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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.
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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
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2
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Gossrau G, Sabatowski R. [Diagnostics and therapy of neuropathic pain]. Anaesthesist 2021; 70:993-1002. [PMID: 34676422 DOI: 10.1007/s00101-021-01039-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2021] [Indexed: 12/11/2022]
Abstract
Neuropathic pain is pain caused by a lesion or disease of the somatosensory nervous system. Scientific studies have shown that neuropathic pain is the result of complex altered signalling processes in the peripheral and central nervous system. Current forms of treatment of neuropathic pain are causally oriented but also aim at symptomatic analgesia by pharmacological and nonpharmacological methods. Furthermore, psychological pain management techniques are used in a supportive role. This review summarizes the contemporary diagnostics of neuropathic pain using frequent diseases as examples and presents the evidence from randomized controlled trials on the treatment of neuropathic pain. Treatment guidelines for pharmacological management of neuropathic pain include evidence-based use of antidepressants, anticonvulsants, opioids, capsaicin and lidocaine.
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Affiliation(s)
- G Gossrau
- Interdisziplinäres UniversitätsSchmerzCentrum, Universitätsklinikum Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland.
| | - R Sabatowski
- Interdisziplinäres UniversitätsSchmerzCentrum, Universitätsklinikum Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland.,Klinik und Poliklinik für Anästhesiologie und Intensivmedizin, TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
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3
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Tansho K, Nakajima-Ohyama KC, Watase K, Hida JI. Management of Phantom Limb Pain after Amputation by Adjunctive Use of Mianserin in a Diabetic Case on Hemodialysis: A Case Report. J Palliat Med 2021; 24:1268-1269. [PMID: 34469231 DOI: 10.1089/jpm.2021.0245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Kosuke Tansho
- Department of Nephrology, Kindai University Nara Hospital, Ikoma City, Nara, Japan
| | | | - Kenji Watase
- Department of Nephrology, Kindai University Nara Hospital, Ikoma City, Nara, Japan
| | - Jin-Ichi Hida
- Department of Surgery, Kindai University Nara Hospital, Ikoma City, Nara, Japan.,Department of Palliative Medicine, Kindai University Nara Hospital, Ikoma City, Nara, Japan
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4
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Bektur E, Şahin E, Ceyhan E, Donmez DB, Canbek M, Baycu C, Can OD. Beneficial effect of mirtazapine on diabetes-induced hyperalgesia: involvement of TRPV1 and ASIC1 channels in the spinal cord and dorsal root ganglion. Neurol Res 2019; 41:544-553. [PMID: 30822229 DOI: 10.1080/01616412.2019.1580462] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Ezgi Bektur
- Histology and Embryology Department, School of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Erhan Şahin
- Histology and Embryology Department, School of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Emre Ceyhan
- Molecular biology department, School of science, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Dilek Burukoglu Donmez
- Histology and Embryology Department, School of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Mediha Canbek
- Molecular biology department, School of science, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Cengiz Baycu
- Histology and Embryology Department, School of Medicine, Okan University, Istanbul, Turkey
| | - Ozgur Devrim Can
- Pharmacology Department, School of pharmacy, Anadolu University, Eskisehir, Turkey
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Development of a Multimodal Analgesia Protocol for Perioperative Acute Pain Management for Lower Limb Amputation. Pain Res Manag 2018; 2018:5237040. [PMID: 29973967 PMCID: PMC6008740 DOI: 10.1155/2018/5237040] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 02/06/2018] [Accepted: 04/10/2018] [Indexed: 01/21/2023]
Abstract
Multimodal analgesia may include pharmacological components such as regional anesthesia, opioid and nonopioid systemic analgesics, nonsteroidal anti-inflammatories, and a variety of adjuvant agents. Multimodal analgesia has been reported for a variety of surgical procedures but not yet for lower limb amputation in vasculopathic patients. Perioperative pain management in these patients presents a particular challenge considering the multiple sources and pathways for acute and chronic pain that are involved, such as chronic ischemic limb pain, postoperative residual limb pain, coexisting musculoskeletal pain, phantom limb sensations, and chronic phantom limb pain. These pain mechanisms are explored and a proposed protocol for multimodal analgesia is outlined taking into account the common patient comorbidities found in this patient population.
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Finn SB, Perry BN, Clasing JE, Walters LS, Jarzombek SL, Curran S, Rouhanian M, Keszler MS, Hussey-Andersen LK, Weeks SR, Pasquina PF, Tsao JW. A Randomized, Controlled Trial of Mirror Therapy for Upper Extremity Phantom Limb Pain in Male Amputees. Front Neurol 2017; 8:267. [PMID: 28736545 PMCID: PMC5500638 DOI: 10.3389/fneur.2017.00267] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 05/26/2017] [Indexed: 01/16/2023] Open
Abstract
Objective Phantom limb pain (PLP) is prevalent in patients post-amputation and is difficult to treat. We assessed the efficacy of mirror therapy in relieving PLP in unilateral, upper extremity male amputees. Methods Fifteen participants from Walter Reed and Brooke Army Medical Centers were randomly assigned to one of two groups: mirror therapy (n = 9) or control (n = 6, covered mirror or mental visualization therapy). Participants were asked to perform 15 min of their assigned therapy daily for 5 days/week for 4 weeks. The primary outcome was pain as measured using a 100-mm Visual Analog Scale. Results Subjects in the mirror therapy group had a significant decrease in pain scores, from a mean of 44.1 (SD = 17.0) to 27.5 (SD = 17.2) mm (p = 0.002). In addition, there was a significant decrease in daily time experiencing pain, from a mean of 1,022 (SD = 673) to 448 (SD = 565) minutes (p = 0.003). By contrast, the control group had neither diminished pain (p = 0.65) nor decreased overall time experiencing pain (p = 0.49). A pain decrement response seen by the 10th treatment session was predictive of final efficacy. Conclusion These results confirm that mirror therapy is an effective therapy for PLP in unilateral, upper extremity male amputees, reducing both severity and duration of daily episodes. Registration NCT0030144 ClinicalTrials.gov.
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Affiliation(s)
- Sacha B Finn
- Walter Reed National Military Medical Center, Bethesda, MD, United States
| | - Briana N Perry
- Walter Reed National Military Medical Center, Bethesda, MD, United States
| | - Jay E Clasing
- Brooke Army Medical Center, Fort Sam Houston, TX, United States
| | - Lisa S Walters
- Brooke Army Medical Center, Fort Sam Houston, TX, United States
| | | | - Sean Curran
- Center for Rehabilitation Sciences Research, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Minoo Rouhanian
- Walter Reed National Military Medical Center, Bethesda, MD, United States
| | - Mary S Keszler
- Walter Reed National Military Medical Center, Bethesda, MD, United States
| | | | - Sharon R Weeks
- Walter Reed National Military Medical Center, Bethesda, MD, United States
| | - Paul F Pasquina
- Walter Reed National Military Medical Center, Bethesda, MD, United States.,Center for Rehabilitation Sciences Research, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Jack W Tsao
- Walter Reed National Military Medical Center, Bethesda, MD, United States.,Center for Rehabilitation Sciences Research, Uniformed Services University of the Health Sciences, Bethesda, MD, United States.,University of Tennessee Health Science Center, Memphis, TN, United States.,Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, TN, United States.,Memphis Veterans Affairs Medical Center, Memphis, TN, United States
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Dalkiran M, Genc A, Dikmen B, Yildirim I, Turan S. Phantom Limb Pain Treated with Duloxetine: A case series. ACTA ACUST UNITED AC 2017. [DOI: 10.5455/bcp.20160411071457] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Mihriban Dalkiran
- Sisli Hamidiye Etfal Training and Research Hospital, Psychiatry Service, Istanbul - Turkey
| | - Abdullah Genc
- Sisli Hamidiye Etfal Training and Research Hospital, Psychiatry Service, Istanbul - Turkey
| | - Besir Dikmen
- Necip Fazıl City Hospital, Department of Orthopedics, Kahramanmaraş - Turkey
| | - Ilknur Yildirim
- University of İstanbul, Institute of Oncology, Department of Anaesthesiology and Reanimation, Istanbul - Turkey
| | - Senol Turan
- University of İstanbul, Medical Faculty of Cerrahpasa, Department of Psychiatry, Istanbul - Turkey
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9
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McCormick Z, Chang-Chien G, Marshall B, Huang M, Harden RN. Phantom limb pain: a systematic neuroanatomical-based review of pharmacologic treatment. PAIN MEDICINE 2013; 15:292-305. [PMID: 24224475 DOI: 10.1111/pme.12283] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Review the current evidence-based pharmacotherapy for phantom limb pain (PLP) in the context of the current understanding of the pathophysiology of this condition. DESIGN We conducted a systematic review of original research papers specifically investigating the pharmacologic treatment of PLP. Literature was sourced from PubMed, Embase, Scopus, and the Cochrane Central Register of Controlled Trials (CENTRAL). Studies with animals, "neuropathic" but not "phantom limb" pain, or without pain scores and/or functional measures as primary outcomes were excluded. A level of evidence 1-4 was ascribed to individual treatments. These levels included meta-analysis or systematic reviews (level 1), one or more well-powered randomized, controlled trials (level 2), retrospective studies, open-label trials, pilot studies (level 3), and anecdotes, case reports, or clinical experience (level 4). RESULTS We found level 2 evidence for gabapentin, both oral (PO) and intravenous (IV) morphine, tramadol, intramuscular (IM) botulinum toxin, IV and epidural Ketamine, level 3 evidence for amitriptyline, dextromethorphan, topiramate, IV calcitonin, PO memantine, continuous perineural catheter analgesia with ropivacaine, and level 4 evidence for methadone, intrathecal (IT) buprenorphine, IT and epidural fentanyl, duloxetine, fluoxetine, mirtazapine, clonazepam, milnacipran, capsaicin, and pregabalin. CONCLUSIONS Currently, the best evidence (level 2) exists for the use of IV ketamine and IV morphine for the short-term perioperative treatment of PLP and PO morphine for an intermediate to long-term treatment effect (8 weeks to 1 year). Level 2 evidence is mixed for the efficacy of perioperative epidural anesthesia with morphine and bupivacaine for short to long-term pain relief (perioperatively up to 1 year) as well as for the use of gabapentin for pain relief of intermediate duration (6 weeks).
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Affiliation(s)
- Zachary McCormick
- Department of Physical Medicine and Rehabilitation, The Rehabilitation Institute of Chicago/Northwestern McGaw Medical Center, Chicago, Illinois, USA
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Knotkova H, Cruciani RA, Tronnier VM, Rasche D. Current and future options for the management of phantom-limb pain. J Pain Res 2012; 5:39-49. [PMID: 22457600 PMCID: PMC3308715 DOI: 10.2147/jpr.s16733] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Phantom-limb pain (PLP) belongs among difficult-to-treat chronic pain syndromes. Treatment options for PLP are to a large degree implicated by the level of understanding the mechanisms and nature of PLP. Research and clinical findings acknowledge the neuropathic nature of PLP and also suggest that both peripheral as well as central mechanisms, including neuroplastic changes in central nervous system, can contribute to PLP. Neuroimaging studies in PLP have indicated a relation between PLP and the neuroplastic changes. Further, it has been shown that the pathological neuroplastic changes could be reverted, and there is a parallel between an improvement (reversal) of the neuroplastic changes in PLP and pain relief. These findings facilitated explorations of novel neuromodulatory treatment strategies, adding to the variety of treatment approaches in PLP. Overall, available treatment options in PLP include pharmacological treatment, supportive non-pharmacological non-invasive strategies (eg, neuromodulation using transcranial magnetic stimulation, visual feedback therapy, or motor imagery; peripheral transcutaneous electrical nerve stimulation, physical therapy, reflexology, or various psychotherapeutic approaches), and invasive treatment strategies (eg, surgical destructive procedures, nerve blocks, or invasive neuromodulation using deep brain stimulation, motor cortex stimulation, or spinal cord stimulation). Venues of further development in PLP management include a technological and methodological improvement of existing treatment methods, an implementation of new techniques and products, and a development of new treatment approaches.
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Affiliation(s)
- Helena Knotkova
- Department of Pain Medicine and Palliative Care, Research Division, Institute for Non-invasive Brain Stimulation, Beth Israel Medical Center, New York, NY, USA
- Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ricardo A Cruciani
- Department of Pain Medicine and Palliative Care, Research Division, Institute for Non-invasive Brain Stimulation, Beth Israel Medical Center, New York, NY, USA
- Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Anesthesiology, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Dirk Rasche
- Department of Neurosurgery, University of Lübeck, Germany
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Subedi B, Grossberg GT. Phantom limb pain: mechanisms and treatment approaches. PAIN RESEARCH AND TREATMENT 2011; 2011:864605. [PMID: 22110933 PMCID: PMC3198614 DOI: 10.1155/2011/864605] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/10/2011] [Accepted: 07/01/2011] [Indexed: 12/31/2022]
Abstract
The vast amount of research over the past decades has significantly added to our knowledge of phantom limb pain. Multiple factors including site of amputation or presence of preamputation pain have been found to have a positive correlation with the development of phantom limb pain. The paradigms of proposed mechanisms have shifted over the past years from the psychogenic theory to peripheral and central neural changes involving cortical reorganization. More recently, the role of mirror neurons in the brain has been proposed in the generation of phantom pain. A wide variety of treatment approaches have been employed, but mechanism-based specific treatment guidelines are yet to evolve. Phantom limb pain is considered a neuropathic pain, and most treatment recommendations are based on recommendations for neuropathic pain syndromes. Mirror therapy, a relatively recently proposed therapy for phantom limb pain, has mixed results in randomized controlled trials. Most successful treatment outcomes include multidisciplinary measures. This paper attempts to review and summarize recent research relative to the proposed mechanisms of and treatments for phantom limb pain.
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Affiliation(s)
- Bishnu Subedi
- Department of Neurology & Psychiatry, Saint Louis University School of Medicine, St. Louis, MO 63104, USA
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Han C, Pae CU, Lee BH, Ko YH, Masand PS, Patkar AA, Joe SH, Jung IK. Venlafaxine versus Mirtazapine in the??Treatment of Undifferentiated Somatoform Disorder. Clin Drug Investig 2008; 28:251-61. [DOI: 10.2165/00044011-200828040-00006] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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