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Roehrich K, Goldberg M, Fiedler G. Robotic-Enhanced Prosthetic Liners for Vibration Therapy: Reducing Phantom Limb Pain in Transfemoral Amputees. SENSORS (BASEL, SWITZERLAND) 2024; 24:5026. [PMID: 39124074 PMCID: PMC11314703 DOI: 10.3390/s24155026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Revised: 07/23/2024] [Accepted: 07/31/2024] [Indexed: 08/12/2024]
Abstract
Phantom limb pain, a common challenge for amputees, lacks effective treatment options. Vibration therapy is a promising non-pharmacologic intervention for reducing pain intensity, but its efficacy in alleviating phantom limb pain requires further investigation. This study focused on developing prosthesis liners with integrated vibration motors to administer vibration therapy for phantom limb pain. The prototypes developed for this study addressed previous issues with wiring the electronic components. Two transfemoral amputees participated in a four-week at-home trial, during which they used the vibration liner and rated their initial and final pain intensity on a numeric rating scale each time they had phantom pain. Semi-structured interviews were conducted to gather feedback following the at-home trial. Both participants described relaxing and soothing sensations in their residual limb and phantom limb while using vibration therapy. One participant reported a relaxation of his phantom limb sensations, while both participants noted a decrease in the intensity of their phantom limb pain. Participants said the vibration liners were comfortable but suggested that the vibration could be stronger and that aligning the contacts could be easier. The results of this study highlight the potential effectiveness of using vibration therapy to reduce the intensity of phantom limb pain and suggest a vibration liner may be a feasible mode of administering the therapy. Future research should address optimizing the performance of the vibration liners to maximize their therapeutic benefits.
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Affiliation(s)
- Kacey Roehrich
- Department of Rehabilitation Science and Technology, School of Health and Rehabilitation Science, University of Pittsburgh, Pittsburgh, PA 15206, USA;
| | | | - Goeran Fiedler
- Department of Rehabilitation Science and Technology, School of Health and Rehabilitation Science, University of Pittsburgh, Pittsburgh, PA 15206, USA;
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Zernitz M, Rizzello C, Rigoni M, Van de Winckel A. Case Report: Phantom limb pain relief after cognitive multisensory rehabilitation. FRONTIERS IN PAIN RESEARCH 2024; 5:1374141. [PMID: 38726352 PMCID: PMC11079144 DOI: 10.3389/fpain.2024.1374141] [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: 01/21/2024] [Accepted: 04/15/2024] [Indexed: 05/12/2024] Open
Abstract
Introduction Relieving phantom limb pain (PLP) after amputation in patients resistant to conventional therapy remains a challenge. While the causes for PLP are unclear, one model suggests that maladaptive plasticity related to cortical remapping following amputation leads to altered mental body representations (MBR) and contributes to PLP. Cognitive Multisensory Rehabilitation (CMR) has led to reduced pain in other neurologic conditions by restoring MBR. This is the first study using CMR to relieve PLP. Methods A 26-year-old woman experienced excruciating PLP after amputation of the third proximal part of the leg, performed after several unsuccessful treatments (i.e., epidural stimulator, surgeries, analgesics) for debilitating neuropathic pain in the left foot for six years with foot deformities resulting from herniated discs. The PLP was resistant to pain medication and mirror therapy. PLP rendered donning a prosthesis impossible. The patient received 35 CMR sessions (2×/day during weekdays, October-December 2012). CMR provides multisensory discrimination exercises on the healthy side and multisensory motor imagery exercises of present and past actions in both limbs to restore MBR and reduce PLP. Results After CMR, PLP reduced from 6.5-9.5/10 to 0/10 for neuropathic pain with only 4-5.5/10 for muscular pain after exercising on the Numeric Pain Rating Scale. McGill Pain Questionnaire scores reduced from 39/78 to 5/78, and Identity (ID)-Pain scores reduced from 5/5 to 0/5. Her pain medication was reduced by at least 50% after discharge. At 10-month follow-up (9/2013), she no longer took Methadone or Fentanyl. After discharge, receiving CMR as outpatient, she learned to walk with a prosthesis, and gradually did not need crutches anymore to walk independently indoors and outdoors (9/2013). At present (3/2024), she no longer takes pain medication and walks independently with the prosthesis without assistive devices. PLP is under control. She addresses flare-ups with CMR exercises on her own, using multisensory motor imagery, bringing the pain down within 10-15 min. Conclusion The case study seems to support the hypothesis that CMR restores MBR which may lead to long-term (12-year) PLP reduction. MBR restoration may be linked to restoring accurate multisensory motor imagery of the remaining and amputated limb regarding present and past actions.
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Affiliation(s)
- Marina Zernitz
- Centro Studi di Riabilitazione Neurocognitiva, Villa Miari, Vicenza, Italy
| | - Carla Rizzello
- Centro Studi di Riabilitazione Neurocognitiva, Villa Miari, Vicenza, Italy
| | - Marco Rigoni
- Centro Studi di Riabilitazione Neurocognitiva, Villa Miari, Vicenza, Italy
| | - Ann Van de Winckel
- Division of Physical Therapy and Rehabilitation Science, Department of Family Medicine and Community Health, Medical School, University of Minnesota Twin Cities, Minneapolis, MN, United States
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Yang H, Yanagisawa T. Is Phantom Limb Awareness Necessary for the Treatment of Phantom Limb Pain? Neurol Med Chir (Tokyo) 2024; 64:101-107. [PMID: 38267056 PMCID: PMC10992984 DOI: 10.2176/jns-nmc.2023-0206] [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] [Received: 09/10/2023] [Accepted: 10/31/2023] [Indexed: 01/26/2024] Open
Abstract
Phantom limb pain is attributed to abnormal sensorimotor cortical representations. Various feedback treatments have been applied to induce the reorganization of the sensorimotor cortical representations to reduce pain. We developed a training protocol using a brain-computer interface (BCI) to induce plastic changes in the sensorimotor cortical representation of phantom hand movements and demonstrated that BCI training effectively reduces phantom limb pain. By comparing the induced cortical representation and pain, the mechanisms worsening the pain have been attributed to the residual phantom hand representation. Based on our data obtained using neurofeedback training without explicit phantom hand movements and hand-like visual feedback, we suggest a direct relationship between cortical representation and pain. In this review, we summarize the results of our BCI training protocol and discuss the relationship between cortical representation and phantom limb pain. We propose a treatment for phantom limb pain based on real-time neuroimaging to induce appropriate cortical reorganization by monitoring cortical activities.
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Affiliation(s)
- Huixiang Yang
- Institute for Advanced Co-creation Studies, Osaka University
| | - Takufumi Yanagisawa
- Institute for Advanced Co-creation Studies, Osaka University
- Department of Neurosurgery, Graduate School of Medicine, Osaka University
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Falbo KJ, Phelan H, Hackman D, Vogsland R, Rich TL. Graded motor imagery and its phases for individuals with phantom limb pain following amputation: A scoping review. Clin Rehabil 2024; 38:287-304. [PMID: 37849299 PMCID: PMC10860367 DOI: 10.1177/02692155231204185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 09/11/2023] [Indexed: 10/19/2023]
Abstract
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.
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Affiliation(s)
- Kierra Jean Falbo
- Research Department, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Rehabilitation Science, University of Minnesota Twin Cities, Minneapolis, MN, USA
| | - Hannah Phelan
- Research Department, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Medical School, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Dawn Hackman
- Health Sciences Library, University of Minnesota Twin Cities, Minneapolis, MN, USA
| | - Rebecca Vogsland
- Rehabilitation and Extended Care, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Tonya L Rich
- Rehabilitation Science, University of Minnesota Twin Cities, Minneapolis, MN, USA
- Rehabilitation and Extended Care, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
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Knorst GRS, Souza PRD, Araújo AGPD, Knorst SAF, Diniz DS, Filho HFDS. Transcranial magnetic stimulation in the treatment of phantom limb pain: a systematic review. ARQUIVOS DE NEURO-PSIQUIATRIA 2024; 82:1-10. [PMID: 38286434 PMCID: PMC10824589 DOI: 10.1055/s-0044-1779051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 10/07/2023] [Indexed: 01/31/2024]
Abstract
BACKGROUND Phantom limb pain (PLP) occurs after amputations and can persist in a chronic and debilitating way. Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive neuromodulation method capable of influencing brain function and modulating cortical excitability. Its effectiveness in treating chronic pain is promising. OBJECTIVE To evaluate the evidence on the efficacy and safety of using rTMS in the treatment of PLP, observing the stimulation parameters used, side effects, and benefits of the therapy. METHODS This is a systematic review of scientific articles published in national and international literature using electronic platforms. RESULTS Two hundred and fifty two articles were identified. Two hundred and forty six publications were removed because they were duplicated or met the exclusion criteria. After selection, six studies were reviewed, those being two randomized clinical trials and four case reports. All evaluated studies indicated some degree of benefit of rTMS to relieve painful symptoms, even temporarily. Pain perception was lower at the end of treatment when compared to the period prior to the sessions and remained during patient follow-up. There was no standardization of the stimulation parameters used. There were no reports of serious adverse events. The effects of long-term therapy have not been evaluated. CONCLUSION There are some benefits, even if temporary, in the use of rTMS to relieve painful symptoms in PLP. High-frequency stimulation at M1 demonstrated a significant analgesic effect. Given the potential that has been demonstrated, but limited by the paucity of high-quality studies, further controlled studies are needed to establish and standardize the clinical use of the method.
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Affiliation(s)
| | - Phamella Rocha de Souza
- Universidade Federal de Goiás, Hospital das Clínicas, Departamento de Neurologia, Goiânia GO, Brazil.
| | | | | | - Denise Sisterolli Diniz
- Universidade Federal de Goiás, Hospital das Clínicas, Departamento de Neurologia, Goiânia GO, Brazil.
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Grant PE, Caneris OA, Gonzalez RG, Iadarola MJ, Sapio MR, Mannes AJ, Borsook D. Analgesia after dorsal root ganglionic injection under CT-guidance in a patient with intractable phantom limb pain. PAIN MEDICINE (MALDEN, MASS.) 2023; 24:1122-1123. [PMID: 36975616 PMCID: PMC10472484 DOI: 10.1093/pm/pnad039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/16/2023] [Accepted: 03/20/2023] [Indexed: 03/29/2023]
Affiliation(s)
- P Ellen Grant
- Departments of Medicine and Radiology, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Onassis A Caneris
- Department of Interventional Spine Treatment and Pain Management, Riverhills Neuroscience, Cincinnati, OH 45212, United States
| | - Ramon G Gonzalez
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
| | - Michael J Iadarola
- Department of Perioperative Medicine, Clinical Center, National Institutes of Health, PHS, DHHS, Bethesda, MD 20892, United States
| | - Matthew R Sapio
- Department of Perioperative Medicine, Clinical Center, National Institutes of Health, PHS, DHHS, Bethesda, MD 20892, United States
| | - Andrew J Mannes
- Department of Perioperative Medicine, Clinical Center, National Institutes of Health, PHS, DHHS, Bethesda, MD 20892, United States
| | - David Borsook
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
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Eberlin KR, Brown DA, Gaston RG, Kleiber GM, Ko JH, Kovach SJ, Loeffler BJ, MacKay BJ, Potter BK, Roubaud MS, Souza JM, Valerio IL, Dumanian GA. A Consensus Approach for Targeted Muscle Reinnervation in Amputees. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4928. [PMID: 37035125 PMCID: PMC10079335 DOI: 10.1097/gox.0000000000004928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 02/21/2023] [Indexed: 04/08/2023]
Abstract
Amputations have been performed with few modifications since the dawn of surgery. Blood vessels are ligated, bones are shortened, and nerves are cut. In a percentage of people, this can result in severe neuropathic, residual limb, and phantom limb pain. Targeted muscle reinnervation is a surgical procedure initially conceived to optimize function for myoelectric prostheses in amputees. Recently, it has been adopted more widely by surgeons for the prevention and treatment of neuropathic pain. Perhaps as a function of its relatively recent development, many authors perform this operation differently, and there has been no overall agreement regarding the principles, indications, technical specifics, and postoperative management guidelines. This article is written as a consensus statement by surgeons focused on the treatment of neuropathic pain and those with extensive experience performing targeted muscle reinnervation. It is designed to serve as a roadmap and template for extremity surgeons to consider when performing targeted muscle reinnervation.
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Affiliation(s)
- Kyle R. Eberlin
- From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - David A. Brown
- Division of Plastic, Maxillofacial, and Oral Surgery, Duke University Medical Center, Durham, N.C
| | - R. Glenn Gaston
- OrthoCarolina Hand and Upper Extremity Department and Atrium Health Department of Orthopedic Surgery, Charlotte, N.C
| | - Grant M. Kleiber
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, D.C
| | - Jason H. Ko
- Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Stephen J. Kovach
- Division of Plastic Surgery, Department of Orthopaedic Surgery, University of Pennsylvania Health System, Philadelphia, Pa
| | - Bryan J. Loeffler
- OrthoCarolina Hand and Upper Extremity Department and Atrium Health Department of Orthopedic Surgery, Charlotte, N.C
| | - Brendan J. MacKay
- Department of Orthopedic Surgery, Texas Tech University Health Science Center, Lubbock, Tex
| | - Benjamin K. Potter
- Uniformed Services University – Walter Reed Department of Surgery, Bethesda, Md
| | - Margaret S. Roubaud
- Department of Plastic and Reconstructive Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Jason M. Souza
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Ian L. Valerio
- From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Gregory A. Dumanian
- Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
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Arizona P, Yulianti E, Fithriyah I. Psychiatric Approach in Phantom Erection Postpenectomy Patient. Case Rep Psychiatry 2023; 2023:4113455. [PMID: 37032998 PMCID: PMC10081895 DOI: 10.1155/2023/4113455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/17/2023] [Accepted: 03/17/2023] [Indexed: 04/03/2023] Open
Abstract
Introduction. Phantom limb pain is a pain sensation experienced in the area of the missing body part. The pain generally appears in the first few days after surgery. PLP could occur in teeth, tongue, breast, eyes, rectum, bladder, testicles, and penis. Phantom pain in the penis is not only felt as pain but sometimes as an erection or urination, even after the removal of the penis. Clinical Case. A 35-year-old man was referred to the psychiatrist due to phantom erection after undergoing reimplantation of the penis by the urologist. A few days before the referral, he was admitted to the emergency department after a penile amputation that his wife performed. During the recovery phase after the penile reimplantation procedure, the patient worried about his penis’ outcome and became depressed. The patient was in severe anxiety and moderate-to-severe depression status. Treatment. The patient was given nonpsychopharmacology such as supportive psychotherapy, family psychoeducation, relaxation and marital therapy, and psychopharmacology, such as amitriptyline 12.5 Mg PO two times a day and clobazam 10 Mg PO each day for 3 months. One and a half months later, his anxiety and depression were better. Conclusion. A psychiatric approach was needed in an amputated limb patient with psychopathologic symptoms. Nonpsychopharmacotherapy and psychopharmacotherapy were needed if the patient had symptoms. Further studies with a large number will be necessary to validate the psychiatric approach in amputated limb patients with psychopathologic symptoms cases.
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Affiliation(s)
- Popy Arizona
- Department of Psychiatry, Dr. Soetomo General Academic Hospital, Universitas Airlangga, Surabaya, Indonesia
| | - Erikavitri Yulianti
- Department of Psychiatry, Dr. Soetomo General Academic Hospital, Universitas Airlangga, Surabaya, Indonesia
| | - Izzatul Fithriyah
- Department of Psychiatry, Dr. Soetomo General Academic Hospital, Universitas Airlangga, Surabaya, Indonesia
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X-reality for Phantom Limb Management for Amputees: A Systematic Review and Meta-Analysis. ENGINEERED REGENERATION 2023. [DOI: 10.1016/j.engreg.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
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Beisheim-Ryan EH, Pohlig RT, Hicks GE, Horne JR, Sions JM. Post-amputation pain: Comparing pain presentations between adults with and without increased amputated-region sensitivity. Pain Pract 2023; 23:155-166. [PMID: 36250812 PMCID: PMC9905279 DOI: 10.1111/papr.13172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 09/27/2022] [Accepted: 10/11/2022] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Emma Haldane Beisheim-Ryan
- University of Delaware Department of Physical Therapy, 540 South College Avenue, Newark, DE, 19713, USA
- VA Eastern Colorado Geriatric Research, Education, and Clinical Center (GRECC), VA Eastern Colorado Health Care System, 1700 N Wheeling Street, Aurora, CO, 80045, USA
| | - Ryan Todd Pohlig
- University of Delaware Biostatistics Core, 102B STAR Tower, Newark, DE, 19713, USA
| | - Gregory Evan Hicks
- University of Delaware Department of Physical Therapy, 540 South College Avenue, Newark, DE, 19713, USA
| | - John Robert Horne
- Independence Prosthetics-Orthotics, Inc., 550 South College Avenue, Suite 111, Newark, DE, 19713, USA
| | - Jaclyn Megan Sions
- University of Delaware Department of Physical Therapy, 540 South College Avenue, Newark, DE, 19713, USA
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Sperry BP, Cheney CW, Kuo KT, Clements N, Burnham T, Conger A, Cushman DM, McCormick ZL. Percutaneous treatments for residual and/or phantom limb pain in adults with lower-extremity amputations: A narrative review. PM R 2023; 15:235-245. [PMID: 34628724 DOI: 10.1002/pmrj.12722] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 09/11/2021] [Accepted: 09/27/2021] [Indexed: 11/10/2022]
Abstract
Residual limb pain (RLP) and phantom limb pain (PLP) profoundly affect the lives of many individuals who have undergone lower- or upper-extremity amputation. Despite the considerable impact of RLP/PLP on quality of life in persons with amputation, there have been few attempts to evaluate the efficacy of percutaneous interventions in the treatment of RLP and/or PLP. This narrative review evaluates the effectiveness of percutaneous treatments for RLP and/or PLP in patients after lower-extremity amputation. Peripheral nerve stimulation, alcohol neurolysis, conventional thermal radiofrequency ablation, perineural corticosteroid injection, botulinum toxin injection, and etanercept injection were associated with varying success rates. Wide confidence intervals and small treatment cohorts impede assessments of overall success. High-quality studies of nonsurgical, percutaneous treatments for RLP and/or PLP are lacking. Well-designed randomized controlled trials and large cohort studies with comparison groups using validated outcomes are needed to determine the effectiveness of nonsurgical interventions for the treatment of RLP and PLP.
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Affiliation(s)
- Beau P Sperry
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Cole W Cheney
- Division of Physical Medicine & Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Keith T Kuo
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Nathan Clements
- Department of Physical Medicine & Rehabilitation, UTSA Health System, San Antonio, Texas, USA
| | - Taylor Burnham
- Division of Physical Medicine & Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Aaron Conger
- Division of Physical Medicine & Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Daniel M Cushman
- Division of Physical Medicine & Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Zachary L McCormick
- Division of Physical Medicine & Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Ilfeld BM, Smith CR, Turan A, Mariano ER, Miller ME, Fisher RL, Trescot AM, Cohen SP, Eisenach JC, Sessler DI, Prologo JD, Mascha EJ, Liu L, Gabriel RA. Ultrasound-guided Percutaneous Cryoneurolysis to Treat Chronic Postamputation Phantom Limb Pain: A Multicenter Randomized Controlled Trial. Anesthesiology 2023; 138:82-97. [PMID: 36512721 PMCID: PMC10374196 DOI: 10.1097/aln.0000000000004429] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Postamputation phantom pain is notoriously persistent with few validated treatments. Cryoneurolysis involves the application of low temperatures to reversibly ablate peripheral nerves. The authors tested the hypothesis that a single cryoneurolysis treatment would decrease phantom pain 4 months later. METHODS The authors enrolled patients with a lower-limb amputation and established phantom pain. Each received a single-injection femoral and sciatic nerve block with lidocaine and was subsequently randomized to receive either ultrasound-guided percutaneous cryoneurolysis or sham treatment at these same locations. The primary outcome was the change in average phantom pain intensity between baseline and 4 months as measured with a numeric rating scale (0 to 10), after which an optional crossover treatment was offered. Investigators, participants, and clinical staff were masked to treatment group assignment with the exception of the treating physician performing the cryoneurolysis, who had no subsequent participant interaction. RESULTS Pretreatment phantom pain scores were similar in both groups, with a median [quartiles] of 5.0 [4.0, 6.0] for active treatment and 5.0 [4.0, 7.0] for sham. After 4 months, pain intensity decreased by 0.5 [-0.5, 3.0] in patients given cryoneurolysis (n = 71) versus 0 [0, 3] in patients given sham (n = 73), with an estimated difference (95% CI) of -0.1 (-1.0 to 0.7), P = 0.759. Following their statistical gatekeeping protocol, the authors did not make inferences or draw conclusions on secondary endpoints. One serious adverse event occurred after a protocol deviation in which a femoral nerve cryolesion was induced just below the inguinal ligament-instead of the sensory-only saphenous nerve-which resulted in quadriceps weakness, and possibly a fall and clavicle fracture. CONCLUSIONS Percutaneous cryoneurolysis did not decrease chronic lower extremity phantom limb pain 4 months after treatment. However, these results were based upon the authors' specific study protocol, and since the optimal cryoneurolysis treatment parameters such as freeze duration and anatomic treatment location remain unknown, further research is warranted. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Brian M. Ilfeld
- Department of Anesthesiology, University of California San Diego, San Diego, California; Outcomes Research Consortium
| | | | - Alparslan Turan
- Departments of General Anesthesia and Outcomes Research, Cleveland Clinic, Cleveland, Ohio; Outcomes Research Consortium
| | - Edward R. Mariano
- Department of Anesthesiology, Perioperative and Pain Medicine, Palo Alto Veterans Affairs, Palo Alto, California
| | - Matthew E. Miller
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Rick L. Fisher
- Department of Anesthesiology, Naval Medical Center San Diego, San Diego, California
| | - Andrea M. Trescot
- Florida Pain Relief Group, Florida Pain Relief Group, Tampa, Florida
| | - Steven P. Cohen
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, Maryland; Johns Hopkins, Baltimore, Maryland
| | - James C. Eisenach
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Daniel I. Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio; Outcomes Research Consortium
| | | | - Edward J. Mascha
- Departments of Quantitative Health Sciences and Outcomes Research, Cleveland Clinic, Cleveland, Ohio; Outcomes Research Consortium
| | - Liu Liu
- Departments of Quantitative Health Sciences and Outcomes Research, Cleveland Clinic, Cleveland, Ohio; Outcomes Research Consortium
| | - Rodney A. Gabriel
- Department of Anesthesiology, University of California San Diego, San Diego, California; Outcomes Research Consortium
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Easing the financial burden on upper limb amputees: Grants to support academics and quality of life in North America. J Plast Reconstr Aesthet Surg 2023; 76:142-144. [PMID: 36516505 DOI: 10.1016/j.bjps.2022.11.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 11/16/2022] [Accepted: 11/17/2022] [Indexed: 11/24/2022]
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14
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Schone HR, Baker CI, Katz J, Nikolajsen L, Limakatso K, Flor H, Makin TR. Making sense of phantom limb pain. J Neurol Neurosurg Psychiatry 2022; 93:jnnp-2021-328428. [PMID: 35609964 PMCID: PMC9304093 DOI: 10.1136/jnnp-2021-328428] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 04/04/2022] [Indexed: 01/01/2023]
Abstract
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.
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Affiliation(s)
- Hunter R Schone
- NIMH, National Institutes of Health, Bethesda, Maryland, USA
- Institute of Cognitive Neuroscience, University College London, London, UK
| | - Chris I Baker
- NIMH, National Institutes of Health, Bethesda, Maryland, USA
| | - Joel Katz
- Department of Psychology, York University, Toronto, Ontario, Canada
- Transitional Pain Service, Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | - Lone Nikolajsen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Katleho Limakatso
- Department of Anaesthesia and Perioperative Medicine, Pain Management Unit, Neuroscience Institute, University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Herta Flor
- Institute of Cognitive and Clinical Neuroscience, Central Institute of Mental Health/Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Center for Neuroplasticity and Pain, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Tamar R Makin
- Institute of Cognitive Neuroscience, University College London, London, UK
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15
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Gupta N, Leung C. The effect of post-amputation pain on health-related quality of life in lower limb amputees. Disabil Rehabil 2022; 44:2325-2331. [DOI: 10.1080/09638288.2020.1832589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- N. Gupta
- Rehabilitation Medicine Department, Westmead Hospital, Sydney, Australia
| | - C. Leung
- Rehabilitation Medicine Department, Westmead Hospital, Sydney, Australia
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16
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Klinisches Update zu Phantomschmerz. Schmerz 2022; 37:195-214. [DOI: 10.1007/s00482-022-00629-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2022] [Indexed: 10/18/2022]
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17
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Browne JD, Fraiser R, Cai Y, Leung D, Leung A, Vaninetti M. Unveiling the phantom: What neuroimaging has taught us about phantom limb pain. Brain Behav 2022; 12:e2509. [PMID: 35218308 PMCID: PMC8933774 DOI: 10.1002/brb3.2509] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 12/05/2021] [Accepted: 01/11/2022] [Indexed: 11/08/2022] Open
Abstract
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.
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Affiliation(s)
- Jonathan D Browne
- School of Medicine, California University of Science and Medicine, Colton, California, USA
| | - Ryan Fraiser
- Center for Pain Medicine, University of California San Diego, La Jolla, California, USA
| | - Yi Cai
- Center for Pain Medicine, University of California San Diego, La Jolla, California, USA
| | - Dillon Leung
- College of Letters and Science, University of California Berkeley, Berkeley, California, USA
| | - Albert Leung
- Center for Pain Medicine, University of California San Diego, La Jolla, California, USA
| | - Michael Vaninetti
- Center for Pain Medicine, University of California San Diego, La Jolla, California, USA
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18
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Lendaro E, Earley EJ, Ortiz-Catalan M. Statistical analysis plan for an international, double-blind, randomized controlled clinical trial on the use of phantom motor execution as a treatment for phantom limb pain. Trials 2022; 23:138. [PMID: 35152915 PMCID: PMC8842736 DOI: 10.1186/s13063-021-05962-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 12/21/2021] [Indexed: 11/19/2022] Open
Abstract
Background Phantom limb pain (PLP) is a detrimental condition that can greatly diminish the quality of life. Purposeful control over the phantom limb activates the affected neural circuitry and leads to dissolution of the pathological relationship linking sensorimotor and pain processing (which gives rise to PLP). An international, double-blind, randomized controlled clinical trial (RCT) on the use of phantom motor execution (PME) as a treatment for PLP is currently undertaken, where PME is compared to an active placebo treatment, namely phantom motor imagery (PMI). Methods and design Sixty-seven subjects suffering from PLP in upper or lower limbs are randomly assigned in 2:1 ratio to PME or PMI interventions respectively. Subjects allocated to either treatment receive 15 interventions where they are exposed to the same VR-AR environments using the same device. The only difference between interventions is whether phantom movements are performed (PME) or imagined (PMI). Results The primary outcome of the study is to examine whether 15 sessions of PME can induce a greater PLP relief, compared to PMI. The secondary objectives are to examine whether 15 sessions of PME provide a greater improvement in different aspects related to PLP compared to PMI, such as pain duration, pain intensity as measured by other metrics, and the patient’s own impression about the effect of treatment. Long-term retention of treatment benefits will be assessed as change in all the variables (both primary and secondary) between baseline and follow-up timepoints (at 1, 3, and 6 months post-treatment). Conclusion This manuscript serves as the formal statistical analysis plan (version 1.0) for the international, double-blind, randomized controlled clinical trial on the use of PME as a treatment for PLP. The statistical analysis plan was completed on 3 August 2021. Trial registration ClinicalTrials.govNCT03112928. Registered on April 13, 2017 SAP version: version: 1.0, date: 2021/08/03 Protocol version: This document has been written based on information contained in the study protocol published in Lendaro et al. (BMJ Open 8:e021039, 2018), in July 2018. SAP revisions: Not applicable
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19
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Bressler M, Merk J, Heinzel J, Butz MV, Daigeler A, Kolbenschlag J, Prahm C. Visualizing the Unseen: Illustrating and Documenting Phantom Limb Sensations and Phantom Limb Pain With C.A.L.A. FRONTIERS IN REHABILITATION SCIENCES 2022; 3:806114. [PMID: 36189032 PMCID: PMC9397903 DOI: 10.3389/fresc.2022.806114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 01/14/2022] [Indexed: 11/13/2022]
Abstract
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.
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Affiliation(s)
- Michael Bressler
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Clinic, University of Tuebingen, Tuebingen, Germany
| | - Joachim Merk
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Clinic, University of Tuebingen, Tuebingen, Germany
| | - Johannes Heinzel
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Clinic, University of Tuebingen, Tuebingen, Germany
| | - Martin V. Butz
- Neuro-Cognitive Modeling Group, Department of Computer Science and Department of Psychology, Faculty of Science, Eberhard Karls University, Tuebingen, Germany
| | - Adrien Daigeler
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Clinic, University of Tuebingen, Tuebingen, Germany
| | - Jonas Kolbenschlag
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Clinic, University of Tuebingen, Tuebingen, Germany
| | - Cosima Prahm
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Clinic, University of Tuebingen, Tuebingen, Germany
- *Correspondence: Cosima Prahm
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20
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Pacheco-Barrios K, Cardenas-Rojas A, de Melo PS, Marduy A, Gonzalez-Mego P, Castelo-Branco L, Mendes AJ, Vásquez-Ávila K, Teixeira PE, Gianlorenco ACL, Fregni F. Home-based transcranial direct current stimulation (tDCS) and motor imagery for phantom limb pain using statistical learning to predict treatment response: an open-label study protocol. PRINCIPLES AND PRACTICE OF CLINICAL RESEARCH (2015) 2021; 7:8-22. [PMID: 35434309 PMCID: PMC9009528 DOI: 10.21801/ppcrj.2021.74.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Background Phantom limb pain (PLP) management has been a challenge due to its response heterogeneity and lack of treatment access. This study will evaluate the feasibility of a remotely home-based M1 anodal tDCS combined with motor imagery in phantom limb patients and assess the preliminary efficacy, safety, and predictors of response of this therapy. Methods This is a pilot, single-arm, open-label trial in which we will recruit 10 subjects with phantom limb pain. The study will include 20 sessions. All participants will receive active anodal M1 tDCS combined with phantom limb motor imagery training. Our primary outcome will be the acceptability and feasibility of this combined intervention. Moreover, we will assess preliminary clinical (pain intensity) and physiological (motor inhibition tasks and heart rate variability) changes after treatment. Finally, we will implement a supervised statistical learning (SL) model to identify predictors of treatment response (to tDCS and phantom limb motor imagery) in PLP patients. We will also use data from our previous clinical trial (total observations=224 [n=112 x timepoints = 2)) for our statistical learning algorithms. The new prospective data from this open-label study will be used as an independent test dataset. Discussion This protocol proposes to assess the feasibility of a novel, neuromodulatory combined intervention that will allow the design of larger remote clinical trials, thus increasing access to safe and effective treatments for PLP patients. Moreover, this study will allow us to identify possible predictors of pain response and PLP clinical endotypes.
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Affiliation(s)
- Kevin Pacheco-Barrios
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, USA
- Universidad San Ignacio de Loyola, Vicerrectorado de Investigación, Unidad de Investigación para la Generación y Síntesis de Evidencias en Salud, Lima, Peru
| | - Alejandra Cardenas-Rojas
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Paulo S. de Melo
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Anna Marduy
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Paola Gonzalez-Mego
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Luis Castelo-Branco
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Augusto J. Mendes
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, USA
- Psychological Neuroscience Laboratory, CIPsi, School of Psychology, University of Minho, Campus de Gualtar, Braga, Portugal
| | - Karen Vásquez-Ávila
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Paulo E.P. Teixeira
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Anna Carolyna Lepesteur Gianlorenco
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, USA
- Department of Physical Therapy, Federal University of Sao Carlos, Brazil
| | - Felipe Fregni
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, USA
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21
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Folch A, Gallo D, Miró J, Salvador-Carulla L, Martínez-Leal R. Mirror therapy for phantom limb pain in moderate intellectual disability. A case report. Eur J Pain 2021; 26:246-254. [PMID: 34464481 DOI: 10.1002/ejp.1859] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 08/30/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Phantom limb pain (PLP) is a common problem after limb amputation. There is mounting evidence supporting the use of mirror therapy (MT) in the treatment of individuals with PLP. However, there is no research studying the effects of MT on PLP in individuals with intellectual developmental disorders (IDD). The aim of this study was to increase our understanding of MT when used with adults with IDD and PLP through a case study approach. METHODS Here, we describe the use of MT with a 53-year-old female with moderate IDD and PLP, related to her left leg being amputated after ulcer complications. The study followed an A-B-A-B design (baseline-treatment-withdrawal of treatment-re-introduction of treatment), lasting 2 years, which included a long-term follow-up. RESULTS The data showed that the PLP sensation decreased after the MT treatment, with a raw change of 3.92 points and a 48% decrease in mean pain intensity ratings from pre- to post-treatment. CONCLUSIONS This is a unique case-report on the use of MT with an individual with IDD suffering from PLP. The findings show that MT helped to significantly reduce the intensity of the PLP in this patient. SIGNIFICANCE This is a case-report that illustrates how mirror therapy can be applied to people with intellectual developmental disorders and phantom limb pain. The results showed that phantom limb pain decreased after the mirror therapy, with a raw change of 3,92 points and a percent change of 48%.
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Affiliation(s)
- Annabel Folch
- UNIVIDD, Intellectual Disability and Developmental Disorders Research Unit, Fundació Villablanca, IISPV, Institut d'Investigació Sanitària Pere Virgili, CIBERSAM, Centro de Investigación Biomédica en Red, Departament de Psicologia, Universitat Rovira i Virgili, Reus, Spain
| | - Daniel Gallo
- UNIVIDD, Intellectual Disability and Developmental Disorders Research Unit, Fundació Villablanca, IISPV, Institut d'Investigació Sanitària Pere Virgili, CIBERSAM, Centro de Investigación Biomédica en Red, Departament de Psicologia, Universitat Rovira i Virgili, Reus, Spain
| | - Jordi Miró
- Unit for the Study and Treatment of Pain-ALGOS, Department of Psychology, Research Center for Behavior Assessment (CRAMC), Universitat Rovira i Virgili, Institut d'Investigació Sanitària Pere Virgili, Tarragona, Spain
| | - Luis Salvador-Carulla
- Centre for Mental Health Research, Research School of Population Health, ANU College of Health and Medicine, Australian National University, Canberra, Australia.,Menzies Centre for Health Policy, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Rafael Martínez-Leal
- UNIVIDD, Intellectual Disability and Developmental Disorders Research Unit, Fundació Villablanca, IISPV, Institut d'Investigació Sanitària Pere Virgili, CIBERSAM, Centro de Investigación Biomédica en Red, Departament de Psicologia, Universitat Rovira i Virgili, Reus, Spain
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22
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Affiliation(s)
- Stanisa Raspopovic
- Neuroengineering Laboratory, Institute for Robotics and Intelligent Systems, Department of Health Sciences and Technology, ETH Zürich, 8092 Zürich, Switzerland.
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23
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Ilfeld BM, Khatibi B, Maheshwari K, Madison SJ, Ali Sakr Esa W, Mariano ER, Kent ML, Hanling S, Sessler DI, Eisenach JC, Cohen SP, Mascha EJ, Yang D, Padwal JA, Turan A. Immediate Effects of a Continuous Peripheral Nerve Block on Postamputation Phantom and Residual Limb Pain: Secondary Outcomes From a Multicenter Randomized Controlled Clinical Trial. Anesth Analg 2021; 133:1019-1027. [PMID: 34314392 DOI: 10.1213/ane.0000000000005673] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND We recently reported that a 6-day continuous peripheral nerve block reduced established postamputation phantom pain 3 weeks after treatment ended. However, the immediate effects of perineural infusion (secondary outcomes) have yet to be reported. METHODS Participants from 5 enrolling academic centers with an upper or lower limb amputation and established phantom pain received a single-injection ropivacaine peripheral nerve block(s) and perineural catheter insertion(s). They were subsequently randomized to receive a 6-day ambulatory perineural infusion of either ropivacaine 0.5% or normal saline in a double-masked fashion. Participants were contacted by telephone 1, 7, 14, 21, and 28 days after the infusion started, with pain measured using the Numeric Rating Scale. Treatment effects were assessed using the Wilcoxon rank-sum test at each time point. Adjusting for 4 time points (days 1, 7, 14, and 21), P < .0125 was deemed statistically significant. Significance at 28 days was reported using methods from the original, previously published article. RESULTS Pretreatment average phantom and residual pain scores were balanced between the groups. The day after infusion initiation (day 1), average phantom, and residual limb pain intensity was lower in patients receiving local anesthetic (n = 71) versus placebo (n = 73): median [quartiles] of 0 [0-2.5] vs 3.3 [0-5.0], median difference (98.75% confidence interval [CI]) of -1.0 (-3.0 to 0) for phantom pain (P = .001) and 0 [0-0] vs 0 [0-4.3], and median difference 0.0 (-2.0 to 0.0) for residual limb pain (P < .001). Pain's interference with physical and emotional functioning as measured with the interference domain of the Brief Pain Inventory improved during the infusion on day 1 for patients receiving local anesthetic versus placebo: 0 [0-10] vs 10 [0-40], median difference (98.75% CI) of 0.0 (-16.0 to 0.0), P = .002. Following infusion discontinuation (day 6), a few differences were found between the active and placebo treatment groups between days 7 and 21. In general, sample medians for average phantom and residual limb pain scores gradually increased after catheter removal for both treatments, but to a greater degree in the control group until day 28, at which time the differences between the groups returned to statistical significance. CONCLUSIONS This secondary analysis suggests that a continuous peripheral nerve block decreases phantom and residual limb pain during the infusion, although few improvements were again detected until day 28, 3 weeks following catheter removal.
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Affiliation(s)
- Brian M Ilfeld
- From the Department of Anesthesiology, University of California San Diego, San Diego, California.,Department of Anesthesiology, The Outcomes Research Consortium, Cleveland, Ohio
| | - Bahareh Khatibi
- From the Department of Anesthesiology, University of California San Diego, San Diego, California
| | - Kamal Maheshwari
- Departments of General Anesthesia and Outcomes Research, Cleveland Clinic, Cleveland, Ohio.,Departments of General Anesthesia and Outcomes Research, The Outcomes Research Consortium, Cleveland, Ohio
| | - Sarah J Madison
- From the Department of Anesthesiology, University of California San Diego, San Diego, California
| | - Wael Ali Sakr Esa
- Departments of General Anesthesia and Outcomes Research, Cleveland Clinic, Cleveland, Ohio.,Departments of General Anesthesia and Outcomes Research, The Outcomes Research Consortium, Cleveland, Ohio
| | - Edward R Mariano
- Department of Anesthesiology, Perioperative and Pain Medicine, Palo Alto Veterans Affairs, Palo Alto, California
| | - Michael L Kent
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Steven Hanling
- Department of Anesthesiology, Naval Medical Center San Diego, San Diego, California
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio.,Department of Outcomes Research, The Outcomes Research Consortium, Cleveland, Ohio
| | - James C Eisenach
- Department of Anesthesiology, The Outcomes Research Consortium, Cleveland, Ohio.,Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Steven P Cohen
- Department of Anesthesiology, Johns Hopkins, Baltimore, Maryland
| | - Edward J Mascha
- Departments of Quantitative Health Sciences and Outcomes Research, Cleveland Clinic, Cleveland, Ohio.,Departments of Quantitative Health Sciences and Outcomes Research, The Outcomes Research Consortium, Cleveland, Ohio
| | - Dongsheng Yang
- Departments of Quantitative Health Sciences and Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Jennifer A Padwal
- Department of Radiology, University of California San Diego, San Diego, California.,Department of Radiology, Stanford University, Stanford, California
| | - Alparslan Turan
- Departments of General Anesthesia and Outcomes Research, Cleveland Clinic, Cleveland, Ohio.,Departments of General Anesthesia and Outcomes Research, The Outcomes Research Consortium, Cleveland, Ohio
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Hyung B, Wiseman-Hakes C. A scoping review of current non-pharmacological treatment modalities for phantom limb pain in limb amputees. Disabil Rehabil 2021; 44:5719-5740. [PMID: 34293999 DOI: 10.1080/09638288.2021.1948116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE Phantom limb pain (PLP) is a chronic neuropathic pain condition of a missing limb following amputation. Pain management is multi-modal, including various non-pharmacological therapies. The purpose of this scoping review was to investigate the evidence surrounding current non-pharmacological treatment modalities for PLP and provide insight into their clinical feasibility. METHOD A systematic search was conducted using four databases (Medline, Embase, PsychInfo, and CINAHL) following the PRISMA-ScR method. Results from papers meeting the inclusion criteria were charted to summarize findings, demographics, and use of neuroimaging. RESULTS A total of 3387 papers were identified, and full texts of 142 eligible papers were assessed. Eleven treatment modalities for PLP were identified with varying levels of evidence. Overall, there were 25 RCTs, 58 case reports, and 59 a combination of pilot, quasi-experimental, observational, and other study designs. CONCLUSIONS Currently, the evidence surrounding most treatment modalities is limited and only a fraction of studies are supported by strong evidence. The findings of this review demonstrated a clear need to conduct more rigorous research with diverse study designs to better understand which modalities provide the most benefit and to incorporate neuroimaging to better determine the neural correlates of PLP and mechanisms of various treatments.Implications for RehabilitationPhantom limb pain (PLP) is a prevalent and debilitating condition following amputation and health care professionals should incorporate an evidence-based pain management protocol into their rehabilitation program.There exist a number of different non-pharmacological therapies to address PLP, however the scientific rigor and levels of evidence vary across modalities.Prescription of interventions for PLP should consider individual patient differences, accessibility to the patient, and quite possibly, a multi-modal approach, particularly for those who also experience residual limb pain.Imagery-based therapies provide the highest level of current evidence based on robust and large randomized control trials, are readily accessible, and are thus most recommended for relief of PLP.
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Affiliation(s)
- Brian Hyung
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Catherine Wiseman-Hakes
- School of Rehabilitation Sciences Institute, McMaster University, Hamilton, Canada.,KITE-University Health Network, Toronto Rehabilitation Institute, Toronto, Canada
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25
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Jergova S, Martinez H, Hernandez M, Schachner B, Gross S, Sagen J. Development of a Phantom Limb Pain Model in Rats: Behavioral and Histochemical Evaluation. FRONTIERS IN PAIN RESEARCH 2021; 2:675232. [PMID: 35295448 PMCID: PMC8915728 DOI: 10.3389/fpain.2021.675232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 05/18/2021] [Indexed: 11/13/2022] Open
Abstract
Therapeutic strategies targeting phantom limb pain (PLP) provide inadequate pain relief; therefore, a robust and clinically relevant animal model is necessary. Animal models of PLP are based on a deafferentation injury followed by autotomy behavior. Clinical studies have shown that the presence of pre-amputation pain increases the risk of developing PLP. In the current study, we used Sprague-Dawley male rats with formalin injections or constriction nerve injury at different sites or time points prior to axotomy to mimic clinical scenarios of pre-amputation inflammatory and neuropathic pain. Animals were scored daily for PLP autotomy behaviors, and several pain-related biomarkers were evaluated to discover possible underlying pathological changes. Majority displayed some degree of autotomy behavior following axotomy. Injury prior to axotomy led to more severe PLP behavior compared to animals without preceding injury. Autotomy behaviors were more directed toward the pretreatment insult origin, suggestive of pain memory. Increased levels of IL-1β in cerebrospinal fluid and enhanced microglial responses and the expression of NaV1.7 were observed in animals displaying more severe PLP outcomes. Decreased expression of GAD65/67 was consistent with greater PLP behavior. This study provides a preclinical basis for future understanding and treatment development in the management of PLP.
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Raut R, Shams S, Rasheed M, Niaz A, Mehdi W, Chaurasia B. Spinal Cord Stimulation in The Treatment of Phantom Limb Pain: A Case Report and Review of Literature. Neurol India 2021; 69:157-160. [PMID: 33642290 DOI: 10.4103/0028-3886.310092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Phantom limb pain is a form of chronic neuropathic pain by which 50-80% of the amputees feel the pain that is not adequately controlled by analgesics. When pain management through pharmacological treatment alone is unsuccessful, surgical treatment options are proven to be effective. We report a case of 61-year-old man who sought consultation with phantom limb pain after his motor vehicular accident and below elbow amputation three years before the consultation. His pain was not relieved by analgesics alone and opted for spinal cord stimulation. Chronic Dual Channel dorsal column stimulation was done using Medtronic Prime Advance SCS System. He was in good pain relief and his VAS decreased from (8/10) to (2/10) but since the last six months follow-up he is complaining of pain again (4/10) for which he is taking analgesics too.
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Affiliation(s)
- Rupesh Raut
- Department of Neurosurgery, King Edward Medical University, Mayo Hospital, Lahore, Pakistan
| | - Shahzad Shams
- Department of Neurosurgery, King Edward Medical University, Mayo Hospital, Lahore, Pakistan
| | - Muddassar Rasheed
- Department of Neurosurgery, King Edward Medical University, Mayo Hospital, Lahore, Pakistan
| | - Azam Niaz
- Department of Neurosurgery, King Edward Medical University, Mayo Hospital, Lahore, Pakistan
| | - Waqas Mehdi
- Department of Neurosurgery, King Edward Medical University, Mayo Hospital, Lahore, Pakistan
| | - Bipin Chaurasia
- Bangabandhu Sheikh Mujib Medical University, Dhaka,, Bangladesh
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Kazezian Z, Yu X, Ramette M, Macdonald W, Bull AMJ. Development of a rodent high-energy blast injury model for investigating conditions associated with traumatic amputations. Bone Joint Res 2021; 10:166-172. [PMID: 33663228 PMCID: PMC7998070 DOI: 10.1302/2046-3758.103.bjr-2020-0367.r1] [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] [Indexed: 11/08/2022] Open
Abstract
AIMS In recent conflicts, most injuries to the limbs are due to blasts resulting in a large number of lower limb amputations. These lead to heterotopic ossification (HO), phantom limb pain (PLP), and functional deficit. The mechanism of blast loading produces a combined fracture and amputation. Therefore, to study these conditions, in vivo models that replicate this combined effect are required. The aim of this study is to develop a preclinical model of blast-induced lower limb amputation. METHODS Cadaveric Sprague-Dawley rats' left hindlimbs were exposed to blast waves of 7 to 13 bar burst pressures and 7.76 ms to 12.68 ms positive duration using a shock tube. Radiographs and dissection were used to identify the injuries. RESULTS Higher burst pressures of 13 and 12 bar caused multiple fractures at the hip, and the right and left limbs. Lowering the pressure to 10 bar eliminated hip fractures; however, the remaining fractures were not isolated to the left limb. Further reducing the pressure to 9 bar resulted in the desired isolated fracture of the left tibia with a dramatic reduction in the fractures to other sites. CONCLUSION In this paper, a rodent blast injury model has been developed in the hindlimb of cadaveric rats that combines the blast and fracture in one insult, necessitating amputation. Experimental setup with 9 bar burst pressure and 9.13 ms positive duration created a fracture at the tibia with total reduction in non-targeted fractures, rendering 9 bar burst pressure suitable for translation to a survivable model to investigate blast injury-associated diseases. Cite this article: Bone Joint Res 2021;10(3):166-172.
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Affiliation(s)
- Zepur Kazezian
- Centre for Blast Injury Studies, Imperial College London, London, UK
- Department of Bioengineering, Imperial College London, London, UK
| | - Xiancheng Yu
- Centre for Blast Injury Studies, Imperial College London, London, UK
- Dyson School of Design Engineering, Imperial College London, London, UK
| | - Martin Ramette
- Centre for Blast Injury Studies, Imperial College London, London, UK
- Department of Bioengineering, Imperial College London, London, UK
| | - Warren Macdonald
- Department of Bioengineering, Imperial College London, London, UK
| | - Anthony M. J. Bull
- Centre for Blast Injury Studies, Imperial College London, London, UK
- Department of Bioengineering, Imperial College London, London, UK
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Ilfeld BM, Khatibi B, Maheshwari K, Madison SJ, Esa WAS, Mariano ER, Kent ML, Hanling S, Sessler DI, Eisenach JC, Cohen SP, Mascha EJ, Ma C, Padwal JA, Turan A. Ambulatory continuous peripheral nerve blocks to treat postamputation phantom limb pain: a multicenter, randomized, quadruple-masked, placebo-controlled clinical trial. Pain 2021; 162:938-955. [PMID: 33021563 PMCID: PMC7920494 DOI: 10.1097/j.pain.0000000000002087] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 09/15/2020] [Accepted: 09/17/2020] [Indexed: 01/13/2023]
Abstract
Phantom limb pain is thought to be sustained by reentrant neural pathways, which provoke dysfunctional reorganization in the somatosensory cortex. We hypothesized that disrupting reentrant pathways with a 6-day-long continuous peripheral nerve block reduces phantom pain 4 weeks after treatment. We enrolled patients who had an upper- or lower-limb amputation and established phantom pain. Each was randomized to receive a 6-day perineural infusion of either ropivacaine or normal saline. The primary outcome was the average phantom pain severity as measured with a Numeric Rating Scale (0-10) at 4 weeks, after which an optional crossover treatment was offered within the following 0 to 12 weeks. Pretreatment pain scores were similar in both groups, with a median (interquartile range) of 5.0 (4.0, 7.0) for each. After 4 weeks, average phantom limb pain intensity was a mean (SD) of 3.0 (2.9) in patients given local anesthetic vs 4.5 (2.6) in those given placebo (difference [95% confidence interval] 1.3 [0.4, 2.2], P = 0.003). Patients given local anesthetic had improved global impression of change and less pain-induced physical and emotional dysfunction, but did not differ on depression scores. For subjects who received only the first infusion (no self-selected crossover), the median decrease in phantom limb pain at 6 months for treated subjects was 3.0 (0, 5.0) vs 1.5 (0, 5.0) for the placebo group; there seemed to be little residual benefit at 12 months. We conclude that a 6-day continuous peripheral nerve block reduces phantom limb pain as well as physical and emotional dysfunction for at least 1 month.
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Affiliation(s)
- Brian M. Ilfeld
- Department of Anesthesiology, University of California San Diego, San Diego, CA, United States
- Outcomes Research Consortium, Cleveland, OH, United States
| | - Bahareh Khatibi
- Department of Anesthesiology, University of California San Diego, San Diego, CA, United States
| | - Kamal Maheshwari
- Outcomes Research Consortium, Cleveland, OH, United States
- Departments of General Anesthesia and Outcomes Research, the Cleveland Clinic, Cleveland, OH, United States
| | - Sarah J. Madison
- Department of Anesthesiology, University of California San Diego, San Diego, CA, United States
| | - Wael Ali Sakr Esa
- Outcomes Research Consortium, Cleveland, OH, United States
- Departments of General Anesthesia and Outcomes Research, the Cleveland Clinic, Cleveland, OH, United States
| | - Edward R. Mariano
- Department of Anesthesiology, Perioperative and Pain Medicine, Palo Alto Veterans Affairs, Palo Alto, CA, United States
| | - Michael L. Kent
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, MD, United States
| | - Steven Hanling
- Department of Anesthesiology, Naval Medical Center San Diego, San Diego, CA, United States
| | - Daniel I. Sessler
- Outcomes Research Consortium, Cleveland, OH, United States
- Department of Outcomes Research, the Cleveland Clinic, Cleveland, OH, United States
| | - James C. Eisenach
- Outcomes Research Consortium, Cleveland, OH, United States
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Steven P. Cohen
- Department of Anesthesiology, Johns Hopkins, Baltimore, MD, United States
| | - Edward J. Mascha
- Outcomes Research Consortium, Cleveland, OH, United States
- Departments of Quantitative Health Sciences and Outcomes Research, the Cleveland Clinic, Cleveland, OH, United States
| | - Chao Ma
- Departments of Quantitative Health Sciences and Outcomes Research, the Cleveland Clinic, Cleveland, OH, United States
| | - Jennifer A. Padwal
- Department of Radiology, University of California San Diego, San Diego, CA, United States
- Department of Radiology, Stanford University, Stanford, CA, United States
| | - Alparslan Turan
- Outcomes Research Consortium, Cleveland, OH, United States
- Departments of General Anesthesia and Outcomes Research, the Cleveland Clinic, Cleveland, OH, United States
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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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Balakhanlou E, Webster J, Borgia M, Resnik L. Frequency and Severity of Phantom Limb Pain in Veterans with Major Upper Limb Amputation: Results of a National Survey. PM R 2020; 13:827-835. [DOI: 10.1002/pmrj.12485] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 08/20/2020] [Accepted: 08/31/2020] [Indexed: 12/26/2022]
Affiliation(s)
- Ellie Balakhanlou
- School of Medicine at Virginia Commonwealth University Richmond VA USA
| | - Joseph Webster
- School of Medicine at Virginia Commonwealth University Richmond VA USA
- Hunter Homes McGuire Veterans Affairs Medical Center Richmond VA USA
| | - Matthew Borgia
- Research Department Providence VA Medical Center Providence RI USA
| | - Linda Resnik
- Research Department Providence VA Medical Center Providence RI USA
- Health Services, Policy and Practice Brown University Providence RI USA
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Managing Neuroma and Phantom Limb Pain in Ontario: The Status of Targeted Muscle Reinnervation. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3287. [PMID: 33425599 PMCID: PMC7787323 DOI: 10.1097/gox.0000000000003287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 09/23/2020] [Indexed: 11/30/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Painful neuromas (PN) and phantom limb pain (PLP) are common following amputation and are unreliably treated, which impacts quality of life. Targeted muscle reinnervation (TMR) is a microsurgical technique that repairs the severed proximal nerve end to a redundant motor nerve in the amputated stump. Evidence supports TMR as effective in treating PN and PLP; however, its adoption has been slow. This study aimed to characterize: (1) the populations experiencing post-amputation PN/PLP; (2) current trends in managing PN/PLP; and (3) attitudes toward routine use of TMR to manage PN/PLP. Methods: A cross-sectional survey was distributed to all orthopedic surgeons, plastic surgeons, and physiatrists practicing in Ontario, via publicly available emails and specialty associations. Data were collected on demographics, experience with amputation, managing post-amputation pain, and attitudes toward routine use of TMR. Results: Sixty-six of 698 eligible participants submitted complete surveys (9.5% response rate). Respondents had a greater experience with surgical management of PN (71% PN versus 10% PLP). However, surgery was considered a 3rd-line option for PN and not an option for PLP in 57% and 59% of respondents, respectively. Thirty participants (45%) were unaware of TMR as an option, and only 8 respondents have currently incorporated TMR into their practice. Many (76%) would be willing to incorporate TMR into their practice as either an immediate or delayed surgical technique. Conclusions: Despite its promise in managing post-amputation pain, awareness of TMR as a surgical option is generally poor. Several barriers to the widespread adoption of this technique are defined.
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Candido Santos L, Gushken F, Gadotti GM, Dias BDF, Marinelli Pedrini S, Barreto MESF, Zippo E, Pinto CB, Piza PVDT, Fregni F. Intracortical Inhibition in the Affected Hemisphere in Limb Amputation. Front Neurol 2020; 11:720. [PMID: 32849197 PMCID: PMC7406670 DOI: 10.3389/fneur.2020.00720] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 06/12/2020] [Indexed: 12/18/2022] Open
Abstract
Phantom limb pain (PLP) affects up to 80% of amputees. Despite the lack of consensus about the etiology and pathophysiology of phantom experiences, previous evidence pointed out the role of changes in motor cortex excitability as an important factor associated with amputation and PLP. In this systematic review, we investigated changes in intracortical inhibition as indexed by transcranial magnetic stimulation (TMS) in amputees and its relationship to pain. Four electronic databases were screened to identify studies using TMS to measure cortical inhibition, such as short intracortical inhibition (SICI), long intracortical inhibition (LICI) and cortical silent period (CSP). Seven articles were included and evaluated cortical excitability comparing the affected hemisphere with the non-affected hemisphere or with healthy controls. None of them correlated cortical disinhibition and clinical parameters, such as the presence or intensity of PLP. However, most studies showed decreased SICI in amputees affected hemisphere. These results highlight that although SICI seems to be changed in the affected hemisphere in amputees, most of the studies did not investigate its clinical correlation. Thus, the question of whether they are a valid diagnostic marker remains unanswered. Also, the results were highly variable for both measurements due to the heterogeneity of study designs and group comparisons in each study. Although these results underscore the role of inhibitory networks after amputation, more studies are needed to investigate the role of a decreased inhibitory drive in the motor cortex to the cause and maintenance of PLP.
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Affiliation(s)
- Ludmilla Candido Santos
- Laboratory of Neuromodulation & Center for Clinical Research Learning, Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Boston, MA, United States
| | | | | | | | | | | | - Emanuela Zippo
- Faculdade Israelita de Ciências da Saúde, São Paulo, Brazil
| | - Camila Bonin Pinto
- Laboratory of Neuromodulation & Center for Clinical Research Learning, Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Boston, MA, United States
| | | | - Felipe Fregni
- Laboratory of Neuromodulation & Center for Clinical Research Learning, Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Boston, MA, United States
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Yanagisawa T, Fukuma R, Seymour B, Tanaka M, Hosomi K, Yamashita O, Kishima H, Kamitani Y, Saitoh Y. BCI training to move a virtual hand reduces phantom limb pain: A randomized crossover trial. Neurology 2020; 95:e417-e426. [PMID: 32675074 PMCID: PMC7455320 DOI: 10.1212/wnl.0000000000009858] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 02/12/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine whether training with a brain-computer interface (BCI) to control an image of a phantom hand, which moves based on cortical currents estimated from magnetoencephalographic signals, reduces phantom limb pain. METHODS Twelve patients with chronic phantom limb pain of the upper limb due to amputation or brachial plexus root avulsion participated in a randomized single-blinded crossover trial. Patients were trained to move the virtual hand image controlled by the BCI with a real decoder, which was constructed to classify intact hand movements from motor cortical currents, by moving their phantom hands for 3 days ("real training"). Pain was evaluated using a visual analogue scale (VAS) before and after training, and at follow-up for an additional 16 days. As a control, patients engaged in the training with the same hand image controlled by randomly changing values ("random training"). The 2 trainings were randomly assigned to the patients. This trial is registered at UMIN-CTR (UMIN000013608). RESULTS VAS at day 4 was significantly reduced from the baseline after real training (mean [SD], 45.3 [24.2]-30.9 [20.6], 1/100 mm; p = 0.009 < 0.025), but not after random training (p = 0.047 > 0.025). Compared to VAS at day 1, VAS at days 4 and 8 was significantly reduced by 32% and 36%, respectively, after real training and was significantly lower than VAS after random training (p < 0.01). CONCLUSION Three-day training to move the hand images controlled by BCI significantly reduced pain for 1 week. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that BCI reduces phantom limb pain.
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Affiliation(s)
- Takufumi Yanagisawa
- From the Institute for Advanced Co-Creation Studies (T.Y.), Osaka University; Departments of Neurosurgery (T.Y., R.F., M.T., K.H., H.K., Y.S.) and Neuromodulation and Neurosurgery (K.H., Y.S.), Osaka University Graduate School of Medicine; Department of Neuroinformatics (T.Y., R.F., Y.K.), ATR Computational Neuroscience Laboratories, Kyoto, Japan; Computational and Biological Learning Laboratory, Department of Engineering (B.S.), University of Cambridge, UK; Center for Information and Neural Networks (B.S.), National Institute for Information and Communications Technology, Osaka; RIKEN Center for Advanced Intelligence Project (O.Y.), Tokyo; Department of Computational Brain Imaging (O.Y.), ATR Neural Information Analysis Laboratories, Kyoto; and Graduate School of Informatics (Y.K.), Kyoto University, Japan.
| | - Ryohei Fukuma
- From the Institute for Advanced Co-Creation Studies (T.Y.), Osaka University; Departments of Neurosurgery (T.Y., R.F., M.T., K.H., H.K., Y.S.) and Neuromodulation and Neurosurgery (K.H., Y.S.), Osaka University Graduate School of Medicine; Department of Neuroinformatics (T.Y., R.F., Y.K.), ATR Computational Neuroscience Laboratories, Kyoto, Japan; Computational and Biological Learning Laboratory, Department of Engineering (B.S.), University of Cambridge, UK; Center for Information and Neural Networks (B.S.), National Institute for Information and Communications Technology, Osaka; RIKEN Center for Advanced Intelligence Project (O.Y.), Tokyo; Department of Computational Brain Imaging (O.Y.), ATR Neural Information Analysis Laboratories, Kyoto; and Graduate School of Informatics (Y.K.), Kyoto University, Japan
| | - Ben Seymour
- From the Institute for Advanced Co-Creation Studies (T.Y.), Osaka University; Departments of Neurosurgery (T.Y., R.F., M.T., K.H., H.K., Y.S.) and Neuromodulation and Neurosurgery (K.H., Y.S.), Osaka University Graduate School of Medicine; Department of Neuroinformatics (T.Y., R.F., Y.K.), ATR Computational Neuroscience Laboratories, Kyoto, Japan; Computational and Biological Learning Laboratory, Department of Engineering (B.S.), University of Cambridge, UK; Center for Information and Neural Networks (B.S.), National Institute for Information and Communications Technology, Osaka; RIKEN Center for Advanced Intelligence Project (O.Y.), Tokyo; Department of Computational Brain Imaging (O.Y.), ATR Neural Information Analysis Laboratories, Kyoto; and Graduate School of Informatics (Y.K.), Kyoto University, Japan
| | - Masataka Tanaka
- From the Institute for Advanced Co-Creation Studies (T.Y.), Osaka University; Departments of Neurosurgery (T.Y., R.F., M.T., K.H., H.K., Y.S.) and Neuromodulation and Neurosurgery (K.H., Y.S.), Osaka University Graduate School of Medicine; Department of Neuroinformatics (T.Y., R.F., Y.K.), ATR Computational Neuroscience Laboratories, Kyoto, Japan; Computational and Biological Learning Laboratory, Department of Engineering (B.S.), University of Cambridge, UK; Center for Information and Neural Networks (B.S.), National Institute for Information and Communications Technology, Osaka; RIKEN Center for Advanced Intelligence Project (O.Y.), Tokyo; Department of Computational Brain Imaging (O.Y.), ATR Neural Information Analysis Laboratories, Kyoto; and Graduate School of Informatics (Y.K.), Kyoto University, Japan
| | - Koichi Hosomi
- From the Institute for Advanced Co-Creation Studies (T.Y.), Osaka University; Departments of Neurosurgery (T.Y., R.F., M.T., K.H., H.K., Y.S.) and Neuromodulation and Neurosurgery (K.H., Y.S.), Osaka University Graduate School of Medicine; Department of Neuroinformatics (T.Y., R.F., Y.K.), ATR Computational Neuroscience Laboratories, Kyoto, Japan; Computational and Biological Learning Laboratory, Department of Engineering (B.S.), University of Cambridge, UK; Center for Information and Neural Networks (B.S.), National Institute for Information and Communications Technology, Osaka; RIKEN Center for Advanced Intelligence Project (O.Y.), Tokyo; Department of Computational Brain Imaging (O.Y.), ATR Neural Information Analysis Laboratories, Kyoto; and Graduate School of Informatics (Y.K.), Kyoto University, Japan
| | - Okito Yamashita
- From the Institute for Advanced Co-Creation Studies (T.Y.), Osaka University; Departments of Neurosurgery (T.Y., R.F., M.T., K.H., H.K., Y.S.) and Neuromodulation and Neurosurgery (K.H., Y.S.), Osaka University Graduate School of Medicine; Department of Neuroinformatics (T.Y., R.F., Y.K.), ATR Computational Neuroscience Laboratories, Kyoto, Japan; Computational and Biological Learning Laboratory, Department of Engineering (B.S.), University of Cambridge, UK; Center for Information and Neural Networks (B.S.), National Institute for Information and Communications Technology, Osaka; RIKEN Center for Advanced Intelligence Project (O.Y.), Tokyo; Department of Computational Brain Imaging (O.Y.), ATR Neural Information Analysis Laboratories, Kyoto; and Graduate School of Informatics (Y.K.), Kyoto University, Japan
| | - Haruhiko Kishima
- From the Institute for Advanced Co-Creation Studies (T.Y.), Osaka University; Departments of Neurosurgery (T.Y., R.F., M.T., K.H., H.K., Y.S.) and Neuromodulation and Neurosurgery (K.H., Y.S.), Osaka University Graduate School of Medicine; Department of Neuroinformatics (T.Y., R.F., Y.K.), ATR Computational Neuroscience Laboratories, Kyoto, Japan; Computational and Biological Learning Laboratory, Department of Engineering (B.S.), University of Cambridge, UK; Center for Information and Neural Networks (B.S.), National Institute for Information and Communications Technology, Osaka; RIKEN Center for Advanced Intelligence Project (O.Y.), Tokyo; Department of Computational Brain Imaging (O.Y.), ATR Neural Information Analysis Laboratories, Kyoto; and Graduate School of Informatics (Y.K.), Kyoto University, Japan
| | - Yukiyasu Kamitani
- From the Institute for Advanced Co-Creation Studies (T.Y.), Osaka University; Departments of Neurosurgery (T.Y., R.F., M.T., K.H., H.K., Y.S.) and Neuromodulation and Neurosurgery (K.H., Y.S.), Osaka University Graduate School of Medicine; Department of Neuroinformatics (T.Y., R.F., Y.K.), ATR Computational Neuroscience Laboratories, Kyoto, Japan; Computational and Biological Learning Laboratory, Department of Engineering (B.S.), University of Cambridge, UK; Center for Information and Neural Networks (B.S.), National Institute for Information and Communications Technology, Osaka; RIKEN Center for Advanced Intelligence Project (O.Y.), Tokyo; Department of Computational Brain Imaging (O.Y.), ATR Neural Information Analysis Laboratories, Kyoto; and Graduate School of Informatics (Y.K.), Kyoto University, Japan
| | - Youichi Saitoh
- From the Institute for Advanced Co-Creation Studies (T.Y.), Osaka University; Departments of Neurosurgery (T.Y., R.F., M.T., K.H., H.K., Y.S.) and Neuromodulation and Neurosurgery (K.H., Y.S.), Osaka University Graduate School of Medicine; Department of Neuroinformatics (T.Y., R.F., Y.K.), ATR Computational Neuroscience Laboratories, Kyoto, Japan; Computational and Biological Learning Laboratory, Department of Engineering (B.S.), University of Cambridge, UK; Center for Information and Neural Networks (B.S.), National Institute for Information and Communications Technology, Osaka; RIKEN Center for Advanced Intelligence Project (O.Y.), Tokyo; Department of Computational Brain Imaging (O.Y.), ATR Neural Information Analysis Laboratories, Kyoto; and Graduate School of Informatics (Y.K.), Kyoto University, Japan
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Mioton LM, Dumanian GA, Fracol ME, Apkarian AV, Valerio IL, Souza JM, Potter BK, Tintle SM, Nanos GP, Ertl WJ, Ko JH, Jordan SW. Benchmarking Residual Limb Pain and Phantom Limb Pain in Amputees through a Patient-reported Outcomes Survey. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2977. [PMID: 32802669 PMCID: PMC7413780 DOI: 10.1097/gox.0000000000002977] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 05/22/2020] [Indexed: 11/26/2022]
Abstract
More than 75% of major limb amputees experience chronic pain; however, data on severity and experience of pain are inconsistent. Without a benchmark using quantitative patient-reported outcomes, it is difficult to critically assess the efficacy of novel treatment strategies. Our primary objective is to report quantitative pain parameters for a large sample of amputees using the validated Patient-reported Outcomes Measurement System (PROMIS). Secondarily, we hypothesize that certain patient factors will be associated with worse pain. METHODS PROMIS and Numerical Rating Scales for residual limb pain (RLP) and phantom limb pain (PLP) were obtained from a cross-sectional survey of upper and lower extremity amputees recruited throughout North America via amputee clinics and websites. Demographics (gender, age, race, and education) and clinical information (cause, amputation level, and time since amputation) were collected. Regression modeling identified factors associated with worse pain scores (P < 0.05). RESULTS Seven hundred twenty-seven surveys were analyzed, in which 73.4% reported RLP and 70.4% reported PLP. Median residual PROMIS scores were 46.6 [interquartile range (IQR), 41-52] for RLP Intensity, 56.7 (IQR, 51-61) for RLP Behavior, and 55.9 (IQR, 41-63) for RLP Interference. Similar scores were calculated for PLP parameters: 46.8 (IQR, 41-54) for PLP Intensity, 56.2 (IQR, 50-61) for PLP Behavior, and 54.6 (IQR, 41-62) for PLP Interference. Female sex, lower education, trauma-related amputation, more proximal amputation, and closer to time of amputation increased odds of PLP. Female sex, lower education, and infection/ischemia-related amputation increased odds of RLP. CONCLUSION This survey-based analysis provides quantitative benchmark data regarding RLP and PLP in amputees with more granularity than has previously been reported.
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Affiliation(s)
- Lauren M. Mioton
- From the Division of Plastic Surgery, Northwestern Feinberg School of Medicine, Chicago, Ill
| | - Gregory A. Dumanian
- From the Division of Plastic Surgery, Northwestern Feinberg School of Medicine, Chicago, Ill
| | - Megan E. Fracol
- From the Division of Plastic Surgery, Northwestern Feinberg School of Medicine, Chicago, Ill
| | - A. Vania Apkarian
- The Department of Physiology, Northwestern Feinberg School of Medicine, Chicago, Ill
| | - Ian L. Valerio
- Department of Plastic Surgery, The Ohio State University, Columbus, Ohio
| | - Jason M. Souza
- The Division of Plastic Surgery and Department of Orthopedics, Uniformed Services University—Walter Reed National Military, Bethesda, Md
| | - Benjamin K. Potter
- The Division of Plastic Surgery and Department of Orthopedics, Uniformed Services University—Walter Reed National Military, Bethesda, Md
| | - Scott M. Tintle
- The Division of Plastic Surgery and Department of Orthopedics, Uniformed Services University—Walter Reed National Military, Bethesda, Md
| | - George P. Nanos
- The Division of Plastic Surgery and Department of Orthopedics, Uniformed Services University—Walter Reed National Military, Bethesda, Md
| | - William J. Ertl
- The Department of Orthopedic Surgery, University of Oklahoma, Oklahoma City, Okla
| | - Jason H. Ko
- From the Division of Plastic Surgery, Northwestern Feinberg School of Medicine, Chicago, Ill
| | - Sumanas W. Jordan
- From the Division of Plastic Surgery, Northwestern Feinberg School of Medicine, Chicago, Ill
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35
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Abstract
In this case study, we investigated the efficacy of mirror therapy and online counseling in the management of phantom limb pain. The patient was a 28-year-old woman who experienced phantom limb pain after a traumatic transhumeral amputation three and a half months before initiating therapy. After a 40-minute educational session with a nurse researcher experienced in pain management and surgical nursing, the patient practiced mirror therapy at home for four weeks and kept in contact with the nurse using a mobile chat application. The patient scored the intensity of her pain before and after each practice session on a 0-to-10 numeric pain scale. The first week was difficult for her because of tiredness and the pain. In the second week she experienced less pain during the day than at night but claimed to feel much better than before. In the fourth week, she reported having difficulty sleeping, but she stated that her pain had decreased. The intensity of the pain didn't change following mirror therapy in the first week; however, her average pain score was 1.15 points lower after mirror therapy in the second week (from 4.57 to 3.42), and 1.57 points lower in the third and fourth weeks (from 5.42 to 3.85 and 4.85 to 3.28). Online counseling for mirror therapy is easy, economical, and time-saving for patient and nurse alike. However, physical and physiological problems experienced during this process may reduce the effectiveness of the therapy, highlighting the importance of a multidisciplinary approach to phantom limb pain management, which may include care from a psychologist, massage therapist, physiotherapist, and specialist in alternative therapies for relaxation, in addition to the surgeon and the nurse.
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Nwosu AG, Anikwe I, Eze B, Ossai E, Onyekwulu F. Amputation-related phantom limb pain in Nigeria: A prospective cohort study. NIGERIAN JOURNAL OF MEDICINE 2020. [DOI: 10.4103/njm.njm_11_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Gozani SN. Remote Analgesic Effects Of Conventional Transcutaneous Electrical Nerve Stimulation: A Scientific And Clinical Review With A Focus On Chronic Pain. J Pain Res 2019; 12:3185-3201. [PMID: 31819603 PMCID: PMC6885653 DOI: 10.2147/jpr.s226600] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 11/02/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Transcutaneous electrical nerve stimulation (TENS) is a safe, noninvasive treatment for chronic pain that can be self-administered. Conventional TENS involves stimulation of peripheral sensory nerves at a strong, non-painful level. Following the original gate-control theory of pain, stimulation is typically near the target pain. As another option, remote stimulation may also be effective and offers potential advantages. OBJECTIVE This narrative review examines mechanisms underlying the remote analgesic effects of conventional TENS and appraises the clinical evidence. METHODS A literature search for English-language articles was performed on PubMed. Keywords included terms related to the location of TENS . Citations from primary references and textbooks were examined for additional articles. RESULTS Over 30 studies reported remote analgesic effects of conventional TENS. The evidence included studies using animal models of pain, experimental pain in humans, and clinical studies in subjects with chronic pain. Three types of remote analgesia were identified: at the contralateral homologous site, at sites distant from stimulation but innervated by overlapping spinal segments, and at unrelated extrasegmental sites. CONCLUSION There is scientific and clinical evidence that conventional TENS has remote analgesic effects. This may occur through modulation of pain processing at the level of the dorsal horn, in brainstem centers mediating descending inhibition, and within the pain matrix. A broadening of perspectives on how conventional TENS produces analgesia may encourage researchers, clinicians, and medical-device manufacturers to develop novel ways of using this safe, cost-effective neuromodulation technique for chronic pain.
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Kulkarni J, Pettifer S, Turner S, Richardson C. An investigation into the effects of a virtual reality system on phantom limb pain: a pilot study. Br J Pain 2019; 14:92-97. [PMID: 32537147 DOI: 10.1177/2049463719859913] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background There is no first-line treatment available for phantom limb pain (PLP). For some years, there has been interest in the use of mirrors and other techniques based on visual feedback. Unfortunately, up until now, all published studies have had methodological weaknesses with two recent systematic reviews concluding that therapies of this kind need more evidence to support their use. Aim To evaluate the effects of a virtual reality (VR) activity on PLP. Methods This was a prospective pilot study of upper limb amputees using questionnaires to evaluate a VR system. Eleven participants were recruited, with nine completing all three sessions of VR. Participants undertook three sessions of VR, one a month for 3 months. Outcome measures were PLP pain intensity using an 11-point numerical rating scale (NRS), number of PLP episodes and duration of the PLP episodes. All participants were also asked for their judgement of change. Open-ended questions captured the qualitative experience of all aspects of the VR experience. Results The mean PLP pain score following three VR sessions reduced (6.11 v 3.56) but this was not a statistical difference (t = 2.1, df = 8, p = 0.07). No statistical difference was found for the number of PLP episodes (Pearson chi-square = 3.43, df = 2, p = 0.18) or the duration of each PLP episode (Pearson chi-square = 22.50, df = 16, p = 0.13). Three groups emerged: those whose pain reduced (the majority), those whose pain remained the same (small number) and one those whose pain increased slightly. Discussion There is insufficient evidence from these results to identify an effect of VR on PLP; however, this is a small group and qualitatively most were content with the treatment and wanted a longer trial.
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Affiliation(s)
- Jai Kulkarni
- Manchester University NHS Foundation Trust, Manchester, UK
| | | | - Sue Turner
- Manchester University NHS Foundation Trust, Manchester, UK
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Carvajal G, Rocha A, Dupoiron D. Multimodal intrathecal therapy for phantom limb pain. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2019. [DOI: 10.1097/cj9.0000000000000106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Chan AWY, Bilger E, Griffin S, Elkis V, Weeks S, Hussey-Anderson L, Pasquina PF, Tsao JW, Baker CI. Visual responsiveness in sensorimotor cortex is increased following amputation and reduced after mirror therapy. NEUROIMAGE-CLINICAL 2019; 23:101882. [PMID: 31226622 PMCID: PMC6587025 DOI: 10.1016/j.nicl.2019.101882] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 04/17/2019] [Accepted: 05/25/2019] [Indexed: 11/07/2022]
Abstract
Phantom limb pain (PLP) following amputation, which is experienced by the vast majority of amputees, has been reported to be relieved with daily sessions of mirror therapy. During each session, a mirror is used to view the reflected image of the intact limb moving, providing visual feedback consistent with the movement of the missing/phantom limb. To investigate potential neural correlates of the treatment effect, we measured brain responses in volunteers with unilateral leg amputation using functional magnetic resonance imaging (fMRI) during a four-week course of mirror therapy. Mirror therapy commenced immediately following baseline scans, which were repeated after approximately two and four week intervals. We focused on responses in the region of sensorimotor cortex corresponding to primary somatosensory and motor representations of the missing leg. At baseline, prior to starting therapy, we found a strong and unexpected response in sensorimotor cortex of amputees to visually presented images of limbs. This response was stronger for images of feet compared to hands and there was no such response in matched controls. Further, this response to visually presented limbs was no longer present at the end of the four week mirror therapy treatment, when perceived phantom limb pain was also reduced. A similar pattern of results was also observed in extrastriate and parietal regions typically responsive to viewing hand actions, but not in regions corresponding to secondary somatosensory cortex. Finally, there was a significant correlation between initial visual responsiveness in sensorimotor cortex and reduction in PLP suggesting a potential marker for predicting efficacy of mirror therapy. Thus, enhanced visual responsiveness in sensorimotor cortex is associated with PLP and modulated over the course of mirror therapy. Visual responsiveness to the sight of limbs in sensorimotor cortex of leg amputees but not matched controls Consistent with prior studies, mirror therapy over 4 weeks reduced phantom limb pain Visual responsiveness in sensorimotor cortex of amputees diminished following mirror therapy Visual responsiveness in sensorimotor cortex might be useful in predicting the potential efficacy of mirror therapy
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Affiliation(s)
- Annie W-Y Chan
- Laboratory of Brain and Cognition, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA; Department of Life Sciences, Division of Psychology, Centre for Cognitive Neuroscience, Brunel University London, UK; University of Tennessee Health Science Center, Department of Radiology, Memphis, TN, USA.
| | - Emily Bilger
- Laboratory of Brain and Cognition, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA; George Washington University Hospital, USA
| | - Sarah Griffin
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Viktoria Elkis
- Laboratory of Brain and Cognition, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Sharon Weeks
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | | | - Paul F Pasquina
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Jack W Tsao
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA; University of Tennessee Health Science Center, Department of Neurology, Memphis, TN, USA; Le Bonheur Children's Hospital, Memphis, TN, USA; Memphis Veterans Affairs Medical Center, Memphis, TN, USA
| | - Chris I Baker
- Laboratory of Brain and Cognition, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
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Nardone R, Versace V, Sebastianelli L, Brigo F, Christova M, Scarano GI, Saltuari L, Trinka E, Hauer L, Sellner J. Transcranial magnetic stimulation in subjects with phantom pain and non-painful phantom sensations: A systematic review. Brain Res Bull 2019; 148:1-9. [DOI: 10.1016/j.brainresbull.2019.03.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 03/03/2019] [Accepted: 03/05/2019] [Indexed: 12/18/2022]
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Limakatso K, Bedwell GJ, Madden VJ, Parker R. The prevalence of phantom limb pain and associated risk factors in people with amputations: a systematic review protocol. Syst Rev 2019; 8:17. [PMID: 30630523 PMCID: PMC6329075 DOI: 10.1186/s13643-018-0938-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 12/26/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The prevalence of phantom limb pain (PLP) in people with amputations is unclear because of the conflicting reports across the literature. It is proposed that the conflicting reports on the prevalence of PLP are a consequence of variations in the time period during which the studies were undertaken, countries in which the studies were conducted and recruitment processes implemented during collection of epidemiological data. In consideration of these factors, we aim to gather and critically appraise relevant literature to determine the prevalence estimate of and risk factors for PLP in people with amputations. METHODS We will use a customised search strategy containing relevant words and terms to search the following databases: MEDLINE/PubMed (via EBSCOhost), PsycINFO (via EBSCOhost), PsycArticles, Cumulative Index to Nursing and Allied Health Literature (CINAHL) (via EBSCOhost), Africa-Wide Information (via EBSCOhost), Health Source: Nursing/Academic Edition (via EBSCOhost) SCOPUS, Web of Science and Academic Search Premier (via EBSCOhost). The risk of bias assessment will be conducted using a risk of bias assessment tool for prevalence studies, and data will be extracted using a piloted customised data extraction sheet. Data extracted from individual studies will be entered into Review Manager 5 and assessed for clinical and statistical heterogeneity. Studies will be pooled for meta-analysis using the random-effects model to determine a summary estimate of the prevalence of PLP across included studies. A statistically significant level will be set at p < 0.05. DISCUSSION As far as we know, a systematic review and meta-analysis on the prevalence of, and risk factors for PLP in people with amputations has not been conducted. Given the varying reports in the literature, it is necessary to determine an estimate of the prevalence of PLP to generate an informed conclusion on this subject. The results of this review will be published in an internationally accredited journal and used to inform researchers, clinicians, policy-makers and the public about the burden of, and risk factors for PLP. This will be done with a further aim to improve the quality of pain management in society. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018094821.
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Affiliation(s)
- Katleho Limakatso
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | - Gillian J. Bedwell
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
- Department of Health and Rehabilitation Sciences, Division of Physiotherapy, University of Cape Town, Cape Town, South Africa
| | - Victoria J. Madden
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
- Department of Psychiatry and Mental Heath, University of Cape Town, Cape Town, South Africa
| | - Romy Parker
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
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Kikkert S, Mezue M, O'Shea J, Henderson Slater D, Johansen-Berg H, Tracey I, Makin TR. Neural basis of induced phantom limb pain relief. Ann Neurol 2019; 85:59-73. [PMID: 30383312 PMCID: PMC6492189 DOI: 10.1002/ana.25371] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 10/29/2018] [Accepted: 10/29/2018] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Phantom limb pain (PLP) is notoriously difficult to treat, partly due to an incomplete understanding of PLP-related disease mechanisms. Noninvasive brain stimulation (NIBS) is used to modulate plasticity in various neuropathological diseases, including chronic pain. Although NIBS can alleviate neuropathic pain (including PLP), both disease and treatment mechanisms remain tenuous. Insight into the mechanisms underlying both PLP and NIBS-induced PLP relief is needed for future implementation of such treatment and generalization to related conditions. METHODS We used a within-participants, double-blind, and sham-controlled design to alleviate PLP via task-concurrent NIBS over the primary sensorimotor missing hand cortex (S1/M1). To specifically influence missing hand signal processing, amputees performed phantom hand movements during anodal transcranial direct current stimulation. Brain activity was monitored using neuroimaging during and after NIBS. PLP ratings were obtained throughout the week after stimulation. RESULTS A single session of intervention NIBS significantly relieved PLP, with effects lasting at least 1 week. PLP relief associated with reduced activity in the S1/M1 missing hand cortex after stimulation. Critically, PLP relief and reduced S1/M1 activity correlated with preceding activity changes during stimulation in the mid- and posterior insula and secondary somatosensory cortex (S2). INTERPRETATION The observed correlation between PLP relief and decreased S1/M1 activity confirms our previous findings linking PLP with increased S1/M1 activity. Our results further highlight the driving role of the mid- and posterior insula, as well as S2, in modulating PLP. Lastly, our novel PLP intervention using task-concurrent NIBS opens new avenues for developing treatment for PLP and related pain conditions. ANN NEUROL 2019;85:59-73.
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Affiliation(s)
- Sanne Kikkert
- Wellcome Centre for Integrative Neuroimaging, FMRIB Centre, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom.,Donders Institute for Brain, Cognition and Behaviour, Radboud University Nijmegen, Nijmegen, the Netherlands.,Neural Control of Movement Laboratory, Department of Health Sciences and Technology, ETH Zürich, Zürich, Switzerland
| | - Melvin Mezue
- Wellcome Centre for Integrative Neuroimaging, FMRIB Centre, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Jacinta O'Shea
- Wellcome Centre for Integrative Neuroimaging, FMRIB Centre, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | | | - Heidi Johansen-Berg
- Wellcome Centre for Integrative Neuroimaging, FMRIB Centre, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Irene Tracey
- Wellcome Centre for Integrative Neuroimaging, FMRIB Centre, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Tamar R Makin
- Wellcome Centre for Integrative Neuroimaging, FMRIB Centre, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom.,Institute of Cognitive Neuroscience, University College London, London, United Kingdom.,Wellcome Centre for Human Neuroimaging, University College London, London, United Kingdom
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Butler S. Support for mirror therapy for phantom and stump pain in landmine-injured patients. Scand J Pain 2018; 18:561-562. [DOI: 10.1515/sjpain-2018-0115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Stephen Butler
- Pain Center, Academic Hospital , Uppsala , Sweden
- Department of Family and Preventive Medicine , Uppsala University , Uppsala , Sweden
- Center for Pain and Complex Disorders , St. Olav’s Hospital , Trondheim , Norway
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Flahaut M, Laurent NL, Michetti M, Hirt-Burri N, Jensen W, Lontis R, Applegate LA, Raffoul W. Patient care for postamputation pain and the complexity of therapies: living experiences. Pain Manag 2018; 8:441-453. [PMID: 30175653 DOI: 10.2217/pmt-2018-0033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
AIM Limb amputation traumatically alters body image. Sensations rapidly prevail that the limb is still present and 85% of patients portray phantom limb pain. Throughout the testimonies of amputated patients with intense phantom limb pain, we show the difficulty in treating this chronic pain with current pharmacological and nonpharmacological therapies. PATIENTS & METHODS We qualitatively analyzed the therapeutic choices of five amputees, the effectiveness of the treatments chosen and the impact on patients' quality-of-life. RESULTS & CONCLUSION In general, patients who are refractory to pharmacological treatments are in favor of trying alternative therapies. It is therefore crucial to design a combined and personalized therapeutic plan under the coordination of a multidisciplinary team for the wellbeing of the patient.
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Affiliation(s)
- Marjorie Flahaut
- Department of Plastic, Reconstructive & Hand Surgery, Unit of Regenerative Therapy, University Hospital of Lausanne, 1066 Epalinges, Switzerland
| | - Nicolas L Laurent
- Department of Plastic, Reconstructive & Hand Surgery, Unit of Regenerative Therapy, University Hospital of Lausanne, 1066 Epalinges, Switzerland
| | - Murielle Michetti
- Department of Plastic, Reconstructive & Hand Surgery, Unit of Regenerative Therapy, University Hospital of Lausanne, 1066 Epalinges, Switzerland
| | - Nathalie Hirt-Burri
- Department of Plastic, Reconstructive & Hand Surgery, Unit of Regenerative Therapy, University Hospital of Lausanne, 1066 Epalinges, Switzerland
| | - Winnie Jensen
- Department of Health Science & Technology, Center for Sensory-Motor Interaction, Aalborg University, 9000 Aalborg, Denmark
| | - Romulus Lontis
- Department of Health Science & Technology, Center for Sensory-Motor Interaction, Aalborg University, 9000 Aalborg, Denmark
| | - Lee A Applegate
- Department of Plastic, Reconstructive & Hand Surgery, Unit of Regenerative Therapy, University Hospital of Lausanne, 1066 Epalinges, Switzerland
| | - Wassim Raffoul
- Department of Plastic, Reconstructive & Hand Surgery, Unit of Regenerative Therapy, University Hospital of Lausanne, 1066 Epalinges, Switzerland
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Rothgangel A, Braun S, Winkens B, Beurskens A, Smeets R. Traditional and augmented reality mirror therapy for patients with chronic phantom limb pain (PACT study): results of a three-group, multicentre single-blind randomized controlled trial. Clin Rehabil 2018; 32:1591-1608. [DOI: 10.1177/0269215518785948] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Objective: To compare the effects of traditional mirror therapy (MT), a patient-centred teletreatment (PACT) and sensomotor exercises without a mirror on phantom limb pain (PLP). Design: Three-arm multicentre randomized controlled trial. Setting: Rehabilitation centres, hospital and private practices. Subjects: Adult patients with unilateral lower limb amputation and average PLP intensity of at least 3 on the 0–10 Numeric Rating Scale (NRS). Interventions: Subjects randomly received either four weeks of traditional MT followed by a teletreatment using augmented reality MT, traditional MT followed by self-delivered MT or sensomotor exercises of the intact limb without a mirror followed by self-delivered exercises. Main measures: Intensity, frequency and duration of PLP and patient-reported outcomes assessing limitations in daily life at baseline, 4 weeks, 10 weeks and 6 months. Results: In total, 75 patients received traditional MT ( n = 25), teletreatment ( n = 26) or sensomotor exercises ( n = 24). Mean (SD) age was 61.1 (14.2) years and mean (SD) pain intensity was 5.7 (2.1) on the NRS. Effects of MT at four weeks on PLP were not significant. MT significantly reduced the duration of PLP at six months compared to the teletreatment ( P = 0.050) and control group ( P = 0.019). Subgroup analyses suggested significant effects on PLP in women, patients with telescoping and patients with a motor component in PLP. The teletreatment had no additional effects compared to self-delivered MT at 10 weeks and 6 months. Conclusion: Traditional MT over four weeks was not more effective than sensomotor exercises without a mirror in reducing PLP, although significant effects were suggested in some subgroups.
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Affiliation(s)
- Andreas Rothgangel
- Research Center of Nutrition, Lifestyle and Exercise, Faculty of Health, Zuyd University of Applied Sciences, Heerlen, The Netherlands
- CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - Susy Braun
- Research Center of Nutrition, Lifestyle and Exercise, Faculty of Health, Zuyd University of Applied Sciences, Heerlen, The Netherlands
- CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - Bjorn Winkens
- CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
- Department of Methodology & Statistics, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Anna Beurskens
- CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
- Research Centre for Autonomy and Participation for Persons with a Chronic Illness, Faculty of Health, Zuyd University of Applied Sciences, Heerlen, The Netherlands
| | - Rob Smeets
- CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
- Libra Rehabilitation & Audiology, Eindhoven, The Netherlands
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Ambron E, Miller A, Kuchenbecker KJ, Buxbaum LJ, Coslett HB. Immersive Low-Cost Virtual Reality Treatment for Phantom Limb Pain: Evidence from Two Cases. Front Neurol 2018. [PMID: 29515513 PMCID: PMC5825921 DOI: 10.3389/fneur.2018.00067] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Up to 90% of amputees experience sensations in their phantom limb, often including strong, persistent phantom limb pain (PLP). Standard treatments do not provide relief for the majority of people who experience PLP, but virtual reality (VR) has shown promise. This study provides additional evidence that game-like training with low-cost immersive VR activities can reduce PLP in lower-limb amputees. The user of our system views a real-time rendering of two intact legs in a head-mounted display while playing a set of custom games. The movements of both virtual extremities are controlled by measurements from inertial sensors mounted on the intact and residual limbs. Two individuals with unilateral transtibial amputation underwent multiple sessions of the VR treatment over several weeks. Both participants experienced a significant reduction of pain immediately after each VR session, and their pre-session pain levels also decreased greatly over the course of the study. Although preliminary, these data support the idea that VR interventions like ours may be an effective low-cost treatment of PLP in lower-limb amputees.
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Affiliation(s)
- Elisabetta Ambron
- Laboratory for Cognition and Neural Stimulation, Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Alexander Miller
- Laboratory for Cognition and Neural Stimulation, Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Katherine J Kuchenbecker
- Haptic Intelligence Department, Max Planck Institute for Intelligent Systems, Stuttgart, Germany
| | - Laurel J Buxbaum
- Cognition and Action Laboratory, Moss Rehabilitation Research Institute, Philadelphia, PA, United States
| | - H Branch Coslett
- Laboratory for Cognition and Neural Stimulation, Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
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