Bakgrund: Postoperativ smärta är ett vanligt tillstånd efter ett kirurgiskt ingrepp som måste behandlas utifrån patienternas unika upplevelser. Underbehandlad postoperativ smärta kan geupphov till komplikationer och lidande hos patienter. Syfte: Att beskriva patienters upplevelse av postoperativ smärta och smärtbehandlingsmetoder. Metod: Litteraturöversikt av tolv kvalitativa originalartiklar. Litteratursökningen genomfördes i databaserna PubMed och CINAHL. Resultat: Patienter upplevde att smärtan varierade i karaktär, intensitet, lokalisation och varaktighet. Faktorer som personalens attityder, patienters preoperativa förväntningar, tidigare upplevelser och social bakgrund påverkade upplevelsen av den postoperativa smärtan. Det fanns delade åsikter om smärtbehandlingarnas metoder och effekt där ett stort antal patienter uppgav en underbehandlad postoperativ smärta med otillräcklig smärtlindring och biverkningar. Fördomar samt tidigare upplevelser av biverkningar kunde påverka patienternas vilja att konsumera opioider. Det noterades en okunskap om den postoperativa smärtbehandlingen. Patienterna använde sig av egna icke-farmakologiska strategier för att lindra den postoperativa smärtan. Slutsats: Patienters upplevelser av den postoperativa smärtan skilde sig mellan olika individer och påverkades av omkringliggande faktorer. Det fanns en variation av upplevelser av den postoperativa smärtbehandlingen, en del upplevde att den farmakologiska smärtlindringen var adekvat och en del upplevde den som bristande. Upplevelser av bristande farmakologisk behandling karakteriserades i form av underbehandlad smärta, komplicerade smärtbehandlingsrutiner, biverkningar, rädsla och bristande kunskap om de aktuella smärtbehandlingarna. Det identifierades att patienterna hade behov av utförlig och individanpassad information om smärta och smärtbehandling, samt ett personcentrerat bemötande från vårdpersonal för att optimera smärtlindringens effekt och minska det mänskliga lidandet. / Background: Postoperative pain is common after a surgical procedure and must be treated based on the patients' unique experiences. Undertreated postoperative pain can lead to complications and patient suffering. Aim: To describe patients experiences of postoperative pain and treatment. Method: Literature review of twelve qualitative original articles. The literature searches were implemented in the databases PubMed and CINAHL. Results: Patients experienced their pain varied in character, intensity, localization and duration. Factors such as staff healthcare professionals’ attitudes, patients’ preoperative expectations, previous experiences and social background influenced the experience of postoperative pain. There were divided opinions on treatment and corresponding efficacy. Some patients reported undertreated postoperative pain with inadequate pain relief and sideeffects. Their preconceptions and previous experiences of side effects influenced consumption of opioids. Patients’ ignorance of the postoperative pain treatment was discovered. Different non-pharmacological strategies to relieve the postoperative pain were used by patients. Conclusion: Patients' experiences of postoperative pain differed and were influenced by various boundary conditions. There was a variety of experiences linked to postoperative pain treatment. Experiences associated with the lack of pharmacological treatment were characterized in the form of undertreated pain, complicated treatment routines, side effects, fear and lack of knowledge about pain treatments. It was identified that the patients had a need for detailed and adapted information about pain and pain treatment as well as a person-centered approach from healthcare professionals in order to optimize the effect of pain relief and reduce human suffering.

Background: Good pain relief can reduce suffering, decrease the prevalence of postoperativecomplications and shorten the hospital stay. The nurse has an important responsibility toevaluate and meet the patient's need for pain relief. There exists several shortages regarding how this is managed today and a need for development of the organization as well as pain reliefin practice. Investigation of patients' experiences of post-operative pain and pain relief can increase the understanding of what it means to have pain and what factors are considered important for good postoperative pain relief. The frame of reference for this article is Katie Eriksson's theory about human suffering.  Aim: The aim was to describe patients' experiences of post-operative pain and pain relief. Method: The study was a qualitative literature study with ten original articles found via PubMed and CINAHL. A content analysis was used. The quality control was performed in accordance to SBU:s form for quality in original articles by qualitative methodology. The content analysis was implemented using the methodology by Forsberg and Wengström. Result: Patients who were sufficiently informed both verbally and by writing experienced better control over the pain. Lacking information and prior experiences of side effects loweredthe expectations of pain relief. The expectations were also influenced by the patient'supbringing and environment. Healthcare personnel who took responsibility and had goodpersonal treatment increased the feeling of safety. Factors that worsened the pain relief and the experience of pain were difficulties in describing the pain, lack of information, stressfulworking conditions for the personnel, side effects of the medicines and a willingness to meet the expectations of the healthcare personnel. Conclusion: Pain is an individual experience and pain relief is a complex field. There existsseveral factors that promote respectively exacerbate the experience of pain and pain relief. The factors show the significance of nurses´ responsiveness and to work in partnership with thepatient. It also indicates a need for change regarding the high workload and lack of routines inpain relief care. Keywords: Pain relief, patient experience, postoperative pain.

Background: There are a number of different anesthetic techniques used in same-day surgery. The aim of the present study was to try to describe the postoperative clinical course and to identify factors that may be associated with the delay time from the surgical procedure was completed until discharge from hospital when intravenous anesthesia was used. Methods: A Quantitative Cross- sectional designed was used by using a self-designed questionnaire. Results: Total of 289 patients were enrolled in the study. The mean age was 40 years and 63% were women and 37% men. Of the 289 patients’ only one required unanticipated admission over night at the hospital. The median delay from completed surgery until discharge from hospital was 2 hours and 5 minutes and the maximum delay was 5 hours and 55 minutes. All patients received general anesthesia with an intravenous as maintenance anesthesia. Important risk factors for increasing postoperative delay were the severity of the postoperative pain and thereby the requirement of opioids in the postoperative phase Conclusion: Then undergoing daytime surgery the median delay from completed surgery until hospital discharge was about two hours. Problems with postoperative pain was associated with a prolonged delay. Thus, in order to shorten the delay to hospital discharge even further the pain-relieving treatment needs to be enhanced.

SAMMANFATTNING Introduktion: Postoperativ smärta är en naturlig följd av kirurgiska ingrepp, vilket kräver noggrann utvärdering och hantering av sjuksköterskor för att säkerställa optimal smärtlindring. Påtaglig smärtproblematik rapporteras ännu av nyopererade patienter, vilket kan resultera i påtagliga konsekvenser för både individ och samhälle. Patienters perspektiv kan ge kunskap om påverkande omständigheter och öka förståelsen för smärta.  Syfte: Syftet var att belysa patienters upplevelser av postoperativ smärta. Metod: En deskriptiv allmän litteraturöversikt med kvalitativ ansats tillämpades enligt Fribergs metod. Databaser som användes var PubMed och CINAHL. Resultat: Delaktighet och information gav patienten möjlighet att etablera trygga, realistiska förväntningar. Smärta som upplevdes oförutsedd och okontrollerad hämmade patientens återhämtning. Patientens vilja att kommunicera sin smärta påverkades av personalens tillgänglighet, engagemang, kontinuitet och attityder. Etablerade vårdrelationer underlättade kommunikationen. Smärtbedömningen varierade beroende på vilken vårdpersonal som tjänstgjorde. Det fanns blandade känslor för smärtstillande läkemedel relaterat till biverkningar och om medicineringen var tillräcklig. Patienter kompletterade smärtlindringen med icke-farmakologiska strategier där mobilisering, kyla eller värme var återkommande.  Slutsats: Postoperativ smärta kan innebära stor påfrestning för patienter, deras upplevelser är individuella och komplexa som påverkas av såväl yttre som inre omständigheter. Inom sjukvården kan utmaningar som hög arbetsbelastning bidra till otillräckligt informationsflöde och sämre patientupplevelser. Att vara välinformerad, delaktig och få personcentrerad vård med stöd från engagerad personal främjar positiva upplevelser. Genom att förstå och inkludera dessa aspekter i helhetsbilden kan det bidra till förbättrad vård för patienter med postoperativ smärta. Ytterligare forskning uppmuntras för att öka förståelsen för patientens perspektiv.  Nyckelord: omvårdnad, patientupplevelse, postoperativ smärta, påverkan, smärthantering / ABSTRACT Introduction: Postoperative pain is a natural consequence of surgical procedures, requiring careful evaluation and management by nurses to ensure optimal pain relief. Substantial pain issues are still reported by postoperative patients, impacting both the individual and society. The patient’s perspective provides valuable insights into the understanding of pain.  Aim: The aim was to illuminate patients’ experiences of postoperative pain. Method: A descriptive general literature review with a qualitative approach was applied according to Friberg’s method. The databases used were PubMed and CINAHL.  Result: Participation and information allowed the patient to establish safe, realistic expectations. Pain experienced as unexpected and uncontrollable inhibited patients’ recovery. Staff availability, commitment, continuity, and attitudes influenced patients’ willingness to communicate pain. Established care relationships facilitated communication. Pain assessment varied depending on which healthcare staff was on duty. Analgesic side effects and adequate medication received mixed feelings. Patients supplemented pain relief with non-pharmacological strategies like mobilization, cold or heat. Conclusion: Postoperative pain can be stressful for patients, their experiences are individual and complex and are affected by external as well as internal circumstances. Within healthcare challenges such as high workload can contribute to insufficient information and worse patient experiences. Being well-informed, involved and receiving person-centered care with the support of dedicated staff promotes positive experiences. Understanding and including these aspects in the overall picture can contribute to improved care for patients with postoperative pain. Further research is encouraged to increase the understanding of the patient’s perspective. Keywords: care, patient’s experience, postoperative pain, impact, pain management

No / Various techniques and drug regimes for thoracic paravertebral block (PVB) have been evaluated for post-thoracotomy analgesia, but there is no consensus on which technique or drug regime is best. We have systematically reviewed the efficacy and safety of different techniques for PVB. Our primary aim was to determine whether local anaesthetic (LA) dose influences the quality of analgesia from PVB. Secondary aims were to determine whether choice of LA agent, continuous infusion, adjuvants, pre-emptive PVB, or addition of patient-controlled opioids improve analgesia. Indirect comparisons between treatment arms of different trials were made using metaregression. Twenty-five trials suitable for metaregression were identified, with a total of 763 patients. The use of higher doses of bupivacaine (890¿990 mg per 24 h compared with 325¿472.5 mg per 24 h) was found to predict lower pain scores at all time points up to 48 h after operation (P=0.006 at 8 h, P=0.001 at 24 h, and P<0.001 at 48 h). The effect-size estimates amount to around a 50% decrease in postoperative pain scores. Higher dose bupivacaine PVB was also predictive of faster recovery of pulmonary function by 72 h (effect-size estimate 20.1% more improvement in FEV1, 95% CI 2.08%¿38.07%, P=0.029). Continuous infusions of LA predicted lower pain scores compared with intermittent boluses (P=0.04 at 8 h, P=0.003 at 24 h, and P<0.001 at 48 h). The use of adjuvant clonidine or fentanyl, pre-emptive PVB, and the addition of patient-controlled opioids to PVB did not improve analgesia. Further well-designed trials of different PVB dosage and drug regimes are needed.

Sammanfattning Bakgrund: Det är fortsatt förekommande med komplikationer relaterat till medelsvår och svår postoperativ smärta. Anestesisjuksköterskan har det samlade omvårdnadsansvaret för patienten perioperativt. En helhetsbedömning av patienten avgör postoperativt smärtlindringsbehov. Den Perioperativa dialogen skapar mening i arbetet och trygghet för patienten. Författarna identifierade avsaknad av riktlinjer vid genomförandet av en individuell helhetsbedömning vid handläggning av postoperativ smärtlindring. Syfte: Syftet var att belysa hur anestesisjuksköterskor planerar, genomför och utvärderar postoperativ smärtlindring i generell anestesi utefter tidsfaserna pre-, intra- och postoperativt samt inverkan av den perioperativa dialogen. Metod: En kvalitativ studie genomfördes med tio semistrukturerade intervjuer. Data analyserades med kvalitativ innehållsanalys med en induktiv ansats. Resultat: I resultatet framkom fyra huvudkategorier med totalt elva underkategorier som berör informanternas handläggning. Preoperativa åtagande - Planeringsprocess Känna ansvar för planering, Skapa vårdrelation, Beakta patientens känslotillstånd. Intraoperativa vårdmoment - Konstant utvärdering av behandling, Anpassa behandling fortlöpande, Självständigt ansvarsområde. Postoperativa förhoppningar - Eftersträva återkoppling, Undvika smärtgenombrott. Perioperativa organisatoriska aspekter - Anpassa utefter arbetsförhållanden, Avsaknad av den Perioperativa dialogen. Slutsats: Handläggningen av postoperativ smärtlindring är ett komplext område vilket kräver beaktning av flera faktorer för ett gott utfall. Den perioperativa dialogen är inte prioriterad. Det saknas konsensus för anestesisjuksköterskans handläggning av postoperativ smärta. Det krävs utveckling och ett utökat samarbete av hela vårdkedjan för att kunna möta den postoperativa smärtproblematiken. / Abstract Background: Complications still occur in connection to moderate and severe postoperative pain. The nurse anaesthetic´s is completely responsible for the patient care perioperative. An overall assessment of the patient all together determine the postoperative need of analgesic. The perioperative dialogue is a method which gives the nurse anaesthetic´s a sense of meaningfulness of the work and creates a perception of safety for the patient. The authors identified the absence of guidelines to make an individual overall assessment when managing postoperative pain. Aim: The aim of the study was to elucidate the nurse anaesthetic´s planning, implement and evaluate postoperative analgesic during total anaesthesia along the time-phases pre-, intra and postoperative and the impact of the perioperative dialogue. Method: A qualitative study was conducted with ten semistructured interviews. A qualitative content analysis was made with an inductive approach. Result: The result is presented in four head categories and eleven sub-categories that illuminate the informants’ experiences. Preoperative undertakings - Feeling responsibility for planning, Create a care-relation, Respect the patients emotional state. Intraoperative steps – Constant evaluation of treatment, Adapt the treatment continuously, Independent responsibility. Postoperative expectations – trying to obtain feedback, Avoid outbreak of pain. Perioperative organizational aspects – Adjustment along work situation, Absence of the perioperative dialogue.    Conclusion: The postoperative pain management is a complex matter that demand consideration of several aspects to achieve a good outcome. The perioperative dialogue is not prioritised. There is a lack of consensus among nurse anaesthetic´s managing postoperative pain. Developing and increasing cooperation along the entire chain of care is necessary to manage the issue of postoperative pain.

INTRODUÇÃO: A cetamina por via regional ou sistêmica melhora a analgesia pós-operatória. A hipótese testada nesse estudo foi a de que o uso profilático da cetamina S(+) por via peridural é melhor que a cetamina S(+) administrada por via venosa durante toda a anestesia, para o controle da dor pós-operatória em crianças submetidas a operações ortopédicas. MÉTODOS: 60 pacientes pediátricos foram aleatoriamente distribuídos em dois grupos de 30 pacientes. Os pacientes do grupo I receberam por via peridural 1 ml.kg-1 de ropivacaína a 0,2%, acrescida de 0,5 mg.kg-1 de cetamina S(+). Os pacientes do grupo II receberam por via peridural a mesma dose de ropivacaína, e antes da incisão cirúrgica receberam por via venosa infusão contínua de cetamina S(+) na dose de 0,2 mg.kg-1.h-1, interrompida ao final da sutura da pele. A mesma técnica anestésica geral complementar foi utilizada para os dois grupos. A dor foi avaliada pela escala Oucher de faces. Também foi avaliado o tempo para a primeira dose do analgésico de resgate e o consumo de morfina nas primeiras 24 h. Os resultados receberam tratamento estatístico pelo teste t de Student, não pareado, para comparação entre os dados demográficos dos grupos, tempo de duração do ato cirúrgico e tempo para recuperação, o teste do Qui quadrado e o teste exato de Fisher para análise de dados não paramétricos, e o teste de análise de variância, para comparar os valores da pressão arterial e da frequência cardíaca. RESULTADOS: Não foram encontradas diferenças estatísticas quanto à intensidade da dor, o tempo para a primeira dose de analgésico de resgate e o consumo de morfina entre os grupos. O valor da frequência cardíaca foi estatisticamente maior no grupo II do que no grupo I. CONCLUSÕES: A intensidade da dor pós-operatória, o tempo para a primeira dose de analgésico de resgate e o consumo de morfina foi semelhante com o uso da cetamina S(+) por via peridural ou sistêmica. A incidência de efeitos adversos foi semelhante com o uso da cetamina por via peridural ou sistêmica, com exceção da frequência cardíaca que foi estatisticamente maior no grupo em que a cetamina S(+) foi empregada em infusão contínua por via venosa. / INTRODUCTION: Ketamine by neuroaxial as well as intravenousroute could improve postoperative analgesia. The hypothesis to be tested here was that the prophylactic epidural use the S(+) ketamine, added to a local anesthetic solution, would improve postoperative pain control after orthopedic surgical procedures in pediatric patients, when compared to intravenous administration. METHODS: 60 pediatric patients were randomly assigned to one of two groups of 30 patients each named I, and II. Before the surgical incision the patients of group I, received by epidural route 1 ml.kg-1 0.2% ropivacaine and 0.5 mg. kg-1 S(+) ketamine. Patients of group II received by epidural route the same ropivacaine dose and 0.2 mg.kg-1h-1 S(+) ketamine IV infusion through all surgical procedure long suspended after the skin suture. The same complement anesthesia technique was provided to all patients. The pain was assessed by Oucher scale, time elicited to first rescue analgesia and 24 h morphine consumption. All data were statistically managed as follow: t test for demographics, surgical procedure duration and time to postoperative recovery; square CHI and Fisher test for nonparametric data and ANOVA for comparing the values of arterial pressure and heart rate. RESULTS: there were no statistical differences on time elicited to the first rescue analgesia, degree of pain complaint or morphine consumption when compared groups I and II. Mild tachycardia was observed for group II with statistical differences when compared to group I (P<0.05). CONCLUSION: the time elicited to the first rescue analgesia, degree of pain complaint and morphine consumption were similar with S(+) ketamine, by epidural and intravenous either. The adverse effects incidence was similar except for the heart rate statistically higher for the group where S(+) ketamine was employed by continuous intravenous route.

A exodontia de terceiros molares pode afetar significativamente a qualidade de vida dos pacientes no período pós-operatório. A resposta inflamatória gerada pelo dano tecidual inerente ao procedimento pode apresentar edema e dor de duração e intensidade variáveis. No presente estudo foi avaliada a eficácia do corticosteroide hidrocortisona, como solução de irrigação durante exodontias de terceiros molares no controle do edema e da dor pós-operatória. Vinte e oito pacientes foram incluídos no estudo e após randomização foram submetidos a exodontia de ambos os terceiros molares inferiores em tempos cirúrgicos distintos, pelo mesmo cirurgião. Foram distribuídos aleatoriamente para receber 250ml de solução contendo 500mg de hidrocortisona (grupo H) ou 250ml de solução salina a 0,9% (grupo C). Para avaliação da eficácia da hidrocortisona no controle da dor pós-operatória três mensurações foram utilizadas: a quantidade de medicação analgésica de resgate consumida, o tempo entre o término da cirurgia e o uso do primeiro comprimido de resgate e a EVA em seis momentos. Para aferição da eficácia da hidrocortisona no controle do edema foram criadas 3 medidas faciais e o edema foi medido por meio da diferença em milímetros entre o segundo dia de pós-operatório e o pré-operatório. A comparação entre os grupos mostrou que a hidrocortisona foi eficaz no controle pós-operatório do edema em duas das medidas aferidas. A dor acompanhou a diminuição do edema, sendo que na média a EVA foi menor no grupo H, no entanto não houve diferença estatisticamente significativa nas outras duas aferições de dor. Conclui-se que a utilização local da hidrocortisona, como solução de irrigação trans-operatória em exodontias de terceiros molares é efetiva na redução do edema e da percepção de dor pós-operatória. / The third molar removal can significantly affect the quality of life of patients in the postoperative period. The inflammatory response caused by tissue damage inherent to the procedure may include edema and pain with variable duration and intensity. In the present study, we evaluated the efficacy of hydrocortisone as irrigation solution during third molars removal for postoperative pain and edema control. Twenty-eight patients were included in the study after randomization and were subjected to removal of both mandibular third molars in different surgical times by the same surgeon. They were randomly assigned to receive 250ml solution containing 500 mg of hydrocortisone (group H) or 250ml 0.9% saline solution (group C). To evaluate the efficacy of hydrocortisone in controlling postoperative pain three measurements were applied: the amount of analgesic medication taken, the time between the end of surgery and the use of the first analgesic tablet and VAS in six moments. To measure the effectiveness of hydrocortisone in edema control three facial measurements were created and swelling was measured by the difference in millimeters between the second postoperative day and preoperative. The comparison between the groups showed that hydrocortisone was effective in postoperative edema control in two of the measurements taken. Pain accompanied the edema reduction and the average VAS was lower in H group, however there was no statistically significant difference in the other two measurements of pain. We concluded that the local use of hydrocortisone as intraoperative irrigation solution for third molar removal is effective in reducing postoperative edema and pain perception.

Introdução: O hálux valgo é uma importante causa de dor e desconforto e acomete 28% dos adultos e 37% dos idosos, com predominância na população feminina. Para atingir a cura desta deformidade, faz-se necessário o tratamento cirúrgico, cuja principal razão é o tratamento da incapacidade relacionada à dor (IRD). No entanto, um ano após a cirurgia de hálux valgo, dor crônica moderada a grave persiste em 21% em repouso e 43% durante a caminhada. Esta resposta anormal faz parte dos sintomas que constitui a síndrome de sensibilização central (SSC), a qual é decorrente de um processo de neuroplasticidade mal adaptativa. Pacientes sensibilizados, não só têm uma maior propensão a desenvolver dor persistente pós-operatória como também experenciam uma dor pós-operatória mais intensa em comparação com pacientes não sensibilizados, devido à amplificação da resposta a estímulos nociceptivos e disfunção dos sistemas inibitórios. Relacionadas ao processo de alterações neuroplásticas, encontramos proteínas tais como o fator neurotrófico derivado do cérebro (BDNF). Esta neurotrofina participa do processo de LTP, mecanismo de neuroplasticidade que sustenta o processo de memória dolorosa. O aumento de BDNF incrementa a LTP, enquanto que a redução de seus níveis atenua este fenômeno. Portanto, a relação de níveis de BDNF com a severidade da doença pode confirmar a influência sistêmica desse biomarcador em estados de dor sustentada. A fim de alterar a neuroplasticidade mal adaptativa induzida pela dor a longo prazo, a estimulação transcraniana por corrente contínua (ETCC), uma técnica não invasiva, que visa à modulação do sistema nervoso central para controle da dor, pode se tornar uma opção terapêutica. No entanto, ainda não foi explorado o efeito da ETCC aplicada no período pré-operatório com intuito de melhorar o controle da dor pós-operatória de pacientes sensibilizadas e melhorar a reabilitação pós-operatória dessas pacientes. Neste estudo optou-se pelo uso da ETCC pelo seu potencial de contra regular as alterações ETCC pré-operatória comparada ao ETCC-sham no controle da dor e reabilitação em pacientes com artralgia da 1ªAMF submetidas a tratamento cirúrgico de hálux valgo. Método: Ensaio clínico, randomizado, duplo-cego, em paralelo, controlado com sham que incluiu 40 pacientes do sexo feminino, entre 18 e 70 anos, candidatas a tratamento cirúrgico de hálux valgo sob técnica combinada de Chevron e Akin por artralgia da 1ªAMF. As pacientes foram randomizadas e divididas em dois grupos que receberam duas sessões de 20 minutos de ETCC-ativa(a) ou ETCC-sham(s) no período pré-operatório. A estimulação foi feita por corrente contínua de 2mA através do eletrodo anodal sobre o córtex motor primário (M1) e o catodal sobre a área supraorbital contralateral. Os desfechos avaliados foram: escores de dor na EAV(0-10), consumo analgésico, IRD avaliada pela B-PCP:S, função do sistema modulador descendente da dor, avaliada pelo teste CPM e os níveis séricos e liquóricos de BDNF. Resultados: O grupo ETCC-a apresentou escores mais baixos na escala Análogo Visual de Dor [EAV(0-10)] em repouso e durante a caminhada (P <0,001). Em repouso, a diferença entre os dois grupos foi de 2,13cm (95% IC = 1,59 a 2,68), enquanto durante a caminhada foi de 1,67cm (IC 95% = 1,05 a 2,28). O grupo ETCC-a, quando comparado ao grupo ETCC-s mostrou menor necessidade de doses analgésicas diárias com média de 1,37 (0,63) contra 1,81 (0,64) doses respectivamente (P <0,001). A ETCC ativa também obteve maior melhora da IRD que a ETCC sham, conforme demostrado pela maior redução na Brazilian Profile of Chronic Pain: Screen (B-PCP:S) (diferença média de 9,41 pontos, IC95% = 0,63 a 18,21) e ainda, aumentou a função do sistema modulador descendente da dor durante o teste da modulação condicionada de dor (CPM) com um tamanho de efeito médio. O aumento da função desse sistema representa a reversão das alterações neuroplásticas mal adaptativas promovidas pela dor crônica. Conclusão: Duas sessões de ETCC anódica aplicadas sobre M1 no pré-operatório melhorou a dor pós-operatória, como demonstrado pela redução dos escores de dor, consumo de analgésicos e IRD. Além disso, sugere-se que os efeitos da ETCC pré-operatória nestes desfechos envolvem a melhora da função dos sistemas moduladores descendentes da dor e mecanismos de neuroplasticidade conforme mensurados pelo BDNF. / Introduction: Hallux valgus, is an important cause of feet pain and discomfort and affects 28% of adults and 37% of elderly, predominantly in female population. To achieve the deformity heal, surgical treatment is needed, which main goal is to treat incapacity related to pain (IRP). However, one year after hallux valgus surgical treatment, moderate to severe chronic pain persists in 21% during rest and 43% during walking. This abnormal response is part of the symptoms that constitute central sensitization syndrome (CSS), which is due to a maladaptive neuroplasticity process. Sensitized patients, not only are more likely to develop postoperative persistent pain, but also experience more intense postoperative pain comparing to non-sensitized patients, due to the amplification of nociceptive inputs and inhibitory systems disfunction. Related to neuroplasticy process, proteins such as brain neurotrophic factor (BDNF) are found. This neurotrophin participates in the LTP process, a mechanism of neuroplasticity that sustains the process of pain memory. The increase of BDNF increases the LTP, while the reduction of its levels attenuates this phenomenon. Therefore, the relationship of BDNF levels with disease severity may confirm the systemic influence of this biomarker on sustained pain states. In order to alter long-term pain-induced maladaptive neuroplasticity, transcranial direct current stimulation (tDCS), a non-invasive technique, which aims for the central nervous system modulation for pain control, may become a therapeutic option for postoperative pain. However, the effect of tDCS applied in the preoperative period has not been explored yet with the intent of improving the postoperative pain control in sensitized patients, neither in postoperative rehabilitation. In this study, it was chosen to use tDCS due to its potential to counter-regulate the maladaptive neuroplastic alterations associated to chronic pain. Objective: to evaluate the effect of preoperative tDCS compared to tDCS-sham in the pain control and in the rehabilitation of patients with arthralgia of the first metatarsalfalangeal articulation submitted to hallux valgus surgical correction. Method: it is a randomized, double-blinded, placebo-sham controlled clinical trial, which includes 40 female patients, between 18 and 70 years old, candidates to hallux valgus surgical treatment by combined Chevron + Akin osteotomy due to arthralgia of the first metatarsalfalangeal articulation. The patients were randomized and divided into two groups that were treated with two tDCS or tDCS-sham sessions of 20 minutes each in preoperative period. The stimulation was done by 2mA continuous current through the anodal electrode on the primary motor cortex (M1) and the catodal on the contralateral supraorbital area. The outcomes were: VAS(0-10) scores, analgesic consumption, DRP assessed by the B-PCP: S, the function of the descending pain modulator system, assessed by the CPM test and the serum and CSF levels of BDNF. Results: a-tDCS group showed lower scores on Visual Analogue Scale [VAS(0-10)] at rest and during walking (P<0.001). At rest, the difference between both groups was 2.13cm (95%CI=1.59 to 2.68) while during walking was 1.67cm (95%CI=1.05 to 2.28). The a-tDCS group, when compared to s-tDCS, showed reduced need of daily analgesic intake from 1.37 (0.63) to 1.81 (0.64) mean doses, respectively (P<0.001). Active tDCS improved the DRP, as demonstrated by a greater reduction in the Brazilian Profile of Chronic Pain: Screen (B-PCP:S) (mean difference of 9.41 points, 95%CI=0.63 to 18.21) and also increased the function of descending pain modulatory system (DPMS) during conditioned pain modulation (CPM-task), with a medium size effect. The increased function of this system represents the reversal of maladaptive neuroplastic changes promoted by chronic pain. Conclusion: Two preoperative anodic tDCS sessions applied over M1 improved postoperative pain, as demonstrated by reduction in the pain scores, analgesic consumption and DRP. In addition, these results suggest that the effects of preoperative tDCS on these outcomes involved improving the function of pain modulation systems and neuroplasticity mechanisms as measured by BDNF.

Submitted by Geyciane Santos (geyciane_thamires@hotmail.com) on 2015-06-11T14:17:28Z No. of bitstreams: 1 Dissertação - João Bosco Formiga Relvas.pdf: 1113617 bytes, checksum: f27453a622baa34891d19a11356a4648 (MD5) / Approved for entry into archive by Divisão de Documentação/BC Biblioteca Central (ddbc@ufam.edu.br) on 2015-06-11T19:09:42Z (GMT) No. of bitstreams: 1 Dissertação - João Bosco Formiga Relvas.pdf: 1113617 bytes, checksum: f27453a622baa34891d19a11356a4648 (MD5) / Approved for entry into archive by Divisão de Documentação/BC Biblioteca Central (ddbc@ufam.edu.br) on 2015-06-11T19:14:31Z (GMT) No. of bitstreams: 1 Dissertação - João Bosco Formiga Relvas.pdf: 1113617 bytes, checksum: f27453a622baa34891d19a11356a4648 (MD5) / Made available in DSpace on 2015-06-11T19:14:31Z (GMT). No. of bitstreams: 1 Dissertação - João Bosco Formiga Relvas.pdf: 1113617 bytes, checksum: f27453a622baa34891d19a11356a4648 (MD5) Previous issue date: 2015-02-20 / CAPES - Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / The aim of this study was to evaluate the postoperative pain after treatment of root canal system using two instrumentation techniques. The study included 78 patients aged 16-64 years (mean 25.6 years), male, with mandibular molar teeth with pulp necrosis asymptomatic (n = 78). Root canal treatment was performed by a single operator specialist in endodontics in one session. Mechanical preparation of the root canal was done using the instrumentation techniques ProTaper® and Reciproc®. Postoperative pain was recorded using a visual analogue scale (VAS) and verbal description, in well-defined categories in three time intervals, 24 hours, 72 hours and 7 days. The evaluation of postoperative pain was recorded as none, mild pain, moderate pain and severe pain or flare-up. Data were analyzed with statistical test nonparametric Mann Whitney, with the help of software STATA. The incidence of post-operative pain for the ProTaper group (PT) after 24 hours was 17.94% and after 72 hours was 5.12%. For Reciproc group (RP) the incidence after 24 hours was 15.38% and after 72 hours was 2.56%. Neither group had severe pain in periods. In this study there was no significant difference (p> 0.05) in postoperative pain between ProTaper® and Reciproc® instrumentation technique in performing endodontic treatment / O objetivo desse estudo foi avaliar a dor pós-operatória após tratamento do sistema de canais radiculares utilizando duas técnicas de instrumentação. Foram incluídos neste estudo, 78 pacientes com faixa etária de 16 a 64 anos (média de 25,6 anos de idade), do sexo masculino, com dentes molares inferiores portadores de necrose pulpar assintomática (n=78). O tratamento endodôntico foi realizado por um único operador especialista em Endodontia em sessão única. O preparo biomecânico dos canais radiculares foi feito utilizando as técnicas de instrumentação ProTaper® e Reciproc®. A dor pós-operatória foi registrada por meio de uma escala visual analógica (VAS) e de descrição verbal, em categorias bem definidas em três intervalos de tempo, 24 horas, 72 horas e 7 dias. A avaliação da dor pós-operatória foi registrada como nenhuma, dor leve, dor moderada e dor severa ou flare-up. Os dados foram analisados com o teste estatístico não paramétrico de Mann Whitney, com o auxílio do Software STATA®. A incidência de dor pós-operatória para o Grupo ProTaper (PT) após 24 horas foi de 17,94% e após 72 horas foi de 5,12%. Para o Grupo Reciproc (RP) esta incidência após 24 horas foi de 15,38% e após 72 horas foi de 2,56%. Nenhum dos grupos apresentaram dor severa nos períodos avaliados. Neste estudo não houve diferença significativa (p> 0,05) na dor pós-operatória entre técnica de instrumentação ProTaper® e Reciproc® na realização do tratamento endodôntico.