A review of current theories and treatments for phantom limb pain

The cerebellum and the Mirror Neuron System: A matter of inhibition? From neurophysiological evidence to neuromodulatory implications. A narrative review

Mirror neurons show activity during both the execution (AE) and observation of actions (AO). The Mirror Neuron System (MNS) could be involved during motor imagery (MI) as well. Extensive research suggests that the cerebellum is interconnected with the MNS and may be critically involved in its activities. We gathered evidence on the cerebellum's role in MNS functions, both theoretically and experimentally. Evidence shows that the cerebellum plays a major role during AO and MI and that its lesions impair MNS functions likely because, by modulating the activity of cortical inhibitory interneurons with mirror properties, the cerebellum may contribute to visuomotor matching, which is fundamental for shaping mirror properties. Indeed, the cerebellum may strengthen sensory-motor patterns that minimise the discrepancy between predicted and actual outcome, both during AE and AO. Furthermore, through its connections with the hippocampus, the cerebellum might be involved in internal simulations of motor programs during MI. Finally, as cerebellar neuromodulation might improve its impact on MNS activity, we explored its potential neurophysiological and neurorehabilitation implications.

Ten-year phantom limb pain with only four sessions of Fu's subcutaneous needling: A case report and systematic review

Phantom limb pain (PLP) is a distressing consequence commonly encountered by individuals who have undergone amputations. The efficacy of treatment options for PLP is limited. In this study, we present a case of a 64-year-old male who suffered from PLP for a duration of 10 years following an above-the-knee amputation. Despite unsuccessful attempts with painkillers and neurotrophic drugs over the course of a decade, the patient sought relief through Fu's Subcutaneous Needling (FSN), an innovative acupuncture therapy that specifically targets the subcutaneous tissue for pain management. Remarkably, the patient experienced a significant reduction in PLP and subsequently decreased his reliance on medication, as well as experiencing improved sleep after undergoing one session of FSN per day for four consecutive days. A follow-up conducted three years later demonstrated positive treatment outcomes. FSN demonstrated a significant influence on PLP, resulting in reduced analgesic requirements and enhanced quality of life. Therefore, FSN may be recommended as an additional treatment option for PLP. In order to gain a comprehensive understanding of the effects of acupuncture on PLP, a systematic review of relevant literature was conducted in PubMed, Embase, Cochrane Library and Web of Science in recent 20 years (from January 1, 2003 to October 16, 2023), using different combinations of the following terms: (phantom acrodynia), (residual limb pain), (phantom limb pain), (acupuncture), (electroacupuncture), (auriculoacupuncture), and (needling). 9 articles with 18 cases including one randomized controlled trial (n = 8) were obtained. This review provided additional evidence supporting the efficacy and safety of needling therapies for PLP. This systematic review offers additional evidence supporting the effectiveness and safety of needling therapies for PLP. However, there were no precedent reports using FSN treatment for PLP. Hence, this case may provide some implications for clinicians in practice.

Phantom limb syndrome: from pathogenesis to treatment. A narrative review

Phantom Limb Syndrome (PLS) can be defined as the disabling or painful sensation of the presence of a body part that is no longer present after its amputation. Anatomical changes involved in Phantom Limb Syndrome, occurring at peripheral, spinal and brain levels and include the formation of neuromas and scars, dorsal horn sensitization and plasticity, short-term and long-term modifications at molecular and topographical levels. The molecular reorganization processes of Phantom Limb Syndrome include NMDA receptors hyperactivation in the dorsal horn of the spinal column leading to inflammatory mechanisms both at a peripheral and central level. At the brain level, a central role has been recognized for sodium channels, BDNF and adenosine triphosphate receptors. In the paper we discuss current available pharmacological options with a final overview on non-pharmacological options in the pipeline.

Insights into optimizing phantom pain management: A human-centered approach to end-user perspectives

BACKGROUND

This report explores and summarizes perspectives from end users on unmet needs in achieving optimal and effective phantom pain management through a human-centered design approach.

OBJECTIVE

To examine current strategies, pharmacological, nonpharmacological, surgical procedures, virtual reality, and mirror therapy, and the evidence supporting them, in the management of phantom limb pain.

DESIGN

This study reviewed and analyzed transcripts acquired in nonresearch contexts from the Veterans Affairs Translational Education and Mentoring Center's commercialization training program and from a Veteran Engagement Panel. Key themes were extracted using quasi-qualitative analysis of one-on-one interviews.

RESULTS

Clinicians and patients report that early patient intervention and education will yield improved management of phantom limb pain, which aligns with the growing recognition of the impact of patient-centered care on overall treatment outcomes. Mirror therapy is viewed as an effective and low-risk therapy, though compliance and buy-in may be barriers to clinical practice. Patient engagement can contribute to better treatment adherence and outcomes.

CONCLUSION

The study highlights implementation barriers, importance of end-user input, and the role of the Veteran Engagement Panel in providing feedback to pain researchers. The findings help explain unaddressed challenges and areas requiring further research to direct phantom pain management.

Virtual and Augmented Reality in Management of Phantom Limb Pain: A Systematic Review

Upper and lower limb amputations are frequently associated with phantom limb pain (PLP). Recently, virtual reality (VR) and augmented reality (AR) have been reported as a potential therapy of PLP. We have conducted a systematic review of literature to evaluate the efficacy of VR and AR in managing PLP. Four databases were searched: PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, and Web of Science. We utilized the Preferred Reporting Items for Systematic Reviews and Meta-Analysis for our organization. The initial search resulted in 164 results. After title, abstract, and full-text screening, 9 studies were included. One study was of good quality and 8 studies were of fair to poor quality. Seven studies utilized VR and 2 studies utilized AR. The number of treatment sessions ranged from 1 to 28 and the duration ranged from 10 minutes to 2 hours. Several pain scales were used to evaluate PLP pre- and postintervention including Numeric Rating Scale, Pain Rating Index, McGill Pain Questionnaire, and Visual Analog Scale. All the studies reported improvement of PLP on one or more of pain scales after one or more sessions of VR or AR. Despite the promising results reported by literature, we cannot recommend using VR or AR for PLP. Most of the studies are of poor design and have limited sample size with high bias levels. Therefore, no substantial evidence can be derived from them. However, we do believe further research with high-quality randomized controlled trials should take place to increase the knowledge of the potential advantages.

Immersive VR for upper-extremity rehabilitation in patients with neurological disorders: a scoping review

BACKGROUND

Neurological disorders, such as stroke and chronic pain syndromes, profoundly impact independence and quality of life, especially when affecting upper extremity (UE) function. While conventional physical therapy has shown effectiveness in providing some neural recovery in affected individuals, there remains a need for improved interventions. Virtual reality (VR) has emerged as a promising technology-based approach for neurorehabilitation to make the patient's experience more enjoyable. Among VR-based rehabilitation paradigms, those based on fully immersive systems with headsets have gained significant attention due to their potential to enhance patient's engagement.

METHODS

This scoping review aims to investigate the current state of research on the use of immersive VR for UE rehabilitation in individuals with neurological diseases, highlighting benefits and limitations. We identified thirteen relevant studies through comprehensive searches in Scopus, PubMed, and IEEE Xplore databases. Eligible studies incorporated immersive VR for UE rehabilitation in patients with neurological disorders and evaluated participants' neurological and motor functions before and after the intervention using clinical assessments.

RESULTS

Most of the included studies reported improvements in the participants rehabilitation outcomes, suggesting that immersive VR represents a valuable tool for UE rehabilitation in individuals with neurological disorders. In addition, immersive VR-based interventions hold the potential for personalized and intensive training within a telerehabilitation framework. However, further studies with better design are needed for true comparison with traditional therapy. Also, the potential side effects associated with VR head-mounted displays, such as dizziness and nausea, warrant careful consideration in the development and implementation of VR-based rehabilitation programs.

CONCLUSION

This review provides valuable insights into the application of immersive VR in UE rehabilitation, offering the foundation for future research and clinical practice. By leveraging immersive VR's potential, researchers and rehabilitation specialists can design more tailored and patient-centric rehabilitation strategies, ultimately improving the functional outcome and enhancing the quality of life of individuals with neurological diseases.

Feasibility study of a home-based graded motor imagery intervention (GraMI protocol) for amputees with phantom limb pain

INTRODUCTION

Phantom limb pain affects 64% of amputees. Graded Motor Imagery comprises three consecutive application techniques designed to reorganize maladaptive changes that have occurred after the amputation.

OBJECTIVE

To assess the feasibility of a home-based Graded Motor Imagery intervention, the GraMI protocol, for amputee people with phantom limb pain.

METHODS

Twenty individuals over 18 years of age with upper or lower limb amputation, experiencing phantom limb pain, who were pharmacologically stable, and had been discharged from the hospital were recruited. The experimental group followed the GraMI protocol. Primary outcomes included study processes, such as recruitment time and rate, adherence, compliance, and the acceptability of digital technologies as a treatment tool. Secondary outcomes assessed the impact on phantom limb pain, quality of life, functionality, and depressive symptoms.

RESULTS

On average, seven participants were recruited monthly over a three-month period. No losses were recorded throughout the nine weeks of intervention. Treatment adherence averaged 89.32%, and all participants demonstrated familiarity with the usability of digital technologies. No significant differences were observed between groups (p = .054). However, within the experimental group, intragroup analysis revealed a significant (p = .005) and clinically relevant reduction (>2 points) with a large effect size (0.89) in phantom limb pain.

CONCLUSION

Conducting a multicenter study with a home-based intervention using the GraMI protocol is feasible. Future clinical trials are needed to verify its effectiveness in managing phantom limb pain.

The effectiveness of graded motor imagery and its components on phantom limb pain in amputated patients: A systematic review

BACKGROUND

Phantom limb pain (PLP) can be defined as pain in a missing part of the limb. It is reported in 50%-80% of people with amputation.

OBJECTIVES

To provide an overview of the effectiveness of graded motor imagery (GMI) and the techniques which form it on PLP in amputees.

STUDY DESIGN

Systematic review.

METHODS

Two authors independently selected relevant studies, screened the articles for methodological validity and risk of bias, and extracted the data. Inclusion criteria used were clinical studies, written in English or Spanish, using GMI, laterality recognition, motor imagery, mirror therapy, or a combination of some of them as an intervention in amputated patients, and one of the outcomes was PLP, and it was assessed using a validated scale. The databases used were PubMed, Scopus, Web of Science, CINAHL, and PEDro.

RESULTS

Fifteen studies were included in the review. After the intervention, all the groups in which the GMI or one of the techniques that comprise it was used showed decrease in PLP.

CONCLUSION

The 3 GMI techniques showed effectiveness in decreasing PLP in amputees, although it should be noted that the application of the GMI showed better results.

Botulinum toxin therapy for management of phantom and residual limb pain following amputation: A systematic review

Chronic pain following amputation is debilitating. Due to its mechanisms in modulating muscle contraction and pain, botulinum toxin has been investigated as a treatment option for phantom limb pain (PLP) and residual limb pain (RLP). The objective of this study was to determine the efficacy of botulinum toxin injection in the management of PLP and RLP following major limb amputation using a systematic review of the literature. The databases Medline, CINAHL, EMBASE, Scopus, Web of Science, and Cochrane were searched from inception through October 30, 2023. The search identified 50 articles; 37 underwent full-text review, and 11 were included in the final review. Eighty-nine individuals with pain were investigated by the included studies; 53 had RLP and 63 had PLP. There was significant variation in botulinum toxin type, injection method, and dosage. Twenty-one (53.9%) and 27 (64.3%) participants had improvement in PLP and RLP following botulinum toxin injection, respectively. Therefore, there is potential for use of botulinum toxin for the treatment of PLP and RLP. However, due to the minimal number of studies, small sample sizes, and heterogenous methodologies, our ability to conclude with certainty the efficacy of botulinum toxin injection on the treatment of PLP and RLP following amputation is limited.

Graded motor imagery and its phases for individuals with phantom limb pain following amputation: A scoping review

OBJECTIVE

Three-phase graded motor imagery (limb laterality, explicit motor imagery, and mirror therapy) has been successful in chronic pain populations. However, when applied to phantom limb pain, an amputation-related pain, investigations often use mirror therapy alone. We aimed to explore evidence for graded motor imagery and its phases to treat phantom limb pain.

DATA SOURCES

A scoping review was conducted following the JBI Manual of Synthesis and Preferred Reporting Items for Systematic Review and Meta-Analyses extension for Scoping Reviews. Thirteen databases, registers, and websites were searched.

REVIEW METHODS

Published works on any date prior to the search (August 2023) were included that involved one or more graded motor imagery phases for participants ages 18+ with amputation and phantom limb pain. Extracted data included study characteristics, participant demographics, treatment characteristics, and outcomes.

RESULTS

Sixty-one works were included representing 19 countries. Most were uncontrolled studies (31%). Many participants were male (75%) and had unilateral amputations (90%) of varying levels, causes, and duration. Most works examined one treatment phase (92%), most often mirror therapy (84%). Few works (3%) reported three-phase intervention. Dosing was inconsistent across studies. The most measured outcome was pain intensity (95%).

CONCLUSION

Despite the success of three-phase graded motor imagery in other pain populations, phantom limb pain research focuses on mirror therapy, largely ignoring other phases. Participant demographics varied, making comparisons difficult. Future work should evaluate graded motor imagery effects and indicators of patient success. The represented countries indicate that graded motor imagery phases are implemented internationally, so future work could have a widespread impact.

Targeted muscle reinnervation: A narrative review of a novel tool for the management of neuropathic pathology in major lower extremity amputations

OBJECTIVE

The purpose of this narrative review is to provide the vascular surgery community with updated recommendations and information regarding the use of Targeted Muscle Reinnervation (TMR) for both the prevention and treatment of chronic pain and phantom limb pain occurring in patients after undergoing lower extremity amputation for peripheral artery disease.

METHODS

Current available literature discussing TMR is reviewed and included in the article in order to provide a succinct overview on the indications, clinical applications, and surgical technique for TMR. Additionally, early studies showing favorable long-term results after TMR are discussed. Patient consent for publication was obtained for this investigation.

RESULTS

TMR has been demonstrated to be an effective means of both treating and preventing neuroma-related symptoms including chronic pain and phantom limb pain. It has been proven to be technically feasible, and can help patients to have improved utilization of prostheses for ambulation, which can conceivably lead to a reduction in mortality.

CONCLUSIONS

TMR is an important tool to consider for any patient undergoing lower extremity amputation for a vascular-related indication. A vascular-plastic surgeon dual team approach is an effective means to prevent and reduce neuromas and associated chronic pain in this patient population.

Cortical Reorganization after Limb Loss: Bridging the Gap between Basic Science and Clinical Recovery

Despite the increasing incidence and prevalence of amputation across the globe, individuals with acquired limb loss continue to struggle with functional recovery and chronic pain. A more complete understanding of the motor and sensory remodeling of the peripheral and central nervous system that occurs postamputation may help advance clinical interventions to improve the quality of life for individuals with acquired limb loss. The purpose of this article is to first provide background clinical context on individuals with acquired limb loss and then to provide a comprehensive review of the known motor and sensory neural adaptations from both animal models and human clinical trials. Finally, the article bridges the gap between basic science researchers and clinicians that treat individuals with limb loss by explaining how current clinical treatments may restore function and modulate phantom limb pain using the underlying neural adaptations described above. This review should encourage the further development of novel treatments with known neurological targets to improve the recovery of individuals postamputation.Significance Statement In the United States, 1.6 million people live with limb loss; this number is expected to more than double by 2050. Improved surgical procedures enhance recovery, and new prosthetics and neural interfaces can replace missing limbs with those that communicate bidirectionally with the brain. These advances have been fairly successful, but still most patients experience persistent problems like phantom limb pain, and others discontinue prostheses instead of learning to use them daily. These problematic patient outcomes may be due in part to the lack of consensus among basic and clinical researchers regarding the plasticity mechanisms that occur in the brain after amputation injuries. Here we review results from clinical and animal model studies to bridge this clinical-basic science gap.

Whole-Body Cryostimulation, a Complementary Treatment for Phantom Limb Syndrome: Preliminary Evidence from a Case Study

Phantom limb pain (PLP) is a challenging condition affecting a significant proportion of amputees. In this article, we describe the case of a 54-year-old Paralympic athlete with phantom limb syndrome following right leg amputation and widespread sports-related enthesitic pain who underwent a whole-body cryostimulation (WBC) cycle, an emerging treatment known for its rapid pain-relieving and anti-inflammatory effects. Assessments were conducted before and after a 10-session WBC cycle, including pain and quality of life assessment and use of medications. A substantial reduction in enthesitic pain, PLP intensity, paresthesia, and tingling related to atmospheric events and improved function and quality of life were reported after the WBC cycle and lasted for two weeks. One month after WBC, the enthesitic pain following sports activity and PLP gradually returned, but with lesser intensity. Similarly, the stump's sensitivity to atmospheric changes returned, but with lower frequency. Pain at night remained lower than before WBC, with significantly improved quality of sleep. This case study suggests that WBC could be a valuable adjuvant treatment for alleviating PLP. Controlled studies are warranted to validate the findings of this case report and elucidate the mechanisms underlying the positive effects of WBC in this condition.

Case Report: Virtual reality training for phantom limb pain after amputation

Several reports have demonstrated the effectiveness of neurorehabilitation, such as mirror therapy or virtual reality, in treating phantom limb pain (PLP). This case study describes the effect of virtual reality training (VRT) on severe, long-term PLP and upper limb activity on the amputated side in a patient who underwent digit amputation 9 years prior. A woman in her 40 s underwent amputation of 2-5 fingers 9 years prior due to a workplace accident. She experienced persistent pain in the palms of her hand near the amputation sites. A single case design (ABA'B') was applied. Periods A and A' were set as periods without VRT intervention, and Periods B and B' were set as periods with VRT intervention. Periods A, B, A', and B' lasted 4, 10, 8, and 10 weeks, respectively. VRT was a task during which visual stimulation and upper limb movements were linked. The task consisted of catching a rolling ball in the display with a virtual hand, operated with both hands using a controller. VRT was performed once every 2-4 weeks for 30 min. Pain intensity was assessed using the short-form McGill Pain Questionnaire-2. Bilateral upper limb activity was measured continuously for 24 h using a triaxial accelerometer attached to the right and left wrist joints. The pain intensity was 147/220 points during Period A, 128 points during Period B, 93 points during Period A', and 100 points during Period B', showing a gradual decrease. Upper limb activity occurred mainly on the intact side during Periods A and B, whereas the activity on the amputated side increased 2-fold after Period A', and both upper extremities were used equally. Virtual reality training resulted in reduced pain intensity and increased activity in the upper limb. VRT may have induced reintegration of the sensory-motor loop, leading to a decrease in the PLP intensity. The upper limb activity on the amputated side may have also increased with the pain reduction. These results suggest that VRT may be valuable in reducing severe, long-term PLP.

Risk Factors Analysis of Phantom Limb Pain in Amputees with Malignant Tumors

Purpose

Postamputation neuropathic pain is a common disease in patients with malignant tumor amputation, seriously affecting amputees' quality of life and mental health. The objective of this study was to identify independent risk factors for phantom limb pain in patients with tumor amputation and to construct a risk prediction model.

Methods

Patients who underwent amputation due to malignant tumors from 2013 to 2023 were retrospectively analyzed and divided into phantom limb pain group and non-phantom limb pain group. To determine which preoperative factors would affect the occurrence of phantom limb pain, we searched for candidate factors by univariate analysis and used multivariate logistic regression analysis to identify independent factors and construct a predictive model. The receiver operating characteristic curve (ROC) was drawn to further evaluate the accuracy of the prediction model in evaluating the phantom limb pain after amputation of bone and soft tissue tumors.

Results

Multivariate analysis showed that age (OR, 1.054; 95% CI, 1.027 to 1.080), preoperative pain (OR, 5.773; 95% CI, 2.362 to 14.104), number of surgeries (OR, 3.425; 95% CI, 1.505 to 7.795), amputation site (OR, 5.848; 95% CI, 1.837 to 18.620), amputation level (OR, 8.031; 95% CI, 2.491 to 25.888) were independent risk factors for phantom limb pain for bone and soft tissue tumors. The the area under the curve (AUC) of this model was 0.834.

Conclusion

Risk factors for postoperative phantom limb pain were the site of amputation, proximal amputation, preoperative pain, multiple amputations, and older age. These factors will help surgeons to individualize and stratify phantom limb pain and help patients with risk counseling. In particular, an informed clinical decision targeting those modifiable factors can be considered when needed.

A Manifesto in Defense of Pain Complexity: A Critical Review of Essential Insights in Pain Neuroscience

Chronic pain has increasingly become a significant health challenge, not just as a symptomatic manifestation but also as a pathological condition with profound socioeconomic implications. Despite the expansion of medical interventions, the prevalence of chronic pain remains remarkably persistent, prompting a turn towards non-pharmacological treatments, such as therapeutic education, exercise, and cognitive-behavioral therapy. With the advent of cognitive neuroscience, pain is often presented as a primary output derived from the brain, aligning with Engel's Biopsychosocial Model that views disease not solely from a biological perspective but also considering psychological and social factors. This paradigm shift brings forward potential misconceptions and over-simplifications. The current review delves into the intricacies of nociception and pain perception. It questions long-standing beliefs like the cerebral-centric view of pain, the forgotten role of the peripheral nervous system in pain chronification, misconceptions around central sensitization syndromes, the controversy about the existence of a dedicated pain neuromatrix, the consciousness of the pain experience, and the possible oversight of factors beyond the nervous system. In re-evaluating these aspects, the review emphasizes the critical need for understanding the complexity of pain, urging the scientific and clinical community to move beyond reductionist perspectives and consider the multifaceted nature of this phenomenon.

Lower jaw-to-forepaw rapid and delayed reorganization in the rat forepaw barrel subfield in primary somatosensory cortex

We used the forepaw barrel subfield (FBS), that normally receives input from the forepaw skin surface, in rat primary somatosensory cortex as a model system to study rapid and delayed lower jaw-to-forepaw cortical reorganization. Single and multi-unit recording from FBS neurons was used to examine the FBS for the presence of "new" lower jaw input following deafferentations that include forelimb amputation, brachial plexus nerve cut, and brachial plexus anesthesia. The major findings are as follows: (1) immediately following forelimb deafferentations, new input from the lower jaw becomes expressed in the anterior FBS; (2) 7-27 weeks after forelimb amputation, new input from the lower jaw is expressed in both anterior and posterior FBS; (3) evoked response latencies recorded in the deafferented FBS following electrical stimulation of the lower jaw skin surface are significantly longer in both rapid and delayed deafferents compared to control latencies for input from the forepaw to reach the FBS or for input from lower jaw to reach the LJBSF; (4) the longer latencies suggest that an additional relay site is imposed along the somatosensory pathway for lower jaw input to access the deafferented FBS. We conclude that different sources of input and different mechanisms underlie rapid and delayed reorganization in the FBS and suggest that these findings are relevant, as an initial step, for developing a rodent animal model to investigate phantom limb phenomena.

Targeted muscle reinnervation in upper extremity amputations

PURPOSE

Targeted muscle reinnervation (TMR) is a relatively recent surgical innovation that involves the coaptation of major peripheral nerves to a recipient motor branch that innervates an expendable muscle target. The original indication for TMR was augmentation and optimization of myoelectric signals in the amputated limb for use of myoelectric prosthetics. Incidentally, surgeons and patients discovered that the technique also could treat and prevent phantom and residual limb pain. TMR is performed at the time of amputation or delayed any time after the amputation, and TMR can also be performed at any level of amputation. In the upper extremity, studies have detailed the various techniques and coaptations possible at each amputation level to create intuitive myoelectric signals and treat neurogenic pain. Treatment of peripheral nerves in the amputee with TMR should be a consideration for all patients with major upper extremity amputations, especially at large institutions able to support multidisciplinary limb salvage teams. This review article summarizes the current literature and authors' techniques and recommendations surrounding TMR in the upper extremity amputee including techniques relevant to each level of upper extremity amputation.

Altered cortical thickness and structural covariance networks in upper limb amputees: A graph theoretical analysis

BACKGROUND

The extensive functional and structural remodeling that occurs in the brain after amputation often results in phantom limb pain (PLP). These closely related phenomena are still not fully understood.

METHODS

Using magnetic resonance imaging (MRI) and graph theoretical analysis (GTA), we explored how alterations in brain cortical thickness (CTh) and structural covariance networks (SCNs) in upper limb amputees (ULAs) relate to PLP. In all, 45 ULAs and 45 healthy controls (HCs) underwent structural MRI. Regional network properties, including nodal degree, betweenness centrality (BC), and node efficiency, were analyzed with GTA. Similarly, global network properties, including global efficiency (Eglob), local efficiency (Eloc), clustering coefficient (Cp), characteristic path length (Lp), and the small-worldness index, were evaluated.

RESULTS

Compared with HCs, ULAs had reduced CThs in the postcentral and precentral gyri contralateral to the amputated limb; this decrease in CTh was negatively correlated with PLP intensity in ULAs. ULAs showed varying degrees of change in node efficiency in regional network properties compared to HCs (p < 0.005). There were no group differences in Eglob, Eloc, Cp, and Lp properties (all p > 0.05). The real-worldness SCN of ULAs showed a small-world topology ranging from 2% to 34%, and the area under the curve of the small-worldness index in ULAs was significantly different compared to HCs (p < 0.001).

CONCLUSION

These results suggest that the topological organization of human CNS functional networks is altered after amputation of the upper limb, providing further support for the cortical remapping theory of PLP.

Mirror Therapy for the Management of Phantom Limb Pain: A Single- Center Experience

BACKGROUND

Phantom limb pain (PLP) can have devastating consequences, affecting up to 90% of amputees. PLP is associated with analgesia dependence and impaired quality of life. Mirror therapy (MT) is a novel treatment that has been applied in other pain syndromes. We prospectively evaluated MT in the management of PLP.

METHODS

A prospective study of patients recruited between 2008 and 2020 who underwent unilateral major limb amputation, with a healthy contralateral limb. Participants were invited to attend weekly MT sessions. Pain in the 7 days prior to each MT session was scored on a Visual Analog Scale (VAS: 0-10 mm) and the short form McGill pain questionnaire.

RESULTS

Ninety eight patients (68 males and 30 females) aged 17-89 years were recruited over 12 years. Forty four percent of patients had amputations due to peripheral vascular disease. Over an average of 2.5 sessions, the final treatment score on the VAS scale was 2.6 (standard deviation ± 3.0) with a reduction of 4.5 points on VAS score. As a comparison using the short form McGill pain questionnaire scoring system, the average final treatment score was 3.2 (± 5.0) with 91% overall improvement.

CONCLUSIONS

MT is a very powerful and effective intervention for PLP. It is an exciting addition to the armory of vascular surgeons in the management of this condition.

Interplay Between Innovation and Intersubjectivity: Therapists Perceptions of Phantom Motor Execution Therapy and Its Effect on Phantom Limb Pain

Purpose

Interpersonal processes, including therapeutic alliance, may modulate the impact of interventions on pain experience. However, the role of interpersonal context on the effects of technology-enhanced interventions remains underexplored. This study elicited therapists' perspectives on how a novel rehabilitative process, involving Phantom Motor Execution (PME), may impact phantom limb pain. The mediating role of therapeutic alliance, and the way PME influenced its formation, was investigated.

Methods

A qualitative descriptive design, using a framework method, was used to explore therapists' (n=11) experiences of delivering PME treatment. Semi-structured online-based interviews were conducted.

Results

A 3-way interaction between therapist, patient, and the PME device was an overarching construct tying four themes together. It formed the context for change in phantom limb experience. The perceived therapeutic effects (theme 1) extended beyond those initially hypothesised and highlighted the mediating role of the key actors and context (theme 2). The therapeutic relationship was perceived as a transformative journey (theme 3), creating an opportunity for communication, collaboration, and bonding. It was seen as a cause and a consequence of therapeutic effects. Future directions, including the role of expertise-informed adaptations and enabling aspects of customised solutions, were indicated (theme 4).

Conclusion

This study pointed to intrapersonal, interpersonal, and contextual factors that should be considered in clinical implementation of novel rehabilitative tools. The results demonstrated that therapists have unique insights and a crucial role in facilitating PME treatment. The study highlighted the need to consider the biopsychosocial model of pain in designing, evaluating, and implementing technology-supported interventions.

The mechanisms and management of persistent postsurgical pain

An estimated 10%-50% of patients undergoing a surgical intervention will develop persistent postsurgical pain (PPP) lasting more than 3 months despite adequate acute pain management and the availability of minimally invasive procedures. The link between early and late pain outcomes for surgical procedures remains unclear-some patients improve while others develop persistent pain. The elective nature of a surgical procedure offers a unique opportunity for prophylactic or early intervention to prevent the development of PPP and improve our understanding of its associated risk factors, such as pre-operative anxiety and the duration of severe acute postoperative pain. Current perioperative pain management strategies often include opioids, but long-term consumption can lead to tolerance, addiction, opioid-induced hyperalgesia, and death. Pre-clinical models provide the opportunity to dissect mechanisms underpinning the transition from acute to chronic, or persistent, postsurgical pain. This review highlights putative mechanisms of PPP, including sensitisation of peripheral sensory neurons, neuroplasticity in the central nervous system and nociceptive signalling along the neuro-immune axis.

Regenerative Peripheral Nerve Interface Surgery: Anatomic and Technical Guide

Regenerative peripheral nerve interface (RPNI) surgery has been demonstrated to be an effective tool as an interface for neuroprosthetics. Additionally, it has been shown to be a reproducible and reliable strategy for the active treatment and for prevention of neuromas. The purpose of this article is to provide a comprehensive review of RPNI surgery to demonstrate its simplicity and empower reconstructive surgeons to add this to their armamentarium. This article discusses the basic science of neuroma formation and prevention, as well as the theory of RPNI. An anatomic review and discussion of surgical technique for each level of amputation and considerations for other etiologies of traumatic neuromas are included. Lastly, the authors discuss the future of RPNI surgery and compare this with other active techniques for the treatment of neuromas.

Calcitonin in the Treatment of Phantom Limb Pain: A Systematic Review

INTRODUCTION

Phantom limb pain (PLP) refers to pain perceived in a part of the body removed by amputation or trauma. Despite the high prevalence of PLP following amputation and the significant morbidity associated with it, robust therapeutic approaches are currently lacking. Calcitonin, a polypeptide hormone, has recently emerged as a novel analgesic with documented benefits in the treatment of several pain-related conditions.

METHODS

We present a systematic review that comprehensively evaluates the analgesic effects of calcitonin for patients with PLP. We searched MEDLINE, OLDMEDLINE, and PubMed Central databases with the key words "calcitonin" "phantom limb pain" and "phantom pain" to identify clinical studies evaluating the efficacy or effectiveness of calcitonin administration, in any form and dose, for the treatment of PLP. Additionally, Google Scholar was searched manually with the search term "calcitonin phantom limb pain". All four databases were searched from inception until 1 December 2022. The methodological quality of each included study was assessed using the Downs and Black checklist and the GRADE criteria were used to assess effect certainty and risk of bias.

RESULTS

Our search identified 4108 citations, of which six ultimately met the criteria for inclusion in the synthesis. The included articles described a mix of open-label (n = 2), prospective observational cohort (n = 1), and randomized clinical trials (n = 3). The most common treatment regimen in the current literature is a single intravenous infusion of 200 IU salmon-derived calcitonin.

CONCLUSION

The available evidence supported the use of calcitonin as either monotherapy or adjuvant therapy in the treatment of PLP during the acute phase, while the evidence surrounding calcitonin treatment in chronic PLP is heterogeneous. Given the limited treatment options for the management of PLP and calcitonin's relatively wide therapeutic index, further research is warranted to determine the role that calcitonin may play in the treatment of PLP and other pain disorders.

Comparative Effects of Interventions on Phantom Limb Pain: A Network Meta-Analysis

BACKGROUND

Phantom limb pain (PLP) is a common type of chronic pain that occurs after limb amputation. Many treatment approaches are available; however, the treatment of PLP is still a challenge. This study aimed to quantify and rank the efficacy of interventions for phantom limb pain.

METHODS

A comprehensive literature search was performed using the databases of PubMed, MEDLINE, Embase, Web of Science, and Cochrane. A network meta-analysis was applied to formulate direct and indirect comparisons among interventions for PLP.

RESULTS

Twenty-two studies comprising 662 patients and 13 different interventions were included in this study. The mirror therapy (MT) (-1.00; 95% confidence interval, -1.94 to -0.07) and MT + phantom exercise (PE) (-6.05; 95% confidence interval, -8.29 to -3.81) group presented significantly lower pain intensity compared with placebo. In SUCRA (surface under the cumulative ranking curve) analysis, the MT+PE and neuromodulation techniques groups had the highest SUCRA value (81.2).

CONCLUSIONS

Our results suggest that MT is the most optimal treatment for PLP, and a combination of therapies would enhance the therapeutic effect.

Post-amputation pain: Comparing pain presentations between adults with and without increased amputated-region sensitivity

OBJECTIVE

Among adults with persistent post-amputation pain, increased amputated-region pain sensitivity may reflect peripheral sensitization or indicate underlying central sensitization. To determine whether underlying central sensitization may contribute to increased pain sensitivity in this population, this study compared clinical signs and symptoms associated with central sensitization between adults with post-amputation pain who demonstrate or lack increased amputated-region sensitivity (as compared to reference data).

DESIGN

Cross-sectional.

SUBJECTS

Ninety-nine adults (60 with a unilateral, transtibial amputation and post-amputation pain, 39 pain-free controls with intact limbs).

METHODS

Participants underwent pain-pressure threshold testing of amputated-region and secondary (non-amputated region) sites and completed outcome measures assessing central sensitization symptoms (Patient-Reported Outcomes Measurement Information System® pain intensity and interference domains, Central Sensitization Inventory). Among the full sample, the presence and frequency of specific central sensitization symptoms were evaluated. Participants with post-amputation pain were then grouped based on whether normalized, amputated-region pain-pressure thresholds fell below (i.e., sensitive) or above (i.e., non-sensitive) the 25th percentile of sex-specific reference data. Between-group differences in normalized secondary-site sensitivity were evaluated using a multivariate analysis of variance; central sensitization symptom scores were compared using a Kruskal-Wallis test.

RESULTS

Noteworthy symptoms associated with central sensitization (e.g., fatigue, sleep disturbance, cognitive difficulty) were reported by 33%-62% of participants. Secondary-site pain sensitivity was greater among individuals with increased amputated-region sensitivity (n = 24) compared to peers without increased amputated-region sensitivity ([n = 36], mean difference > 1.33 standard deviation [SD], p < 0.001). Central sensitization symptom scores, however, were similar between groups (p > 0.187).

CONCLUSIONS

Participants with increased amputated-region sensitivity demonstrate generalized, secondary-site pain hypersensitivity, potentially indicating underlying central sensitization. Central sensitization symptom scores, however, were similar between groups, suggesting differences in physiological pain sensitivity may not manifest in subjective post-amputation pain descriptions.

Ghost Fat: Altered Female Body Perception After Bariatric Surgery

Body perception is an individual's ability to recognize their body in attitudinal and/or dimensional aspects. We investigated women's body perceptions before and after bariatric surgery. Participants were 31 women (M age = 36.23, SD = 7.95 years old) with an average pre-operative body mass index of 44.58 (SD = 4.65) kg/m². We collected anthropometric and body perception measures (attitudinal body image [ABI] and dimensional body image [DBI]) before bariatric surgery and 30, 60, 90, and 120 days after it. There was an average decrease of 21.09% in participants' body weight over the 120 days. Regarding ABI, 51.61% of participants had high body dissatisfaction before surgery, and this proportion of dissatisfied participants decreased to 3.23% 120 days after surgery. We observed no statistically significant differences in DBI perceptions. Fast weight loss caused by bariatric surgery appeared to generate a perception of ghost fat. Somatosensory interventions and/or a longer follow-up are needed to alter this persistent distortion of body dimensions.

Electrically-evoked referred sensations induce embodiment of rubber limb

Introduction

Electrical stimulation is increasingly relevant in a variety of medical treatments. In this study, the quality of referred sensations evoked using surface electrical stimulation was evaluated using the rubber hand and foot illusions.

Methods

The rubber hand and foot illusions were attempted under 4 conditions: (1) multi-location tapping; (2) one-location tapping; (3) electrical stimulation of sensation referred to the hand or foot; (4) asynchronous control. The strength of each illusion was quantified using a questionnaire and proprioceptive drift, where a stronger response suggested embodiment of the rubber limb.

Results

45 able-bodied individuals and two individuals with amputations participated in this study. Overall, the illusion evoked by nerve stimulation was not as strong as illusions evoked by physically tapping but stronger than the control illusion.

Conclusion

This study has found that the rubber hand and foot illusion can be performed without touching the distal limb of the participant. Electrical stimulation that produced referred sensation in the distal extremity was realistic enough to partially incorporate the rubber limb into a person's body image.

Sustained-Release Esketamine Based Nanoparticle-Hydrogel Delivery System for Neuropathic Pain Management

Introduction

Esketamine, one of the few non-opioid potent analgesics, has demonstrated efficacy in the treatment of various chronic pain, particularly neuropathic pain. However, its potential clinical applications are confined due to its short half-life and severe side effects including delirium, hallucinations, and other psychiatric symptoms. Here, we reported a nanosized drug delivery system for sustained-release esketamine based on polylactic-co-glycolic acid (PLGA) nanoparticles and hyaluronic acid (HA) hydrogel.

Results

In this study, esketamine in the delivery system was continuously released in vitro for at least 21 days, and spinal nerve root administration of the delivery system successfully attenuated (spinal nerve ligation) SNL-induced pain hypersensitivity for at least 14 days. Notably, the excitability of neurons in murine dorsal root ganglion (DRG) was inhibited and the activation of astrocytes in the spinal cord was additionally reduced after administration. Finally, there was no obvious pathophysiological change in the nerves at the administration site after treatment at 14 days.

Conclusion

These results indicate that the sustained-release esketamine based on the nanoparticle-hydrogel delivery system can safely produce a lasting analgesic effect on SNL mice, and its mechanism might be related to modulating the activation of astrocytes in the spinal cord and inhibiting the excitability of neurons in DRG.

Altered intra- and inter-network brain functional connectivity in upper-limb amputees revealed through independent component analysis

Although cerebral neuroplasticity following amputation has been observed, little is understood about how network-level functional reorganization occurs in the brain following upper-limb amputation. The objective of this study was to analyze alterations in brain network functional connectivity (FC) in upper-limb amputees (ULAs). This observational study included 40 ULAs and 40 healthy control subjects; all participants underwent resting-state functional magnetic resonance imaging. Changes in intra- and inter-network FC in ULAs were quantified using independent component analysis and brain network FC analysis. We also analyzed the correlation between FC and clinical manifestations, such as pain. We identified 11 independent components using independent component analysis from all subjects. In ULAs, intra-network FC was decreased in the left precuneus (precuneus gyrus) within the dorsal attention network and left precentral (precentral gyrus) within the auditory network; but increased in the left Parietal_Inf (inferior parietal, but supramarginal and angular gyri) within the ventral sensorimotor network, right Cerebelum_Crus2 (crus II of cerebellum) and left Temporal_Mid (middle temporal gyrus) within the ventral attention network, and left Rolandic_Oper (rolandic operculum) within the auditory network. ULAs also showed decreased inter-network FCs between the dorsal sensorimotor network and ventral sensorimotor network, the dorsal sensorimotor network and right frontoparietal network, and the dorsal sensorimotor network and dorsal attention network. Correlation analyses revealed negative correlations between inter-network FC changes and residual limb pain and phantom limb pain scores, but positive correlations between inter-network FC changes and daily activity hours of stump limb. These results show that post-amputation plasticity in ULAs is not restricted to local remapping; rather, it also occurs at a network level across several cortical regions. This observation provides additional insights into the plasticity of brain networks after upper-limb amputation, and could contribute to identification of the mechanisms underlying post-amputation pain.

[Practice of perioperative phantom limb pain prevention in Germany: a nationwide survey]

BACKGROUND

The prevalence of phantom limb pain after major amputation remains high and affected patients suffer from relevant impairments in the quality of life. Perioperative treatment strategies may prevent phantom limb pain. This study aims to assess the state of the perioperative anesthesiological pain management for major amputations. Furthermore, it analyzes potentials for optimization and barriers towards a better treatment of patients with amputations.

MATERIAL AND METHODS

This online survey was distributed by the German Society of Anesthesiology and Intensive Care Medicine (DGAI) mailing list of anesthesiological consultants. It was approved by the Charité ethics board.

RESULTS

Overall, 402 persons participated in this survey. Mostly, general anesthesia (85%), regional anesthesia (63%) and neuraxial anesthesia (49%) were performed in different combinations. Furthermore, 72% of participants reported using i.v. opioids postoperatively, mostly applied via patient-controlled analgesia (PCA). In contrast, preoperative regional anesthesia (74%) and gabapentinoids (67%) were seen as potential methods to improve treatment; however, barrier analysis revealed that treatment options are limited especially by organizational aspects and intrinsic patient factors.

CONCLUSION

This survey describes the current practice of phantom limb pain prevention in Germany. It shows an unmet need for specialized perioperative pain treatment. As the evidence regarding treatment recommendations is limited, further research questions can be deduced from this study.

An Algorithm Approach to Phantom Limb Pain

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.

Virtual and Augmented Reality-based Treatments for Phantom Limb Pain: A Systematic Review

Objective

To evaluate the literature on the effectiveness of virtual reality (VR)- and augmented reality (AR)-based treatments for phantom limb pain (PLP) in postamputation or brachial plexus avulsion (BPA) populations.

Methods

Multiple databases were queried in July 2021 with the keywords "virtual reality," "augmented reality," and "phantom limb pain." Included studies utilized VR or AR to treat PLP with outcome measurement. Two independent reviewers assessed methodological quality using the Physiotherapy Evidence Databsae (PEDro) Scale and the Methodological Index for Nonrandomized Studies (MINORS) scoring. Studies were separated into immersive and nonimmersive AR/VR systems, with further categorization according to the specific methodologies used.

Results

Of 110 results from the database queries, 20 publications met the inclusion criteria. There was one unblinded, randomized, control trial (RCT), one single-blinded, randomized, crossover trial (RCxT), three comparative case series, 13 noncomparative case series, and two case reports. Seven of the 20 studies were classified as nonimmersive. Six studies reported decreased PLP after AR/VR treatments, of which four reported significant reductions. One study reported a reduction in PLP with no significant difference from control conditions. Thirteen of the 20 studies were classified as immersive AR/VR. Twelve studies reported decreased PLP after AR/VR treatments, of which eight reported significant reductions. One study found no change in PLP, compared to baseline.

Conclusion

The number of studies using AR/VR in PLP treatment has expanded since a 2017 review on the topic. The majority of these studies offer support for the efficacy of treating PLP with AR/VR-based treatments. Research has expanded on the customization, outcome measurements, and statistical analysis of AR/VR treatments. While results are promising, most publications remain at the case series level, and clinical indications should be cautioned. With improvements in the quality of evidence, there remain avenues for further investigations, including increased sampling, randomization, optimization of treatment duration, and comparisons to alternative therapies.

Pathophysiological and Neuroplastic Changes in Postamputation and Neuropathic Pain: Review of the Literature

Despite advancements in surgical and rehabilitation strategies, extremity amputations are frequently associated with disability, phantom limb sensations, and chronic pain. Investigation into potential treatment modalities has focused on the pathophysiological changes in both the peripheral and central nervous systems to better understand the underlying mechanism in the development of chronic pain in persons with amputations.

Methods

Presented in this article is a discussion outlining the physiological changes that occur in the peripheral and central nervous systems following amputation. In this review, the authors examine the molecular and neuroplastic changes occurring in the nervous system, as well as the state-of-the-art treatment to help reduce the development of postamputation pain.

Results

This review summarizes the current literature regarding neurological changes following amputation. Development of both central sensitization and neuronal remodeling in the spinal cord and cerebral cortex allows for the development of neuropathic and phantom limb pain postamputation. Recently developed treatments targeting these pathophysiological changes have enabled a reduction in the severity of pain; however, complete resolution remains elusive.

Conclusions

Changes in the peripheral and central nervous systems following amputation should not be viewed as separate pathologies, but rather two interdependent mechanisms that underlie the development of pathological pain. A better understanding of the physiological changes following amputation will allow for improvements in therapeutic treatments to minimize pathological pain caused by amputation.

Effectiveness of graded motor imagery protocol in phantom limb pain in amputed patient: Protocol of a randomized clinical trial

Objective

The aim of this study is to analyse the effectiveness of the Graded Motor Imagery (GraMI) protocol in phantom limb pain in amputee patients.

Materials and methods

A randomised clinical trial will be conducted, with two parallel groups and simple blinding, and a phenomenological study with semi-structured interviews. People over the age of 18, with amputation of one limb, with a minimum score of 3 on the visual analogue scale of pain, who are pharmacologically stable and have been discharged from hospital, will be recruited. An initial assessment, a post-intervention assessment (9 weeks) and a follow-up assessment (12 weeks post-intervention) will be performed, in which pain, quality of life, functionality and psychological aspects will be assessed. The aim of the qualitative study is to find out about the experience of living with phantom limb pain and to identify the satisfaction with the intervention. A descriptive, univariate and bivariate quantitative statistical analysis will be performed using the SPSS program, with a 95% confidence level and a statistical significance level of p < 0.05. The qualitative analysis will be carried out using the Atlas.ti 8.0 program, where the different interviews will be analysed, coded and categorised.

Discussion

The GraMI protocol allows the patient to work on motor learning through brain reorganisation, analytical movements, sensory stimulation, and functional activities. In addition, it can help to standardise the use of graded motor imagery in future studies and in clinical practice with this patient profile.

Trial registration

NCT05083611.

Correlation between kinesthetic motor imagery of an amputated limb and phantom limb pain

BACKGROUND

Phantom limb pain (PLP) is a frequent painful sensation in amputees, and motor imagery (MI) is a useful approach for the treatment of this type of pain. However, it is not clear regarding the best MI modality for PLP.

OBJECTIVES

The purpose of this study was to investigate the relationship between the PLP and MI modality in upper limb amputees.

STUDY DESIGN

Observational study.

METHODS

Eleven patients who underwent unilateral upper limb amputation participated in this study. The MI modality (kinesthetic and visual) and PLP intensity were evaluated using the Kinesthetic and Visual Imagery Questionnaire (KVIQ)-20 and a visual analog scale. MI ability was also assessed during the hand mental rotation task. We examined the correlation between MI modalities, ability, and pain intensity.

RESULTS

The total KVIQ kinesthetic score was negatively correlated with pain intensity (r = -0.71, P < 0.01): the more vivid the kinesthetic imagery, the weaker the pain. In particular, the reduction in pain intensity was associated with strong kinesthetic imagery of opposing movements of the deficient thumb (r = -0.81, P < 0.01). The KVIQ visual score and MI ability were not associated with pain intensity.

CONCLUSIONS

Our data showed that the reduction of PLP could be associated with the kinesthetic modality of MI but not with visual modality or MI ability. In other words, it was suggested that the more vivid the sensation of moving muscles and joints in the defect area, the lower the PLP intensity. To reduce PLP, clinicians may prefer interventions using the kinesthetic modality.

Involvement of visual signals in kinaesthesia: A virtual reality study

Body movements are invariably accompanied by various proprioceptive, visual, tactile and/or motor signals. It is therefore difficult to completely dissociate these various signals from each other in order to study their specific involvement in the perception of movement (kinaesthesia). Here, we manipulated visual motion signals in a virtual reality display by using a humanoid avatar. The visual signals of movement could therefore be manipulated freely, relative to the participant's actual movement or lack of movement. After an embodiment phase in which the avatar's movements were coupled to the participant's voluntary movements, kinaesthetic illusions were evoked by moving the avatar's right forearm (flexion or extension) while the participant's right arm remained static. The avatar's left forearm was hidden from view. In parallel, somaesthetic signals could be masked by agonist-antagonist co-vibration or be amplified (by agonist vibration only or antagonist vibration only) so that the real impact of visual cues of movement in kinaesthesia could be studied. In a study of 24 participants, masking the somaesthetic signals (which otherwise provide signals indicating that the arm is static) was associated with a greater intensity and shorter latency of the visually evoked illusions. These results confirm the importance of carefully considering somaesthetic signals when assessing the contribution of vision to kinaesthesia. The use of a combination of virtual reality and somaesthetic signal manipulation might be of clinical value.

Deep brain stimulation for phantom limb pain

Phantom limb pain is a rare cause of chronic pain in children but it is associated with extremely refractory pain and disability. The reason for limb amputation is often due to treatment for cancer or trauma and it has a lower incidence compared to adults. The mechanism of why phantom pain exists remains uncertain and may be a result of cortical reorganisation as well as ectopic peripheral input. Treatment is aimed at reducing both symptoms as well as managing pain related disability and functional restoration. Neuromodulatory approaches using deep brain stimulation for phantom limb pain is reserved for only the most refractory cases. The targets for brain stimulation include the thalamic nuclei and motor cortex. Novel targets such as the anterior cingulate cortex remain experimental as cases of serious adverse effects such as seziures have limited their widespread uptake. A multidisciplinary approach is crucial to successful rehabilitation using a biopsychosocial pain management approach.

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.

Advances in targeting central sensitization and brain plasticity in chronic pain

Maladaptation in sensory neural plasticity of nociceptive pathways is associated with various types of chronic pain through central sensitization and remodeling of brain connectivity. Within this context, extensive research has been conducted to evaluate the mechanisms and efficacy of certain non-pharmacological pain treatment modalities. These include neurostimulation, virtual reality, cognitive therapy and rehabilitation. Here, we summarize the involved mechanisms and review novel findings in relation to nociceptive desensitization and modulation of plasticity for the management of intractable chronic pain and prevention of acute-to-chronic pain transition.

Unveiling the phantom: What neuroimaging has taught us about phantom limb pain

Phantom limb pain (PLP) is a complicated condition with diverse clinical challenges. It consists of pain perception of a previously amputated limb. The exact pain mechanism is disputed and includes mechanisms involving cerebral, peripheral, and spinal origins. Such controversy limits researchers' and clinicians' ability to develop consistent therapeutics or management. Neuroimaging is an essential tool that can address this problem. This review explores diffusion tensor imaging, functional magnetic resonance imaging, electroencephalography, and magnetoencephalography in the context of PLP. These imaging modalities have distinct mechanisms, implications, applications, and limitations. Diffusion tensor imaging can outline structural changes and has surgical applications. Functional magnetic resonance imaging captures functional changes with spatial resolution and has therapeutic applications. Electroencephalography and magnetoencephalography can identify functional changes with a strong temporal resolution. Each imaging technique provides a unique perspective and they can be used in concert to reveal the true nature of PLP. Furthermore, researchers can utilize the respective strengths of each neuroimaging technique to support the development of innovative therapies. PLP exemplifies how neuroimaging and clinical management are intricately connected. This review can assist clinicians and researchers seeking a foundation for applications and understanding the limitations of neuroimaging techniques in the context of PLP.

Visualizing the Unseen: Illustrating and Documenting Phantom Limb Sensations and Phantom Limb Pain With C.A.L.A

Currently, there is neither a standardized mode for the documentation of phantom sensations and phantom limb pain, nor for their visualization as perceived by patients. We have therefore created a tool that allows for both, as well as for the quantification of the patient's visible and invisible body image. A first version provides the principal functions: (1) Adapting a 3D avatar for self-identification of the patient; (2) modeling the shape of the phantom limb; (3) adjusting the position of the phantom limb; (4) drawing pain and cramps directly onto the avatar; and (5) quantifying their respective intensities. Our tool (C.A.L.A.) was evaluated with 33 occupational therapists, physiotherapists, and other medical staff. Participants were presented with two cases in which the appearance and the position of the phantom had to be modeled and pain and cramps had to be drawn. The usability of the software was evaluated using the System Usability Scale and its functional range was evaluated using a self-developed questionnaire and semi-structured interview. In addition, our tool was evaluated on 22 patients with limb amputations. For each patient, body image as well as phantom sensation and pain were modeled to evaluate the software's functional scope. The accuracy of the created body image was evaluated using a self-developed questionnaire and semi-structured interview. Additionally, pain sensation was assessed using the SF-McGill Pain Questionnaire. The System Usability Scale reached a level of 81%, indicating high usability. Observing the participants, though, identified several operational difficulties. While the provided functions were considered useful by most participants, the semi-structured interviews revealed the need for an improved pain documentation component. In conclusion, our tool allows for an accurate visualization of phantom limbs and phantom limb sensations. It can be used as both a descriptive and quantitative documentation tool for analyzing and monitoring phantom limbs. Thus, it can help to bridge the gap between the therapist's conception and the patient's perception. Based on the collected requirements, an improved version with extended functionality will be developed.

Central nervous system stimulation therapies in phantom limb pain: a systematic review of clinical trials

Phantom limb pain is a chronic pain syndrome that is difficult to cope with. Despite neurostimulation treatment is indicated for refractory neuropathic pain, there is scant evidence from randomized controlled trials to recommend it as the treatment choice. Thus, a systematic review was performed to analyze the efficacy of central nervous system stimulation therapies as a strategy for pain management in patients with phantom limb pain. A literature search for studies conducted between 1970 and September 2020 was carried out using the MEDLINE and Embase databases. Principles of The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline were followed. There were a total of 10 full-text articles retrieved and included in this review. Deep brain stimulation, repetitive transcranial magnetic stimulation, transcranial direct current stimulation, and motor cortex stimulation were the treatment strategies used in the selected clinical trials. Repetitive transcranial magnetic stimulation and transcranial direct current stimulation were effective therapies to reduce pain perception, as well as to relieve anxiety and depression symptoms in phantom limb pain patients. Conversely, invasive approaches were considered the last treatment option as evidence in deep brain stimulation and motor cortex stimulation suggests that the value of phantom limb pain treatment remains controversial. However, the findings on use of these treatment strategies in other forms of neuropathic pain suggest that these invasive approaches could be a potential option for phantom limb pain patients.

Challenges and Potential in Targeted Muscle Reinnervation in Pediatric Amputees

Targeted muscle reinnervation (TMR) is a powerful new tool in preventing and treating residual limb and phantom limb pain. In the adult population, TMR is rapidly becoming standard of care; however, there is a paucity of literature regarding indications and outcomes of TMR in the pediatric population. We present 2 cases of pediatric patients who sustained amputations and the relevant challenges associated with TMR in their cases. One is a 7-year-old patient who developed severe phantom and residual limb pain after a posttraumatic above-knee amputation. He failed pharmacologic measures and underwent TMR. He obtained complete relief of his symptoms and is continuing to do well 1.5 years postoperatively. The other is a 2-year-old boy with bilateral wrist and below-knee amputations as sequelae of sepsis. TMR was not performed because the patient never demonstrated evidence of phantom limb pain or symptomatic neuroma formation. We use these 2 cases to explore the challenges particular to pediatric patients when considering treatment with TMR, including capacity to report pain, risks of anesthesia, and cortical plasticity. These issues will be critical in determining how TMR will be applied to pediatric patients.

Psychedelics in the Treatment of Headache and Chronic Pain Disorders

The therapeutic potential of psychedelics in headache and chronic pain disorders is documented over decades of anecdotal and early investigational reports, which have paved the way for the first controlled studies of psilocybin and lysergic acid diethylamide (LSD) in these disorders. The reported lasting clinical effects after limited dosing with psychedelics present a novel means for disease management, but considerable further study will be required to address disease-specific treatments, uncover mechanism(s) of action, and verify safety. In this chapter, these topics are reviewed with particular attention to the neurobiological systems that offer potential sources of psychedelics' unique clinical effects in headache and pain.