1
|
Jadidi AF, Jensen W, Zarei AA, Lontis ER, Atashzar SF. From pulse width modulated TENS to cortical modulation: based on EEG functional connectivity analysis. Front Neurosci 2023; 17:1239068. [PMID: 37600002 PMCID: PMC10433172 DOI: 10.3389/fnins.2023.1239068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 07/18/2023] [Indexed: 08/22/2023] Open
Abstract
Modulation in the temporal pattern of transcutaneous electrical nerve stimulation (TENS), such as Pulse width modulated (PWM), has been considered a new dimension in pain and neurorehabilitation therapy. Recently, the potentials of PWM TENS have been studied on sensory profiles and corticospinal activity. However, the underlying mechanism of PWM TENS on cortical network which might lead to pain alleviation is not yet investigated. Therefore, we recorded cortical activity using electroencephalography (EEG) from 12 healthy subjects and assessed the alternation of the functional connectivity at the cortex level up to an hour following the PWM TENS and compared that with the effect of conventional TENS. The connectivity between eight brain regions involved in sensory and pain processing was calculated based on phase lag index and spearman correlation. The alteration in segregation and integration of information in the network were investigated using graph theory. The proposed analysis discovered several statistically significant network changes between PWM TENS and conventional TENS, such as increased local strength and efficiency of the network in high gamma-band in primary and secondary somatosensory sources one hour following stimulation. Our findings regarding the long-lasting desired effects of PWM TENS support its potential as a therapeutic intervention in clinical research.
Collapse
Affiliation(s)
- Armita Faghani Jadidi
- Center for Neuroplasticity and Pain (CNAP), Department of Health Science and Technology, Aalborg University, Aalborg East, Denmark
| | - Winnie Jensen
- Center for Neuroplasticity and Pain (CNAP), Department of Health Science and Technology, Aalborg University, Aalborg East, Denmark
| | - Ali Asghar Zarei
- Center for Neuroplasticity and Pain (CNAP), Department of Health Science and Technology, Aalborg University, Aalborg East, Denmark
| | - Eugen Romulus Lontis
- Center for Neuroplasticity and Pain (CNAP), Department of Health Science and Technology, Aalborg University, Aalborg East, Denmark
| | - S. Farokh Atashzar
- Department of Electrical and Computer Engineering, New York University, New York, NY, United States
- Department of Mechanical and Aerospace Engineering, New York University, New York, NY, United States
- Department of Biomedical Engineering, New York University, New York, NY, United States
- NYU WIRELESS, New York University (NYU), New York, NY, United States
- NYU Center for Urban Science and Progress (CUSP), New York University (NYU), New York, NY, United States
| |
Collapse
|
2
|
Pinto CB, Bielefeld J, Barroso J, Yip B, Huang L, Schnitzer T, Apkarian AV. Chronic pain domains and their relationship to personality, abilities, and brain networks. Pain 2023; 164:59-71. [PMID: 35612403 PMCID: PMC9582040 DOI: 10.1097/j.pain.0000000000002657] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 02/23/2022] [Indexed: 01/09/2023]
Abstract
Abstract
Chronic pain is a multidimensional pathological state. Recent evidence suggests that specific brain properties and patients' psychological and physical traits are distorted in chronic pain patients. However, the relationship between these alterations and pain dimensions remains poorly understood. Here, we first evaluated multiple dimensions of chronic pain by assessing a broad battery of pain-related questionnaire scores (23 outcomes) of 107 chronic low back pain patients and identified 3 distinct chronic pain domains: magnitude, affect & disability, and quality. Second, we investigated the pain domains relationship with measures of personality, social interaction, psychological traits, and ability traits (77 biopsychosocial & ability [biopsy&ab] outcomes). Pain magnitude (out-of-sample [OOS]
) is associated with emotional control, attention, and working memory, with higher pain scores showing lower capacity to regulate and adapt behaviorally. Pain affect & disability (OOS
associated with anxiety, catastrophizing and social relationships dysfunction. Pain quality did not relate significantly to biopsy&ab variables. Third, we mapped these 3 pain domains to brain functional connectivity. Pain magnitude mainly associated with the sensorimotor and the cingulo-opercular networks (OOS
). Pain affect & disability related to frontoparietal and default mode networks (OOS
. Pain quality integrated sensorimotor, auditory, and cingulo-opercular networks (OOS
). Mediation analysis could link functional connectivity and biopsy&ab models to respective pain domains. Our results provide a global overview of the complexity of chronic pain, showing how underlying distinct domains of the experience map to different biopsy&ab correlates and underlie unique brain network signatures.
Collapse
Affiliation(s)
- Camila Bonin Pinto
- Department of Neuroscience, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
- Center for Translational Pain Research, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Jannis Bielefeld
- Department of Neuroscience, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
- Center for Translational Pain Research, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Joana Barroso
- Department of Neuroscience, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
- Center for Translational Pain Research, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Byron Yip
- Departments of Physical Medicine and Rehabilitation
| | - Lejian Huang
- Department of Neuroscience, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
- Center for Translational Pain Research, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Thomas Schnitzer
- Departments of Physical Medicine and Rehabilitation
- Anesthesiology, and
- Medicine (Rheumatology), Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - A Vania Apkarian
- Department of Neuroscience, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
- Center for Translational Pain Research, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
- Departments of Physical Medicine and Rehabilitation
- Anesthesiology, and
| |
Collapse
|
3
|
Boomgaardt J, Dastan K, Chan T, Shilling A, Abd-Elsayed A, Kohan L. An Algorithm Approach to Phantom Limb Pain. J Pain Res 2022; 15:3349-3367. [PMID: 36320223 PMCID: PMC9618240 DOI: 10.2147/jpr.s355278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 10/14/2022] [Indexed: 11/06/2022] Open
Abstract
Phantom limb pain (PLP) is a common condition that occurs following both upper and lower limb amputation. First recognized and described in 1551 by Ambroise Pare, research into its underlying pathology and effective treatments remains a very active and growing field. To date, however, there is little consensus regarding the optimal management of phantom limb pain. With few large well-designed clinical trials of which to make treatment recommendations, as well as significant heterogeneity in clinical response to available treatments, the management of PLP remains challenging. Below we summarize the current state of knowledge in the field, as well as propose an algorithm for the approach to the treatment of PLP.
Collapse
Affiliation(s)
- Jacob Boomgaardt
- Department of Physical Medicine and Rehabilitation, University of Virginia, Charlottesville, VA, USA
| | - Kovosh Dastan
- Department of Physical Medicine and Rehabilitation, University of Virginia, Charlottesville, VA, USA
| | - Tiffany Chan
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA
| | - Ashley Shilling
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesiology, University of Wisconsin-Madison, Madison, WI, USA
| | - Lynn Kohan
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA,Correspondence: Lynn Kohan, Department of Anesthesiology, University of Virginia, 545 Ray C Hunt Suite 3168, Charlottesville, VA, 22903, USA, Tel +1-434-243-5676, Fax +1-434-243-5689, Email
| |
Collapse
|
4
|
Johnson MI, Paley CA, Wittkopf PG, Mulvey MR, Jones G. Characterising the Features of 381 Clinical Studies Evaluating Transcutaneous Electrical Nerve Stimulation (TENS) for Pain Relief: A Secondary Analysis of the Meta-TENS Study to Improve Future Research. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58060803. [PMID: 35744066 PMCID: PMC9230499 DOI: 10.3390/medicina58060803] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 06/08/2022] [Accepted: 06/10/2022] [Indexed: 12/29/2022]
Abstract
Background and Objectives: Characterising the features of methodologies, clinical attributes and intervention protocols, of studies is valuable to advise directions for research and practice. This article reports the findings of a secondary analysis of the features from studies screened as part of a large systematic review of TENS (the meta-TENS study). Materials and Methods: A descriptive analysis was performed on information associated with methodology, sample populations and intervention protocols from 381 randomised controlled trials (24,532 participants) evaluating TENS delivered at a strong comfortable intensity at the painful site in adults with pain, irrespective of diagnosis. Results: Studies were conducted in 43 countries commonly using parallel group design (n = 334) and one comparator group (n = 231). Mean ± standard deviation (SD) study sample size (64.05 ± 58.29 participants) and TENS group size (27.67 ± 21.90 participants) were small, with only 13 of 381 studies having 100 participants or more in the TENS group. Most TENS interventions were ‘high frequency’ (>10 pps, n = 276) and using 100 Hz (109/353 reports that stated a pulse frequency value). Of 476 comparator groups, 54.2% were active treatments (i.e., analgesic medication(s), exercise, manual therapies and electrophysical agents). Of 202 placebo comparator groups, 155 used a TENS device that did not deliver currents. At least 216 of 383 study groups were able to access other treatments whilst receiving TENS. Only 136 out of 381 reports included a statement about adverse events. Conclusions: Clinical studies on TENS are dominated by small parallel group evaluations of high frequency TENS that are often contaminated by concurrent treatment(s). Study reports tended focus on physiological and clinical implications rather than the veracity of methodology and findings. Previously published criteria for designing and reporting TENS studies were neglected and this should be corrected in future research using insights gleaned from this analysis.
Collapse
Affiliation(s)
- Mark I. Johnson
- Centre for Pain Research, School of Health, Leeds Beckett University, Leeds LS1 3HE, UK; (C.A.P.); (P.G.W.); (G.J.)
- Correspondence: ; Tel.: +44-113-812-30-83
| | - Carole A. Paley
- Centre for Pain Research, School of Health, Leeds Beckett University, Leeds LS1 3HE, UK; (C.A.P.); (P.G.W.); (G.J.)
- Research & Development Department, Airedale NHS Foundation Trust, Steeton, Keighley BD20 6TD, UK
| | - Priscilla G. Wittkopf
- Centre for Pain Research, School of Health, Leeds Beckett University, Leeds LS1 3HE, UK; (C.A.P.); (P.G.W.); (G.J.)
| | - Matthew R. Mulvey
- Academic Unit of Primary and Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds LS2 9NL, UK;
| | - Gareth Jones
- Centre for Pain Research, School of Health, Leeds Beckett University, Leeds LS1 3HE, UK; (C.A.P.); (P.G.W.); (G.J.)
| |
Collapse
|
5
|
Gunduz ME, Pacheco-Barrios K, Bonin Pinto C, Duarte D, Vélez FGS, Gianlorenco ACL, Teixeira PEP, Giannoni-Luza S, Crandell D, Battistella LR, Simis M, Fregni F. Effects of Combined and Alone Transcranial Motor Cortex Stimulation and Mirror Therapy in Phantom Limb Pain: A Randomized Factorial Trial. Neurorehabil Neural Repair 2021; 35:704-716. [PMID: 34060934 PMCID: PMC10042175 DOI: 10.1177/15459683211017509] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Phantom limb pain (PLP) is a frequent complication in amputees, which is often refractory to treatments. We aim to assess in a factorial trial the effects of transcranial direct current stimulation (tDCS) and mirror therapy (MT) in patients with traumatic lower limb amputation; and whether the motor cortex plasticity changes drive these results. In this large randomized, blinded, 2-site, sham-controlled, 2 × 2 factorial trial, 112 participants with traumatic lower limb amputation were randomized into treatment groups. The interventions were active or covered MT for 4 weeks (20 sessions, 15 minutes each) combined with 2 weeks of either active or sham tDCS (10 sessions, 20 minutes each) applied to the contralateral primary motor cortex. The primary outcome was PLP changes on the visual analogue scale at the end of interventions (4 weeks). Motor cortex excitability and cortical mapping were assessed by transcranial magnetic stimulation (TMS). We found no interaction between tDCS and MT groups (F = 1.90, P = .13). In the adjusted models, there was a main effect of active tDCS compared to sham tDCS (beta coefficient = -0.99, P = .04) on phantom pain. The overall effect size was 1.19 (95% confidence interval: 0.90, 1.47). No changes in depression and anxiety were found. TDCS intervention was associated with increased intracortical inhibition (coefficient = 0.96, P = .02) and facilitation (coefficient = 2.03, P = .03) as well as a posterolateral shift of the center of gravity in the affected hemisphere. MT induced no motor cortex plasticity changes assessed by TMS. These findings indicate that transcranial motor cortex stimulation might be an affordable and beneficial PLP treatment modality.
Collapse
Affiliation(s)
- Muhammed Enes Gunduz
- Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, USA.,Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kevin Pacheco-Barrios
- Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, USA.,Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Universidad San Ignacio de Loyola, Lima, Peru
| | - Camila Bonin Pinto
- Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, USA.,Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Northwestern University, Chicago, IL, USA
| | - Dante Duarte
- Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, USA.,Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,McMaster University, Hamilton, Ontario, Canada
| | - Faddi Ghassan Saleh Vélez
- Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, USA.,Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,University of Chicago Medical Center, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Anna Carolyna Lepesteur Gianlorenco
- Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, USA.,Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Federal University of Sao Carlos, Sao Carlos, Brazil
| | - Paulo Eduardo Portes Teixeira
- Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, USA.,Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Stefano Giannoni-Luza
- Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, USA.,Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - David Crandell
- Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | - Felipe Fregni
- Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, USA.,Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
6
|
DI Pino G, Piombino V, Carassiti M, Ortiz-Catalan M. Neurophysiological models of phantom limb pain: what can be learnt. Minerva Anestesiol 2021; 87:481-487. [PMID: 33432796 DOI: 10.23736/s0375-9393.20.15067-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Phantom Limb Pain (PLP) is a dysesthesic painful sensations perceived in the lost limb, resulting from complex interactions between structural and functional nervous systems changes. We analyze its main pathogenetic models and speculate on candidate therapeutic targets. The neuroma model considers PLP to arise from spontaneous activity of residual limb injured axons. Other peripheral-origin models attribute PLP to damage of somatosensory receptors or vascular changes. According to the cortical remapping model, the loss of bidirectional nervous flow and the need to enhance alternative functions trigger reorganization and arm and face skin afferents "invade" the hand territory. On the contrary, the persistent representation model suggests that continued inputs preserve the lost limb representation and that, instead to a shrinkage, PLP is associated with larger representation and stronger cortical activity. In the neuromatrix model, the mismatch between body representation, which remains intact despite limb amputation, and real body appearance generates pain. Another hypothesis is that proprioceptive memories associate specific limb positions with pre-amputation pain and may be recalled by those positions. Finally, the stochastic entanglement model offers a direct relationship between sensorimotor neural reorganization and pain. Amputation disrupts motor and somatosensory circuits, allowing for maladaptive wiring with pain circuits and causing pain without nociception. Relief of PLP depends solely on motor and somatosensory circuitry engagement, making anthropomorphic visual feedback dispensable. Existing and apparently contradicting theories might not be mutually exclusive. All of them involve several intertwined potential mechanisms by which replacing the amputated limb by an artificial one could counteract PLP.
Collapse
Affiliation(s)
- Giovanni DI Pino
- Research Unit of Neurophysiology and Neuroengineering of Human-Technology Interaction (NeXTlab), Campus Bio-Medico University, Rome, Italy -
| | - Valeria Piombino
- Research Unit of Neurophysiology and Neuroengineering of Human-Technology Interaction (NeXTlab), Campus Bio-Medico University, Rome, Italy
| | - Massimiliano Carassiti
- Unit of Anesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio-Medico University, Rome, Italy
| | - Max Ortiz-Catalan
- Center for Bionics and Pain Research, Mölndal, Sweden.,Department of Electrical Engineering, Chalmers University of Technology, Gothenburg, Sweden.,Operational Area 3, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Orthopedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| |
Collapse
|
7
|
Mallik AK, Pandey SK, Srivastava A, Kumar S, Kumar A. Comparison of Relative Benefits of Mirror Therapy and Mental Imagery in Phantom Limb Pain in Amputee Patients at a Tertiary Care Center. Arch Rehabil Res Clin Transl 2020; 2:100081. [PMID: 33543104 PMCID: PMC7853377 DOI: 10.1016/j.arrct.2020.100081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To determine the relative benefit of mirror therapy and mental imagery in phantom limb pain. DESIGN Prospective randomized controlled trial. SETTING Physical Medicine and Rehabilitation Department, All India Institute of Medical Sciences, Patna. PARTICIPANTS Amputees (N=92) with no significant difference in baseline characteristics. There was a male predominance in both groups (mirror therapy: 36 men, 10 women; mental imagery: 37 men, 9 women). INTERVENTION Patients of both groups underwent a conventional amputee rehabilitation program and daily treatment of either mirror therapy or mental imagery on a regular basis, first in a rehabilitation care unit and later at home. MAIN OUTCOME MEASURES Phantom limb pain (PLP) was measured by visual analog scale (VAS) score at baseline (0) and at 4, 8, and 12 months. RESULTS This study included 92 patients ranging in age from 12 to 75 years (average, 34.79y). There was no significant difference in VAS score between the groups at baseline, but we found a significant reduction of pain in both groups at follow-up. However, upon comparing the improvement in both groups, we determined that the mirror therapy group had better improvement (from 7.07±1.74 to 2.74±0.77) compared with the mental imagery group (from 7.85±0.76 to 5.87±1.41). CONCLUSIONS Mirror therapy and mental imagery are both good and cost-effective rehabilitation aids for amputee patients to reduce PLP, but mirror therapy appears to be more effective than mental imagery.
Collapse
Affiliation(s)
- Amit Kumar Mallik
- Department of Physical Medicine and Rehabilitation, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Sanjay Kumar Pandey
- Department of Physical Medicine and Rehabilitation, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Ashish Srivastava
- Department of Physical Medicine and Rehabilitation, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Sanyal Kumar
- Department of Physical Medicine and Rehabilitation, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Anjani Kumar
- Department of Physical Medicine and Rehabilitation, All India Institute of Medical Sciences, Patna, Bihar, India
| |
Collapse
|
8
|
Pacheco-Barrios K, Meng X, Fregni F. Neuromodulation Techniques in Phantom Limb Pain: A Systematic Review and Meta-analysis. PAIN MEDICINE (MALDEN, MASS.) 2020; 21:2310-2322. [PMID: 32176286 PMCID: PMC7593798 DOI: 10.1093/pm/pnaa039] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To evaluate the effects of neuromodulation techniques in adults with phantom limb pain (PLP). METHODS A systematic search was performed, comprising randomized controlled trials (RCTs) and quasi-experimental (QE) studies that were published from database inception to February 2019 and that measured the effects of neuromodulation in adults with PLP. Hedge's g effect size (ES) and 95% confidence intervals were calculated, and random-effects meta-analyses were performed. RESULTS Fourteen studies (nine RCTs and five QE noncontrolled studies) were included. The meta-analysis of RCTs showed significant effects for i) excitatory primary motor cortex (M1) stimulation in reducing pain after stimulation (ES = -1.36, 95% confidence interval [CI] = -2.26 to -0.45); ii) anodal M1 transcranial direct current stimulation (tDCS) in lowering pain after stimulation (ES = -1.50, 95% CI = -2.05 to 0.95), and one-week follow-up (ES = -1.04, 95% CI = -1.64 to 0.45). The meta-analysis of noncontrolled QE studies demonstrated a high rate of pain reduction after stimulation with transcutaneous electrical nerve stimulation (rate = 67%, 95% CI = 60% to 73%) and at one-year follow-up with deep brain stimulation (rate = 73%, 95% CI = 63% to 82%). CONCLUSIONS The evidence from RCTs suggests that excitatory M1 stimulation-specifically, anodal M1 tDCS-has a significant short-term effect in reducing pain scale scores in PLP. Various neuromodulation techniques appear to have a significant and positive impact on PLP, but due to the limited amount of data, it is not possible to draw more definite conclusions.
Collapse
Affiliation(s)
- Kevin Pacheco-Barrios
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Boston, Massachusetts, USA
- Universidad San Ignacio de Loyola, Vicerrectorado de Investigación, Unidad de Investigación para la Generación y Síntesis de Evidencias en Salud, Lima, Peru
| | - Xianguo Meng
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Boston, Massachusetts, USA
- Shandong First Medical University & Shandong Academy of Medical Sciences, College of Sport Medicine and Rehabilitation, Jinan, Shandong Province, P.R. China
| | - Felipe Fregni
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Boston, Massachusetts, USA
| |
Collapse
|
9
|
Therapeutic Sensations: A New Unifying Concept. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2020; 2020:7630190. [PMID: 32831879 PMCID: PMC7428881 DOI: 10.1155/2020/7630190] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 06/03/2020] [Accepted: 06/11/2020] [Indexed: 12/19/2022]
Abstract
Physical sensations of tingling, warmth, dull pain, and heaviness are a common phenomenon in mind-body interventions, such as acupuncture, hypnotherapy, osteopathy, qigong, meditation, and progressive muscle relaxation. Even though there are striking parallels between sensations produced by many different interventions, no attempt has yet been made to understand them from a unifying perspective that combines information from different therapies and practices. Therefore, this narrative systematic review introduces the concept of therapeutic sensations and summarizes studies of their sensory quality, bodily topography, and the meaning that patients attach to them. Furthermore, it highlights the essential role of therapeutic sensations in the development of vital energy concepts, such as qi, prana, pneuma, and orgone, in various traditional medicine systems, body-oriented psychotherapy, and so-called energy medicine. Finally, the assessment of therapeutic sensations may help to gain a deeper understanding of such concepts, finding a common language between scientists, patients and practitioners, and bridging the wide gap between materialistic and vitalistic views.
Collapse
|
10
|
Chagger J, Sivapragasam K, Wong M. Commentary: Preliminary Evidence for Training-Induced Changes of Morphology and Phantom Limb Pain. Front Hum Neurosci 2019; 13:211. [PMID: 31275127 PMCID: PMC6593358 DOI: 10.3389/fnhum.2019.00211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 06/04/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jaskaran Chagger
- Bachelor of Health Sciences Program, McMaster University, Hamilton, ON, Canada
| | | | - Michael Wong
- Psychology Department, University of Wisconsin - La Crosse, La Crosse, WI, United States
- *Correspondence: Michael Wong
| |
Collapse
|
11
|
Kaur A, Guan Y. Phantom limb pain: A literature review. Chin J Traumatol 2018; 21:366-368. [PMID: 30583983 PMCID: PMC6354174 DOI: 10.1016/j.cjtee.2018.04.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 05/05/2018] [Accepted: 05/23/2018] [Indexed: 02/04/2023] Open
Abstract
Since the phantom limb sensation was first described by the French military surgeon Ambroise Pare in the 16th century, the number of studies surrounding phantom limb pain has increased every year. Especially in recent decades, scientists have achieved a better understanding of the mechanism and treatment of phantom limb pain. Although many hypotheses have been agreed and many treatments have been proven effective, scientists still do not have a very systematic understanding of the phantom limbs. The purpose of this review article is to summarize recent researches focusing on phantom limb in order to discuss its definition, mechanisms, and treatments.
Collapse
|
12
|
Okonkwo UP, Ibeneme SC, Ihegihu EY, Egwuonwu AV, Ezema IC, Maruf AF, Okoye EC, Ibikunle OP, Ezekwu AO. Effects of transcutaneous electrical nerve stimulation in the Management of Post-Injection Sciatic Pain in a non-randomized controlled clinical trial in Nnewi, Nigeria. BMC COMPLEMENTARY AND ALTERNATIVE MEDICINE 2018; 18:310. [PMID: 30477485 PMCID: PMC6258320 DOI: 10.1186/s12906-018-2373-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 11/07/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Many studies on transcutaneous electrical nerve stimulation (TENS) had been undertaken to explore its pain relieving efficiency on several medicals/surgical conditions but none, specifically, had been carried out to determine the effect it has on post-injection sciatic pain (PISP) which comes about from wrong administration of intramuscular pain. This study aims to assess the effects of TENS in the management of PISP. METHODS A total of 72 PISP subjects comprising 40 test subjects and 32 control subjects participated in a non-randomized controlled clinical trial in the current study. Participants were recruited from Department of Physiotherapy, Nnamdi Azikiwe University Teaching Hospital, Nnewi and Landmark Physiotherapy Services, Nnewi. The participants were however blinded to the intervention method they will receive before being allotted conveniently to test/experimental group (TG) or control group (CG). A written informed consent was obtained from participants before enrollments in the study. TENS and sham TENS (STENS) was applied to 40 test and 32 subjects respectively, 3 times a week, and 1 hour per session for the 10 weeks the study lasted. The Visual Analogue Scale was used to collect baseline data as well as those of 2nd, 4th, 6th, 8th and 10th weeks after TENS and STENS interventions. The data analysis was performed with the Descriptive statistic of Mean ± SD, mean comparison test, repeated analysis of variance and paired wise t-test. Statistical level of significance was set at P < 0.05. RESULT Results of repeated measure ANOVA showed that the pain level among participants in the treatment group at the end (after 10 weeks) of the intervention was significantly lower than that of their counterparts in the control group (F = 16.26; p = 0.01); with the intervention accounting for the 19% of the variance. The effect size (partial eta squared) = 0.19. CONCLUSION The outcome of this research has proved the effectiveness of TENS in the management of PISP and is being recommended in the management of PISP. TRIAL REGISTRATION Pan Africa Clinical Trial Registry ( PACTR201805003408271 ). The study was registered retrospectively on the 29th May, 2018.
Collapse
Affiliation(s)
- Uchenna Prosper Okonkwo
- Department of Physiotherapy, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State PMB 5025 Nigeria
| | - Sam Chidi Ibeneme
- Department of Medical Rehabilitation, Faculty of Health Sciences and Technology, University of Nigeria|, Enugu Campus, Enugu State Nigeria
| | - Ebere Yvonne Ihegihu
- Department of Physiotherapy, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State PMB 5025 Nigeria
| | - Afamefuna Victor Egwuonwu
- Department of Medical Rehabilitation, Faculty of Health Sciences and Technology, Nnamdi Azikiwe University, Awka, Anambra State Nigeria
| | - Ikechukwu Charles Ezema
- Department of Medical Rehabilitation, Faculty of Health Sciences and Technology, University of Nigeria|, Enugu Campus, Enugu State Nigeria
| | - Adesina Fatai Maruf
- Department of Medical Rehabilitation, Faculty of Health Sciences and Technology, Nnamdi Azikiwe University, Awka, Anambra State Nigeria
| | - Emmanuel Chiebuka Okoye
- Department of Medical Rehabilitation, Faculty of Health Sciences and Technology, Nnamdi Azikiwe University, Awka, Anambra State Nigeria
| | - Olanrewaju Peter Ibikunle
- Department of Medical Rehabilitation, Faculty of Health Sciences and Technology, Nnamdi Azikiwe University, Awka, Anambra State Nigeria
| | - Antoninus Obinna Ezekwu
- Department of Medical Rehabilitation, Faculty of Health Sciences and Technology, University of Nigeria|, Enugu Campus, Enugu State Nigeria
| |
Collapse
|
13
|
Abstract
OBJECTIVE To review the literature related to different treatment strategies for the general population of individuals with amputation, spinal cord injury, and cerebral palsy, as well as how this may impact pain management in a correlated athlete population. DATA SOURCES A comprehensive literature search was performed linking pain with terms related to different impairment types. MAIN RESULTS There is a paucity in the literature relating to treatment of pain in athletes with impairment; however, it is possible that the treatment strategies used in the general population of individuals with impairment may be translated to the athlete population. There are a wide variety of treatment options including both pharmacological and nonpharmacological treatments which may be applicable in the athlete. CONCLUSIONS It is the role of the physician to determine which strategy of the possible treatment options will best facilitate the management of pain in the individual athlete in a sport-specific setting.
Collapse
|
14
|
Abstract
BACKGROUND This is an updated version of the original Cochrane Review published in 2010, Issue 9, and last updated in 2014, Issue 4. Non-invasive brain stimulation techniques aim to induce an electrical stimulation of the brain in an attempt to reduce chronic pain by directly altering brain activity. They include repetitive transcranial magnetic stimulation (rTMS), cranial electrotherapy stimulation (CES), transcranial direct current stimulation (tDCS), transcranial random noise stimulation (tRNS) and reduced impedance non-invasive cortical electrostimulation (RINCE). OBJECTIVES To evaluate the efficacy of non-invasive cortical stimulation techniques in the treatment of chronic pain. SEARCH METHODS For this update we searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, LILACS and clinical trials registers from July 2013 to October 2017. SELECTION CRITERIA Randomised and quasi-randomised studies of rTMS, CES, tDCS, RINCE and tRNS if they employed a sham stimulation control group, recruited patients over the age of 18 years with pain of three months' duration or more, and measured pain as an outcome. Outcomes of interest were pain intensity measured using visual analogue scales or numerical rating scales, disability, quality of life and adverse events. DATA COLLECTION AND ANALYSIS Two review authors independently extracted and verified data. Where possible we entered data into meta-analyses, excluding studies judged as high risk of bias. We used the GRADE system to assess the quality of evidence for core comparisons, and created three 'Summary of findings' tables. MAIN RESULTS We included an additional 38 trials (involving 1225 randomised participants) in this update, making a total of 94 trials in the review (involving 2983 randomised participants). This update included a total of 42 rTMS studies, 11 CES, 36 tDCS, two RINCE and two tRNS. One study evaluated both rTMS and tDCS. We judged only four studies as low risk of bias across all key criteria. Using the GRADE criteria we judged the quality of evidence for each outcome, and for all comparisons as low or very low; in large part this was due to issues of blinding and of precision.rTMSMeta-analysis of rTMS studies versus sham for pain intensity at short-term follow-up (0 to < 1 week postintervention), (27 studies, involving 655 participants), demonstrated a small effect with heterogeneity (standardised mean difference (SMD) -0.22, 95% confidence interval (CI) -0.29 to -0.16, low-quality evidence). This equates to a 7% (95% CI 5% to 9%) reduction in pain, or a 0.40 (95% CI 0.53 to 0.32) point reduction on a 0 to 10 pain intensity scale, which does not meet the minimum clinically important difference threshold of 15% or greater. Pre-specified subgroup analyses did not find a difference between low-frequency stimulation (low-quality evidence) and rTMS applied to the prefrontal cortex compared to sham for reducing pain intensity at short-term follow-up (very low-quality evidence). High-frequency stimulation of the motor cortex in single-dose studies was associated with a small short-term reduction in pain intensity at short-term follow-up (low-quality evidence, pooled n = 249, SMD -0.38 95% CI -0.49 to -0.27). This equates to a 12% (95% CI 9% to 16%) reduction in pain, or a 0.77 (95% CI 0.55 to 0.99) point change on a 0 to 10 pain intensity scale, which does not achieve the minimum clinically important difference threshold of 15% or greater. The results from multiple-dose studies were heterogeneous and there was no evidence of an effect in this subgroup (very low-quality evidence). We did not find evidence that rTMS improved disability. Meta-analysis of studies of rTMS versus sham for quality of life (measured using the Fibromyalgia Impact Questionnaire (FIQ) at short-term follow-up demonstrated a positive effect (MD -10.80 95% CI -15.04 to -6.55, low-quality evidence).CESFor CES (five studies, 270 participants) we found no evidence of a difference between active stimulation and sham (SMD -0.24, 95% CI -0.48 to 0.01, low-quality evidence) for pain intensity. We found no evidence relating to the effectiveness of CES on disability. One study (36 participants) of CES versus sham for quality of life (measured using the FIQ) at short-term follow-up demonstrated a positive effect (MD -25.05 95% CI -37.82 to -12.28, very low-quality evidence).tDCSAnalysis of tDCS studies (27 studies, 747 participants) showed heterogeneity and a difference between active and sham stimulation (SMD -0.43 95% CI -0.63 to -0.22, very low-quality evidence) for pain intensity. This equates to a reduction of 0.82 (95% CI 0.42 to 1.2) points, or a percentage change of 17% (95% CI 9% to 25%) of the control group outcome. This point estimate meets our threshold for a minimum clinically important difference, though the lower confidence interval is substantially below that threshold. We found evidence of small study bias in the tDCS analyses. We did not find evidence that tDCS improved disability. Meta-analysis of studies of tDCS versus sham for quality of life (measured using different scales across studies) at short-term follow-up demonstrated a positive effect (SMD 0.66 95% CI 0.21 to 1.11, low-quality evidence).Adverse eventsAll forms of non-invasive brain stimulation and sham stimulation appear to be frequently associated with minor or transient side effects and there were two reported incidences of seizure, both related to the active rTMS intervention in the included studies. However many studies did not adequately report adverse events. AUTHORS' CONCLUSIONS There is very low-quality evidence that single doses of high-frequency rTMS of the motor cortex and tDCS may have short-term effects on chronic pain and quality of life but multiple sources of bias exist that may have influenced the observed effects. We did not find evidence that low-frequency rTMS, rTMS applied to the dorsolateral prefrontal cortex and CES are effective for reducing pain intensity in chronic pain. The broad conclusions of this review have not changed substantially for this update. There remains a need for substantially larger, rigorously designed studies, particularly of longer courses of stimulation. Future evidence may substantially impact upon the presented results.
Collapse
Affiliation(s)
- Neil E O'Connell
- Brunel University LondonHealth Economics Research Group, Institute of Environment, Health and Societies, Department of Clinical SciencesKingston LaneUxbridgeMiddlesexUKUB8 3PH
| | - Louise Marston
- University College LondonResearch Department of Primary Care & Population HealthRoyal Free Campus, Rowland HillLondonUKNW3 2PF
| | - Sally Spencer
- Edge Hill UniversityPostgraduate Medical InstituteSt Helens RoadOrmskirkLancashireUKL39 4QP
| | - Lorraine H DeSouza
- Brunel University LondonDepartment of Clinical Sciences/Health Ageing Research Group, Institute of Environment, Health and SocietiesKingston LaneUxbridgeMiddlesexUKUB8 3PH
| | - Benedict M Wand
- The University of Notre Dame Australia FremantleSchool of Physiotherapy19 Mouat Street (PO Box 1225)PerthWest AustraliaAustralia6959
| | | |
Collapse
|
15
|
O'Connell NE, Marston L, Spencer S, DeSouza LH, Wand BM. Non-invasive brain stimulation techniques for chronic pain. Cochrane Database Syst Rev 2018; 3:CD008208. [PMID: 29547226 PMCID: PMC7039253 DOI: 10.1002/14651858.cd008208.pub4] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND This is an updated version of the original Cochrane Review published in 2010, Issue 9, and last updated in 2014, Issue 4. Non-invasive brain stimulation techniques aim to induce an electrical stimulation of the brain in an attempt to reduce chronic pain by directly altering brain activity. They include repetitive transcranial magnetic stimulation (rTMS), cranial electrotherapy stimulation (CES), transcranial direct current stimulation (tDCS), transcranial random noise stimulation (tRNS) and reduced impedance non-invasive cortical electrostimulation (RINCE). OBJECTIVES To evaluate the efficacy of non-invasive cortical stimulation techniques in the treatment of chronic pain. SEARCH METHODS For this update we searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, LILACS and clinical trials registers from July 2013 to October 2017. SELECTION CRITERIA Randomised and quasi-randomised studies of rTMS, CES, tDCS, RINCE and tRNS if they employed a sham stimulation control group, recruited patients over the age of 18 years with pain of three months' duration or more, and measured pain as an outcome. Outcomes of interest were pain intensity measured using visual analogue scales or numerical rating scales, disability, quality of life and adverse events. DATA COLLECTION AND ANALYSIS Two review authors independently extracted and verified data. Where possible we entered data into meta-analyses, excluding studies judged as high risk of bias. We used the GRADE system to assess the quality of evidence for core comparisons, and created three 'Summary of findings' tables. MAIN RESULTS We included an additional 38 trials (involving 1225 randomised participants) in this update, making a total of 94 trials in the review (involving 2983 randomised participants). This update included a total of 42 rTMS studies, 11 CES, 36 tDCS, two RINCE and two tRNS. One study evaluated both rTMS and tDCS. We judged only four studies as low risk of bias across all key criteria. Using the GRADE criteria we judged the quality of evidence for each outcome, and for all comparisons as low or very low; in large part this was due to issues of blinding and of precision.rTMSMeta-analysis of rTMS studies versus sham for pain intensity at short-term follow-up (0 to < 1 week postintervention), (27 studies, involving 655 participants), demonstrated a small effect with heterogeneity (standardised mean difference (SMD) -0.22, 95% confidence interval (CI) -0.29 to -0.16, low-quality evidence). This equates to a 7% (95% CI 5% to 9%) reduction in pain, or a 0.40 (95% CI 0.53 to 0.32) point reduction on a 0 to 10 pain intensity scale, which does not meet the minimum clinically important difference threshold of 15% or greater. Pre-specified subgroup analyses did not find a difference between low-frequency stimulation (low-quality evidence) and rTMS applied to the prefrontal cortex compared to sham for reducing pain intensity at short-term follow-up (very low-quality evidence). High-frequency stimulation of the motor cortex in single-dose studies was associated with a small short-term reduction in pain intensity at short-term follow-up (low-quality evidence, pooled n = 249, SMD -0.38 95% CI -0.49 to -0.27). This equates to a 12% (95% CI 9% to 16%) reduction in pain, or a 0.77 (95% CI 0.55 to 0.99) point change on a 0 to 10 pain intensity scale, which does not achieve the minimum clinically important difference threshold of 15% or greater. The results from multiple-dose studies were heterogeneous and there was no evidence of an effect in this subgroup (very low-quality evidence). We did not find evidence that rTMS improved disability. Meta-analysis of studies of rTMS versus sham for quality of life (measured using the Fibromyalgia Impact Questionnaire (FIQ) at short-term follow-up demonstrated a positive effect (MD -10.80 95% CI -15.04 to -6.55, low-quality evidence).CESFor CES (five studies, 270 participants) we found no evidence of a difference between active stimulation and sham (SMD -0.24, 95% CI -0.48 to 0.01, low-quality evidence) for pain intensity. We found no evidence relating to the effectiveness of CES on disability. One study (36 participants) of CES versus sham for quality of life (measured using the FIQ) at short-term follow-up demonstrated a positive effect (MD -25.05 95% CI -37.82 to -12.28, very low-quality evidence).tDCSAnalysis of tDCS studies (27 studies, 747 participants) showed heterogeneity and a difference between active and sham stimulation (SMD -0.43 95% CI -0.63 to -0.22, very low-quality evidence) for pain intensity. This equates to a reduction of 0.82 (95% CI 0.42 to 1.2) points, or a percentage change of 17% (95% CI 9% to 25%) of the control group outcome. This point estimate meets our threshold for a minimum clinically important difference, though the lower confidence interval is substantially below that threshold. We found evidence of small study bias in the tDCS analyses. We did not find evidence that tDCS improved disability. Meta-analysis of studies of tDCS versus sham for quality of life (measured using different scales across studies) at short-term follow-up demonstrated a positive effect (SMD 0.66 95% CI 0.21 to 1.11, low-quality evidence).Adverse eventsAll forms of non-invasive brain stimulation and sham stimulation appear to be frequently associated with minor or transient side effects and there were two reported incidences of seizure, both related to the active rTMS intervention in the included studies. However many studies did not adequately report adverse events. AUTHORS' CONCLUSIONS There is very low-quality evidence that single doses of high-frequency rTMS of the motor cortex and tDCS may have short-term effects on chronic pain and quality of life but multiple sources of bias exist that may have influenced the observed effects. We did not find evidence that low-frequency rTMS, rTMS applied to the dorsolateral prefrontal cortex and CES are effective for reducing pain intensity in chronic pain. The broad conclusions of this review have not changed substantially for this update. There remains a need for substantially larger, rigorously designed studies, particularly of longer courses of stimulation. Future evidence may substantially impact upon the presented results.
Collapse
Affiliation(s)
- Neil E O'Connell
- Brunel UniversityDepartment of Clinical Sciences/Health Economics Research Group, Institute of Environment, Health and SocietiesKingston LaneUxbridgeUKUB8 3PH
| | - Louise Marston
- University College LondonResearch Department of Primary Care & Population HealthRoyal Free Campus, Rowland HillLondonUKNW3 2PF
| | - Sally Spencer
- Edge Hill UniversityPostgraduate Medical InstituteSt Helens RoadOrmskirkUKL39 4QP
| | - Lorraine H DeSouza
- Brunel University LondonDepartment of Clinical Sciences/Health Ageing Research Group, Institute of Environment, Health and SocietiesKingston LaneUxbridgeUKUB8 3PH
| | - Benedict M Wand
- The University of Notre Dame AustraliaSchool of Physiotherapy19 Mouat Street (PO Box 1225)FremantleAustralia6959
| |
Collapse
|
16
|
Gibson W, Wand BM, O'Connell NE. Transcutaneous electrical nerve stimulation (TENS) for neuropathic pain in adults. Cochrane Database Syst Rev 2017; 9:CD011976. [PMID: 28905362 PMCID: PMC6426434 DOI: 10.1002/14651858.cd011976.pub2] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Neuropathic pain, which is due to nerve disease or damage, represents a significant burden on people and society. It can be particularly unpleasant and achieving adequate symptom control can be difficult. Non-pharmacological methods of treatment are often employed by people with neuropathic pain and may include transcutaneous electrical nerve stimulation (TENS). This review supersedes one Cochrane Review 'Transcutaneous electrical nerve stimulation (TENS) for chronic pain' (Nnoaham 2014) and one withdrawn protocol 'Transcutaneous electrical nerve stimulation (TENS) for neuropathic pain in adults' (Claydon 2014). This review replaces the original protocol for neuropathic pain that was withdrawn. OBJECTIVES To determine the analgesic effectiveness of TENS versus placebo (sham) TENS, TENS versus usual care, TENS versus no treatment and TENS in addition to usual care versus usual care alone in the management of neuropathic pain in adults. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, PsycINFO, AMED, CINAHL, Web of Science, PEDro, LILACS (up to September 2016) and various clinical trials registries. We also searched bibliographies of included studies for further relevant studies. SELECTION CRITERIA We included randomised controlled trials where TENS was evaluated in the treatment of central or peripheral neuropathic pain. We included studies if they investigated the following: TENS versus placebo (sham) TENS, TENS versus usual care, TENS versus no treatment and TENS in addition to usual care versus usual care alone in the management of neuropathic pain in adults. DATA COLLECTION AND ANALYSIS Two review authors independently screened all database search results and identified papers requiring full-text assessment. Subsequently, two review authors independently applied inclusion/exclusion criteria to these studies. The same review authors then independently extracted data, assessed for risk of bias using the Cochrane standard tool and rated the quality of evidence using GRADE. MAIN RESULTS We included 15 studies with 724 participants. We found a range of treatment protocols in terms of duration of care, TENS application times and intensity of application. Briefly, duration of care ranged from four days through to three months. Similarly, we found variation of TENS application times; from 15 minutes up to hourly sessions applied four times daily. We typically found intensity of TENS set to comfortable perceptible tingling with very few studies titrating the dose to maintain this perception. Of the comparisons, we had planned to explore, we were only able to undertake a quantitative synthesis for TENS versus sham TENS. Insufficient data and large diversity in the control conditions prevented us from undertaking a quantitative synthesis for the remaining comparisons.For TENS compared to sham TENS, five studies were suitable for pooled analysis. We described the remainder of the studies in narrative form. Overall, we judged 11 studies at high risk of bias, and four at unclear risk. Due to the small number of eligible studies, the high levels of risk of bias across the studies and small sample sizes, we rated the quality of the evidence as very low for the pooled analysis and very low individual GRADE rating of outcomes from single studies. For the individual studies discussed in narrative form, the methodological limitations, quality of reporting and heterogeneous nature of interventions compared did not allow for reliable overall estimates of the effect of TENS.Five studies (across various neuropathic conditions) were suitable for pooled analysis of TENS versus sham TENS investigating change in pain intensity using a visual analogue scale. We found a mean postintervention difference in effect size favouring TENS of -1.58 (95% confidence interval (CI) -2.08 to -1.09, P < 0.00001, n = 207, six comparisons from five studies) (very low quality evidence). There was no significant heterogeneity in this analysis. While this exceeded our prespecified minimally important difference for pain outcomes, we assessed the quality of evidence as very low meaning we have very little confidence in this effect estimate and the true effect is likely to be substantially different from that reported in this review. Only one study of these five investigated health related quality of life as an outcome meaning we were unable to report on this outcome in this comparison. Similarly, we were unable to report on global impression of change or changes in analgesic use in this pooled analysis.Ten small studies compared TENS to some form of usual care. However, there was great diversity in what constituted usual care, precluding pooling of data. Most of these studies found either no difference in pain outcomes between TENS versus other active treatments or favoured the comparator intervention (very low quality evidence). We were unable to report on other primary and secondary outcomes in these single trials (health-related quality of life, global impression of change and changes in analgesic use).Of the 15 included studies, three reported adverse events which were minor and limited to 'skin irritation' at or around the site of electrode placement (very low quality evidence). Three studies reported no adverse events while the remainder did not report any detail with regard adverse events. AUTHORS' CONCLUSIONS In this review, we reported on the comparison between TENS and sham TENS. The quality of the evidence was very low meaning we were unable to confidently state whether TENS is effective for pain control in people with neuropathic pain. The very low quality of evidence means we have very limited confidence in the effect estimate reported; the true effect is likely to be substantially different. We make recommendations with respect to future TENS study designs which may meaningfully reduce the uncertainty relating to the effectiveness of this treatment modality.
Collapse
Affiliation(s)
- William Gibson
- School of Physiotherapy, The University of Notre Dame Australia, 19 Mouat Street (PO Box 1225), Fremantle, Western Australia, Australia, 6959
| | | | | |
Collapse
|
17
|
Richardson C, Kulkarni J. A review of the management of phantom limb pain: challenges and solutions. J Pain Res 2017; 10:1861-1870. [PMID: 28860841 PMCID: PMC5558877 DOI: 10.2147/jpr.s124664] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Phantom limb pain (PLP) occurs in 50% and 80% of amputees. Although it is often classified as a neuropathic pain, few of the large-scale trials of treatments for neuropathic pain included sufficient numbers of PLP sufferers to have confidence that they are effective in this condition. Many therapies have been administered to amputees with PLP over the years; however, as of yet, there appears to be no first-line treatment. OBJECTIVES To comprehensively review the literature on treatment modalities for PLP and to identify the challenges currently faced by clinicians dealing with this pain. METHOD MEDLINE, EMBASE, CINAHL, British Nursing Index, Cochrane and psycINFO databases were searched using "Phantom limb" initially as a MeSH term to identify treatments that had been tried. Then, a secondary search combining phantom limb with each treatment was performed to find papers specific to each therapy. Each paper was assessed for its research strength using the GRADE system. RESULTS Thirty-eight therapies were identified. Overall, the quality of evidence was low. There was one high-quality study which used repetitive transcutaneous magnetic stimulation and found a statistical reduction in pain at day 15 but no difference at day 30. Significant results from single studies of moderate level quality were available for gabapentin, ketamine and morphine; however, there was a risk of bias in these papers. Mirror therapy and associated techniques were assessed through two systematic reviews, which conclude that there is insufficient evidence to support their use. CONCLUSION No decisions can be made for the first-line management of PLP, as the level of evidence is too low. Robust studies on homogeneous populations, an understanding of what amputees consider a meaningful reduction in PLP and agreement of whether pain intensity is the legitimate therapeutic target are urgently required.
Collapse
Affiliation(s)
- Cliff Richardson
- University of Manchester, Division of Nursing Midwifery and Social Work, Manchester, UK
| | - Jai Kulkarni
- Specialized Ability Centre (Manchester), University Hospitals of South Manchester NHS Foundation Trust, Manchester, UK
| |
Collapse
|
18
|
Batsford S, Ryan CG, Martin DJ. Non-pharmacological conservative therapy for phantom limb pain: A systematic review of randomized controlled trials. Physiother Theory Pract 2017; 33:173-183. [DOI: 10.1080/09593985.2017.1288283] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- Sarah Batsford
- School of Health and Social Care, Teesside University, Middlesbrough, UK
- MSK CATS, South Tyneside NHS Foundation Trust, South Shields, Tyne and Wear, UK
| | - Cormac G. Ryan
- Health and Social Care Institute, Teesside University, Middlesbrough, UK
| | - Denis J. Martin
- Health and Social Care Institute, Teesside University, Middlesbrough, UK
| |
Collapse
|
19
|
Hazelgrove JF, Rogers PD. Phantom Limb Pain—A Complication of Lower Extremity Wound Management. INT J LOW EXTR WOUND 2016; 1:112-24. [PMID: 15871961 DOI: 10.1177/1534734602001002006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Amputation is one treatment option for patients with critical limb ischemia, diabetic foot wounds, and occasionally, even venous leg ulcers. Amputation of the whole limb or part of it or the digits can cause complications including pain. Post-amputation pain, and especially phantom limb pain (PLP), is a poorly understood phenomenon. Effective management of established pain is a major challenge. This reviewis for wound workers who are a multiprofessional group. Any amputated limb, appendage, or viscera can be affected by PLP, though the focus of this article will be the treatment of PLP following limb loss. The pathophysiology is still not fully understood. The size of the problem of PLP, possible underlying physiological mechanisms, and potential preventative measures are presented in this article.
Collapse
|
20
|
Zeng Y, Wang X, Guo Y, He L, Ni J. Coblation of Femoral and Sciatic Nerve for Stump Pain and Phantom Limb Pain: A Case Report. Pain Pract 2015; 16:E35-41. [PMID: 26603590 DOI: 10.1111/papr.12400] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 07/20/2015] [Indexed: 12/25/2022]
Affiliation(s)
- Yuanjie Zeng
- Department of Pain Management; Xuanwu Hospital of Capital Medical University; Beijing China
| | - Xiaoping Wang
- Department of Pain Management; Xuanwu Hospital of Capital Medical University; Beijing China
| | - Yuna Guo
- Department of Pain Management; Xuanwu Hospital of Capital Medical University; Beijing China
| | - Liangliang He
- Department of Pain Management; Xuanwu Hospital of Capital Medical University; Beijing China
| | - Jiaxiang Ni
- Department of Pain Management; Xuanwu Hospital of Capital Medical University; Beijing China
| |
Collapse
|
21
|
Johnson MI, Mulvey MR, Bagnall AM. Transcutaneous electrical nerve stimulation (TENS) for phantom pain and stump pain following amputation in adults. Cochrane Database Syst Rev 2015; 8:CD007264. [PMID: 26284511 PMCID: PMC7209768 DOI: 10.1002/14651858.cd007264.pub3] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND This is the first update of a Cochrane review published in Issue 5, 2010 on transcutaneous electrical nerve stimulation (TENS) for phantom pain and stump pain following amputation in adults. Pain may present in a body part that has been amputated (phantom pain) or at the site of amputation (stump pain), or both. Phantom pain and stump pain are complex and multidimensional and the underlying pathophysiology remains unclear. The condition remains a severe burden for those who are affected by it. The mainstay treatments are predominately pharmacological, with increasing acknowledgement of the need for non-drug interventions. TENS has been recommended as a treatment option but there has been no systematic review of available evidence. Hence, the effectiveness of TENS for phantom pain and stump pain is currently unknown. OBJECTIVES To assess the analgesic effectiveness of TENS for the treatment of phantom pain and stump pain following amputation in adults. SEARCH METHODS For the original version of the review we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, AMED, CINAHL, PEDRO and SPORTDiscus (February 2010). For this update, we searched the same databases for relevant randomised controlled trials (RCTs) from 2010 to 25 March 2015. SELECTION CRITERIA We only included RCTs investigating the use of TENS for the management of phantom pain and stump pain following an amputation in adults. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted data. We planned that where available and appropriate, data from outcome measures were to be pooled and presented as an overall estimate of the effectiveness of TENS. MAIN RESULTS In the original review there were no RCTs that examined the effectiveness of TENS for the treatment of phantom pain and stump pain in adults. For this update, we did not identify any additional RCTs for inclusion. AUTHORS' CONCLUSIONS There were no RCTs to judge the effectiveness of TENS for the management of phantom pain and stump pain. The published literature on TENS for phantom pain and stump pain lacks the methodological rigour and robust reporting needed to confidently assess its effectiveness. Further RCT evidence is required before an assessment can be made. Since publication of the original version of this review, we have found no new studies and our conclusions remain unchanged.
Collapse
Affiliation(s)
- Mark I Johnson
- Faculty of Health and Social Sciences, Leeds Beckett University, City Campus, Calverley Street, Leeds, UK, LS1 3HE
| | | | | |
Collapse
|
22
|
Taub E, Uswatte G, Mark VW. The functional significance of cortical reorganization and the parallel development of CI therapy. Front Hum Neurosci 2014; 8:396. [PMID: 25018720 PMCID: PMC4072972 DOI: 10.3389/fnhum.2014.00396] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Accepted: 05/17/2014] [Indexed: 12/22/2022] Open
Abstract
For the nineteenth and the better part of the twentieth centuries two correlative beliefs were strongly held by almost all neuroscientists and practitioners in the field of neurorehabilitation. The first was that after maturity the adult CNS was hardwired and fixed, and second that in the chronic phase after CNS injury no substantial recovery of function could take place no matter what intervention was employed. However, in the last part of the twentieth century evidence began to accumulate that neither belief was correct. First, in the 1960s and 1970s, in research with primates given a surgical abolition of somatic sensation from a single forelimb, which rendered the extremity useless, it was found that behavioral techniques could convert the limb into an extremity that could be used extensively. Beginning in the late 1980s, the techniques employed with deafferented monkeys were translated into a rehabilitation treatment, termed Constraint Induced Movement therapy or CI therapy, for substantially improving the motor deficit in humans of the upper and lower extremities in the chronic phase after stroke. CI therapy has been applied successfully to other types of damage to the CNS such as traumatic brain injury, cerebral palsy, multiple sclerosis, and spinal cord injury, and it has also been used to improve function in focal hand dystonia and for aphasia after stroke. As this work was proceeding, it was being shown during the 1980s and 1990s that sustained modulation of afferent input could alter the structure of the CNS and that this topographic reorganization could have relevance to the function of the individual. The alteration in these once fundamental beliefs has given rise to important recent developments in neuroscience and neurorehabilitation and holds promise for further increasing our understanding of CNS function and extending the boundaries of what is possible in neurorehabilitation.
Collapse
Affiliation(s)
- Edward Taub
- Department of Psychology, University of Alabama at BirminghamBirmingham, AL, USA
| | - Gitendra Uswatte
- Departments of Psychology and Physical Therapy, University of Alabama at BirminghamBirmingham, AL, USA
| | - Victor W. Mark
- Departments of Physical Medicine and Rehabilitation, Neurology, and Psychology, University of Alabama at BirminghamBirmingham, AL, USA
| |
Collapse
|
23
|
Hu X, Trevelyan E, Yang G, Lee MS, Lorenc A, Liu J, Robinson N. The effectiveness of acupuncture/TENS for phantom limb syndrome. I: A systematic review of controlled clinical trials. Eur J Integr Med 2014. [DOI: 10.1016/j.eujim.2014.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
24
|
Griffin SC, Tsao JW. A mechanism-based classification of phantom limb pain. Pain 2014; 155:2236-2242. [PMID: 24857794 DOI: 10.1016/j.pain.2014.05.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 04/18/2014] [Accepted: 05/15/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Sarah C Griffin
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA Department of Neurology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | | |
Collapse
|
25
|
O'Connell NE, Wand BM, Marston L, Spencer S, Desouza LH. Non-invasive brain stimulation techniques for chronic pain. Cochrane Database Syst Rev 2014:CD008208. [PMID: 24729198 DOI: 10.1002/14651858.cd008208.pub3] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND This is an updated version of the original Cochrane review published in 2010, Issue 9. Non-invasive brain stimulation techniques aim to induce an electrical stimulation of the brain in an attempt to reduce chronic pain by directly altering brain activity. They include repetitive transcranial magnetic stimulation (rTMS), cranial electrotherapy stimulation (CES), transcranial direct current stimulation (tDCS) and reduced impedance non-invasive cortical electrostimulation (RINCE). OBJECTIVES To evaluate the efficacy of non-invasive brain stimulation techniques in chronic pain. SEARCH METHODS We searched CENTRAL (2013, Issue 6), MEDLINE, EMBASE, CINAHL, PsycINFO, LILACS and clinical trials registers. The original search for the review was run in November 2009 and searched all databases from their inception. To identify studies for inclusion in this update we searched from 2009 to July 2013. SELECTION CRITERIA Randomised and quasi-randomised studies of rTMS, CES, tDCS or RINCE if they employed a sham stimulation control group, recruited patients over the age of 18 with pain of three months duration or more and measured pain as a primary outcome. DATA COLLECTION AND ANALYSIS Two authors independently extracted and verified data. Where possible we entered data into meta-analyses. We excluded studies judged as being at high risk of bias from the analysis. We used the GRADE system to summarise the quality of evidence for core comparisons. MAIN RESULTS We included an additional 23 trials (involving 773 participants randomised) in this update, making a total of 56 trials in the review (involving 1710 participants randomised). This update included a total of 30 rTMS studies, 11 CES, 14 tDCS and one study of RINCE(the original review included 19 rTMS, eight CES and six tDCS studies). We judged only three studies as being at low risk of bias across all criteria.Meta-analysis of studies of rTMS (involving 528 participants) demonstrated significant heterogeneity. Pre-specified subgroup analyses suggest that low-frequency stimulation is ineffective (low-quality evidence) and that rTMS applied to the dorsolateral prefrontal cortex is ineffective (very low-quality evidence). We found a short-term effect on pain of active high-frequency stimulation of the motor cortex in single-dose studies (low-quality evidence, standardised mean difference (SMD) 0.39 (95% confidence interval (CI) -0.27 to -0.51 P < 0.01)). This equates to a 12% (95% CI 8% to 15%) reduction in pain, which does not exceed the pre-established criteria for a minimal clinically important difference (≥ 15%). Evidence for multiple-dose studies was heterogenous but did not demonstrate a significant effect (very low-quality evidence).For CES (six studies, 270 participants) no statistically significant difference was found between active stimulation and sham (low-quality evidence).Analysis of tDCS studies (11 studies, 193 people) demonstrated significant heterogeneity and did not find a significant difference between active and sham stimulation (very low-quality evidence). Pre-specified subgroup analysis of tDCS applied to the motor cortex (n = 183) did not demonstrate a statistically significant effect and this lack of effect was consistent for subgroups of single or multiple-dose studies.One small study (n = 91) at unclear risk of bias suggested a positive effect of RINCE over sham stimulation on pain (very low-quality evidence).Non-invasive brain stimulation appears to be frequently associated with minor and transient side effects, though there were two reported incidences of seizure related to active rTMS in the included studies. AUTHORS' CONCLUSIONS Single doses of high-frequency rTMS of the motor cortex may have small short-term effects on chronic pain. It is likely that multiple sources of bias may exaggerate this observed effect. The effects do not meet the predetermined threshold of minimal clinical significance and multiple-dose studies do not consistently demonstrate effectiveness. The available evidence suggests that low-frequency rTMS, rTMS applied to the pre-frontal cortex, CES and tDCS are not effective in the treatment of chronic pain. While the broad conclusions for rTMS and CES have not changed substantially, the addition of this new evidence and the application of the GRADE system has modified some of our interpretation and the conclusion regarding the effectiveness of tDCS has changed. We recommend that previous readers should re-read this update. There is a need for larger, rigorously designed studies, particularly of longer courses of stimulation. It is likely that future evidence may substantially impact upon the presented results.
Collapse
Affiliation(s)
- Neil E O'Connell
- Centre for Research in Rehabilitation, School of Health Sciences and Social Care, Brunel University, Kingston Lane, Uxbridge, Middlesex, UK, UB8 3PH
| | | | | | | | | |
Collapse
|
26
|
Mulvey MR, Bagnall AM, Marchant PR, Johnson MI. Transcutaneous electrical nerve stimulation (TENS) for phantom pain and stump pain following amputation in adults: an extended analysis of excluded studies from a Cochrane systematic review. PHYSICAL THERAPY REVIEWS 2014. [DOI: 10.1179/1743288x13y.0000000128] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
|
27
|
Lenggenhager B, Arnold CA, Giummarra MJ. Phantom limbs: pain, embodiment, and scientific advances in integrative therapies. WILEY INTERDISCIPLINARY REVIEWS. COGNITIVE SCIENCE 2014; 5:221-31. [PMID: 26304309 DOI: 10.1002/wcs.1277] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 11/30/2013] [Accepted: 12/29/2013] [Indexed: 11/10/2022]
Abstract
Research over the past two decades has begun to identify some of the key mechanisms underlying phantom limb pain and sensations; however, this continues to be a clinically challenging condition to manage. Treatment of phantom pain, like all chronic pain conditions, demands a holistic approach that takes into consideration peripheral, spinal, and central neuroplastic mechanisms. In this review, we focus on nonpharmacological treatments tailored to reverse the maladaptive neuroplasticity associated with phantom pain. Recent scientific advances emerging from interdisciplinary research between neuroscience, virtual reality, robotics, and prosthetics show the greatest promise for alternative embodiment and maintaining the integrity of the multifaceted representation of the body in the brain. Importantly, these advances have been found to prevent and reduce phantom limb pain. In particular, therapies that involve sensory and/or motor retraining, most naturally through the use of integrative prosthetic devices, as well as peripheral (e.g., transcutaneous electrical nerve stimulation) or central (e.g., transcranial magnetic stimulation or deep brain stimulation) stimulation techniques, have been found to both restore the neural representation of the missing limb and to reduce the intensity of phantom pain. While the evidence for the efficacy of these therapies is mounting, but well-controlled and large-scale studies are still needed. WIREs Cogn Sci 2014, 5:221-231. doi: 10.1002/wcs.1277 CONFLICT OF INTEREST: The authors have no financial or other relationship that might lead to a conflict of interest. For further resources related to this article, please visit the WIREs website.
Collapse
Affiliation(s)
- Bigna Lenggenhager
- Neuropsychology Unit, Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Carolyn A Arnold
- Caulfield Pain Management & Research Centre, Caulfield Hospital, Caulfield, Victoria, Australia.,Academic Board of Anaesthesia and Perioperative Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Melita J Giummarra
- Caulfield Pain Management & Research Centre, Caulfield Hospital, Caulfield, Victoria, Australia.,School of Psychological Science, Monash University, Clayton, Victoria, Australia
| |
Collapse
|
28
|
Flor H. Maladaptive plasticity, memory for pain and phantom limb pain: review and suggestions for new therapies. Expert Rev Neurother 2014; 8:809-18. [DOI: 10.1586/14737175.8.5.809] [Citation(s) in RCA: 118] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
29
|
|
30
|
Use of Yamamoto New Scalp Acupuncture for Treatment of Chronic, Severe Phantom Leg Pain. Med Acupunct 2012. [DOI: 10.1089/acu.2011.0854] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
31
|
Hsiao AF, York R, Hsiao I, Hansen E, Hays RD, Ives J, Coulter ID. A randomized controlled study to evaluate the efficacy of noninvasive limb cover for chronic phantom limb pain among veteran amputees. Arch Phys Med Rehabil 2012; 93:617-22. [PMID: 22464089 PMCID: PMC3788569 DOI: 10.1016/j.apmr.2011.11.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Revised: 09/07/2011] [Accepted: 11/02/2011] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To assess the efficacy of a noninvasive limb cover for treating chronic phantom limb pain (PLP). DESIGN Randomized, double-blind, placebo-controlled trial. SETTING Outpatient clinic. PARTICIPANTS We randomly assigned 57 subjects to 2 groups: true noninvasive limb cover (n=30) and sham noninvasive limb cover (n=27). Inclusion criteria included age of 18 years or greater, upper or lower extremity amputation with healed residual limb, and 3 or more episodes of PLP during the previous 6 weeks. INTERVENTIONS Subjects received 2 true or sham noninvasive limb covers to be worn over the prosthesis and residual limbs 24 hours a day for 12 weeks. MAIN OUTCOME MEASURES Primary outcome measure was the numerical pain rating scale of PLP level (0-10). Secondary outcomes included overall pain level (0-10), PLP frequency per week, and the Veterans RAND 12-Item Health Survey (VR-12). We collected data at baseline and at 6- and 12-week follow-up visits. RESULTS Demographic and clinical characteristics were not significantly different between groups. The true noninvasive limb cover group reported nonsignificant reductions in PLP from 5.9±1.9 at baseline to 3.9±1.7 at the 12-week follow-up. The sham noninvasive limb cover group also had nonsignificant reducations in PLP from 6.5±1.8 to 4.2±2.3. PLP did not differ significantly between the 2 groups at 6 weeks (mean difference, 0.8; 95% confidence interval [CI], -1.4 to 3) or at 12 weeks (mean difference, 0.2; 95% CI, -1.9 to 2.3). Similarly, overall pain level, PLP episodes per week, and VR-12 physical and mental health component scores did not differ between the 2 groups at 6 and 12 weeks. CONCLUSIONS A true noninvasive limb cover did not significantly decrease PLP levels or the frequency of PLP episodes per week, overall bodily pain levels, or VR-12 physical and mental health component scores compared with a sham noninvasive limb cover in our veteran amputee sample.
Collapse
Affiliation(s)
- An-Fu Hsiao
- VA Long Beach Healthcare System, Long Beach, CA, USA.
| | | | | | | | | | | | | |
Collapse
|
32
|
Use of the LION procedure on the sensitive branches of the lumbar plexus for the treatment of intractable postherniorrhaphy neuropathic inguinodynia. Hernia 2011; 17:333-7. [PMID: 22131009 DOI: 10.1007/s10029-011-0894-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Accepted: 11/13/2011] [Indexed: 10/15/2022]
Abstract
PURPOSE To report on the use of the laparoscopic implantation of neuroprosthesis (LION) procedure on the sensitive branches of the lumbar plexus for the treatment of refractory postherniorrhaphy neuropathic inguinodynia. METHODS Laparoscopic exposure and implantation of an electrode to the different nerves is undertaken by the transumbilical transperitoneal approach. The genitofemoral nerve is identified on the anterior surface of the psoas major muscle, the ilioinguinal, iliohypogastric, and of the lateral femoral cutaneous nerves on the anterior surface of the quadratus lumborum muscle behind the kidney and colon. A quadripolar electrode is placed laparoscopically in direct contact with the injured nerve(s). RESULTS All patients included in this series had reported failure of all previous treatments. Twenty-three consecutive patients were included in this series. Success, defined as visual analog scale (VAS) reduction >50%, was obtained in 19 patients. To date (mean follow-up 28.61 months [± 16.2; min. 6 months to max. 68 months]), 11 patients report a reduction of the mean VAS of more than 80% and eight report a reduction of between 50 and 80%; the mean VAS score could be reduced, so far, from 8.1 (± 8.1; range 6-10) preoperatively to 3.1 (± 2.8; range 0-5) postoperatively (P < 0.001). CONCLUSIONS The presented technique of laparoscopic implantation permits a selective implantation and neuromodulation of all sensitive branches of the lumbar plexus. These preliminary results suggest that the technique described is effective, safe, minimally invasive, and must be indicated in patients after failure of all other treatments.
Collapse
|
33
|
|
34
|
A randomized controlled trial of auricular transcutaneous electrical nerve stimulation for managing posthysterectomy pain. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2011; 2011:276769. [PMID: 21716709 PMCID: PMC3118782 DOI: 10.1155/2011/276769] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2010] [Revised: 02/26/2011] [Accepted: 03/29/2011] [Indexed: 11/29/2022]
Abstract
Background. A patient- and assessor-blinded randomized controlled trial was conducted to examine the effectiveness of auricular transcutaneous electrical nerve stimulation (TENS) in relieving posthysterectomy pain.
Method. Forty-eight women who had undergone a total abdominal hysterectomy were randomly assigned into three groups (n = 16 each) to receive either (i) auricular TENS to therapeutic points (the true TENS group), (ii) auricular TENS to inappropriate points (the sham TENS group), or (iii) 20 minutes of bed rest with no stimulation (the control group). The intervention was delivered about 24 hours after the operation. A visual analogue scale was used to assess pain while resting (VAS-rest) and upon huffing (VAS-huff) and coughing (VAS-cough), and the peak expiratory flow rate (PEFR) was assessed before and at 0, 15, and 30 minutes after the intervention.
Result. As compared to the baseline, only the true TENS group reported a significant reduction in VAS-rest (P = .001), VAS-huff (P = .004), and VAS-cough (P = .001), while no significant reduction in any of the VAS scores was seen in the sham TENS group (all P > .05). In contrast, a small rising trend was observed in the VAS-rest and VAS-huff scores of the control group, while the VAS-cough score remained largely unchanged during the period of the study. A between-group comparison revealed that all three VAS scores of the true TENS group were significantly lower than those of the control group at 15 and 30 minutes after the intervention (all P < .02). No significant between-group difference was observed in PEFR at any point in time. Conclusion. A single session of auricular TENS applied at specific therapeutic points significantly reduced resting (VAS-rest) and movement-evoked pain (VAS-huff, VAS-cough), and the effects lasted for at least 30 minutes after the stimulation. The analgesic effects of auricular TENS appeared to be point specific and could not be attributed to the placebo effect alone. However, auricular TENS did not produce any significant improvement in the performance of PEFR.
Collapse
|
35
|
Chung WY, Zhang HQ, Zhang SP. Peripheral muscarinic receptors mediate the anti-inflammatory effects of auricular acupuncture. Chin Med 2011; 6:3. [PMID: 21251313 PMCID: PMC3033863 DOI: 10.1186/1749-8546-6-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2010] [Accepted: 01/21/2011] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND The cholinergic and opioid systems play important roles in modulating inflammation. This study tests whether auricular acupuncture (AA) produces anti-inflammatory effects via opioid and peripheral cholinergic receptors in a rat model. METHODS Rats were anesthetized with chloral hydrate and inflammation was induced by intraplantar injection of carrageenan. Electroacupuncture was performed at auricular points bilaterally. The severity of inflammation was assessed using changes in paw volume and thermal and mechanical pain thresholds of the rats during recovery from anesthesia. RESULTS Electroacupuncture at selected auricular acupoints significantly reduced paw edema and mechanical hyperalgesia, with no significant effect on thermal hyperalgesia. The anti-edematous and analgesic effects of AA were abolished by blockade of peripheral cholinergic muscarinic receptors with methyl atropine. Blockade of local muscarinic receptors at the inflamed site with a small dose of atropine also antagonized the anti-edematous effect of AA. By contrast, systemic opioid receptor blockade with naloxone did not antagonize the anti-inflammatory effects of AA. CONCLUSION This study discovers a role of peripheral muscarinic receptors in mediating the anti-inflammatory effects of AA. The cholinergic muscarinic mechanism appears to be more important than the opioid mechanism in the anti-inflammatory action of AA.
Collapse
Affiliation(s)
- Wai Yeung Chung
- School of Chinese Medicine, Hong Kong Baptist University, Kowloon Tong, Hong Kong, China.
| | | | | |
Collapse
|
36
|
O'Connell NE, Wand BM, Marston L, Spencer S, Desouza LH. Non-invasive brain stimulation techniques for chronic pain. Cochrane Database Syst Rev 2010:CD008208. [PMID: 20824873 DOI: 10.1002/14651858.cd008208.pub2] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Non-invasive brain stimulation techniques aim to induce an electrical stimulation of the brain in an attempt to reduce chronic pain by directly altering brain activity. They include repetitive transcranial magnetic stimulation (rTMS), cranial electrotherapy stimulation (CES) and transcranial direct current stimulation (tDCS). OBJECTIVES To evaluate the efficacy of non-invasive brain stimulation techniques in chronic pain. SEARCH STRATEGY We searched CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, LILACS, the Cochrane PaPaS Group Trials Register and clinical trials registers. SELECTION CRITERIA Randomised and quasi-randomised studies of rTMS, CES or tDCS if they employed a sham stimulation control group, recruited patients over the age of 18 with pain of three months duration or more and measured pain as a primary outcome. DATA COLLECTION AND ANALYSIS Two authors independently extracted and verified data. Where possible we entered data into meta-analyses. We excluded studies judged as being at high risk of bias from the analysis. MAIN RESULTS We included 33 trials in the review (involving 937 people)(19 rTMS, eight CES and six tDCS). Only one study was judged as being at low risk of bias.Studies of rTMS (involving 368 participants ) demonstrated significant heterogeneity. Pre-specified subgroup analyses suggest that low-frequency stimulation is ineffective. A short-term effect on pain of active high-frequency stimulation of the motor cortex in single-dose studies was suggested (standardised mean difference (SMD) -0.40, 95% confidence interval (CI) -0.26 to -0.54, P < 0.00001). This equates to a 15% (95% CI 10% to 20%) reduction in pain which does not clearly exceed the pre-established criteria for a minimally clinically important difference (> 15%).For CES (four studies, 133 participants) no statistically significant difference was found between active stimulation and sham. Analysis of tDCS studies (five studies, 83 people) demonstrated significant heterogeneity and did not find a significant difference between active and sham stimulation. Pre-specified subgroup analysis of tDCS applied to the motor cortex suggested superiority of active stimulation over sham (SMD -0.59, 95% CI -1.10 to -0.08).Non-invasive brain stimulation appears to be associated with minor and transient side effects. AUTHORS' CONCLUSIONS Single doses of high-frequency rTMS of the motor cortex may have small short-term effects on chronic pain. The effects do not clearly exceed the predetermined threshold of minimal clinical significance. Low-frequency rTMS is not effective in the treatment of chronic pain. There is insufficient evidence from which to draw firm conclusions regarding the efficacy of CES or tDCS. The available evidence suggests that tDCS applied to the motor cortex may have short-term effects on chronic pain and that CES may be ineffective. There is a need for further, rigorously designed studies of all types of stimulation.
Collapse
Affiliation(s)
- Neil E O'Connell
- Centre for Research in Rehabilitation, School of Health Sciences and Social Care, Brunel University, Kingston Lane, Uxbridge, Middlesex, UK, UB8 3PH
| | | | | | | | | |
Collapse
|
37
|
|
38
|
West M, Wu H. Pulsed Radiofrequency Ablation for Residual and Phantom Limb Pain: A Case Series. Pain Pract 2010; 10:485-91. [DOI: 10.1111/j.1533-2500.2009.00353.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
39
|
Mulvey MR, Bagnall AM, Johnson MI, Marchant PR. Transcutaneous electrical nerve stimulation (TENS) for phantom pain and stump pain following amputation in adults. Cochrane Database Syst Rev 2010:CD007264. [PMID: 20464749 DOI: 10.1002/14651858.cd007264.pub2] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Amputee pain may present in a body part that has been amputated (phantom pain) or at the site of amputation (stump pain), or both. Phantom pain and stump pain are complex and multidimensional and the underlying pathophysiology remains unclear. The mainstay treatments for phantom pain and stump pain are predominately pharmacological. The condition remains a severe burden for those who are affected by it. There is increasing acknowledgement of the need for non-drug interventions and Transcutaneous Electrical Nerve Stimulation (TENS) may have an important role to play. TENS has been recommended as a treatment option for phantom pain and stump pain. To date there has been no systematic review of available evidence and the effectiveness of TENS for phantom pain and stump pain is currently unknown. OBJECTIVES To assess the analgesic effectiveness of TENS for the treatment of phantom pain and stump pain following amputation in adults. SEARCH STRATEGY We searched MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, PsycINFO, AMED, CINAHL, PEDRO and SPORTDiscus (February 2010). SELECTION CRITERIA Only randomised controlled trials (RCTs) investigating the use of TENS for the management of phantom pain and stump pain following an amputation in adults were included. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted data. It was planned that where available and appropriate, data from outcome measures were to be pooled and presented as an overall estimate of the effectiveness of TENS. MAIN RESULTS No RCTs that examined the effectiveness of TENS for the treatment of phantom pain and stump pain in adults were identified by the searches. AUTHORS' CONCLUSIONS There were no RCTs on which to judge the effectiveness of TENS for the management of phantom pain and stump pain. The published literature on TENS for phantom pain and stump pain lacks the methodological rigour and robust reporting needed to confidently assess its effectiveness. Further RCT evidence is required before such a judgement can be made.
Collapse
Affiliation(s)
- Matthew R Mulvey
- Faculty of Health, Leeds Metropolitan University, Civic Quarter, Leeds, West Yorkshire, UK, LS1 3HE
| | | | | | | |
Collapse
|
40
|
|
41
|
Ketz AK. The experience of phantom limb pain in patients with combat-related traumatic amputations. Arch Phys Med Rehabil 2008; 89:1127-32. [PMID: 18503810 DOI: 10.1016/j.apmr.2007.11.037] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2007] [Revised: 10/25/2007] [Accepted: 11/01/2007] [Indexed: 01/12/2023]
Abstract
OBJECTIVES To describe the prevalence and characteristics of phantom limb pain (PLP) and the use and perceived effectiveness of standard medical and self-treatment methods by traumatic amputees with combat-related injuries. DESIGN A retrospective descriptive questionnaire study. SETTING Outpatient amputee clinic at a major military medical center. PARTICIPANTS Convenience sample of military members (N=30) with single or multiple traumatic amputations from combat and/or training. Inclusion criteria were 18 to 50 years old and amputation within 5 years of the study. Exclusion criteria were nontraumatic amputees and amputation or most recent surgical revision within 3 months before the study. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The primary dependent variables were pain and relief, as measured by an investigator-developed questionnaire. RESULTS Seventy-seven percent of participants experienced PLP at some time since their amputation. Of those with PLP, the mean average intensity was 3.3+/-2.0 out of 10 and the mean worst intensity was 5.4+/-2.6 out of 10. The PLP was intermittent, and 78% reported episodes of PLP at least weekly. Sixty-eight percent of participants with PLP were receiving treatment from their health care providers. The most common medical treatment was gabapentin, although some patients reported greater pain relief from self-treatment methods such as distraction and relaxation techniques. CONCLUSIONS With over 750 service members living with amputations from recent combat, PLP will continue to be a troubling problem that requires effective interventions. The discrepancy between perceived effectiveness of different treatment types supports the need for highly individualized pain management plans.
Collapse
Affiliation(s)
- Ann K Ketz
- Landstuhl Regional Medical Center, Landstuhl, Germany.
| |
Collapse
|
42
|
Abstract
Traumatic amputees may experience a variety of acute and chronic pain issues, including phantom limb pain and residual limb pain. Research continues to determine the causes of these problems and to find the most appropriate and effective treatments for each of these phenomena. It is important for health care providers to be knowledgeable about the variety of treatments available, including medications, surgical procedures, complementary and alternative therapies, and self-treatment methods to ensure that amputees receive the best practices for individualized, effective pain management that they deserve.
Collapse
|
43
|
Richardson C, Glenn S, Horgan M, Nurmikko T. A Prospective Study of Factors Associated With the Presence of Phantom Limb Pain Six Months After Major Lower Limb Amputation in Patients With Peripheral Vascular Disease. THE JOURNAL OF PAIN 2007; 8:793-801. [PMID: 17631056 DOI: 10.1016/j.jpain.2007.05.007] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2006] [Revised: 05/03/2007] [Accepted: 05/15/2007] [Indexed: 11/26/2022]
Abstract
UNLABELLED Because of a lack of evidence to support any treatment for phantom limb pain (PLP), interest has turned to preventing it instead. However, like other areas of PLP research, there is little consensus regarding factors that may be associated with the development of PLP. This study was devised to identify physical and psychological factors associated with PLP development and maintenance. It was a prospective study of 59 patients listed for amputation of a lower limb due to peripheral vascular disease. Each was interviewed before amputation, and the survivors were reinterviewed 6 months afterward. Pain and coping style were the primary outcome measures. The use of high levels of passive coping strategies (P = .001), especially catastrophizing (P = .02) before amputation, were found to be associated with PLP development. Pain was only weakly associated with the presence of PLP 6 months after amputation. The ability to move the phantom (P = .01) and stump pain (P = .01) were postamputation factors associated with PLP. The complexity of the relationship between previous pain and coping style and the development of PLP is discussed alongside aspects of pain memory. Pre-emptive treatment of PLP will need to include psychological as well as physical interventions. PERSPECTIVE During this study, preamputation passive coping (especially catastrophizing) was found to be associated with the development of PLP. This knowledge will help researchers and clinicians to identify future targets for pre-emption of this condition because once established, PLP is difficult to treat.
Collapse
|
44
|
Allen RJ. Physical agents used in the management of chronic pain by physical therapists. Phys Med Rehabil Clin N Am 2006; 17:315-45. [PMID: 16616270 DOI: 10.1016/j.pmr.2005.12.007] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Evidence supporting the use of specific physical agents in the management of chronic pain conditions is not definitive; it is largely incomplete and sometimes contradictory. However, the use of agents in chronic pain management programs is common. Within the broad use of physical agents, they are rarely the sole modality of treatment. A 1995 American Physical Therapy Association position statement asserts that "Without documentation which justifies the necessity of the exclusive use of physical agents/modalities, the use of physical agents/modalities, in the absence of other skilled therapeutic or educational intervention, should not be considered physical therapy". Physical agents may serve as useful adjunctive modalities of pain relief or to enhance the effectiveness of other elements in therapy geared toward resolution of movement impairments and restoration of physical function. Given that a conclusive aggregate of findings is unlikely to exist for all permutations of patient conditions, combined with interacting therapeutic modalities, an evidence-based approach to pain management is not always possible or beneficial to the patient. In the face of inconclusive evidence, a theory-based approach may help determine if the therapeutic effect ofa given physical agent has the possibility of being a useful clinical tool in the context of treating a particular patient's mechanism of pain generation. Until controlled efficacy findings are definitive, careful individual patient response monitoring of thoughtful theoretical application of adjunctive physical agents may be a prudent approach to the management of chronic pain.
Collapse
Affiliation(s)
- Roger J Allen
- Department of Physical Therapy, University of Puget Sound, 1500 North Warner, CMB 1070, Tacoma, WA 98416, USA.
| |
Collapse
|
45
|
Richardson C, Glenn S, Nurmikko T, Horgan M. Incidence of Phantom Phenomena Including Phantom Limb Pain 6 Months After Major Lower Limb Amputation in Patients With Peripheral Vascular Disease. Clin J Pain 2006; 22:353-8. [PMID: 16691088 DOI: 10.1097/01.ajp.0000177793.01415.bd] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Contentions exist regarding the true incidence of phantom limb pain (PLP) and other associated post-amputation phenomena. Recognizing and understanding these phenomena would assist in the rehabilitation of amputees. This study was designed to investigate all post-amputation phenomena in a homogenous group of amputees. METHODS Prospective amputees were recruited prior to amputation of a lower limb due to peripheral vascular disease. All survivors were followed 6 months after surgery and interviewed to identify post-amputation phenomena, including phantom sensations, PLP, and stump pain. RESULTS Sixty amputees were recruited and 52 survived until the 6-month interview. Phantom sensations were universal, and aspects of the non-painful phenomena, including kinetic, kinesthetic, and exteroceptive components, were identified at varying rates within the sample. PLP was found in 78.8% of the survivors, and 51.2% had stump pain. Super-added phenomena occurred in 15.4%. Links were found between PLP and stump pain (P=0.01) and PLP and the ability to move the phantom (P=0.01). No link was found between PLP and telescoping of the phantom (P=0.47). CONCLUSIONS Phantom phenomena are associated with many myths. This study starts to unravel myth from fact, but further study is required before this enigmatic condition and its influence on rehabilitation are fully understood.
Collapse
|
46
|
Nikolajsen L, Brandsborg B. Chapter 45 Postamputation pain. HANDBOOK OF CLINICAL NEUROLOGY 2006; 81:679-686. [PMID: 18808867 DOI: 10.1016/s0072-9752(06)80049-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
|
47
|
Zoghi M, Jaberzadeh S. Effects of High Voltage Electro-auriculotherapy on Experimental Pain Threshold. Physiotherapy 2002. [DOI: 10.1016/s0031-9406(05)60108-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
48
|
Abstract
Phantom-limb pain is a common sequela of amputation, occurring in up to 80% of people who undergo the procedure. It must be differentiated from non-painful phantom phenomena, residual-limb pain, and non-painful residual-limb phenomena. Central changes seem to be a major determinant of phantom-limb pain; however, peripheral and psychological factors may contribute to it. A comprehensive model of phantom-limb pain is presented that assigns major roles to pain occurring before the amputation and to central as well as peripheral changes related to it. So far, few mechanism-based treatments for phantom-limb pain have been proposed. Most published reports are based on anecdotal evidence. Interventions targeting central changes seem promising. The prevention of phantom-limb pain by peripheral analgesia has not yielded consistent results. Additional measures that reverse or prevent the formation of central memory processes might be more effective.
Collapse
Affiliation(s)
- Herta Flor
- Department of Clinical and Cognitive Neuroscience, University of Heidelberg, Central Institute of Mental Health, Mannheim, Germany.
| |
Collapse
|
49
|
Halbert J, Crotty M, Cameron ID. Evidence for the optimal management of acute and chronic phantom pain: a systematic review. Clin J Pain 2002; 18:84-92. [PMID: 11882771 DOI: 10.1097/00002508-200203000-00003] [Citation(s) in RCA: 152] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The objective was to examine the evidence to determine the optimal management of phantom limb pain in the preoperative and postoperative phase of amputations. METHODS Trials were identified by a systematic search of MEDLINE, review articles, and references of relevant trials from the period 1966-1999, including only English-language articles. Included trials involved a control group, any intervention, and reported phantom pain as an outcome. RESULTS Twelve trials were identified, including 375 patients whose follow-ups ranged in duration from 1 week to 2 years. Only three randomized, controlled studies with parallel groups and three randomized crossover trials were identified. Eight trials examined treatment of acute phantom pain, including epidural treatments (three trials), regional nerve blocks (three trials), treatment with calcitonin (one trial), and transcutaneous electrical nerve stimulation (one trial). Three trials demonstrated a positive impact of the intervention on phantom limb pain, but the remainder demonstrated no difference between the intervention and control groups. Four trials examined late postoperative interventions, including transcutaneous electrical nerve stimulation (two trials) and the use of Farabloc (a metal threaded sock) and ketamine (one trial each). With regard to late postoperative interventions, three of the four trials showed modest short-term reduction of phantom limb pain. There was no relation between the quality of the trial and a positive result of the intervention. CONCLUSIONS Although up to 70% of patients have phantom limb pain after amputation, there is little evidence from randomized trials to guide clinicians with treatment. Evidence on preemptive epidurals, early regional nerve blocks, and mechanical vibratory stimulation provides inconsistent support for these treatments. There is currently a gap between research and practice in the area of phantom limb pain.
Collapse
Affiliation(s)
- Julie Halbert
- Department of Rehabilitation and Aged Care, Flinders University, Bedford Park, South Australia, Australia.
| | | | | |
Collapse
|
50
|
Abstract
Research suggesting that psychological factors play a role in phantom limb pain abounds in the literature. Despite recent research suggesting that these factors exacerbate rather than cause phantom limb pain, clinicians still frequently use personality as a rationale to explain amputees' phantom limb pain. The present study aimed to examine psychological distress in a working-age population of amputees not specifically seeking help for their pain. The study was conducted in two phases. Phase 1 included 315 amputees who completed the General Health Questionnaire (GHQ). Phase 2 included a subset of the original sample who completed the Beck Depression Inventory (BDI). In Phase 1, although over 50% of the sample reported GHQ scores over the threshold used to detect "caseness," this was not related to phantom limb pain. In Phase 2 of the study, only 15% of the sample reported moderate to severe symptoms of depression. Only 4% of the variance in phantom limb pain was accounted for using the overall BDI score. When BDI items were examined individually within regression models, a number significantly predicted phantom limb pain. However, the items most related to phantom limb pain were those involved in "performance difficulties" rather than "negative affect." The present study suggests that negative affect in amputees may be related to disability rather than pain.
Collapse
Affiliation(s)
- A S Whyte
- Scottish Network for Chronic Pain Research, University of Stirling, Stirling FK9 4LA, United Kingdom
| | | |
Collapse
|