Long-term Follow-up of Iranian Veteran Upper Extremity Amputees From the Iran-Iraq War (1980???1988)

A systematic review of the prevalence of postamputation and chronic neuropathic pain associated with combat injury in military personnel

ABSTRACT

Combat trauma can lead to widespread tissue damage and limb loss. This may result in chronic neuropathic and post amputation pain, including phantom limb pain (PLP) and residual limb pain (RLP). The military population is distinct with respect to demographic, injury, and social characteristics compared with other amputation and trauma cohorts. We undertook a systematic review of studies of military personnel, with a history of combat injury, that reported a prevalence of any type of postamputation pain or chronic neuropathic pain, identified from Embase and MEDLINE databases.Using the inverse variance method with a random-effects model, we undertook a meta-analysis to determine an overall prevalence and performed exploratory analyses to identify the effect of the type of pain, conflict, and time since injury on prevalence. Pain definitions and types of pain measurement tools used in studies were recorded. Thirty-one studies (14,738 participants) were included. The pooled prevalence of PLP, RLP, and chronic neuropathic pain were 57% (95% CI: 46-68), 61% (95% CI: 50-71), and 26% (95% CI: 10-54), respectively. Between-study heterogeneity was high (I 2 : 94%-98%). Characterisation of duration, frequency, and impact of pain was limited. Factors reported by included studies as being associated with PLP included the presence of RLP and psychological comorbidity. The prevalence of postamputation pain and chronic neuropathic pain after combat trauma is high. We highlight inconsistency of case definitions and terminology for pain and the need for consensus in future research of traumatic injury.

Systematic Review and Meta-Analysis of Global Neuroma Incidence in Upper Extremity Amputees

BACKGROUND

Neuromas substantially decrease a patient's quality of life and obstruct the use of prosthetics. This systematic review and meta-analysis aimed to determine the global incidence of neuroma formation in upper extremity amputees.

METHODS

A literature search was performed using 3 databases: Web of Science, MEDLINE, and Cochrane. Inclusion criteria for the systematic review were those studies investigating only upper extremity amputees and reported postamputation neuroma. A random-effects, inverse-variance analysis was conducted to determine the pooled proportion of neuromas within the upper extremity amputation population. Critical appraisal using the JBI Checklist for Studies Reporting Prevalence Data of each individual article were performed for the systematic review.

RESULTS

Eleven studies met the inclusion criteria collating a total of 1931 patients across 8 countries. More than three-fourth of patients are young men (77%; age range, 19-54 years) and had an amputation due to trauma. The random-effects analysis found the pooled combined proportion of neuromas to be 13% (95% confidence interval, 8%-18%). The treatment of neuroma is highly variable, with some patients receiving no treatment.

CONCLUSIONS

The pooled proportion of neuroma incidence in the 1931 patients was 13%. With the known global prevalence of upper extremity amputees, this translates to nearly 3 million amputees suffering from a neuroma globally. Increasing training in preventative surgical methods could contribute to lowering this incidence and improving the outcomes of this patient population.

Making sense of phantom limb pain

Phantom limb pain (PLP) impacts the majority of individuals who undergo limb amputation. The PLP experience is highly heterogenous in its quality, intensity, frequency and severity. This heterogeneity, combined with the low prevalence of amputation in the general population, has made it difficult to accumulate reliable data on PLP. Consequently, we lack consensus on PLP mechanisms, as well as effective treatment options. However, the wealth of new PLP research, over the past decade, provides a unique opportunity to re-evaluate some of the core assumptions underlying what we know about PLP and the rationale behind PLP treatments. The goal of this review is to help generate consensus in the field on how best to research PLP, from phenomenology to treatment. We highlight conceptual and methodological challenges in studying PLP, which have hindered progress on the topic and spawned disagreement in the field, and offer potential solutions to overcome these challenges. Our hope is that a constructive evaluation of the foundational knowledge underlying PLP research practices will enable more informed decisions when testing the efficacy of existing interventions and will guide the development of the next generation of PLP treatments.

Prevention is better than cure: Surgical methods for neuropathic pain prevention following amputation - A systematic review

BACKGROUND

Pain after amputation can be known as residual limb pain (RLP) or phantom limb pain (PLP); however, both can be disabling in daily life with reported incidences of 8% for finger amputations and up to 85% for major limb amputations. The current treatment is focused on reducing the pain after neuropathic pain occurs. However, surgical techniques to prevent neuropathic pain after amputation are available and effective, but they are underutilized. The purpose of the review is to investigate the effects of techniques during amputation to prevent neuropathic pain.

METHODS

A systematic review was performed in multiple databases (Embase, Medline, Web of Science, Scopus, Cochrane, and Google Scholar) and following the PRISMA guidelines. Studies that reported surgical techniques to prevent neuropathic pain during limb amputation were included.

RESULTS

Of the 6188 selected studies, 13 eligible articles were selected. Five articles reported techniques for finger amputation: neurovascular island flap, centro-central union (CCU), and epineural ligatures, and flaps. For finger amputations, the use of prevention techniques resulted in a decrease of incidences from 8% to 0-3% with CCU being the most beneficial. For major limb amputations, the incidences for RLP were decreased to 0 to 55% with TMR and RPNI and compared to 64-91% for the control group. Eight articles reported techniques for amputations on major limbs: targeted muscle reinnervation (TMR), targeted nerve implantation, concomitant nerve coaptation, and regenerative peripheral nerve interface (RPNI).

CONCLUSIONS

Based on the current literature, we state that during finger and major limb amputation, the techniques to prevent neuropathic pain and PLP should be performed.

Psychiatric Disease after Isolated Traumatic Upper Extremity Amputation

Introduction  Psychiatric disease after traumatic limb loss impacts rehabilitation, prosthesis use, and quality of life. The purpose of this study was to evaluate the prevalence of psychiatric disease in civilians after isolated, traumatic upper extremity amputation and determine if any risk factors are associated with developing psychiatric disease.

Materials and Methods  Demographics, time since injury, mechanism of injury, amputation level, hand affected (dominant vs. nondominant), Bureau of Workers’ Compensation (BWC) status, and prosthesis use were retrospectively reviewed for all patients treated from 2012 to 2017. For patients with an International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) diagnosed psychiatric disease, the diagnosis and length of treatment were recorded. Patients were grouped by presence or absence of psychiatric diagnosis and data analysis was performed using descriptive statistics, Fisher’s exact test, and relative risk.

Results  Forty-six patients met the inclusion criteria. Thirty-one patients (67.4%) had at least one diagnosed psychiatric condition. Major depressive disorder was the most common ( n = 14), followed by posttraumatic stress disorder ( n = 11), adjustment disorder ( n = 11), anxiety ( n = 6), and panic disorder ( n = 2). No statistically significant correlation was seen between psychiatric illness and gender, age at the time of injury, time since injury, current employment status, BWC status, hand injured (dominant vs. nondominant), prosthetic use, or level of amputation.

Conclusion  The rates of depression and anxiety after traumatic upper limb loss in the civilian population are similar to reported rates after combat injury. While we were unable to identify a statistically significant association with any of the studied variables, upper extremity surgeons should be aware of the high prevalence of psychiatric disease after traumatic upper extremity amputation.

Effect of one session of mirror therapy on phantom limb pain and recognition of limb laterality in military traumatic lower limb amputees: a pilot study

Up to 70 % of military amputees suffer phantom limb pain (PLP), which is difficult to treat. PLP has been attributed to cortical reorganisation and associated with impaired laterality. Repeated sessions of mirror therapy (MT) can benefit PLP; however, anecdotal evidence suggests one MT session could be effective. In a one-group pretest and post-test design, 16 UK military unilateral lower limb amputees (median age: 31.0, 95% CI 25.0 to 36.8 years) undertook one 10 min MT session. Visual analogue scale (VAS) pain and laterality (accuracy and reaction time) measurements were taken pre-MT and post-MT. Median VAS PLP did not differ significantly between pre-MT 15 mm (2-53 mm) and post-MT 12 mm (1-31) (p=0.875) scores. For the amputated limb, there were no significant differences between pre-MT and post-MT scores for laterality accuracy, 95.3%, 95% CI 90.5% to 97.6% and 96.7%, 95% CI 90.0% to 99.4%, respectively (p=0.778), or reaction time, 1.42 s, 95% CI 1.11 to 2.11 s and 1.42 s, 95% CI 1.08 to 2.02 s, respectively (p=0.629). Laterality was also not different between limbs for accuracy, p=0.484, or reaction time, p=0.716, and did not correlate with PLP severity. No confounding variables predicted individual responses to MT. Therefore, one 10 min MT session does not affect laterality and is not effective as standard treatment for PLP in military lower limb amputees. However, substantial PLP improvement for one individual and resolution of a stuck phantom limb for another infers that MT may benefit specific patients. No correlation found between PLP and laterality implies associated cortical reorganisation may not be the main driver for PLP. Further research, including neuroimaging, is needed to help clinicians effectively target PLP.

Characteristics of phantom upper limb mobility encourage phantom-mobility-based prosthesis control

There is an increasing need to extend the control possibilities of upper limb amputees over their prosthetics, especially given the development of devices with numerous active joints. One way of feeding pattern recognition myoelectric control is to rely on the myoelectric activities of the residual limb associated with phantom limb movements (PLM). This study aimed to describe the types, characteristics, potential influencing factors and trainability of upper limb PLM. Seventy-six below- and above-elbow amputees with major amputation underwent a semi-directed interview about their phantom limb. Amputation level, elapsed time since amputation, chronic pain and use of prostheses of upper limb PLM were extracted from the interviews. Thirteen different PLM were found involving the hand, wrist and elbow. Seventy-six percent of the patients were able to produce at least one type of PLM; most of them could execute several. Amputation level, elapsed time since amputation, chronic pain and use of myoelectric prostheses were not found to influence PLM. Five above-elbow amputees participated in a PLM training program and consequently increased both endurance and speed of their PLM. These results clearly encourage further research on PLM-associated muscle activation patterns for future PLM-based modes of prostheses control.

Evaluation of disabilities and activities of daily living of war-related bilateral lower extremity amputees

BACKGROUND

Long-term consequences and the activities of daily living of bilateral lower limb amputation are not well documented.

OBJECTIVES

The aims of our study were to identify the long-term effects of bilateral lower extremity amputations on daily activities and understand how these amputees cope with their mobility assistive devices.

STUDY DESIGN

Cross-sectional study.

METHODS

A total of 291 veterans with war bilateral lower limb amputations accepted to participate in a cross-sectional study.

RESULTS

The average of follow-up was 25.4 years. A total of 152 amputees (54%) were involved in sports averagely 6.7 h per week. Bilateral amputees walk 10 m by the average of 15 ± 33 s, and they could walk continuously with their prosthesis 315 ± 295 m. They wore their prosthesis 6.8 ± 1.7 days per week and 7.9 ± 8.1 h per day. Of these, 6.7% of bilateral lower limb amputees needed help to wear their prosthesis; 88.3% of amputees used assistant device for walking. According to this survey, 73 (42%) prostheses in right limb were appropriate, 95 (54.6%) needed to be replaced, and 6 (3.4) needed to be fixed. On the left side, it was 76 (42%), 92 (52.0%), and 9 (5.1%), respectively. A total of 203 (74.9%) amputees reported limitations in at least one domain of the activities of daily living. The most common single item that affected the patients was ascending and descending stairs by the score of 66% of normal population.

CONCLUSION

Veterans with bilateral lower limb amputations suffering from vast categories of daily problems.

CLINICAL RELEVANCE

This study and its results confirm that bilateral lower limb amputees have major progressive disabilities in daily activities and their social performance. This should attract the attention of amputees' administrative organizations, social workers, health-care providers and caregiver providers.

The appropriate use of neurostimulation of the spinal cord and peripheral nervous system for the treatment of chronic pain and ischemic diseases: the Neuromodulation Appropriateness Consensus Committee

INTRODUCTION

The Neuromodulation Appropriateness Consensus Committee (NACC) of the International Neuromodulation Society (INS) evaluated evidence regarding the safety and efficacy of neurostimulation to treat chronic pain, chronic critical limb ischemia, and refractory angina and recommended appropriate clinical applications.

METHODS

The NACC used literature reviews, expert opinion, clinical experience, and individual research. Authors consulted the Practice Parameters for the Use of Spinal Cord Stimulation in the Treatment of Neuropathic Pain (2006), systematic reviews (1984 to 2013), and prospective and randomized controlled trials (2005 to 2013) identified through PubMed, EMBASE, and Google Scholar.

RESULTS

Neurostimulation is relatively safe because of its minimally invasive and reversible characteristics. Comparison with medical management is difficult, as patients considered for neurostimulation have failed conservative management. Unlike alternative therapies, neurostimulation is not associated with medication-related side effects and has enduring effect. Device-related complications are not uncommon; however, the incidence is becoming less frequent as technology progresses and surgical skills improve. Randomized controlled studies support the efficacy of spinal cord stimulation in treating failed back surgery syndrome and complex regional pain syndrome. Similar studies of neurostimulation for peripheral neuropathic pain, postamputation pain, postherpetic neuralgia, and other causes of nerve injury are needed. International guidelines recommend spinal cord stimulation to treat refractory angina; other indications, such as congestive heart failure, are being investigated.

CONCLUSIONS

Appropriate neurostimulation is safe and effective in some chronic pain conditions. Technological refinements and clinical evidence will continue to expand its use. The NACC seeks to facilitate the efficacy and safety of neurostimulation.

The relationship between prosthesis use, phantom pain and psychiatric symptoms in male traumatic limb amputees

OBJECTIVES

The purpose of this study was to identify psychiatric symptoms by comparing male patients with traumatic leg amputations (LAs) with healthy controls and to determine the association between these psychiatric symptoms and phantom pain and prosthesis use characteristics.

METHODS

One hundred four volunteers, 51 LA patients (group 1) and 53 healthy controls (group 2) were included. Demographic data including age, height, weight, time since amputation, duration of prosthesis use, and Satisfaction with Prosthesis Questionnaire scores were recorded. Phantom pain was measured a visual analog scale (VAS). Psychiatric symptoms were measured using the Symptom Checklist-90-R, Beck Depression Inventory, Pittsburgh Sleep Quality Index, Rosenberg Self-Esteem Scale, and State-Trait Anxiety Inventory. Correlations were determined between time since amputation, duration of prosthesis use and satisfaction with prosthesis questionnaire scores and psychiatric scale scores.

RESULTS

Amputee patients had higher phobic anxiety, state anxiety, trait anxiety and sleep disturbance scores (p<0.05) than the controls. No difference was determined in terms of psychiatric symptoms between the phantom pain and no phantom pain groups (p>0.05). There were significant negative correlations between time since amputation, duration of prosthesis use, duration of daily prosthesis use, and satisfaction with prosthesis questionnaire scores and psychiatric symptoms.

CONCLUSIONS

Apart from anxiety (state, trait or phobic) and disturbed sleep, other psychiatric symptoms in amputee patients undergoing lengthy prosthetic rehabilitation may not differ from those of healthy controls. The presence and severity of phantom pain appear to be unrelated to general psychiatric symptomatology. Length of time since amputation, length of prosthesis use, daily length of prosthesis use and prosthesis satisfaction are negatively correlated with general psychiatric symptoms. These characteristics must be borne in mind in psychiatric and prosthetic rehabilitation.

Long-term clinical outcomes of war-related bilateral lower extremities amputations

In a cross-sectional study, 291 out of 500 veterans with war-related bilateral lower limb amputations from Iran-Iraq war (1980-1988) accepted to participate in our study. Information related to amputees and amputated limbs were gathered and a Persian version of the Medical Outcomes Study Short Form 36 (SF-36) was filled. To evaluate the effect of amputation level on health related quality of life, we classified patients to seven types according to the functional remainder of major joints (ankles, knees, hips). 97% of patients were male and the average age at the time of injury was 20 years. The major cause of war injury was shells in 50. 54% of amputees were involved in sport activities. The most common amputation level was transtibial (48%).The major stump complaint was muscle spasm. History of being hospitalized for a psychiatric disorder was reported in 5.6%. The average SF-36 score in type 2 to type 6 were 68, 60, 60, 56, and 62, respectively. Except Energy/Fatigue domain, all the other domains were different from normal population. There was not any significant statistical correlation between amputation type and any domain of the SF-36. Type 6 amputees showed an increase in physical health domains compared with former types.

Mental health disorders in child and adolescent survivors of post-war landmine explosions

BACKGROUND

To describe the mental health status of 78 child and adolescent survivors of post-war landmine explosions.

METHODS

Child and adolescent survivors of landmine explosions who were younger than 18 years old at the time of the study were identified and enrolled in this study. The mental health status of the participants was assessed by general health assessment and psychiatric examinations. Psychiatric assessment and diagnosis were undertaken using the Diagnostic and Statistical Manual for mental disorders (DSM-IV) criteria. A psychiatrist visited and interviewed each survivor and identified psychiatric disorders.

RESULTS

Seventy-eight child and adolescent survivors with a mean age of 16.11 ± 2 years old were identified and agreed to participate in the study. The mean age of the victims at the time of injury was 8.2 ± 3.12 years old (range 2-15). Thirty-seven (47.4 %) of the adolescent survivors suffered from at least one psychiatric disorder. Twenty-nine survivors (37.1 %) were newly diagnosed and needed to start medication and psychiatric treatment. The most common findings were anxiety disorders (34.6 %), including posttraumatic stress disorder (PTSD) in 20 (25.6 %), and generalized anxiety disorder (GAD) in 7 (9 %) subjects. Mild-Moderate depression was found in 5 (6.4 %) subjects. No personality disorders were observed, and two patients suffered from mental retardation. The study results revealed a significant association between age of casualty, duration of injury and limb amputation, and types of psychological disorders.

CONCLUSION

Child and adolescent survivors of landmine explosions had a high prevalence of psychiatric disorders.

Disabilities and activities of daily living among veterans with old hip disarticulation and transpelvic amputation

Background:

The Iran-Iraq imposed war lasted eight years and was one of the longest wars of the last century. Twenty-three years have passed since the war ended, but little has been discussed about the long-term results of war amputations in the literature.

Objectives:

In this long-term study, we have evaluated the activities of daily living among veterans with hip or hemipelvis amputations.

Patients and Methods:

A cross-sectional study was performed on Iran-Iraq war veterans with hip or hemipelvis amputations in Iran. Eighty-four (96.5%) veterans out of 87 registered veterans with hip or hemipelvis amputations participated in the study. The degree of independence for activities of daily living (ADL) was assessed by the Barthel index. The degree of independence for instrumental activities of daily living (IADL) was assessed by the Lawton-Brody scale.

Results:

The average follow-up time was 26.6 ± 3.7 years. The average age of veterans was 44.1±7 years old. Of 84 amputees, 57 (67.85%) had limitations in at least one domain of the ADL. The most common single item that affected the patients was ascending and descending stairs seen in 45 (78.9%) veterans, followed by eating seen in 4 (7.01%) veterans. In addition, 70 (83.33%) had limitations in at least one domain of the IADL. The most common single item that affected the veterans was shopping seen in 56 (80%), followed by responsibility for own medications seen in 13 (18.57%) veterans. Spearman correlation coefficient of the sum scores of ADL and IADL showed an intermediate to strong correlation (r = 0.58).

Conclusions:

Increasing dependency in ADL is accompanied by increasing dependency in IADL. In the past, the duty of health care providers was saving the life of veterans due to injuries while at present, because these injuries occurred in young and healthy individuals, the need for increased function is being highlighted.

Long-term clinical outcomes of war-related hip disarticulation and transpelvic amputation

BACKGROUND

The Iran-Iraq war (1980 to 1988) was one of the longest wars of the twentieth century. Few studies are available in the current literature evaluating the long-term results of proximal lower-extremity war-related amputations. The purpose of the present cross-sectional study was to evaluate the current health-related quality of life and clinical musculoskeletal function of Iranian veterans with hip or hemipelvic amputation.

METHODS

Seventy-six patients from a cohort of eighty-four veterans with hip disarticulation and transpelvic amputation participated in this study. A Persian version of Medical Outcomes Study Short Form-36 (SF-36) was completed for all of the veterans.

RESULTS

The average duration of follow-up was 26.6 ± 3.7 years. The average age (and standard deviation) of the veterans was 44.1 ± 7.0 years. The average scores for the physical and mental health dimensions of the SF-36 were 45.85 ± 21.56 and 57.98 ± 25.19, respectively. These data indicate that the amputees were doing better in the mental domain than in the physical domain. Forty-five patients with a primary amputation (97.8%) and ten with a secondary amputation (33.3%) complained of pain in the amputation stump.

CONCLUSIONS

Veterans with proximal lower-extremity amputation will need life-long care. Supervision starts with stump management and the application of appropriate surgical techniques at the time of the injury and continues with periodic examination throughout life.

Dorsal column stimulator applications

Background:

Spinal cord stimulation (SCS) has been used to treat neuropathic pain since 1967. Following that, technological progress, among other advances, helped SCS become an effective tool to reduce pain.

Methods:

This article is a non-systematic review of the mechanism of action, indications, results, programming parameters, complications, and cost-effectiveness of SCS.

Results:

In spite of the existence of several studies that try to prove the mechanism of action of SCS, it still remains unknown. The mechanism of action of SCS would be based on the antidromic activation of the dorsal column fibers, which activate the inhibitory interneurons within the dorsal horn. At present, the indications of SCS are being revised constantly, while new applications are being proposed and researched worldwide. Failed back surgery syndrome (FBSS) is the most common indication for SCS, whereas, the complex regional pain syndrome (CRPS) is the second one. Also, this technique is useful in patients with refractory angina and critical limb ischemia, in whom surgical or endovascular treatment cannot be performed. Further indications may be phantom limb pain, chronic intractable pain located in the head, face, neck, or upper extremities, spinal lumbar stenosis in patients who are not surgical candidates, and others.

Conclusion:

Spinal cord stimulation is a useful tool for neuromodulation, if an accurate patient selection is carried out prior, which should include a trial period. Undoubtedly, this proper selection and a better knowledge of its underlying mechanisms of action, will allow this cutting edge technique to be more acceptable among pain physicians.

The outcome of British combat amputees in relation to military service

BACKGROUND

The study aim was to determine the outcome, in relation to military service in UK military combat amputees.

PATIENTS AND METHODS

Casualties were assessed at mean 2.4 years after injury and graded by a Functional Activity Assessment (FAA) ranging from 1 (fully fit) to 5 (unfit all duties) to score vocational functional outcome. ISS were calculated and the patients were categorised as having unilateral or multiple amputations. The Short Form-36 Health Survey (SF-36) was completed.

RESULTS

Of the 52, 8 patients had left the forces by medical discharge, with 44 continuing to serve. 33 of the 44 had returned to work. 50 patients had FAA grades and were at least 7.6 months post-injury. No patients were graded as FAA1, 8 as FAA2, 18 as FAA3, 19 as FAA4 and 5 as FAA5. There was a trend for the FAA score to increase with injury severity, as measured by ISS i.e. vocational functional outcome was worse with more severe injuries, although this did not reach statistical significance (p=0.095). Multiple amputee patients had significantly higher FAA grades (p<0.001) and were all FAA 4 or 5. Of the 33 patients who had returned to work, 8 were FAA2, 12 FAA3 and 12 FAA4. The mean SF-36 scores for Physical Component Summary (PCS) increased significantly from 36.4 to 43.4 (p=0.001) with rehabilitation, while Mental Component Summary (MCS) was 53.0 and remained similar at 53.6 (p=0.987). MCS scores were similar in these patients to the normal population, 50 (SD 10).

CONCLUSIONS

This study is the first to report the outcomes, with regards to return to work, of the UK military amputees injured in Afghanistan and Iraq Soldiers are surviving more severe and complex injuries than before and the majority are able to return successfully to military work. SF-36 PCS scores improve significantly with rehabilitation, and while MCS scores remain constant, the initial assessments are comparable with a normal population.

Achievements and challenges in composite tissue allotransplantation

Overall, more than 60 hand/forearm/arm transplantations and 16 face transplantations have been performed in the past 12 years. In the European experience summarized here, three grafts have been lost in response to a vascular thrombosis (n = 1), rejection and incompliance with immunosuppression (n = 1) and death (n = 1). The overall functional and esthetic outcome is very satisfactory, but serious side effects and complications related to immunosuppression are challenges hindering progress in this field. The high levels of immunosuppression, skin rejection, nerve regeneration, donor legislation and the acceptance level need to be addressed to promote growth of this promising new field in transplantation and reconstructive surgery.

21. Phantom pain

Phantom pain is pain caused by elimination or interruption of sensory nerve impulses by destroying or injuring the sensory nerve fibers after amputation or deafferentation. The reported incidence of phantom limb pain after trauma, injury or peripheral vascular diseases is 60% to 80%. Over half the patients with phantom pain have stump pain as well. Phantom pain can also occur in other parts of the body; it has been described after mastectomies and enucleation of the eye. Most patients with phantom pain have intermittent pain, with intervals that range from 1 day to several weeks. Even intervals of over a year have been reported. The pain often presents itself in the form of attacks that vary in duration from a few seconds to minutes or hours. In most cases, the pain is experienced distally in the missing limb, in places with the most extensive innervation density and cortical representation. Although there are still many questions as to the underlying mechanisms, peripheral as well as central neuronal mechanisms seem to be involved. Conservative therapy consists of drug treatment with amitriptyline, tramadol, carbamazepine, ketamine, or morphine. Based on the available evidence some effect may be expected from drug treatment. When conservative treatment fails, pulsed radiofrequency treatment of the stump neuroma or of the spinal ganglion (DRG) or spinal cord stimulation could be considered (evidence score 0). These treatments should only be applied in a study design.

Long-term clinical outcomes of Iranian veterans with unilateral transfemoral amputation

AIM

To study long-term outcome of unilateral above-knee amputation.

OBJECTIVE

Long-term clinical symptoms and functional status of above-knee amputees are not well documented. The purpose of this study was to document the long-term outcome of war related above-knee amputations.

CONTEXT

The study consisted of a comprehensive assessment and examination and review of history and wartime medical records of 31 Iranian above-knee amputees from the Iraq-Iran war by using a detailed questionnaire. The average follow-up was 17.5 years (range from 15 to 22 years). All patients were males and had been combatants.

RESULTS

The most common agent of war injury was a shell with an incidence of 45.1%, while land mines and direct bullet shots were the following causes of war injury resulting in amputation in 41.9% and 12.9%, respectively. Clinical symptoms included phantom sensation in 27 patients (87%), phantom pain in 14 patients (45.1%), phantom movement in 5 patients (16.1%) patients and stump pain in 20 patients (64.5%). Additionally, 19 patients (61.2%) suffered from back pain, 17 patients (54.8%) complained of contra lateral (non-amputated) knee pain and 4 patients (14.8%) complained of ipsilateral hip pain. Seventeen patients (54%) reported psychological problems. Eighteen cases (58%) were employed or had been employed for multiple years after amputation. All patients (100%) were married and 30 (96.7%) had offspring.

CONCLUSIONS

The study showed that our patients had significant rates of amputation symptoms after an average of two decades of amputation, but on the other hand good family and social function of the patients were recorded. Amputation is not a static disability but a progressive deteriorating condition that affects the health condition of the amputee over time.

Novel model for end-neuroma formation in the amputated rabbit forelimb

BACKGROUND

The forelimb amputee poses many reconstructive challenges in the clinical setting, and there is a paucity of established surgical models for study. To further elucidate the pathogenic process in amputation neuroma formation, we created a reproducible, well-tolerated rabbit forelimb amputation model.

METHODS

Upon approval from the Institutional Animal Care and Use Committee, 5 New Zealand White rabbits underwent left forelimb amputation. During this initial surgery, the median, radial and ulnar nerves were transected 1.6-2.5 (mean 2.0) cm distal to the brachial plexus, transposed onto the anterior chest wall and preserved at length. Six weeks subsequent to the amputation, the distal 5 mm of each neuroma was excised, and the remaining stump underwent histomorphometric analysis.

RESULTS

The nerve cross sectional areas increased by factors of 1.99, 3.17, and 2.59 in the median (p = 0.077), radial (p < 0.0001) and the ulnar (p = 0.0026) nerves, respectively. At the axonal level, the number and cross-sectional area of myelinated fibers demonstrated an inverse relationship whereby the number of myelinated fibers in the median, radial and ulnar nerves increased by factors of 5.13 (p = 0.0043), 5.25 (p = 0.0056) and 5.59 (p = 0.0027), and the cross-sectional areas of these myelinated fibers decreased by factors of 4.62 (p < 0.001), 3.51 (p < 0.01), and 4.29 (p = 0.0259), respectively.

CONCLUSION

Given that the surgical model appears well-tolerated by the rabbits and that patterns of morphologic change are consistent and reproducible, we are encouraged to further investigate the utility of this model in the pathogenesis of neuroma formation.

Quality of life among veterans with war-related unilateral lower extremity amputation: a long-term survey in a prosthesis center in Iran

OBJECTIVE

To determine the factors that have an adverse effect on the long-term health-related quality of life (HRQOL) of veterans who have lost their extremities on the battlefield.

DESIGN

Cross-sectional study.

SETTING

Tertiary prosthesis center.

PARTICIPANTS

One hundred forty-one male Iranian veterans who have sustained unilateral lower extremity amputation during the Iran-Iraq War (1980-1988) were evaluated after an average of 21.6 years (range, 20-27 years) after amputation.

INTERVENTION

No intervention.

MAIN OUTCOME MEASUREMENTS

Physical and mental HRQOL according to the Short Form-36 (SF-36) Health Survey. A cutoff point to define poor versus good HRQOL was calculated using the first quartile of SF-36 physical and mental component scores.

RESULTS

Poor physical HRQOL was positively associated with transfemoral amputation, phantom movement, low back pain, and a lower Barthel Index [odds ratios (ORs): 4.1, 7.8, 9.1, and 0.9, respectively). Poor mental HRQOL was associated with education level lower than high school diploma and the articular pain of the sound leg (OR = 2.9 and 6.5, respectively). Being employed or receiving disability was a factor that had a lower OR to associate with poor mental HRQOL (OR = 0.2).

CONCLUSIONS

Alleviation of complaints such as low back pain and articular pain of the sound leg through appropriate medical management, granting facilities for continuing education, and employment are issues that should be considered by authorities and rehabilitative centers to increase HRQOL in amputee veterans.

Long-term follow-up evaluation of bilateral total hand loss

PURPOSE

Bilateral total hand loss is rare, and the challenges faced by the patient immediately after the loss are quite different from the long-term responses to the physical loss of both hands. This study evaluates the problems of these patients years after their injuries. The goal is to evaluate long-term adaptation to the loss and the degree of successful coping achieved by the patients.

METHODS

Seven subjects in this descriptive study participated in an interview and physical exam. They were asked about their physical, psychological, and social problems. Functional Independence Measure (FIM) and Functional Assessment Measure (FAM) were used to assess the levels of the major functional areas.

RESULTS

All of the subjects considered their handicap a serious disfigurement but not an impediment to finding a marriage partner or pursuing educational goals. All of the subjects, however, were dependent economically although they wanted to be employed based on their capabilities. Although 2 subjects used prostheses for activities of daily living, they all needed assistance for self-care. Three of the subjects had diagnosed psychological problems of anxiety and depression.

CONCLUSIONS

Bilateral total hand loss does not simply represent double the problems of unilateral hand loss. The problems resulting from the loss of both hands are physical, social, psychological, and economic and unique to these patients. The strength of the subjects came from having good family relations, stable environments, and family emotional support to help solve the numerous problems encountered on a daily basis. The subjects are able to maintain stable personal lives because they experience respect and comprehension of their problems by family members.