSES AND OBJECTIVES: The aim of this study was to map the scientific evidence on pain management in patients in the postoperative period of amputation surgeries. DESIGN: Scoping review with elaboration based on the recommendations of the Joanna Briggs Institute, supported by The PAGER framework and guided by the PRISMA-ScR Checklist. METHODS: The survey was conducted in August 2022 in 10 data sources. The 3300 publications found were analysed by two independent reviewers, after applying inclusion and exclusion criteria, 16 studies were selected. RESULTS: Publications occurred between the years 1997 and 2022 and mainly dealt with the management of residual pain and phantom limb through pharmacological measures with pain assessment made by numerical scales. CONCLUSIONS: The literature pointed out strategic uses of analgesics and highlighted technologies for neurostimulation through catheters. The need for new studies with non-pharmacological measures and with designs that can prove their effectiveness is reinforced. RELEVANCE TO CLINICAL PRACTICE: The knowledge of these strategies by health professionals allows adequate pain management and patient follow-up for a less traumatic recovery. PATIENT OR PUBLIC CONTRIBUTION: To patient or public involvement in this scoping review.

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BACKGROUND: Amputation is described as the removal of an external part of the body by trauma, medical illness or surgery. Amputations caused by vascular diseases (dysvascular amputations) are increasingly frequent, commonly due to peripheral arterial disease (PAD), associated with an ageing population, and increased incidence of diabetes and atherosclerotic disease. Interventions for motor rehabilitation might work as a precursor to enhance the rehabilitation process and prosthetic use. Effective rehabilitation can improve mobility, allow people to take up activities again with minimum functional loss and may enhance the quality of life (QoL). Strength training is a commonly used technique for motor rehabilitation following transtibial (below-knee) amputation, aiming to increase muscular strength. Other interventions such as motor imaging (MI), virtual environments (VEs) and proprioceptive neuromuscular facilitation (PNF) may improve the rehabilitation process and, if these interventions can be performed at home, the overall expense of the rehabilitation process may decrease. Due to the increased prevalence, economic impact and long-term rehabilitation process in people with dysvascular amputations, a review investigating the effectiveness of motor rehabilitation interventions in people with dysvascular transtibial amputations is warranted. OBJECTIVES: To evaluate the benefits and harms of interventions for motor rehabilitation in people with transtibial (below-knee) amputations resulting from peripheral arterial disease or diabetes (dysvascular causes). SEARCH METHODS: We used standard, extensive Cochrane search methods. The latest search date was 9 January 2023. SELECTION CRITERIA: We included randomised controlled trials (RCT) in people with transtibial amputations resulting from PAD or diabetes (dysvascular causes) comparing interventions for motor rehabilitation such as strength training (including gait training), MI, VEs and PNF against each other. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were 1. prosthesis use, and 2. ADVERSE EVENTS: Our secondary outcomes were 3. mortality, 4. QoL, 5. mobility assessment and 6. phantom limb pain. We use GRADE to assess certainty of evidence for each outcome. MAIN RESULTS: We included two RCTs with a combined total of 30 participants. One study evaluated MI combined with physical practice of walking versus physical practice of walking alone. One study compared two different gait training protocols. The two studies recruited people who already used prosthesis; therefore, we could not assess prosthesis use. The studies did not report mortality, QoL or phantom limb pain. There was a lack of blinding of participants and imprecision as a result of the small number of participants, which downgraded the certainty of the evidence. We identified no studies that compared VE or PNF with usual care or with each other. MI combined with physical practice of walking versus physical practice of walking (one RCT, eight participants) showed very low-certainty evidence of no difference in mobility assessment assessed using walking speed, step length, asymmetry of step length, asymmetry of the mean amount of support on the prosthetic side and on the non-amputee side and Timed Up-and-Go test. The study did not assess adverse events. One study compared two different gait training protocols (one RCT, 22 participants). The study used change scores to evaluate if the different gait training strategies led to a difference in improvement between baseline (day three) and post-intervention (day 10). There were no clear differences using velocity, Berg Balance Scale (BBS) or Amputee Mobility Predictor with PROsthesis (AMPPRO) in training approaches in functional outcome (very low-certainty evidence). There was very low-certainty evidence of little or no difference in adverse events comparing the two different gait training protocols. AUTHORS' CONCLUSIONS: Overall, there is a paucity of research in the field of motor rehabilitation in dysvascular amputation. We identified very low-certainty evidence that gait training protocols showed little or no difference between the groups in mobility assessments and adverse events. MI combined with physical practice of walking versus physical practice of walking alone showed no clear difference in mobility assessment (very low-certainty evidence). The included studies did not report mortality, QoL, and phantom limb pain, and evaluated participants already using prosthesis, precluding the evaluation of prosthesis use. Due to the very low-certainty evidence available based on only two small trials, it remains unclear whether these interventions have an effect on the prosthesis use, adverse events, mobility assessment, mortality, QoL and phantom limb pain. Further well-designed studies that address interventions for motor rehabilitation in dysvascular transtibial amputation may be important to clarify this uncertainty.

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At least two million people in the United States of America live with lost limbs, and the number is expected to double by 2050, although the incidence of amputations is significantly greater in other parts of the world. Within days to weeks of the amputation, up to 90% of these individuals develop neuropathic pain, presenting as phantom limb pain (PLP). The pain level increases significantly within one year and remains chronic and severe for about 10%. Amputation-induced changes are considered to underlie the causation of PLP. Techniques applied to the central nervous system (CNS) and peripheral nervous system (PNS) are designed to reverse amputation-induced changes, thereby reducing/eliminating PLP. The primary treatment for PLP is the administration of pharmacological agents, some of which are considered but provide no more than short-term pain relief. Alternative techniques are also discussed, which provide only short-term pain relief. Changes induced by various cells and the factors they release are required to change neurons and their environment to reduce/eliminate PLP. It is concluded that novel techniques that utilize autologous platelet-rich plasma (PRP) may provide long-term PLP reduction/elimination.

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OBJECTIVE: Painful Phantom Limb Syndrome (PPLS) occurs in 50 to 80% of patients undergoing amputation, having a great impact on quality of life, productivity and psychosocial sphere. The objective of this review is to summarize the pharmacological and non-pharmacological strategies, surgical optimization, and provide a multidisciplinary approach aimed at reducing the incidence of chronic pain associated with PPLS in patients undergoing limb amputation. METHODS: A narrative review was carried out using Medline, Pubmed, Proquest, LILACS and Cochrane, searching for articles between 2000 and 2021. Articles describing the epidemiology, pathophysiological considerations, and current treatments were selected after a screening process. RESULTS: A multidisciplinary and multimodal approach is required in PPLS, and should include the use of regional techniques, and adjuvants such as NSAIDs, ketamine, lidocaine and gabapentinoids. In addition, an evaluation and continuous management of risk factors for chronic pain in conjunction with the surgical team is necessary. CONCLUSION: The current literature does not support that a single technique is effective inthe prevention of PPLS. However, adequate acute pain control, rehabilitation and early restoration of the body scheme under a multidisciplinary and multimodal approach have shown benefit in the acute setting.

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Phantom limb syndrome (PLS) is a condition that occurs in amputee patients that has a wide array of different treatment approaches. We present the case of a patient diagnosed with complex regional pain syndrome (CRPS) of the right upper limb secondary to polytrauma with complete brachial plexus injury, who, after being subjected to multiple successful therapies, was finally taken to amputation. Later, he developed a painful PLS that was difficult to manage, which was treated with a stellate ganglion block (SGB), achieving a significant decrease in pain. This article aims to present a case in which a SGB was used as an adjunct to control acute postoperative PLS in a patient with previous sensitization due to CRPS. The SGB, in this case, performed with local anesthetic plus corticosteroid, constitutes a useful therapeutic alternative for intense postoperative pain in PLS, achieving adequate pain relief without adverse effects. However, its routine use as in acute postoperative pain still lacks sufficient evidence for complete support, therefore we urge the scientific community to undertake more in-depth research concerning this topic in order to create clear guidelines and recommendations.

El síndrome del miembro fantasma (PLS, por sus siglas en inglés) es una condición que se presenta en pacientes amputados con un campo extenso para los diferentes enfoques de tratamiento. Presentamos el caso de un paciente diagnosticado con síndrome complejo de dolor regional (SCDR) del miembro superior derecho secundario a politraumatismo con lesión completa del plexo braquial, quien, tras ser sometido a múltiples tratamientos exitosos, fue finalmente llevado a amputación. Posteriormente, desarrolló un PLS doloroso de difícil manejo, el cual fue tratado con un bloqueo del ganglio estrellado (BGE), logrando una disminución significativa del dolor. Este artículo tiene como objetivo presentar un caso en el que se utilizó un BGE como coadyuvante para el control del PLS en el posoperatorio de manera aguda en un paciente con sensibilización previa por SCDR. EL BGE, en este caso, realizado con anestésico local más corticosteroide, constituye una alternativa terapéutica útil para el dolor posoperatorio intenso en PLS, consiguiendo un adecuado alivio del dolor sin efectos adversos. Sin embargo, su uso rutinario como en el dolor postoperatorio agudo, aún carece de evidencia suficiente para un respaldo completo, por lo que invitamos a la comunidad científica a realizar una investigación más profunda sobre este tema para crear pautas y recomendaciones claras.

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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

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INTRODUCTION: There is no diagnosis for phantom limb pain (PLP), and its investigation is based on anamnesis, which is subject to several biases. Therefore, it is important to describe and standardize the diagnostic methodology for PLP. OBJECTIVE: To characterise PLP and, secondarily, to determine predictors for its diagnosis. Methodology. This is a cross-sectional study involving patients with unilateral traumatic lower-limb amputation aged over 18 years. Those with clinical decompensation or evidence of disease, trauma, or surgery in the central or peripheral nervous system were excluded. Sociodemographic and rehabilitative data were collected; PLP was characterised using the visual analogue scale (VAS), pain descriptors, and weekly frequency. RESULTS: A total of 55 eligible patients participated in the study; most were male, young, above-knee amputees in the preprosthetic phase of the rehabilitation. The median PLP VAS was 60 (50-79.3) mm characterised by 13 (6-20) different descriptors in the same patient, which coexist, alternate, and add up to a frequency of 3.94 (2.5-4.38) times per week. The most frequent descriptor was movement of the phantom limb (70.91%). Tingling, numbness, flushing, itchiness, spasm, tremor, and throbbing are statistically significant PLP descriptor numbers per patient predicted by above-knee amputation, prosthetic phase, higher education level, and greater PLP intensity by VAS (p < 0.05). CONCLUSION: PLP is not a single symptom, but a set with different sensations and perceptions that need directed and guided anamnesis for proper diagnosis.

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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.

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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.

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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).

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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

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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)

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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.

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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)

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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)

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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.

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