Perioperative Management of Painful Phantom Limb Syndrome: A Narrative Review and Clinical Management Proposal.

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.

Pain Management Strategies in Rheumatoid Arthritis: A Narrative Review.

Rheumatoid Arthritis (RA) is a systemic autoimmune disease characterized by chronic inflammation and progressive deterioration of the joints, which generates pain and stiffness. The origin of this pain is multifactorial, with inflammation, secondary osteoarthritis, as well as central and peripheral sensitization playing important roles in the development. Up to 90.4% of RA patients visit a health professional for severe pain, and despite new therapies and sophisticated treatments, there are a limited number of options for analgesic management. We conducted a narrative review using the Medline and Pubmed search engines for articles in English and Spanish between 2000 and 2021, with the keywords "pain," "rheumatoid arthritis," "non-steroidal anti-inflammatory drugs" (NSAIDs), "opioids," "glucocorticoids," "disease modifying antirheumatic drugs" (DMARDs), "neuromodulators," "antidepressants," and "cannabinoids." The articles describing epidemiology, pathophysiological considerations and current treatments were selected after a screening process carried out by the authors. It was found that DMARDs are the fundamental basis of treatment, since the main mechanism of pain in this entity is inflammation. Nonetheless, a significant number of patients continue to have pain despite optimal treatment. The available evidence for pain management in RA is scarce, however, medications such as NSAIDs, topical capsaicin, weak opioids, and treatments such as joint infiltrations or surgical management, play an important role in its management. We believe more research efforts are needed to optimize analgesic treatment recommendations, however, based on the current existing evidence, we propose a stepwise algorithm in order to properly approach these cases.Key PointsRA is a systemic autoimmune disease characterized by chronic inflammation, in which the main symptom is pain.Pain in RA is multifactorial, with inflammation, secondary osteoarthritis, as well as central and peripheral sensitization playing determining roles.DMARDs are the mainstay of RA treatment, although many patients continue to experience pain despite optimal management.Medications such as glucocorticoids, NSAIDs, topical capsaicin, and weak opioids are key elements when achieving analgesia in RA.Other pharmacological groups such as neuromodulators, antidepressants, muscle relaxants and cannabinoids currently do not have enough evidence to be recommended.

Características clínicas de los pacientes que consultan a la Clínica de Dolor Crónico del Hospital Militar Central: histórico de 20 años / Clinical characteristics of patients consulting Chronic Pain Clinic of Hospital Militar Central, 20-year history / Características clínicas dos pacientes que consultam á Clínica de Dor Crônica de Hospital Militar Central, 20 anos de história

En este estudio se pretende identificar el perfil demográfico de los pacientes que acuden a la clínica del dolor del Hospital Militar Central que consultan por dolor crónico no maligno, a quienes se les ha valorado de manera integral y multidisciplinaria. Se revisaron los expedientes clínicos de los pacientes atendidos en la clínica de dolor del Hospital Militar Central (HMC) entre abril de 1989 y abril de 2009. Un total de 291 pacientes se tomaron de manera aleatoria simple como muestra representativa para un intervalo de confianza del 95%. Se utilizó un cuestionario que incluyó 26 descriptores que evaluaron datos demográficos, epidemiológicos, respuesta emocional y afectación en áreas de ajuste por la presencia de dolor crónico en estos pacientes. Se encontraron múltiples datos estadísticos, como relevante se halló un perfil de pacientes relacionados con las fuerzas militares en un 90% (nivel de confianza 95%, IC 86-93) entre funcionarios militares, no militares y sus beneficiarios. El 49,4% son militares (nivel de confianza 95%, IC 43-55%). Prevalece como entidad más importante el dolor lumbar crónico 41,2% (nivel de confianza 95%, IC 35-47%) y el relacionado a miembros superiores e inferiores 11,6% (nivel de confianza 95%, IC 7,8 - 15%). Los diagnósticos más comunes en salud mental dados por psicología o psiquiatría fueron el trastorno de adaptación en el 59% de los casos (nivel de confianza 95%, IC 53-64,9%) y el trastorno de depresión en un 18% (Nivel de confianza 95%, IC 14-22,8%). Se encontró un 81% de compromiso en el área laboral en pacientes menores de 65 años (nivel de confianza 95%, IC 76-86%) por causa del dolor crónico y un 86,3 % (nivel de confianza 95%, IC 80-92%) entre aquellos con edades entre los 15 y los 30 años. En conclusión, el dolor crónico como enfermedad de alto costo en la población general, es un factor importante de incapacidad o inhabilidad laboral en los pacientes que consultan a la clínica de dolor del HMC, faltan estudios para definir si la población militar es más susceptible comparada con la población no militar...

This study aims to identify the demographic profile of patients who come to the Chronic Pain Clinic of the Hospital Militar Central to consult regarding chronic nonmalignant pain, who have been evaluated in an integral and multidisciplinary way. The medical records of the patients assisted in the Chronic Pain Clinic of the Hospital Militar Central (HMC) between April 1989 and April 2009. A total of 291 patients were randomly selected as a representative sample for a trust interval of 95%. A survey questionnaire was used, which included 26 descriptors evaluating demographic and epidemiological data, and emotional response and affectation in adjustment areas due to the presence of chronic pain in these patients. Multiple statistical data were found. A relevant datum was to find a profile of patients related to the military forces by 90% (95% significance level, CI 86-93%) among military and non-military officers and their beneficiaries. 49.4% are military personnel (95% significance level, CI 43-55% ). Chronic lumbar pain stands out as the most prevalent item - 41.2% (95% significance level, CI 35-47%), and the one related to upper or lower limbs, 11.6% (95% significance level, CI 7.8-15%). Most common diagnoses in mental health provided by the psychology and psychiatry sections were adjustment disorders in 59% of the cases (95% significance level, CI 53-64.9%), and depression disorder at 18% (95% significance level, CI 14-22.8%). An 81% commitment degree was found in the work force in patients aged less than 65 (95% significance level, CI 76.65%) due to chronic pain, and 86.3% (0.5% significance level, CI 80-92%) among those from 15 to 30 years old. To conclude, chronic pain as a high-cost disorder in the general population is an important factor in labor absence leaves or inability among patients consulting at the Chronic Pain Clinic of the HMC. There is a lack of studies to define whether the military population is more susceptible in comparison with the non-military population...