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Chien TJ, Huang YS, Liao LL, Chu CC, Pai JH. Head-to-Head Comparison of Electroacupuncture and Laser Acupuncture Effects on Autonomic Regulation and Clinical Effects in Dysmenorrhea: A Randomized Crossover Clinical Trial. JOURNAL OF INTEGRATIVE AND COMPLEMENTARY MEDICINE 2024; 30:560-575. [PMID: 38364185 DOI: 10.1089/jicm.2023.0183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
Introduction: Electroacupuncture (EA) has been applied in dysmenorrhea and has shown good efficacy. The mechanisms of EA are associated with autonomic nervous system adjustments and neuroendocrine regulation. Laser acupuncture (LA), however, has been widely investigated for its noninvasiveness. However, it remains uncertain whether LA is as effective as EA. This study aimed to compare EA and LA head to head in dysmenorrhea. Methods: A crossover, randomized clinical trial was conducted. EA or LA was applied to selected acupuncture points. Participants were randomized into two sequence treatment groups who received either EA or LA twice per week in luteal phase for 3 months followed by 2-month washout, then shifted to other groups (sequence 1: EA > LA; sequence 2: LA > EA). Outcome measures were heart rate variability (HRV), prostaglandins (PGs), pain, and quality-of-life (QoL) assessment (QoL-SF12). We also compared the effect of EA and LA in low and high LF/HF (low frequency/high frequency) status. Results: Totally, 43 participants completed all treatments. Both EA and LA significantly improved HRV activity and were effective in reducing pain (Visual Analog Scale [VAS]; EA: p < 0.001 and LA: p = 0.010) and improving QoL (SF12: EA: p < 0.001, LA, p = 0.017); although without intergroup difference. EA reduced PGs significantly (p < 0.001; δ p = 0.068). In low LF/HF, EA had stronger effects than LA in increasing parasympathetic tone in respect of percentage of successive RR intervals that differ by more than 50 ms (pNN50; p = 0.053) and very low-frequency band (VLF; p = 0.035). Conclusion: There is no significant difference between EA and LA in improving autonomic nervous system dysfunction, pain, and QoL in dysmenorrhea. EA is prominent in PGs changing and preserving vagus tone in low LF/HF; yet LA is noninvasive for those who have needle phobia. Whether LA is equivalent with EA and the mechanism warrants further study. Clinical trial identification number: NCT04178226.
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Affiliation(s)
- Tsai-Ju Chien
- Division of Hemato-Oncology, Department of Internal Medicine, Branch of Zhong-Zhou, Taipei City Hospital, Taipei, Taiwan
- Institute of Traditional Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Shuo Huang
- Institute of Traditional Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Department of Traditional Medicine, Branch of Yang-Ming, Taipei City Hospital, Taipei, Taiwan
| | - Li-Lan Liao
- Department of Traditional Medicine, Branch of Kunming, Taipei City Hospital, Taipei, Taiwan
| | - Chi-Chang Chu
- Department of Gynecology and Obstetrics, Branch of Yang-Ming, Taipei City Hospital, Taipei, Taiwan
| | - Juo-Hsiang Pai
- Division of Hemato-Oncology, Department of Internal Medicine, Branch of Zhong-Zhou, Taipei City Hospital, Taipei, Taiwan
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Scholl L, Schmidt A, Alfuth M. Efficacy of Mirror Therapy in Patients with Phantom Pain after Amputation of a Lower Limb: A Systematic Literature Review. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2023. [PMID: 37967831 DOI: 10.1055/a-2188-3565] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
Up to 80% of patients after amputation are affected by phantom limb pain. This may be due to various mechanisms of cortical reorganisation. Non-surgical treatment of the neuropathic phantom limb pain involves mirror therapy. Thereby, the use of a mirror should induce the illusion that the extremity has been preserved. This illusion should initiate processes to restore the original organisation of the somatosensory and motor cortex and thus to reduce pain. Evidence of mirror therapy to treat lower extremity phantom limb pain is rare. Therefore, the aim of this systematic review is to qualitatively analyse the efficacy of mirror therapy for treatment of phantom limb pain in adult patients after unilateral amputations of the lower extremity.The databases Medline (PubMed), Physiotherapy Evidence Database (PEDro), Cochrane Library (Central), and OPENGREY were systematically searched until 26th November 2020, followed by continued searches in these databases to provide a review of updated literature. Study selection, data extraction, and risk of bias evaluation (Risk of Bias Tool [RoB]) of included studies were conducted by two reviewers independently. The primary outcome was pain intensity, and secondary outcomes were pain frequency, pain duration, activities of daily life (ADL), and quality of life. The methodology of this review follows the recommendations of Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and the Cochrane Handbook for Systematic Reviews of Interventions.The search revealed 234 articles. Four articles were included in the analysis. A reduction in pain intensity due to mirror therapy was reported in all studies, however, in only 2 studies there were significant differences between mirror therapy and the comparison after 4 weeks of treatment (p < 0.001; p < 0.05). This significant difference was maintained after 3 and 6 months follow-up in one of those studies (p < 0.001). The outcomes pain frequency, pain duration, and ADL were decreased after 4 and 10 weeks of mirror therapy compared to comparison, but with no statistical significance (p > 0.05). After 6 months, there was a significant improvement in the duration of pain and in ADL after mirror therapy compared with the control group (p < 0.05). Differences in the results quality of life between the intervention group and comparison were observed in 2 studies.Mirror therapy of high frequency and duration is an effective intervention to reduce phantom limb pain in patients after unilateral lower extremity amputation. The superiority of mirror therapy to other interventions cannot be concluded, as the evidence was of low quality.
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Affiliation(s)
- Lorena Scholl
- Fachbereich Gesundheitswesen, Therapiewissenschaften, Hochschule Niederrhein, Krefeld, Deutschland
| | - Annette Schmidt
- Fachbereich Gesundheitswesen, Therapiewissenschaften, Hochschule Niederrhein, Krefeld, Deutschland
| | - Martin Alfuth
- Fachbereich Gesundheitswesen, Therapiewissenschaften, Hochschule Niederrhein, Krefeld, Deutschland
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Schlienger R, De Giovanni C, Guerraz M, Kavounoudias A. When proprioceptive feedback enhances visual perception of self-body movement: rehabilitation perspectives. Front Hum Neurosci 2023; 17:1144033. [PMID: 37250699 PMCID: PMC10213410 DOI: 10.3389/fnhum.2023.1144033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 04/17/2023] [Indexed: 05/31/2023] Open
Abstract
Introduction Rehabilitation approaches take advantage of vision's important role in kinesthesia, using the mirror paradigm as a means to reduce phantom limb pain or to promote recovery from hemiparesis. Notably, it is currently applied to provide a visual reafferentation of the missing limb to relieve amputees' pain. However, the efficiency of this method is still debated, possibly due to the absence of concomitant coherent proprioceptive feedback. We know that combining congruent visuo-proprioceptive signals at the hand level enhances movement perception in healthy people. However, much less is known about lower limbs, for which actions are far less visually controlled in everyday life than upper limbs. Therefore, the present study aimed to explore, with the mirror paradigm, the benefit of combined visuo-proprioceptive feedback from the lower limbs of healthy participants. Methods We compared the movement illusions driven by visual or proprioceptive afferents and tested the extent to which adding proprioceptive input to the visual reflection of the leg improved the resulting movement illusion. To this end, 23 healthy adults were exposed to mirror or proprioceptive stimulation and concomitant visuo-proprioceptive stimulation. In the visual conditions, participants were asked to voluntarily move their left leg in extension and look at its reflection in the mirror. In the proprioceptive conditions, a mechanical vibration was applied to the hamstring muscle of the leg hidden behind the mirror to simulate an extension of the leg, either exclusively or concomitantly, to the visual reflection of the leg in the mirror. Results (i) Visual stimulation evoked leg movement illusions but with a lower velocity than the actual movement reflection on the mirror; (ii) proprioceptive stimulation alone provided more salient illusions than the mirror illusion; and (iii) adding a congruent proprioceptive stimulation improved the saliency, amplitude, and velocity of the illusion. Conclusion The present findings confirm that visuo-proprioceptive integration occurs efficiently when the mirror paradigm is coupled with mechanical vibration at the lower limbs, thus providing promising new perspectives for rehabilitation.
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Affiliation(s)
- Raphaëlle Schlienger
- Aix-Marseille Université, CNRS, Laboratoire de Neurosciences Cognitives (LNC – UMR 7291), Marseille, France
| | - Claire De Giovanni
- Aix-Marseille Université, CNRS, Laboratoire de Neurosciences Cognitives (LNC – UMR 7291), Marseille, France
| | - Michel Guerraz
- Université Grenoble Alpes, Université Savoie Mont Blanc, CNRS, Laboratoire de Psychologie et NeuroCognition (LPNC – UMR 5105), Grenoble, France
| | - Anne Kavounoudias
- Aix-Marseille Université, CNRS, Laboratoire de Neurosciences Cognitives (LNC – UMR 7291), Marseille, France
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Zaheer A, Malik AN, Masood T, Fatima S. Effects of phantom exercises on pain, mobility, and quality of life among lower limb amputees; a randomized controlled trial. BMC Neurol 2021; 21:416. [PMID: 34706654 PMCID: PMC8554869 DOI: 10.1186/s12883-021-02441-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 10/15/2021] [Indexed: 01/16/2023] Open
Abstract
Background The objective of the current study is to evaluate the effects of phantom exercises on phantom limb pain, mobility status, and quality of life in lower limb amputees treated with mirror therapy and routine physiotherapy. Methods It is a randomized controlled trial in which 24 unilateral lower limb amputees (above and below the knee) were randomly assigned to two equal groups i.e., control group (mirror therapy and conventional physical therapy) and experimental group in which, phantom exercises were given, additionally. Physical therapy included conventional therapeutic exercises while phantom exercises include imagining the movement of the phantom limb and attempting to execute these movements Data were collected at baseline, after 2 and 4 weeks of intervention using VAS (pain), AMP (mobility) and RAND SF-36 Version 1.0 (QOL) questionnaires. All statistical analyses were done with IBM SPSS 25.0 with 95% CI. Results Twenty-four amputees (17 males and 7 females) participated in this trial. The Mean age of the participants in experimental and control groups was 45.3 ± 11.1 years and 40.5 ± 12.5 years respectively. After the intervention, the pain (VAS score) was significantly lower in the experimental group (p = 0.003). Similarly, the experimental group demonstrated a significantly better score in the “bodily pain” domain of SF-36 (p = 0.012). Both groups significantly (p < 0.05) improved in other domains of SF-36 and ambulatory potential with no significant (p > 0.05) between-group differences. Conclusions The Addition of phantom exercises resulted in significantly better pain management in lower limb amputees treated with mirror therapy and routine physiotherapy. Trial registration This study is registered in the U.S National Library of Medicine. The clinical trials registration number for this study is NCT04285138 (ClinicalTrials.gov Identifier) (Date: 26/02/2020). Supplementary Information The online version contains supplementary material available at 10.1186/s12883-021-02441-z.
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Affiliation(s)
- Anna Zaheer
- Faculty of Rehabilitation and Allied Health Sciences, Riphah International University, Lahore, Pakistan.
| | - Arshad Nawaz Malik
- Faculty of Rehabilitation and Allied Health Sciences, Riphah International University, Islamabad Campus, Rawalpindi, Pakistan
| | - Tahir Masood
- Department of Physical Therapy and Health Rehabilitation, College of Applied Medical Sciences, Jouf University, Sakakah, Saudi Arabia
| | - Sahar Fatima
- Faculty of Allied Health Sciences, University Institute of Physical Therapy, The University of Lahore, Lahore, Pakistan
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Mallik AK, Pandey SK, Srivastava A, Kumar S, Kumar A. Comparison of Relative Benefits of Mirror Therapy and Mental Imagery in Phantom Limb Pain in Amputee Patients at a Tertiary Care Center. Arch Rehabil Res Clin Transl 2020; 2:100081. [PMID: 33543104 PMCID: PMC7853377 DOI: 10.1016/j.arrct.2020.100081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To determine the relative benefit of mirror therapy and mental imagery in phantom limb pain. DESIGN Prospective randomized controlled trial. SETTING Physical Medicine and Rehabilitation Department, All India Institute of Medical Sciences, Patna. PARTICIPANTS Amputees (N=92) with no significant difference in baseline characteristics. There was a male predominance in both groups (mirror therapy: 36 men, 10 women; mental imagery: 37 men, 9 women). INTERVENTION Patients of both groups underwent a conventional amputee rehabilitation program and daily treatment of either mirror therapy or mental imagery on a regular basis, first in a rehabilitation care unit and later at home. MAIN OUTCOME MEASURES Phantom limb pain (PLP) was measured by visual analog scale (VAS) score at baseline (0) and at 4, 8, and 12 months. RESULTS This study included 92 patients ranging in age from 12 to 75 years (average, 34.79y). There was no significant difference in VAS score between the groups at baseline, but we found a significant reduction of pain in both groups at follow-up. However, upon comparing the improvement in both groups, we determined that the mirror therapy group had better improvement (from 7.07±1.74 to 2.74±0.77) compared with the mental imagery group (from 7.85±0.76 to 5.87±1.41). CONCLUSIONS Mirror therapy and mental imagery are both good and cost-effective rehabilitation aids for amputee patients to reduce PLP, but mirror therapy appears to be more effective than mental imagery.
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Affiliation(s)
- Amit Kumar Mallik
- Department of Physical Medicine and Rehabilitation, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Sanjay Kumar Pandey
- Department of Physical Medicine and Rehabilitation, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Ashish Srivastava
- Department of Physical Medicine and Rehabilitation, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Sanyal Kumar
- Department of Physical Medicine and Rehabilitation, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Anjani Kumar
- Department of Physical Medicine and Rehabilitation, All India Institute of Medical Sciences, Patna, Bihar, India
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Amrutsagar L, Parit G, Ghyar R, Bhallamudi R. Parametric Design and Hybrid Fabrication of Above-Knee Prosthesis. Indian J Orthop 2020; 54:381-390. [PMID: 32399160 PMCID: PMC7205932 DOI: 10.1007/s43465-020-00059-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 08/25/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND India has a large number of above-knee amputation patients who require a prosthetic leg that is affordable, conformal, functional, and durable. Available low-cost solutions, such as Jaipur foot, employ gypsum plaster in the process of fabricating a fitting socket. This has four shortcomings: (1) requirement of trained technicians, (2) high possibility of manual errors leading to rework, (3) long production time of several hours, and (4) difficulty in scaling up for widespread application. MATERIALS AND METHODS An improved approach is presented here, which combines computer-aided parametric design and numerically controlled machining with manual thermoforming to overcome the above issues. The socket is semi-automatically designed based on 60 parameters, derived from 23 measurements obtained on the natural stump of a patient. The three-dimensional (3D) computer-aided design model of the socket can be used for additive manufacturing (3D printing), which was found to be accurate, but time-consuming and expensive. Hence, a hybrid process was evolved with the following three steps: computer numeric control machining of the stump and shank replica in polyurethane (PU) foam, followed by coating with suitable epoxy, and finally high-density polyethylene pipe thermoforming over the PU foam replicas. RESULTS Three prostheses were fabricated using both conventional and hybrid processes and provided to volunteer patients. The hybrid process resulted in 28% reduction in overall fabrication time and improved satisfaction of patients due to better fit and comfort. CONCLUSION The proposed approach can be adapted for mass customization, required to meet the large gap in demand and supply, especially in resource-constrained settings.
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Affiliation(s)
- Lalitrao Amrutsagar
- grid.417971.d0000 0001 2198 7527Department of Mechanical Engineering, Bio-Medical Engineering and Technology Incubation Center/OrthoCAD Lab, Indian Institute of Technology Bombay, Near Power House, Hill-Side Road, Mumbai, Maharashtra 400 076 India
| | - Gaurav Parit
- grid.417971.d0000 0001 2198 7527Department of Mechanical Engineering, Bio-Medical Engineering and Technology Incubation Center/OrthoCAD Lab, Indian Institute of Technology Bombay, Near Power House, Hill-Side Road, Mumbai, Maharashtra 400 076 India
| | - Rupesh Ghyar
- grid.417971.d0000 0001 2198 7527Department of Mechanical Engineering, Bio-Medical Engineering and Technology Incubation Center/OrthoCAD Lab, Indian Institute of Technology Bombay, Near Power House, Hill-Side Road, Mumbai, Maharashtra 400 076 India
| | - Ravi Bhallamudi
- grid.417971.d0000 0001 2198 7527Department of Mechanical Engineering, Bio-Medical Engineering and Technology Incubation Center/OrthoCAD Lab, Indian Institute of Technology Bombay, Near Power House, Hill-Side Road, Mumbai, Maharashtra 400 076 India
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Abstract
Post-amputation phantom limb pain (PLP) is highly prevalent and very difficult to treat. The high-prevalence, high-pain intensity levels, and decreased quality of life associated with PLP compel us to explore novel avenues to prevent, manage, and reverse this chronic pain condition. This narrative review focuses on recent advances in the treatment of PLP and reviews evidence of mechanism-based treatments from randomized controlled trials published over the past 5 years. We review recent evidence for the efficacy of targeted muscle reinnervation, repetitive transcranial magnetic stimulation, imaginal phantom limb exercises, mirror therapy, virtual and augmented reality, and eye movement desensitization and reprocessing therapy. The results indicate that not one of the above treatments is consistently better than a control condition. The challenge remains that there is little level 1 evidence of efficacy for PLP treatments and most treatment trials are underpowered (small sample sizes). The lack of efficacy likely speaks to the multiple mechanisms that contribute to PLP both between and within individuals who have sustained an amputation. Research approaches are called for to classify patients according to shared factors and evaluate treatment efficacy within classes. Subgroup analyses examining sex effects are recommended given the clear differences between males and females in pain mechanisms and outcomes. Use of novel data analytical approaches such as growth mixture modeling for multivariate latent classes may help to identify sub-clusters of patients with common outcome trajectories over time.
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Affiliation(s)
- Andrea Aternali
- Department of Psychology, York University, Toronto, Ontario, Canada
| | - Joel Katz
- Department of Psychology, York University, Toronto, Ontario, Canada
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Singh PP, Goel I, Mondal A, Khan FA, Singh AK, Dubey P, Chaudhary S, Reddy PVAK, Rodrigues V, Bassi V, Ahuja K, Shetty A, Sahu AK, Jodha K, Singh N, Das S, Sharma R, Bagaria R, Poojary S, Gohil SM, Bonu A, Vazirani S, Esfandiari L, Shukla S, Shukla S, Khurana S. Acceptability of Mental Health Facilities and De-addiction Centers in India. J Exp Neurosci 2019; 13:1179069519839990. [PMID: 31001063 PMCID: PMC6454643 DOI: 10.1177/1179069519839990] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 03/01/2019] [Indexed: 11/07/2022] Open
Abstract
Not much is known about disease prevalence, treatment outcomes, trained manpower,
programs, and patients’ awareness of diseases from South Asia, compared with the
Western world. While other aspects are improving, the quantitative evaluation of
awareness of diseases is lagging. Compared with other diseases, the situation
for mental health disorders and addiction is worse. While no single study can
fully quantify all aspects of awareness, a good starting point is to understand
if increasing the number of mental health facilities is beneficial by
understanding people’s perception toward the likelihood of contracting various
diseases, their preferred approach to treatment, and their perception of whether
there are enough current facilities. We surveyed over 8000 families across
several states of India and asked if they would treat a particular problem at
home, visit a local healer, seek religious council, or go to a modern hospital
for treatment. Our questions also included non-medical options to assess how
likely people are to avoid trained medical help. We also asked people about
their perceived likelihood of a family member ever suffering from (1) diarrhea,
(2) high fever, (3) alcoholism, and (4) schizophrenia and other mental health
problems. We reversed the order of diseases in our questions for a fraction of
the population to evaluate the effect of order of questioning. Finally, we
asked, if people feel they have enough local healers, religious places, general
hospitals, de-addiction centers, and mental health facilities. Despite the taboo
around mental health, many people claimed that their family members were
unlikely to contract mental health or addiction problems, people recognized the
severe paucity of mental health facilities and de-addiction centers. This raises
hope for improving the mental health situation in India. We also found a
significant relation between education levels and choices people make,
underscoring the positive role education has in improving mental health.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Sunil Shukla
- Department of Zoology, Government Meera Girls College, Udaipur, India
| | - Shubha Shukla
- Department of Pharmacology, CSIR-Central Drug Research Institute (CSIR-CDRI), Lucknow, India
| | - Sukant Khurana
- Department of Pharmacology, CSIR-Central Drug Research Institute (CSIR-CDRI), Lucknow, India
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Russell HG, Tsao JW. Phantom Sensations Following Brachial Plexus Nerve Block: A Case Report. Front Neurol 2018; 9:436. [PMID: 29951033 PMCID: PMC6008534 DOI: 10.3389/fneur.2018.00436] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 05/24/2018] [Indexed: 11/13/2022] Open
Abstract
Following the administration of brachial plexus anesthesia for right thumb carpometacarpal arthroplasty with ligament reconstruction, a 54-year-old woman with all limbs intact developed phantom limb sensations, including the misperception of the placement of her right arm and frozen limb sensations in her fingers. Immobility of her fingers in a stacked position was experienced for ~3.5 days after surgery, and she described her phantom sensations as the hand experiencing "tingling" and feeling "heavy." While the onset of these phantom sensations occurred almost immediately after administration of brachial plexus anesthesia, they lasted for ~69 h after anesthesia wear off, suggesting that cortical effects from denervation resolves much more slowly than initial remapping, giving insight into the mechanisms behind phantom limb sensations that are often experienced by amputees.
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Affiliation(s)
- Hannah G Russell
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Jack W Tsao
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, United States.,Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, TN, United States.,Department of Neurology, Memphis Veterans Affairs Medical Center, Memphis, TN, United States
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