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Rich T, Phelan H, Gravely A, Falbo K, Krebs E, Finn J, Matsumoto M, Muschler K, Kiecker J, Hansen A. Examining patient reported outcome measures for phantom limb pain: measurement use in a sample of Veterans with amputation. Disabil Rehabil 2024:1-9. [PMID: 38813752 DOI: 10.1080/09638288.2024.2356017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 05/12/2024] [Indexed: 05/31/2024]
Abstract
PURPOSE Phantom limb pain (PLP) is treated with medications and non-drug treatments. Best clinical practices for measuring treatment outcomes have not been defined. The objective of this study was to evaluate the internal consistency of patient-reported outcomes measures (PROMs) in a sample of Veterans with lower limb amputation. MATERIALS AND METHODS The Veteran phone survey included administering PROMs [1) PLP numeric rating scale (NRS), 2) general pain NRS, 3) Pain, Enjoyment, and General Activity (PEG) scale, 4) Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference Short Form 6b Replacement, 5) PROMIS Short Form Depression 4a and 6) PROMIS Short Form Anxiety 4a]. RESULTS Fifty Veterans (48 male, 2 female; average age: 66 years) completed PROMs. In our sample, 40 Veterans (80%) experienced PLP with an average PLP NRS of 5 (±3.4). Internal consistency of each measure was good to excellent based on Cronbach's alpha co-efficient of >0.80. Correlations were moderate between PLP NRS and all other measures (≤0.32). Although many Veterans expressed bothersome PLP, the scores reflecting pain interference and impact on function were lower than pain intensity. Consistent use of outcome measures is needed to determine the effect of interventions for amputation-related pain.
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Affiliation(s)
- Tonya Rich
- Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Department of Family Medicine and Community Health, University of MN, Minneapolis, MN, USA
| | - Hannah Phelan
- Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Medical College of WI, Milwaukee, WI, USA
| | - Amy Gravely
- Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Kierra Falbo
- Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Department of Family Medicine and Community Health, University of MN, Minneapolis, MN, USA
| | - Erin Krebs
- Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Jacob Finn
- Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MNUSA
| | - Mary Matsumoto
- Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, MN, USA
| | | | - Jessica Kiecker
- Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Andrew Hansen
- Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Department of Family Medicine and Community Health, University of MN, Minneapolis, MN, USA
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN, USA
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Pursel A, Nichols R, Evans D, Lindquist K. The Exploration of the GWOT Combat Amputee's Experience With Longitudinal Care: A Qualitative Study. Mil Med 2023:usad490. [PMID: 38150398 DOI: 10.1093/milmed/usad490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 11/18/2023] [Accepted: 12/12/2023] [Indexed: 12/29/2023] Open
Abstract
INTRODUCTION Contemporary advances in combat medicine have allowed greater numbers of wounded service members to survive their injuries. An estimated 1,705 combat veterans sustained major lower or upper extremity amputations between 2001 and 2017 during the Global War on Terror. This study intends to answer the following question utilizing a qualitative study design: What were the common and abnormal experiences of the Global War on Terror combat amputees relative to their mechanism of injury, perception of injury, and systems of care utilized during their recovery and rehabilitation process?. METHODS During the months of December 2022 and January 2023, individual semi-structured interviews were conducted with U.S. Marines that served in the Global War on Terror (total n = 10). Deductive and inductive approaches were employed to identify codes, themes, and meta-themes in the data. RESULTS All participants deployed to Afghanistan between the years 2010 and 2014 and were assigned to the following military occupational specialties: Explosive Ordnance Disposal technicians (total n = 2); combat engineers (total n = 2); and infantrymen (total n = 6). Analysis of data collected from interviews highlighted these key observations: (1) Themes in the combat amputee experience include support, systems of care, and mindset and (2) the themes synergistically contribute to the meta-themes mental health and pain and vice versa. As all participants were subjected to a blast mechanism of injury, it is difficult to determine if this played a role in deviating rehabilitation and recovery processes. Perception of injury and how well participants adapted to their new lifestyle, meaning how optimistic they were, appeared to play a significant role in recovery. Participants had mixed feelings about the care they had received but generally spoke favorably of military hospitals and were frustrated with the Veteran Affairs, and there was no clear consensus on their relationship with civilian health care, though most participants chose to seek most of their care through the Veteran Affairs. CONCLUSION Based on the research question, this study found an intricate relationship between mental health, pain, and the experiences of the participants regarding their care and rehabilitation. However, the nature of qualitative research makes it impossible to determine generalizations that can be used to create meaningful change to address improving combat amputee veteran care. Further research into long-term health outcomes based on hypotheses not evaluated in existing literature would further improve the ability of health care providers to care for this unique patient population.
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Affiliation(s)
- Alexander Pursel
- Elson S Floyd College of Medicine, Washington State University, Spokane, WA 99202, USA
| | - Ryoma Nichols
- Elson S Floyd College of Medicine, Washington State University, Spokane, WA 99202, USA
| | - Dan Evans
- Elson S Floyd College of Medicine, Washington State University, Spokane, WA 99202, USA
| | - Kristina Lindquist
- Elson S Floyd College of Medicine, Washington State University, Spokane, WA 99202, USA
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Schmied EA, Boltz J, Levine JA, Koenig H, Forbang N, Shero J, Dearth CL, Thomsen CJ. All-cause and cause-specific mortality rates after severe extremity injuries among previously deployed active duty service members. PM R 2023; 15:1300-1308. [PMID: 36730162 DOI: 10.1002/pmrj.12954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 12/30/2022] [Accepted: 01/17/2023] [Indexed: 02/03/2023]
Abstract
BACKGROUND Previous research has shown that active duty military personnel who sustain extremity injuries while in service are at elevated risk for serious physical and psychological health issues that could affect their long-term functioning and quality of life yet longer-term mortality has not been studied in this population. OBJECTIVE To determine whether rates of all-cause and cause-specific mortality are elevated for active duty U.S. service members who sustained traumatic limb injuries in service, compared to the broader population of deploying service members. To assess differences in mortality rates between service members with traumatic limb injuries that did versus did not result in amputation. DESIGN Retrospective cohort study; archival Department of Defense deployment, personnel, medical, and death records were combined and analyzed. Standardized mortality ratios (SMR) adjusted for age, sex, and ethnoracial group, along with associated 95% confidence intervals (CIs), were calculated to directly compare all-cause and cause-specific mortality rates in each of the two injury groups to rates in the total study population. SETTING Not applicable. PARTICIPANTS Service members who deployed in support of the global war on terror between 2001 and 2016 were eligible for inclusion; the final sample included 1,875,206 individuals surveilled through 2019. INTERVENTION Not applicable. MAIN OUTCOME MEASURES All-cause and cause-specific mortality rates. RESULTS Overall, the number of deaths was over three times higher than expected among service members with amputations (SMR = 3.01; CI: 2.36-3.65), and nearly two times higher among those with serious limb injuries not resulting in amputation (SMR = 1.72; CI: 1.54-1.90) when compared to the larger study population. Rates for both internal and external causes of death were significantly elevated among those with limb injuries. CONCLUSIONS Long-term mortality rates are elevated among service members with traumatic limb injuries, though mortality patterns may differ based on whether the injury results in amputation. Although further research into causal mechanisms is needed, these results may inform the development of interventions to improve long-term health outcomes among injured military personnel.
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Affiliation(s)
- Emily A Schmied
- School of Public Health, San Diego State University, San Diego, California, USA
- Institute for Behavioral and Community Health, San Diego, California, USA
- Health and Behavioral Sciences Department, Naval Health Research Center, San Diego, California, USA
- Leidos, San Diego, California, USA
| | - Jessamyn Boltz
- Health and Behavioral Sciences Department, Naval Health Research Center, San Diego, California, USA
- Leidos, San Diego, California, USA
| | - Jordan A Levine
- Health and Behavioral Sciences Department, Naval Health Research Center, San Diego, California, USA
- Leidos, San Diego, California, USA
| | | | - Nketi Forbang
- Health and Behavioral Sciences Department, Naval Health Research Center, San Diego, California, USA
- The Department of Defense and Veterans Affairs Extremity Trauma and Amputation Center of Excellence, Joint Base San Antonio, San Antonio, Texas, USA
| | - John Shero
- The Department of Defense and Veterans Affairs Extremity Trauma and Amputation Center of Excellence, Joint Base San Antonio, San Antonio, Texas, USA
| | - Christopher L Dearth
- The Department of Defense and Veterans Affairs Extremity Trauma and Amputation Center of Excellence, Joint Base San Antonio, San Antonio, Texas, USA
| | - Cynthia J Thomsen
- Health and Behavioral Sciences Department, Naval Health Research Center, San Diego, California, USA
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Thompson JR, Figy SC, Chandra SR, O'Neill Y, Cheung SS, Tecos ME, Pipinos II. A novel nerve isolation technique for targeted muscle reinnervation during below knee amputation. J Vasc Surg Cases Innov Tech 2023; 9:101219. [PMID: 37408948 PMCID: PMC10319316 DOI: 10.1016/j.jvscit.2023.101219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/01/2023] [Indexed: 07/07/2023] Open
Affiliation(s)
| | - Sean C. Figy
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | | | - Yohanis O'Neill
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | | | - Maria E. Tecos
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE
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Zagorulko OI, Medvedeva LA. [Treatment and prevention phantom pain syndrome in mine-explosive injuries]. Khirurgiia (Mosk) 2023:83-88. [PMID: 38088844 DOI: 10.17116/hirurgia202312183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Phantom pain syndrome significantly impairs the quality of life and effectiveness of surgical treatment after limb amputations. The authors consider possible strategies for treatment and prevention in elective surgical intervention and mine-explosive injuries.
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Affiliation(s)
- O I Zagorulko
- Petrovsky National Research Center of Surgery, Moscow, Russian Federation
| | - L A Medvedeva
- Petrovsky National Research Center of Surgery, Moscow, Russian Federation
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Wu J, Zhang Y, Zhang X, Lin Z, Li G. Regenerative Peripheral Nerve Interfaces Effectively Prevent Neuroma Formation After Sciatic Nerve Transection in Rats. Front Mol Neurosci 2022; 15:938930. [PMID: 35875668 PMCID: PMC9301297 DOI: 10.3389/fnmol.2022.938930] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 06/15/2022] [Indexed: 11/13/2022] Open
Abstract
Objective The disordered growth of nerve stumps after amputation leading to the formation of neuromas is an important cause of postoperative pain in amputees. This severely affects the patients' quality of life. Regenerative peripheral nerve interfaces (RPNIs) are an emerging method for neuroma prevention, but its postoperative nerve growth and pathological changes are yet to be studied. Methods The rat sciatic nerve transection model was used to study the effectiveness of RPNI in this experiment. The RPNI (experimental) group (n = 11) underwent RPNI implantation after sciatic nerve transection, while the control group (n = 11) only underwent sciatic nerve transection. Autotomy behavior, ultrasonography, and histopathology were observed for 2 months postoperatively. Results Compared to the control group, the incidence and size of the neuromas formed and the incidence and extent of autotomy were significantly reduced in the RPNI group. The axon density in the stump and degree of stump fibrosis were also significantly reduced in the RPNI group. Conclusion RPNI effectively prevented the formation of neuromas.
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Affiliation(s)
- Jiaqing Wu
- Department of Plastic Surgery, Peking University People's Hospital, Beijing, China
| | - Yajun Zhang
- Trauma Medicine Center, Peking University People's Hospital, Beijing, China
| | - Xiaoyuan Zhang
- Department of Plastic Surgery, Peking University People's Hospital, Beijing, China
| | - Zhiyu Lin
- Department of Plastic Surgery, Peking University Third Hospital, Beijing, China
| | - Guangxue Li
- Department of Plastic Surgery, Peking University People's Hospital, Beijing, China
- *Correspondence: Guangxue Li
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Kannenberg A, Morris AR, Hibler KD. Free-Living User Perspectives on Musculoskeletal Pain and Patient-Reported Mobility With Passive and Powered Prosthetic Ankle-Foot Components: A Pragmatic, Exploratory Cross-Sectional Study. FRONTIERS IN REHABILITATION SCIENCES 2022; 2:805151. [PMID: 36188863 PMCID: PMC9397861 DOI: 10.3389/fresc.2021.805151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 12/22/2021] [Indexed: 11/13/2022]
Abstract
Introduction Studies with a powered prosthetic ankle-foot (PwrAF) found a reduction in sound knee loading compared to passive feet. Therefore, the aim of the present study was to determine whether anecdotal reports on reduced musculoskeletal pain and improved patient-reported mobility were isolated occurrences or reflect a common experience in PwrAF users. Methods Two hundred and fifty individuals with transtibial amputation (TTA) who had been fitted a PwrAF in the past were invited to an online survey on average sound knee, amputated side knee, and low-back pain assessed with numerical pain rating scales (NPRS), the PROMIS Pain Interference scale, and the PLUS-M for patient-reported mobility in the free-living environment. Subjects rated their current foot and recalled the ratings for their previous foot. Recalled scores were adjusted for recall bias by clinically meaningful amounts following published recommendations. Statistical comparisons were performed using Wilcoxon's signed rank test. Results Forty-six subjects, all male, with unilateral TTA provided data suitable for analysis. Eighteen individuals (39%) were current PwrAF users, whereas 28 subjects (61%) had reverted to a passive foot. After adjustment for recall bias, current PwrAF users reported significantly less sound knee pain than they recalled for use of a passive foot (−0.5 NPRS, p = 0.036). Current PwrAF users who recalled sound knee pain ≥4 NPRS with a passive foot reported significant and clinically meaningful improvements in sound knee pain (−2.5 NPRS, p = 0.038) and amputated side knee pain (−3 NPRS, p = 0.042). Current PwrAF users also reported significant and clinically meaningful improvements in patient-reported mobility (+4.6 points PLUS-M, p = 0.016). Individuals who had abandoned the PwrAF did not recall any differences between the feet. Discussion Current PwrAF users reported significant and clinically meaningful improvements in patient-reported prosthetic mobility as well as sound knee and amputated side knee pain compared to recalled mobility and pain with passive feet used previously. However, a substantial proportion of individuals who had been fitted such a foot in the past did not recall improvements and had reverted to passive feet. The identification of individuals with unilateral TTA who are likely to benefit from a PwrAF remains a clinical challenge and requires further research.
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Affiliation(s)
- Andreas Kannenberg
- Department of Clinical Research and Services, Otto Bock Healthcare LP, Austin, TX, United States
- *Correspondence: Andreas Kannenberg
| | - Arri R. Morris
- Department of Clinical Research and Services, Otto Bock Healthcare LP, Austin, TX, United States
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von Falck C, Orgel M, Wacker F, Aschoff HH, Krettek C, Ringe KI. Icing the Pain-Ultrasound-Guided Cryoablation of Symptomatic Post-Amputation Stump Neuroma. Cardiovasc Intervent Radiol 2021; 45:223-227. [PMID: 34820693 PMCID: PMC8807464 DOI: 10.1007/s00270-021-02998-9] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 10/24/2021] [Indexed: 11/28/2022]
Abstract
Purpose To assess the feasibility and outcome of ultrasound-guided cryoablation in patients with a sensitized stump neuroma after limb amputation. Material and Methods Seven patients (3 females, 4 males; mean age 42 years) were included in this retrospective study. Ultrasound-guided cryoablation of a previously identified painful stump neuroma was performed. Pain was assessed on the visual analogue scale (VAS) and compared before and after cryoablation (Wilcoxon Test). The degree of pain alleviation was correlated with patient age, duration of pain before ablation and time interval between amputation and ablation (Spearman correlation). A p-value less than 0.05 was deemed statistically significant. Results Nine cryoablations were performed for 8 neuromas. Technical success was 100%, there were no major complications. Mean follow-up was 27 months. There was a statistically significant decrease of pain from mean 8.3 / 10 (baseline) to 4 /10 (on day one), 2.1 / 10 (at one week) and 3 / 10 (at last follow-up) (p < 0.05). Patient satisfaction with cryoablation treatment was very high (median score 70 / 100). Conclusion In our small population observational study, ultrasound-guided cryoablation of a sensitized stump neuroma was effective and safe for pain alleviation with very good long-term results. Level of Evidence Level 2, Observational study with dramatic effect
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Affiliation(s)
- C von Falck
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Carl-Neuberg Str. 1, 30625, Hannover, Germany
| | - M Orgel
- Department of Trauma Surgery, Hannover Medical School, Carl-Neuberg Str. 1, 30625, Hannover, Germany
| | - F Wacker
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Carl-Neuberg Str. 1, 30625, Hannover, Germany
| | - H H Aschoff
- Department of Trauma Surgery, Hannover Medical School, Carl-Neuberg Str. 1, 30625, Hannover, Germany
| | - C Krettek
- Department of Trauma Surgery, Hannover Medical School, Carl-Neuberg Str. 1, 30625, Hannover, Germany
| | - K I Ringe
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Carl-Neuberg Str. 1, 30625, Hannover, Germany.
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Management of Phantom Limb Pain through Thalamotomy of the Centro-Median Nucleus. Neurol Int 2021; 13:587-593. [PMID: 34842785 PMCID: PMC8628935 DOI: 10.3390/neurolint13040058] [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: 09/07/2021] [Revised: 10/18/2021] [Accepted: 10/22/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Phantom limb syndrome is defined as the perception of intense pain or other sensations that are secondary to a neural lesion in a limb that does not exist. It can be treated using pharmacological and surgical interventions. Most medications are prescribed to improve patients’ lives; however, the response rate is low. In this case report, we present a case of phantom limb syndrome in a 42-year-old female with a history of transradial amputation of the left thoracic limb due to an accidental compression one year before. The patient underwent placement of a deep brain stimulator at the ventral posteromedial nucleus (VPM) on the right side and removal secondary to loss of battery. The patient continued to have a burning pain throughout the limb with a sensation of still having the limb, which was subsequently diagnosed as phantom limb syndrome. After a thorough discussion with the patient, a right stereotactic centro-median thalamotomy was offered. An immediate response was reported with a reduction in pain severity on the visual analogue scale (VAS) from a value of 9–10 preoperative to a value of 2 postoperative, with no postoperative complications. Although phantom limb pain is one of the most difficult to treat conditions, centro-median thalamotomy may provide an effective stereotactic treatment procedure with adequate outcomes.
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Ilfeld BM, Gelfand H, Dhanjal S, Hackworth R, Plunkett A, Turan A, Vijjeswarapu AM, Cohen SP, Eisenach JC, Griffith S, Hanling S, Mascha EJ, Sessler DI. Ultrasound-Guided Percutaneous Peripheral Nerve Stimulation: A Pragmatic Effectiveness Trial of a Nonpharmacologic Alternative for the Treatment of Postoperative Pain. PAIN MEDICINE 2021; 21:S53-S61. [PMID: 33313729 DOI: 10.1093/pm/pnaa332] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Percutaneous peripheral nerve stimulation (PNS) is an analgesic modality involving the insertion of a lead through an introducer needle followed by the delivery of electric current after needle withdrawal. This modality has been used extensively to treat chronic pain, but only small series have been published involving postoperative pain. The ultimate objective of this study is to determine the postoperative effects of percutaneous PNS following moderately to severely painful ambulatory surgery within a real-world clinical practice setting. The primary hypothesis is that surgical pain and opioid consumption during the initial 7 days after surgery will be reduced by percutaneous PNS compared with usual and customary analgesia (dual primary outcome measures). DESIGN A multicenter pragmatic effectiveness trial. We are randomizing participants having painful orthopedic surgical procedures of the upper and lower extremity to receive 14 days of either 1) electrical stimulation or 2) sham in a double-masked fashion. End points are being assessed at various time points over 12 postoperative months. SUMMARY The postoperative experience will be much improved if percutaneous PNS provides potent analgesia while concurrently decreasing opioid requirements following painful surgery. Because this modality can be administered for up to 60 days at home, it may provide postoperative analgesia that outlasts surgical pain yet has relatively few risks and, unlike opioids, has no systemic side effects or potential for abuse, addiction, and overdose. Percutaneous PNS has the potential to revolutionize postoperative analgesia as it has been practiced for the past century. This study will inform key stakeholders regarding an evidence-based nonpharmacologic approach to the management of postoperative pain.
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Affiliation(s)
- Brian M Ilfeld
- Department of Anesthesiology, University of California, San Diego, San Diego, California
| | - Harold Gelfand
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Sandeep Dhanjal
- Department of Anesthesiology, Brooke Army Medical Center, Fort Sam Houston, San Antonio, Texas
| | - Robert Hackworth
- Department of Anesthesiology, Naval Medical Center San Diego, San Diego, California
| | - Anthony Plunkett
- Department of Anesthesiology, Womack Army Medical Center, Fort Bragg, Fayetteville, North Carolina
| | - Alparslan Turan
- Department of General Anesthesiology and Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Alice M Vijjeswarapu
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Steven P Cohen
- Department of Anesthesiology, Johns Hopkins University, Baltimore, Maryland
| | - James C Eisenach
- Department of Anesthesiology, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Scott Griffith
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Steven Hanling
- Department of Physical Medicine and Rehabilitation, Columbia Veterans Affairs Health Care System, Columbia, South Carolina
| | - Edward J Mascha
- Department of Anesthesiology and Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
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Jo SH, Kang SH, Seo WS, Koo BH, Kim HG, Yun SH. Psychiatric understanding and treatment of patients with amputations. Yeungnam Univ J Med 2021; 38:194-201. [PMID: 33971697 PMCID: PMC8225497 DOI: 10.12701/yujm.2021.00990] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 04/02/2021] [Indexed: 11/25/2022] Open
Abstract
Amputation changes the lives of patients and their families. Consequently, the patient must adapt to altered body function and image. During this adaptation process, psychological problems, such as depression, anxiety, and posttraumatic stress disorder, can occur. The psychological difficulties of patients with amputation are often accepted as normal responses that are often poorly recognized by patients, family members, and their primary physicians. Psychological problems can interfere with rehabilitation and cause additional psychosocial problems. Therefore, their early detection and treatment are important. A multidisciplinary team approach, including mental health professionals, is ideal for comprehensive and biopsychosocial management. Mental health professionals could help patients set realistic goals and use adaptive coping styles. Psychiatric approaches should consider the physical, cognitive, psychological, social, and spiritual functions and social support systems before and after amputation. The abilities and limitations of physical, cognitive, psychological, and social functions should also be considered. To improve the patient’s adaptation, psychological interventions such as short-term psychotherapy, cognitive behavioral therapy, mindfulness meditation, biofeedback, and group psychotherapy can be helpful.
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Affiliation(s)
- So-Hye Jo
- Department of Psychiatry, Yeungnam University Hospital, Daegu, Korea
| | - Suk-Hun Kang
- Department of Psychiatry, Yeungnam University Hospital, Daegu, Korea
| | - Wan-Seok Seo
- Department of Psychiatry, Yeungnam University College of Medicine, Daegu, Korea
| | - Bon-Hoon Koo
- Department of Psychiatry, Yeungnam University College of Medicine, Daegu, Korea
| | - Hye-Geum Kim
- Department of Psychiatry, Yeungnam University College of Medicine, Daegu, Korea
| | - Seok-Ho Yun
- Department of Psychiatry, Yeungnam University Hospital, Daegu, Korea
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Jaffe E, Patzkowski MS, Hodgson JA, Foerschler DL, Gonzalez SC, Giordano NA, Scott-Richardson MP, Highland KB. Practice Variation in Regional Anesthesia Utilization by Current and Former U.S. Military Anesthesiology Residents. Mil Med 2021; 186:e98-e103. [PMID: 33038251 DOI: 10.1093/milmed/usaa269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/20/2020] [Accepted: 08/03/2020] [Indexed: 11/14/2022] Open
Abstract
ABSTRACT
Introduction
Per Joint Trauma System guidelines, military anesthesiologists are expected to be ready to lead an Acute Pain Service with regional anesthesia in combat casualty care. However, regional anesthesia practice volume has not been assessed in the military. The objective of this study was to assess regional anesthesia utilization among current residents and graduates of U.S. military anesthesiology residency programs.
Materials and Methods
All current and former active duty military anesthesiology program residents, trained at any of the four military anesthesiology residency programs between 2013 and 2019, were anonymously surveyed about their regional anesthesia practice. Bivariate statistics described the total single-injection and catheter block techniques utilized in the last month. Cluster analysis assessed for the presence of distinct practice groups within the sample. Follow-up analyses explored potential associations between cluster membership and other variables (e.g., residency training site, residency graduation year, overall confidence in performing regional anesthesia, etc.). This protocol received exemption determination separately from each site’s institutional review board.
Results
Current and former residents reported broad variation in regional anesthesia practice and clustered into four distinct practice groups. Less than half of respondents utilized a moderate to high number of different single-injection and catheter blocks.
Conclusions
These findings highlight the need for creative solutions to increase regional anesthesia training in military anesthesiology programs and continued ability to implement skills, such that all military anesthesiologists have adequate practice for deployed responsibilities.
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Affiliation(s)
- Edward Jaffe
- School of Medicine, Uniformed Services University, Bethesda, MD 20814, USA
| | | | - John A Hodgson
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | - Derek L Foerschler
- Department of Anesthesia, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
| | - Sara C Gonzalez
- Department of Anesthesiology, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Nicholas A Giordano
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation Inc., Rockville, MD 20852, USA
| | - Maya P Scott-Richardson
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation Inc., Rockville, MD 20852, USA
| | - Krista B Highland
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation Inc., Rockville, MD 20852, USA
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Abstract
Phantom limb pain is highly prevalent after amputation. Treatment results will probably benefit from an interdisciplinary team and individually adapted surgical, prosthetic and pain medicine approaches. Introduction: Most patients with amputation (up to 80%) suffer from phantom limb pain postsurgery. These are often multimorbid patients who also have multiple risk factors for the development of chronic pain from a pain medicine perspective. Surgical removal of the body part and sectioning of peripheral nerves result in a lack of afferent feedback, followed by neuroplastic changes in the sensorimotor cortex. The experience of severe pain, peripheral, spinal, and cortical sensitization mechanisms, and changes in the body scheme contribute to chronic phantom limb pain. Psychosocial factors may also affect the course and the severity of the pain. Modern amputation medicine is an interdisciplinary responsibility. Methods: This review aims to provide an interdisciplinary overview of recent evidence-based and clinical knowledge. Results: The scientific evidence for best practice is weak and contrasted by various clinical reports describing the polypragmatic use of drugs and interventional techniques. Approaches to restore the body scheme and integration of sensorimotor input are of importance. Modern techniques, including apps and virtual reality, offer an exciting supplement to already established approaches based on mirror therapy. Targeted prosthesis care helps to obtain or restore limb function and at the same time plays an important role reshaping the body scheme. Discussion: Consequent prevention and treatment of severe postoperative pain and early integration of pharmacological and nonpharmacological interventions are required to reduce severe phantom limb pain. To obtain or restore body function, foresighted surgical planning and technique as well as an appropriate interdisciplinary management is needed.
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Beisheim EH, Seth M, Horne JR, Hicks GE, Pohlig RT, Sions JM. Sex-specific Differences in Multisite Pain Presentation among Adults with Lower-Limb Loss. Pain Pract 2020; 21:419-427. [PMID: 33251680 DOI: 10.1111/papr.12969] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 11/05/2020] [Accepted: 11/23/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Multisite pain remains significantly understudied following lower-limb loss (LLL), especially among females. This study aimed to explore sex-specific differences in the presentation of multisite pain post LLL. Hypotheses were multisite pain would be more prevalent among females post LLL as compared with males, and female sex would be significantly associated with multisite pain prevalence. METHODS In this cross-sectional study, participants answered standardized questions regarding the presence of amputation-specific (ie, phantom-limb, residual-limb) and secondary (ie, contralateral-limb, low-back) pain. Multisite pain was defined as pain in ≥ 2 locations. Sex-specific differences in pain prevalence were evaluated using chi-square tests (P ≤ 0.050). Using logistic regression, the association between sex and multisite pain was examined after controlling for covariates (age, body mass index, time since amputation, amputation etiology and level). RESULTS The sample included 303 adults (33% females) ≥ 1 year post unilateral LLL. More females than males reported pain in the residual limb (53.0% vs. 38.4%), low back (56.0% vs. 39.9%), contralateral knee (37.0% vs. 24.1%), and contralateral hip (25.0% vs. 12.3%; P < 0.050). More females than males were classified as having multisite pain (72.0% vs. 54.7%; P = 0.004). While patterns of multisite pain were similar (ie, pain affected both amputation-specific and secondary sites) between sexes, being female was independently associated with higher odds of having multisite pain (odds ratio: 2.40, 95% confidence interval: 1.40 to 4.12). DISCUSSION Female sex appears to be associated with multisite pain ≥ 1 year after LLL. Future work is needed to identify mechanisms underlying sex-specific differences in pain presentation and evaluate the impact of sex on pain-related outcomes post amputation.
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Affiliation(s)
| | - Mayank Seth
- Department of Physical Therapy, University of Delaware, Newark, Delaware, U.S.A
| | | | - Gregory Evan Hicks
- Department of Physical Therapy, University of Delaware, Newark, Delaware, U.S.A
| | - Ryan Todd Pohlig
- University of Delaware Biostatistics Core Facility, Newark, Delaware, U.S.A
| | - Jaclyn Megan Sions
- Department of Physical Therapy, University of Delaware, Newark, Delaware, U.S.A
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15
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Zhou HY, Jiang S, Ma FX, Lu H. Peripheral nerve tumors of the hand: Clinical features, diagnosis, and treatment. World J Clin Cases 2020; 8:5086-5098. [PMID: 33269245 PMCID: PMC7674743 DOI: 10.12998/wjcc.v8.i21.5086] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 09/15/2020] [Accepted: 09/25/2020] [Indexed: 02/05/2023] Open
Abstract
The majority of the tumors arising from the peripheral nerves of the hand are relatively benign. However, a tumor diagnosed as malignant peripheral nerve sheath tumor (MPNST) has destructive consequences. Clinical signs and symptoms are usually caused by direct and indirect effects of the tumor, such as nerve invasion or compression and infiltration of surrounding tissues. Definitive diagnosis is made by tumor biopsy. Complete surgical removal with maximum reservation of residual neurologic function is the most appropriate intervention for most symptomatic benign peripheral nerve tumors (PNTs) of the hand; however, MPNSTs require surgical resection with a sufficiently wide margin or even amputation to improve prognosis. In this article, we review the clinical presentation and radiographic features, summarize the evidence for an accurate diagnosis, and discuss the available treatment options for PNTs of the hand.
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Affiliation(s)
- Hai-Ying Zhou
- Department of Orthopedics, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
| | - Shuai Jiang
- Department of Orthopedics, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
| | - Fei-Xia Ma
- Department of Breast Surgery, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310000, Zhejiang Province, China
| | - Hui Lu
- Department of Orthopedics, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
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16
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Dezfouli SMM, Khosravi S. Pain in child patients: A review on managements. Eur J Transl Myol 2020; 30:8712. [PMID: 32782752 PMCID: PMC7385698 DOI: 10.4081/ejtm.2019.8712] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 12/15/2019] [Indexed: 12/14/2022] Open
Abstract
Pain has been known as one of the major universal health concerns about ill children, because of its morbidity and potential mortality. Pain suitable evaluation is a challenge in children because the verbalization is difficult. Low clinical information, few pediatric researches, and the worry of opioid side effects make difficult to provide satisfactory treatments. Many pharmacologic and non-pharmacologic strategies to manage pain exist for pediatric pain treatment. The purpose of this review article is to describe exhaustively pain mechanism, evaluation and management by review literature from January 2000 to January 2019 using PubMed, EMBASE, MEDLINE, LILACS databases. Pharmacological and integrative non-pharmacological therapies has been indicated in acute and chronic pain treatment. Opioids and opioid-sparing agents target nociceptive and neuropathic pain. With due attention to available results, an early combination of pharmacological and integrative non pharmacological treatments are indicated in children pain management.
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Affiliation(s)
| | - Shaqayeq Khosravi
- (1) Department of Emergency Medicine, School of Medicine, Iran University of Medical Sciences, Aliasghar children Hospital, Tehran, Iran
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17
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Cho HS, Kim S, Kim CS, Kim YJ, Lee JH, Leem JG. Effects of different anesthetic techniques on the incidence of phantom limb pain after limb amputation: a population-based retrospective cohort study. Korean J Pain 2020; 33:267-274. [PMID: 32606271 PMCID: PMC7336353 DOI: 10.3344/kjp.2020.33.3.267] [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] [Received: 03/13/2020] [Revised: 05/22/2020] [Accepted: 05/22/2020] [Indexed: 12/19/2022] Open
Abstract
Background General anesthesia (GA) has been considered the anesthetic technique which most frequent leads to phantom limb pain (PLP) after a limb amputation. However, these prior reports were limited by small sample sizes. The aims of this study were to evaluate the incidence of PLP according to the various anesthetic techniques used for limb amputation and also to compare the occurrence of PLP according to amputation etiology using the Korean Health Insurance Review and Assessment Service for large-scale demographic information. Methods The claims of patients who underwent limb amputation were reviewed by analyzing the codes used to classify standardized medical behaviors. The patients were categorized into three groups—GA, neuraxial anesthesia (NA), and peripheral nerve block (PNB)—in accordance with the anesthetic technique. The recorded diagnosis was confirmed using the diagnostic codes for PLP registered within one year after the limb amputation. Results Finally, 7,613 individuals were analyzed. According to the recorded diagnoses, 362 patients (4.8%) developed PLP after amputation. Among the 2,992 patients exposed to GA, 191 (6.4%) were diagnosed with PLP, whereas 121 (4.3%) of the 2,840 patients anesthetized with NA, and 50 (2.8%) of the 1,781 patients anesthetized under PNB developed PLP. The relative risks were 0.67 (95% confidence interval [CI], 0.53–0.84; P < 0.001) for NA and 0.43 (95% CI, 0.32–0.59; P < 0.001) for PNB. Conclusions In this retrospective cohort study, using large-scale population-based databases, the incidence rates of PLP after limb amputations were, in the order of frequency, GA, NA, and PNB.
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Affiliation(s)
- Hyun-Seok Cho
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sooyoung Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chan Sik Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ye-Jee Kim
- Department Clinical Epidemiology and Biostatistics, Asan Medical Center, Seoul, Korea
| | - Jong-Hyuk Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong-Gill Leem
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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18
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Allami M, Faraji E, Mohammadzadeh F, Soroush MR. Chronic musculoskeletal pain, phantom sensation, phantom and stump pain in veterans with unilateral below-knee amputation. Scand J Pain 2019; 19:779-787. [DOI: 10.1515/sjpain-2019-0045] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Accepted: 05/21/2019] [Indexed: 11/15/2022]
Abstract
Abstract
Background and aims
Many individuals with lower limb loss report concerns about other musculoskeletal symptoms resulting from amputation. The objective of this study was to assess chronic musculoskeletal pain in Iranian veterans with unilateral below-knee amputation.
Methods
The participants agreed to take part in a health needs assessment and were interviewed face-to-face by trained interviewers. The assessment consisted of demographic information, wearing a prosthesis, pain locations in extremities, stump complications, severity of pains related to amputation and low back pain.
Results
Of 247 unilateral below knee amputees, 97.9% wore a prosthetic limb and times walking or standing with the prosthesis were 12.47 ± 3.84 and 4.22 ± 3.53 h a day, respectively. Low soft tissue coverage of the stump (15.4%) and symptomatic osteoarthritis in the contralateral lower extremity (40.1%) were the most common complications. The prevalence of stump pain, phantom sensations, phantom pain, low back pain, and knee pain was 84.2%, 77.3%, 73.7%, 78.1%, and 54.7% respectively. The odds ratio of stump pain in amputees with phantom pain was 2.22 times higher than those who did not experience phantom pain [OR = 2.22 (CI: 1.19–4.17); p = 0.012] and the odds ratio of low back pain was higher in amputees with stump pain [OR = 3.06 (CI: 1.50–6.21); p = 0.002].
Conclusions
This research enhances our understanding of comorbid musculoskeletal problems in below-knee amputees which can help health providers to identify rehabilitation needs and emphasizes the importance of regular assessments.
Implications
These findings underline the importance of paying closer attention to different dimensions and aspects of musculoskeletal complications in veterans with unilateral below-knee amputation.
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Affiliation(s)
- Mostafa Allami
- Janbazan Medical and Engineering Research Center (JMERC) , Tehran , IR Iran
| | - Elahe Faraji
- Department of Medical Device and Rehabilitation , Janbazan Medical and Engineering Research Center (JMERC) , No. 17, Farokh Street, Mogadase Ardabili Street , Tehran , Iran
| | - Fatemeh Mohammadzadeh
- Basic Sciences Department, Medical Faculty , Gonabad University of Medical Sciences , Gonabad , Iran
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19
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Alexander JH, Jordan SW, West JM, Compston A, Fugitt J, Bowen JB, Dumanian GA, Pollock R, Mayerson JL, Scharschmidt TJ, Valerio IL. Targeted muscle reinnervation in oncologic amputees: Early experience of a novel institutional protocol. J Surg Oncol 2019; 120:348-358. [PMID: 31197851 DOI: 10.1002/jso.25586] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 05/14/2019] [Accepted: 05/25/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND We describe a multidisciplinary approach for comprehensive care of amputees with concurrent targeted muscle reinnervation (TMR) at the time of amputation. METHODS Our TMR cohort was compared to a cross-sectional sample of unselected oncologic amputees not treated at our institution (N = 58). Patient-Reported Outcomes Measurement Information System (NRS, PROMIS) were used to assess postamputation pain. RESULTS Thirty-one patients underwent amputation with concurrent TMR during the study; 27 patients completed pain surveys; 15 had greater than 1 year follow-up (mean follow-up 14.7 months). Neuroma symptoms occurred significantly less frequently and with less intensity among the TMR cohort. Mean differences for PROMIS pain intensity, behavior, and interference for phantom limb pain (PLP) were 5.855 (95%CI 1.159-10.55; P = .015), 5.896 (95%CI 0.492-11.30; P = .033), and 7.435 (95%CI 1.797-13.07; P = .011) respectively, with lower scores for TMR cohort. For residual limb pain, PROMIS pain intensity, behavior, and interference mean differences were 5.477 (95%CI 0.528-10.42; P = .031), 6.195 (95%CI 0.705-11.69; P = .028), and 6.816 (95%CI 1.438-12.2; P = .014), respectively. Fifty-six percent took opioids before amputation compared to 22% at 1 year postoperatively. CONCLUSIONS Multidisciplinary care of amputees including concurrent amputation and TMR, multimodal postoperative pain management, amputee-centered rehabilitation, and peer support demonstrates reduced incidence and severity of neuroma and PLP.
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Affiliation(s)
- John H Alexander
- Department of Orthopaedics, The Ohio State University James Wexner Medical Center, Columbus, Ohio
| | - Sumanas W Jordan
- Division of Plastic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Julie M West
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Amy Compston
- Department of Oncologic Rehabilitation, The Ohio State University James Comprehensive Cancer Center, Columbus, Ohio
| | - Jennifer Fugitt
- Division of Plastic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - J Byers Bowen
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Gregory A Dumanian
- Division of Plastic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Raphael Pollock
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Joel L Mayerson
- Department of Orthopaedics, The Ohio State University James Wexner Medical Center, Columbus, Ohio
| | - Thomas J Scharschmidt
- Department of Orthopaedics, The Ohio State University James Wexner Medical Center, Columbus, Ohio
| | - Ian L Valerio
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Faraji E, Allami M, Feizollahi N, Karimi A, Yavari A, Soroush M, Moudi M. Health concerns of veterans with high-level lower extremity amputations. Mil Med Res 2018; 5:36. [PMID: 30360763 PMCID: PMC6203280 DOI: 10.1186/s40779-018-0183-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 10/07/2018] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND The aim of the study was to identify health concerns of veterans with high-level lower extremity amputations. METHODS Through a cross-sectional study, general practitioners, an orthopedic specialist, psychologists, psychiatrists, physiotherapist and prosthetists examined 100 veterans using a short-form health-related quality of life questionnaire (SF-36) that assessed their ability to perform activities of daily living (ADL), instrumental activities of daily living (IADL) and life satisfaction (SWLS) after hip disarticulation or hemi-pelvectomy amputations. The assessment tool was designed to gather statistically useful information about their health needs. RESULTS The means of the Physical Component Summary (PCS), Mental Component Summary (MCS), SWLS, ADL and IADL were 48.58 ± 29.6, 33.33 ± 22.0, 19.30 ± 7.7, 48.10 ± 10.5 and 5.08 ± 1.8, respectively. Somatization, depression, and anxiety were the most prevalent disorders; among the veterans who were visited by psychiatrists, 11.6% had a history of hospitalization in a psychiatry section, and 53.2% had a psychiatric visit. Regardless of their injury in battle, 34% of veterans were hospitalized. Hearing problems were common, and about four-fifths of the participants suffered from at least one orthopedic condition. Neuroma (49%) was the most common stump-related complication during orthopedic evaluations, though the prevalence of phantom pain was 81% during the pain assessment. A total of 87% of the participants had a history of wearing a prosthesis, but only 29% wore a prosthesis at the time of the present study. The Canadian-type of prosthesis was uncomfortable and not useful (27%) and excessively heavy (10%) according to the amputees. CONCLUSIONS Understanding veterans' characteristics and special needs are important to make sure that enough facilities and services are afforded to them. These findings emphasize the importance of paying close attention to different dimensions of health in veterans and can help health providers identify health needs and make regular assessments.
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Affiliation(s)
- Elahe Faraji
- Janbazan Medical and Engineering Research Center (JMERC), NO.17, Farrokh St., Moghaddas Ardebily Ave., Chamran Highway, Tehran, Iran
| | - Mostafa Allami
- Janbazan Medical and Engineering Research Center (JMERC), NO.17, Farrokh St., Moghaddas Ardebily Ave., Chamran Highway, Tehran, Iran.
| | - Nafiseh Feizollahi
- Janbazan Medical and Engineering Research Center (JMERC), NO.17, Farrokh St., Moghaddas Ardebily Ave., Chamran Highway, Tehran, Iran
| | - Amir Karimi
- Janbazan Medical and Engineering Research Center (JMERC), NO.17, Farrokh St., Moghaddas Ardebily Ave., Chamran Highway, Tehran, Iran
| | - Amir Yavari
- Janbazan Medical and Engineering Research Center (JMERC), NO.17, Farrokh St., Moghaddas Ardebily Ave., Chamran Highway, Tehran, Iran
| | - Mohammadreza Soroush
- Janbazan Medical and Engineering Research Center (JMERC), NO.17, Farrokh St., Moghaddas Ardebily Ave., Chamran Highway, Tehran, Iran
| | - Majid Moudi
- Janbazan Medical and Engineering Research Center (JMERC), NO.17, Farrokh St., Moghaddas Ardebily Ave., Chamran Highway, Tehran, Iran
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21
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Abstract
This study was designed to characterize morphologic stages during neuroma development post amputation with an eye toward developing better treatment strategies that intervene before neuromas are fully formed. Right forelimbs of 30 Sprague Dawley rats were amputated and limb stumps were collected at 3, 7, 28, 60 and 90 Days Post Amputation (DPA). Morphology of newly formed nerves and neuromas were assessed via general histology and neurofilament protein antibody staining. Analysis revealed six morphological characteristics during nerve and neuroma development; 1) normal nerve, 2) degenerating axons, 3) axonal sprouts, 4) unorganized bundles of axons, 5) unorganized axon growth into muscles, and 6) unorganized axon growth into fibrotic tissue (neuroma). At early stages (3 & 7 DPA) after amputation, normal nerves could be identified throughout the limb stump and small areas of axonal sprouts were present near the site of injury. Signs of degenerating axons were evident from 7 to 90 DPA. From day 28 on, variability of nerve characteristics with signs of unorganized axon growth into muscle and fibrotic tissue and neuroma formation became visible in multiple areas of stump tissue. These pathological features became more evident on days 60 and 90. At 90 DPA frank neuroma formation was present in all stump tissue. By following nerve regrowth and neuroma formation after amputation we were able to identify 6 separate histological stages of nerve regrowth and neuroma development. Axonal regrowth was observed as early as 3 DPA and signs of unorganized axonal growth and neuroma formation were evident by 28 DPA. Based on these observations we speculate that neuroma treatment and or prevention strategies might be more successful if targeted at the initial stages of development and not after 28 DPA.
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22
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Abstract
Study design Narrative review. Method Eight bibliographic databases were searched for studies published in the (last five years up until Feb 2017). For the two database searches (Cochrane and DARE), the time frame was unlimited. The review involved keyword searches of the term 'Amputation' AND 'chronic pain'. Studies selected were interrogated for any association between peri-operative factors and the occurrence of chronic post amputation pain (CPAP). Results Heterogeneity of study populations and outcome measures prevented a systematic review and hence a narrative synthesis of results was undertaken. The presence of variation in two gene alleles (GCH1 and KCNS1) may be relevant for development of CPAP. There was little evidence to draw conclusions on the association between age, gender and CPAP. Pre-operative anxiety and depression influenced pain intensity post operatively and long-term post amputation pain (CPAP). The presence of pre-amputation pain is correlated to the development of acute and chronic post amputation pain while evidence for the association of post-operative pain with CPAP is modest. Regional anaesthesia and peri-neural catheters improve acute postoperative pain relief but evidence on their efficacy to prevent CPAP is limited. A suggested whole system pathway based on current evidence to optimize peri-operative amputation pain is described. Conclusion The current evidence suggests that optimized peri-operative analgesia reduces the incidence of acute peri-operative pain but no firm conclusion can be drawn on reducing risk for CPAP.
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Affiliation(s)
- Devjit Srivastava
- Department of Anaesthesia, Raigmore Hospital, Inverness, Scotland, United Kingdom, IV2 3UJ
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23
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Farrokhi S, Mazzone B, Schneider M, Gombatto S, Mayer J, Highsmith MJ, Hendershot BD. Biopsychosocial risk factors associated with chronic low back pain after lower limb amputation. Med Hypotheses 2017; 108:1-9. [DOI: 10.1016/j.mehy.2017.07.030] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 07/18/2017] [Accepted: 07/21/2017] [Indexed: 11/27/2022]
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Morgan SJ, Friedly JL, Amtmann D, Salem R, Hafner BJ. Cross-Sectional Assessment of Factors Related to Pain Intensity and Pain Interference in Lower Limb Prosthesis Users. Arch Phys Med Rehabil 2017; 98:105-113. [PMID: 27742450 PMCID: PMC5183499 DOI: 10.1016/j.apmr.2016.09.118] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 09/10/2016] [Accepted: 09/13/2016] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine relationships between pain sites and pain intensity/interference in people with lower limb amputations (LLAs). DESIGN Cross-sectional survey. SETTING Community. PARTICIPANTS Lower limb prosthesis users with unilateral or bilateral amputations (N=1296; mean time since amputation, 14.1y). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Patient-Reported Outcomes Measurement Information System (PROMIS) pain intensity (1 item to assess average pain), PROMIS pain interference (4-item short form to assess the consequences of pain in desired activities), and questions that asked participants to rate the extent to which each of the following were a problem: residual limb pain (RLP), phantom limb pain (PLP), knee pain on the nonamputated side, back pain, and shoulder pain. RESULTS Nearly three quarters (72.1%) of participants reported problematic pain in 1 or more of the listed sites. Problematic PLP, back pain, and RLP were reported by 48.1%, 39.2%, and 35.1% of participants, respectively. Knee pain and shoulder pain were less commonly identified as problems (27.9% and 21.7%, respectively). Participants also reported significantly (P<.0001) higher pain interference (T-score ± SD, 54.7±9.0) than the normative sample based on the U.S. population (T-score ± SD, 50.0±10.0). Participants with LLAs rated their pain intensity on average ± SD at 3.3±2.4 on a 0-to-10 scale. Pain interference (ρ=.564, P<.0001) and intensity (ρ=.603, P<.0001) were positively and significantly correlated with number of pain sites reported. CONCLUSIONS Problematic pain symptoms, especially RLP, PLP, and back pain, affect most prosthetic limb users and have the potential to greatly restrict participation in life activities.
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Affiliation(s)
- Sara J Morgan
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA
| | - Janna L Friedly
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA
| | - Dagmar Amtmann
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA
| | - Rana Salem
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA
| | - Brian J Hafner
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA.
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