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Molecular Neurobiology Jan 2018Phantom limb pain (PLP) is a chronic neuropathic pain occurring in 45-85% of patients who undergo major amputations of the upper and lower extremities. Chronic pain is... (Review)
Review
Phantom limb pain (PLP) is a chronic neuropathic pain occurring in 45-85% of patients who undergo major amputations of the upper and lower extremities. Chronic pain is physically and mentally debilitating, affecting an individual's potential for self-care and the performance of daily living activities essential for personal and economic independence. In addition, chronic pain may lead to depression and feelings of hopelessness. A National Center for Biotechnology Information study found that in the USA alone, the annual cost of dealing with neuropathic pain is more than $600 billion, with an estimated 20 million people in the USA suffering this condition. PLP manifest predominantly during two time frames post-amputation: during days to a month and again at around 1 year. In most patients, the frequency and intensity of the chronic neuropathic pain diminish over time, but severe pain persists in about 5-10% of patients. The development and maintenance of neuropathic pain is attributed to extremity amputations causing changes in peripheral axon properties and neuronal circuitry in both the peripheral and central nervous systems: peripheral axons, dorsal root ganglia, the spinal cord, and the cortex. However, it is not clear how the changes in neuronal properties in these different locations affect neuropathic pain. Is pain initiated by one set of post-amputation changes while the pain is maintained by another set of changes? If one set of amputation-induced changes, such as those of peripheral axons, are reverted to normal, is the chronic pain reduced or eliminated, while reversing another set of neuronal changes and neuronal circuits to normal do not reduce or eliminate the pain? Or, must all the amputation-induced changes be reverted to normal for pain to be eliminated? While this review examines the mechanisms underlying the induction or maintenance of PLP, it is beyond its scope to examine the mechanisms that may permanently reduce or eliminate neuropathic pain. This paper is the first of two reviews in this journal and deals with the causes of chronic PLP development and maintenance, while the second review examines potential mechanisms that may be responsible for promoting the capacity to coping with PLP by reducing or eliminating it.
Topics: Amputation, Surgical; Animals; Ganglia, Spinal; Humans; Nerve Net; Neuralgia; Phantom Limb; Spinal Cord
PubMed: 28921474
DOI: 10.1007/s12035-017-0717-x -
European Journal of Pain (London,... Aug 2014
Topics: Amputees; Humans; Pain; Phantom Limb; Virtual Reality Exposure Therapy
PubMed: 25045000
DOI: 10.1002/ejp.559 -
Der Orthopade Jan 2021Problems in prosthetic fitting or mobility of amputated patients are often caused primarily by insufficient stump quality. To achieve better rehabilitation results and... (Review)
Review
Problems in prosthetic fitting or mobility of amputated patients are often caused primarily by insufficient stump quality. To achieve better rehabilitation results and a higher quality of life it is mandatory that the physician treating the patient is able to diagnose stump problems and to indicate stump correction surgery. A skilled knowledge of amputation techniques, different levels of amputation, as well as of prosthetic fitting methods is needed. The physician has to have knowledge of the differences between phantom sensation, phantom pain and stump pain, as well as their possible causes. Especially with stump pain caused by stump problems revision surgery has to be considered with the patient. A well-done surgical stump correction should result in a better end-bearing capacity, less pain, improved rehabilitation potential and better life quality. Stump revision surgery should be indicated more often, and this type of surgery should be a standard procedure in every orthopaedic and trauma department.
Topics: Amputation, Surgical; Amputation Stumps; Humans; Phantom Limb; Quality of Life
PubMed: 33284356
DOI: 10.1007/s00132-020-04039-8 -
Current Opinion in Anaesthesiology Oct 2023Chronic postamputation pain (cPAP) remains a clinical challenge, and current understanding places a high emphasis on prevention strategies. Unfortunately, there is still... (Review)
Review
PURPOSE OF REVIEW
Chronic postamputation pain (cPAP) remains a clinical challenge, and current understanding places a high emphasis on prevention strategies. Unfortunately, there is still no evidence-based regimen to reliably prevent chronic pain after amputation.
RECENT FINDINGS
Risk factors for the development of phantom limb pain have been proposed. Analgesic preventive interventions are numerous and no silver bullet has been found. Novel techniques such as neuromodulation and cryoablation have been proposed. Surgical techniques focusing on reimplantation of the injured nerve might reduce the incidence of phantom limb pain after surgery.
SUMMARY
Phantom limb pain is a multifactorial process involving profound functional and structural changes in the peripheral and central nervous system. These changes interact with individual medical, psychosocial and genetic patient risk factors. The patient collective of amputees is very heterogeneous. Available evidence suggests that efforts should focus on prevention of phantom limb pain, since treatment is notoriously difficult. Questions as yet unanswered include the evidence-base of specific analgesic interventions, their optimal "window of opportunity" where they may be most effective, and whether patient stratification according to biopsychosocial risk factors can help guide preventive therapy.
Topics: Humans; Phantom Limb; Chronic Pain; Amputation, Surgical; Amputees; Analgesics
PubMed: 37552016
DOI: 10.1097/ACO.0000000000001298 -
Experimental Biology and Medicine... Apr 2023At least two million people in the United States of America live with lost limbs, and the number is expected to double by 2050, although the incidence of amputations is... (Review)
Review
At least two million people in the United States of America live with lost limbs, and the number is expected to double by 2050, although the incidence of amputations is significantly greater in other parts of the world. Within days to weeks of the amputation, up to 90% of these individuals develop neuropathic pain, presenting as phantom limb pain (PLP). The pain level increases significantly within one year and remains chronic and severe for about 10%. Amputation-induced changes are considered to underlie the causation of PLP. Techniques applied to the central nervous system (CNS) and peripheral nervous system (PNS) are designed to reverse amputation-induced changes, thereby reducing/eliminating PLP. The primary treatment for PLP is the administration of pharmacological agents, some of which are considered but provide no more than short-term pain relief. Alternative techniques are also discussed, which provide only short-term pain relief. Changes induced by various cells and the factors they release are required to change neurons and their environment to reduce/eliminate PLP. It is concluded that novel techniques that utilize autologous platelet-rich plasma (PRP) may provide long-term PLP reduction/elimination.
Topics: Humans; United States; Phantom Limb; Amputation, Surgical; Neuralgia; Extremities
PubMed: 37158119
DOI: 10.1177/15353702231168150 -
Muscle & Nerve Feb 2019Post-amputation phantom limb pain (PLP) is a widespread phenomenon that can have physical, psychological, and functional impacts on amputees who experience the... (Review)
Review
Post-amputation phantom limb pain (PLP) is a widespread phenomenon that can have physical, psychological, and functional impacts on amputees who experience the condition. The varying presentations and mechanisms of PLP make it difficult to effectively provide long-term pain relief. Multiple neuromodulatory approaches to treating PLP have focused on electrical stimulation of the peripheral nervous system, with varying degrees of success. More recently, research has been done to study the effects of neuroprosthetic approaches on PLP. Neuroprosthetics combine the use of a functional prosthetic with stimulation to the peripheral nerves in the residual limb. Although many of the neuroprosthetic studies focus on improving function, several have shown preliminary evidence for the reduction of severity of PLP. In this review we provide an overview of the current understanding of the neurological mechanisms that initiate and sustain PLP, as well as the neuromodulatory and neuroprosthetic approaches under development for treatment of the condition. Muscle Nerve 59:154-167, 2019.
Topics: Artificial Limbs; Humans; Peripheral Nerves; Phantom Limb; Transcutaneous Electric Nerve Stimulation
PubMed: 30152101
DOI: 10.1002/mus.26294 -
Annals of Plastic Surgery May 2022Neuromas, neuralgia, and phantom limb pain commonly occur after lower-extremity amputations; however, incidence of these issues is poorly reported and understood....
BACKGROUND
Neuromas, neuralgia, and phantom limb pain commonly occur after lower-extremity amputations; however, incidence of these issues is poorly reported and understood. Present literature is limited to small cohort studies of amputees, and the reported incidence of chronic pain after amputation ranges as widely as 0% to 80%. We sought to objectively investigate the incidence of postamputation pain and nerve-related complications after lower-extremity amputation.
METHODS
Patients who underwent lower-extremity amputation between 2007 and 2017 were identified using a national insurance-based claims database. Incidence of reporting of postoperative neuroma, neuralgia, and phantom limb pain were identified. Patient demographics and comorbidities were assessed. Average costs of treatment were determined in the year after lower-extremity amputation. Logistic regression analyses and resulting odds ratios were calculated to determine statistically significant increases in incidence of postamputation nerve-related pain complications in the setting of demographic factors and comorbidities.
RESULTS
There were 29,507 lower amputations identified. Postoperative neuralgia occurred in 4.4% of all amputations, neuromas in 0.4%, and phantom limb pain in 10.9%. Nerve-related pain complications were most common in through knee amputations (20.3%) and below knee amputations (16.7%). Male sex, Charlson Comorbidity Index > 3, diabetes mellitus, diabetic neuropathy, diabetic angiopathy, diabetic retinopathy, obesity, peripheral vascular disease, and tobacco abuse were associated with statistically significant increases in incidence of 1-year nerve-related pain or phantom limb pain.
CONCLUSIONS
Given the incidence of these complications after operative extremity amputations and associated increased treatment costs, future research regarding their pathophysiology, treatment, and prevention would be beneficial to both patients and providers.
Topics: Amputation, Surgical; Amputation Stumps; Humans; Lower Extremity; Male; Neuralgia; Neuroma; Phantom Limb; Retrospective Studies
PubMed: 35443269
DOI: 10.1097/SAP.0000000000003009 -
Scandinavian Journal of Pain Jan 2022The population of Americans with limb loss is on the rise, with a different profile than in previous generations (e.g., greater incidence of amputation due to diabetes)....
OBJECTIVES
The population of Americans with limb loss is on the rise, with a different profile than in previous generations (e.g., greater incidence of amputation due to diabetes). This study aimed to identify the key characteristics of phantom limb sensation (PLS) and pain (PLP) in a current sample of Americans with limb loss.
METHODS
This cross-sectional study is the first large-scale (n=649) study on PLP in the current population of Americans with limb loss. A convenience sample of military and civilian persons missing one or more major limbs was surveyed regarding their health history and experience with phantom limb phenomena.
RESULTS
Of the participants surveyed, 87% experienced PLS and 82% experienced PLP. PLS and PLP typically first occurred immediately after amputation (47% of cases), but for a small percentage (3-4%) onset did not occur until over a year after amputation. Recent PLP severity decreased over time (β=0.028, 95% CI: -0.05-0.11), but most participants reported PLP even 10 years after amputation. Higher levels of recent PLP were associated with telescoping (β=0.123, 95% CI: 0.04-0.21) and higher levels of pre-amputation pain (β=0.104, 95% CI: 0.03-0.18). Those with congenitally missing limbs experienced lower levels of recent PLP (t (37.93)=3.93, p<0.01) but there were no consistent differences in PLP between other amputation etiologies.
CONCLUSIONS
Phantom limb phenomena are common and enduring. Telescoping and pre-amputation pain are associated with higher PLP. Persons with congenitally missing limbs experience lower levels of PLP than those with amputation(s), yet PLP is common even in this subpopulation.
Topics: Amputation, Surgical; Amputees; Cross-Sectional Studies; Humans; Incidence; Phantom Limb
PubMed: 34529903
DOI: 10.1515/sjpain-2021-0139 -
PM & R : the Journal of Injury,... Mar 2023Following lower-limb amputation, phantom limb pain (i.e., pain perceived as coming from the amputated portion of the limb) is common. Phantom limb pain may be associated...
BACKGROUND
Following lower-limb amputation, phantom limb pain (i.e., pain perceived as coming from the amputated portion of the limb) is common. Phantom limb pain may be associated with impaired body image and perception, which may be targets for rehabilitative intervention.
OBJECTIVE
To compare measures of body image and perception between adults with and without phantom limb pain post amputation and evaluate associations between measures of body image and perception and phantom limb pain.
DESIGN
Survey.
SETTING
Online, remote assessment.
PARTICIPANTS
Seventy-two adults ≥1 year post unilateral lower-limb loss (n = 42 with phantom limb pain, n = 30 without phantom limb pain or pain in the remaining portion of the limb).
INTERVENTIONS
Not applicable.
MAIN OUTCOME MEASURES
Self-reported outcome measures assessing body image (i.e., Amputee Body Image Scale-Revised), perceptual disturbances associated with the phantom limb (i.e., a modified Bath Complex Regional Pain Syndrome Body Perception Disturbance Scale), and prosthesis satisfaction (i.e., Trinity Amputation and Prosthesis Experience Scale) were administered; participants with phantom limb pain reported pain interference via the Brief Pain Inventory-Short Form. Between-group comparisons of self-reported outcome measure scores were conducted using Mann Whitney U or chi-square tests, as appropriate (a = .05).
RESULTS
Compared to peers without phantom limb pain, adults with phantom limb pain reported more negative body image; increased phantom limb ownership, attention, and awareness; and reduced prosthesis satisfaction and embodiment (U = 175.50-364.00, p < .001 to .034). Disturbances in phantom limb perception (i.e., size, weight, pressure, temperature) were similar between groups (p = .086 to >.999). More negative body image was associated with increased phantom limb pain interference (τ = .25, p = .026).
CONCLUSIONS
Adults with phantom limb pain demonstrate more negative body image and hypervigilance of the phantom limb as compared to peers with nonpainful phantom sensations. Mind-body treatments that target impaired body image and perception may be critical interventions for adults with phantom limb pain.
Topics: Adult; Humans; Phantom Limb; Body Image; Amputation, Surgical; Lower Extremity; Amputees; Artificial Limbs
PubMed: 34914201
DOI: 10.1002/pmrj.12750 -
Vascular and Endovascular Surgery Feb 2024Phantom limb pain (PLP) and symptomatic neuroma can be debilitating and significantly impact the quality of life of amputees. However, the prevalence of PLP and... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Phantom limb pain (PLP) and symptomatic neuroma can be debilitating and significantly impact the quality of life of amputees. However, the prevalence of PLP and symptomatic neuromas in patients following dysvascular lower limb amputation (LLA) has not been reliably established. This systematic review and meta-analysis evaluates the prevalence and incidence of phantom limb pain and symptomatic neuroma after dysvascular LLA.
METHODS
Four databases (Embase, MEDLINE, Cochrane Central, and Web of Science) were searched on October 5, 2022. Prospective or retrospective observational cohort studies or cross-sectional studies reporting either the prevalence or incidence of phantom limb pain and/or symptomatic neuroma following dysvascular LLA were identified. Two reviewers independently conducted the screening, data extraction, and the risk of bias assessment according to the PRISMA guidelines. To estimate the prevalence of phantom limb pain, a meta-analysis using a random effects model was performed.
RESULTS
Twelve articles were included in the quantitative analysis, including 1924 amputees. A meta-analysis demonstrated that 69% of patients after dysvascular LLA experience phantom limb pain (95% CI 53-86%). The reported pain intensity on a scale from 0-10 in LLA patients ranged between 2.3 ± 1.4 and 5.5 ± .7. A single study reported an incidence of symptomatic neuroma following dysvascular LLA of 5%.
CONCLUSIONS
This meta-analysis demonstrates the high prevalence of phantom limb pain after dysvascular LLA. Given the often prolonged and disabling nature of neuropathic pain and the difficulties managing it, more consideration needs to be given to strategies to prevent it at the time of amputation.
Topics: Humans; Phantom Limb; Retrospective Studies; Cross-Sectional Studies; Quality of Life; Prospective Studies; Treatment Outcome; Amputation, Surgical; Neuroma; Extremities; Lower Extremity
PubMed: 37616476
DOI: 10.1177/15385744231197097