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Current Pain and Headache Reports Jul 2019Phantom sensations are incompletely understood phenomena which take place following an amputation or deafferentation of a limb. They can present as kinetic, kinesthetic,... (Review)
Review
PURPOSE OF REVIEW
Phantom sensations are incompletely understood phenomena which take place following an amputation or deafferentation of a limb. They can present as kinetic, kinesthetic, or exteroceptive perceptions. It is estimated that phantom limb pain (PLP) affects anywhere from 40 to 80% of amputees.
RECENT FINDINGS
Psychiatric illnesses such as depression, anxiety, and mood disorders have higher prevalence in amputees than in the general population. Pharmacologic treatment has been used as first-line therapy for amputees suffering from PLP with agents including gabapentinoids, amitriptyline, and other tricyclic anti-depressants, opioids, and local anesthetics. Non-invasive treatment modalities exist for PLP including sensory motor training, mirror visual therapy, and non-invasive neuromodulation. Non-invasive neuromodulation includes interventions like transcutaneous electrical nerve stimulation (TENS) and transcranial magnetic stimulation. While many promising therapies for PLP exist, more clinical trials are required to determine the efficacy and protocols needed for maximum benefit in patients suffering from PLP.
Topics: Analgesics; Humans; Pain Management; Pain Measurement; Phantom Limb; Transcutaneous Electric Nerve Stimulation; Treatment Outcome
PubMed: 31359171
DOI: 10.1007/s11916-019-0802-0 -
Rhode Island Medical Journal (2013) May 2020The prevalence of amputation and post-amputation pain (PAP) is rising. There are two main types of PAP: residual limb pain (RLP) and phantom limb pain (PLP), with an... (Review)
Review
INTRODUCTION
The prevalence of amputation and post-amputation pain (PAP) is rising. There are two main types of PAP: residual limb pain (RLP) and phantom limb pain (PLP), with an estimated 95% of people with amputations experiencing one or both. Medical Management: The majority of chronic PAP is due to phantom limb pain, which is neurogenic in nature. Common medications used include tricyclic antidepressants, gabapentin, and opioids. Newer studies are evaluating alternative drugs such as ketamine and local anesthetics. Rehabilitation Management: Mirror visual feedback and cognitive behavioral therapy are often effective adjunct therapies and have minimal adverse effects. Surgical Management: Neuromodulatory treatment and surgery for neuromas have been found to help select patients with PAP.
CONCLUSION
PAP is a complex condition with mechanisms that can be located at the residual limb, spinal cord, and brain - or a combination. This complex pain can be difficult to treat. The mainstays of treatment are largely medical, but several surgical options are also being studied.
Topics: Amputation, Surgical; Humans; Pain; Pain Management; Pain Measurement; Phantom Limb
PubMed: 32357588
DOI: No ID Found -
F1000Research 2019Post-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... (Review)
Review
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.
Topics: Amputation, Surgical; Augmented Reality; Exercise Therapy; Female; Humans; Male; Phantom Limb; Quality of Life; Transcranial Magnetic Stimulation; Treatment Outcome
PubMed: 31354940
DOI: 10.12688/f1000research.19355.1 -
Archives of Physical Medicine and... May 2022To evaluate the effectiveness of mirror therapy (MT) for phantom limb pain (PLP). (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To evaluate the effectiveness of mirror therapy (MT) for phantom limb pain (PLP).
DATA SOURCES
PubMed, EMBASE, Ovid MEDLINE, Scopus, Cochrane Library, Physiotherapy Evidence Database, CNKI, and WanFang Data were used to search for studies published up to March 31, 2021.
STUDY SELECTION
Randomized controlled trials (RCTs) comparing the pain intensity of MT for PLP were performed. A total of 2094 articles were found. Among them, 10 were eligible for the final analysis.
DATA EXTRACTION
The quality of the RCTs was assessed using the Physiotherapy Evidence Database (PEDro) scale by 2 independent reviewers. Outcome data were pooled according to follow-up intervals (1, 3, 6, and 12mo). Duration times were used as a basis for distinguishing subgroups. The primary evaluation was by visual analog scale. The PEDro scale was used to assess the methodological quality of studies.
DATA SYNTHESIS
Meta-analysis revealed a statistically significant decrease in pain in the MT group vs the control group within 1 month (I=0%; standardized mean difference [SMD]=-0.46, 95% confidence interval [CI], -0.79 to -0.13; P = .007). The patients with pain for longer than 1 year benefited more from MT (I=0%; SMD=-0.46; 95% CI, -0.85 to -0.07; P = .02).
CONCLUSIONS
MT has beneficial effects for patients with PLP in the short-term, as evidenced by their improved pain scores. There was no evidence that MT had a long-term effect, but that may be a product of limited data. For patients with long-term PLP, MT may be an effective treatment.
Topics: Humans; Mirror Movement Therapy; Pain Measurement; Phantom Limb; Physical Therapy Modalities; Treatment Outcome
PubMed: 34461084
DOI: 10.1016/j.apmr.2021.07.810 -
Pain Physician Oct 2022Phantom limb pain (PLP), defined as a painful sensation in a portion of the body that has been amputated, occurs in upwards of 80% of limb amputees and can significantly... (Review)
Review
BACKGROUND
Phantom limb pain (PLP), defined as a painful sensation in a portion of the body that has been amputated, occurs in upwards of 80% of limb amputees and can significantly impact a patient's quality of life. First hypothesized in 1551, the disease has been poorly understood for much of this time. Still today, the exact etiology of the condition is yet to be elucidated. In the periphery, PLP resembles the neuronal changes seen in other neuropathic pain conditions. However, in the central nervous system (CNS), imaging studies suggest changes unique to PLP, such as cortical reorganization. Despite a growing understanding of its underpinnings, a mechanism-based treatment is not yet available. Rather, a plethora of treatment methodologies are available with varying levels of supporting evidence and many treatments being utilized based on efficacy seen in non-PLP patients.
OBJECTIVES
In this review, we provide a thorough summary of the current literature regarding PLP's etiology, diagnosis, treatment, and attempts to prevent the development of PLP following amputation.
STUDY DESIGN
A narrative review.
METHODS
This was a narrative review conducted after an extensive and thorough review of available literature on the topic from a variety of sources.
RESULTS
Current evidence supports a central reorganization process with potential amplification of aberrant peripheral inputs as the etiology of PLP. This conclusion is supported by functional neuroimaging as well as the failure of peripherally focused treatments. Treatment of PLP remains difficult due to varying response rates to therapies. Nonetheless, there are several treatment modalities that have proven effective in the majority of patients tested, ranging from noninvasive systemic pharmacotherapy to more invasive neuromodulation, such as spinal cord stimulation. While opioid therapy remains the most evidence-based treatment, the newer neuromodulation techniques appear to be superior in symptom reduction with minimal side effects.
LIMITATIONS
Evidence for the treatment of PLP is largely restricted to uncontrolled case reports and/or small single-site uncontrolled case series. Some research is further hampered by the presence of confounding factors such as concurrent treatment regimens.
CONCLUSIONS
While PLP remains a difficult-to-treat condition, practitioners can greatly improve the quality of life of patients suffering from the condition with a wide range of developing treatments. For pain intractable to traditional pharmacologic treatment, neuromodulation therapies have proven to be highly effective with minimal side effect profiles.
Topics: Humans; Phantom Limb; Analgesics, Opioid; Quality of Life; Amputees; Spinal Cord Stimulation
PubMed: 36288580
DOI: No ID Found -
Neurologia Oct 2022Phantom limb pain (PLP) is a type of neuropathic pain that affects the territory of an amputated limb or other surgically removed body parts. Between 60% and 90% of... (Review)
Review
INTRODUCTION
Phantom limb pain (PLP) is a type of neuropathic pain that affects the territory of an amputated limb or other surgically removed body parts. Between 60% and 90% of amputees suffer from PLP during follow-up. There are a range of therapeutic options for PLP, both pharmacological (gabapentin, amitriptyline, tricyclic antidepressants, etc) and non-pharmacological (transcutaneous electrical nerve stimulation, hypnosis, acupuncture, etc). A widely accepted hypothesis considers PLP to be the consequence of postamputation cortical reorganisation. New treatment approaches, such as mirror therapy (MT), have been developed as a result of Ramachandran's groundbreaking research in the 1990s. This review analyses the current evidence on the efficacy of MT for treating PLP.
DEVELOPMENT
We performed a literature review of publications registered from 2012 to 2017 on the CINAHL, Cochrane, Scopus, and PubMed (including Medline) databases using the descriptors "phantom limb" and "mirror therapy." We identified 115 publications addressing MT in PLP. Of these, 17 (15%) contributed useful information for pooled analysis.
CONCLUSIONS
MT seems to be effective in relieving PLP, reducing the intensity and duration of daily pain episodes. It is a valid, simple, and inexpensive treatment for PLP. The methodological quality of most publications in this field is very limited, highlighting the need for additional, high-quality studies to develop clinical protocols that could maximise the benefits of MT for patients with PLP.
Topics: Amitriptyline; Antidepressive Agents, Tricyclic; Gabapentin; Humans; Mirror Movement Therapy; Phantom Limb
PubMed: 36195376
DOI: 10.1016/j.nrleng.2018.08.005 -
Innovations in Clinical Neuroscience 2022To evaluate the literature on the effectiveness of virtual reality (VR)- and augmented reality (AR)-based treatments for phantom limb pain (PLP) in postamputation or... (Review)
Review
OBJECTIVE
To evaluate the literature on the effectiveness of virtual reality (VR)- and augmented reality (AR)-based treatments for phantom limb pain (PLP) in postamputation or brachial plexus avulsion (BPA) populations.
METHODS
Multiple databases were queried in July 2021 with the keywords "virtual reality," "augmented reality," and "phantom limb pain." Included studies utilized VR or AR to treat PLP with outcome measurement. Two independent reviewers assessed methodological quality using the Physiotherapy Evidence Databsae (PEDro) Scale and the Methodological Index for Nonrandomized Studies (MINORS) scoring. Studies were separated into immersive and nonimmersive AR/VR systems, with further categorization according to the specific methodologies used.
RESULTS
Of 110 results from the database queries, 20 publications met the inclusion criteria. There was one unblinded, randomized, control trial (RCT), one single-blinded, randomized, crossover trial (RCxT), three comparative case series, 13 noncomparative case series, and two case reports. Seven of the 20 studies were classified as nonimmersive. Six studies reported decreased PLP after AR/VR treatments, of which four reported significant reductions. One study reported a reduction in PLP with no significant difference from control conditions. Thirteen of the 20 studies were classified as immersive AR/VR. Twelve studies reported decreased PLP after AR/VR treatments, of which eight reported significant reductions. One study found no change in PLP, compared to baseline.
CONCLUSION
The number of studies using AR/VR in PLP treatment has expanded since a 2017 review on the topic. The majority of these studies offer support for the efficacy of treating PLP with AR/VR-based treatments. Research has expanded on the customization, outcome measurements, and statistical analysis of AR/VR treatments. While results are promising, most publications remain at the case series level, and clinical indications should be cautioned. With improvements in the quality of evidence, there remain avenues for further investigations, including increased sampling, randomization, optimization of treatment duration, and comparisons to alternative therapies.
PubMed: 36591552
DOI: No ID Found -
BMC Neurology Oct 2021The 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... (Randomized Controlled Trial)
Randomized Controlled Trial
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).
Topics: Adult; Amputees; Female; Humans; Lower Extremity; Male; Middle Aged; Pain Measurement; Phantom Limb; Quality of Life
PubMed: 34706654
DOI: 10.1186/s12883-021-02441-z -
The Lancet. Neurology Oct 2020Dreams are experiences that occur during sleep, while we are disconnected from the environment. Thanks to recent progress in neuroimaging techniques, it is now becoming... (Review)
Review
Dreams are experiences that occur during sleep, while we are disconnected from the environment. Thanks to recent progress in neuroimaging techniques, it is now becoming possible to relate dream features to specific patterns of brain activity. Some conditions occurring in patients with neurological disorders, such as lucid dreams and parasomnias, not only have diagnostic value, but also offer a window into the dream process. They show that dreaming is reflected in physiological signals, behaviours, and brain activity patterns, and that the body can enact dream content. Yet, the dream body can also be distinct from the real body; in their dreams, patients with congenital paraplegia can walk, those with sleep apnoea rarely suffocate, and phantom limb pain can disappear. These conditions provide valuable models for future studies investigating the mechanisms that underlie oneiric experiences.
Topics: Adult; Dreams; Humans; Nervous System Diseases; Sleep; Sleep Stages; Sleep Wake Disorders
PubMed: 32949545
DOI: 10.1016/S1474-4422(20)30275-1