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Pain Jan 2020Postamputation stump and phantom pain are highly prevalent but remain a difficult condition to treat. The underlying mechanisms are not fully clarified, but growing...
Postamputation stump and phantom pain are highly prevalent but remain a difficult condition to treat. The underlying mechanisms are not fully clarified, but growing evidence suggests that changes in afferent nerves, including the formation of neuromas, play an important role. The main objective of this cross-sectional study was to investigate whether ultrasound-verified neuroma swellings are more frequent in amputees with postamputation pain than in amputees without pain (primary outcome). Sixty-seven amputees were included. Baseline characteristics including the frequency and intensity of spontaneous stump and phantom pain were obtained, and sensory characteristics and evoked responses were assessed. A high-frequency ultrasound examination of the amputated extremity was performed to obtain information on the presence, size, and elasticity of swollen neuromas and pressure pain thresholds. Swollen neuromas were present in 53 (79.1%) of the 67 amputees included in the study, in 47 (82.5%) of 57 amputees with pain and in 6 (60.0%) of 10 amputees without pain (P = 0.2). No difference was found in stump pain intensity (P = 0.42) during the last week or in phantom pain intensity in the last month (P = 0.74) between amputees with and without swollen neuromas. Our findings suggest that it is not the presence of swollen neuromas itself that drives postamputation pain. However, changes in the transected nerve endings may still be crucial for driving postamputation pain because a positive Tinel sign was significantly more frequent in amputees with pain, irrespectively of the degree of neuroma swelling.
Topics: Adult; Aged; Aged, 80 and over; Amputation, Surgical; Amputees; Cross-Sectional Studies; Female; Humans; Male; Middle Aged; Neuroma; Pain Measurement; Phantom Limb; Young Adult
PubMed: 31568042
DOI: 10.1097/j.pain.0000000000001705 -
Neurosurgery Clinics of North America Jul 2022Deep brain stimulation (DBS) is a neurosurgical intervention well known for the treatment of movement disorders as well as epilepsy, Tourette syndrome, and... (Review)
Review
Deep brain stimulation (DBS) is a neurosurgical intervention well known for the treatment of movement disorders as well as epilepsy, Tourette syndrome, and obsessive-compulsive disorders. DBS was pioneered in the 1950s, however, as a tool for treating facial pain, phantom limb pain, post-stroke pain, and brachial plexus pain among other disease states. Various anatomic targets exist, including the sensory thalamus (ventral posterior lateral and ventral posterior medial), the periaqueductal gray and periventricular gray matter, and the anterior cingulate cortex.
Topics: Chronic Pain; Deep Brain Stimulation; Humans; Neurosurgical Procedures; Periaqueductal Gray; Thalamus
PubMed: 35718401
DOI: 10.1016/j.nec.2022.02.013 -
Journal of Neurology, Neurosurgery, and... May 2022Phantom limb pain (PLP) impacts the majority of individuals who undergo limb amputation. The PLP experience is highly heterogenous in its quality, intensity, frequency... (Review)
Review
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.
PubMed: 35609964
DOI: 10.1136/jnnp-2021-328428 -
NeuroRehabilitation 2020Acquired limb loss, whether from accident or amputation, occurs with an incidence of greater than 175,000 per year in the United States. Current prevalence is estimated... (Review)
Review
Acquired limb loss, whether from accident or amputation, occurs with an incidence of greater than 175,000 per year in the United States. Current prevalence is estimated at greater than 1.5 million and is expected to double within 30 years. While many patients with amputations may have no significant pain or sensory issues after healing from the initial loss, one-quarter to one-half of patients may have ongoing difficulties with residual limb pain, phantom limb pain, or phantom limb sensation. This review explores the potential etiologies of those symptoms, as well as a variety of treatment options that a practitioner may consider when approaching this condition.
Topics: Amputation, Surgical; Amputees; Evidence-Based Medicine; Humans; Inflammation Mediators; Longitudinal Studies; Pain Measurement; Phantom Limb; Sensation
PubMed: 32986622
DOI: 10.3233/NRE-208005 -
Pain Mar 2024Neuromas are a substantial cause of morbidity and reduction in quality of life. This is not only caused by a disruption in motor and sensory function from the underlying... (Review)
Review
Neuromas are a substantial cause of morbidity and reduction in quality of life. This is not only caused by a disruption in motor and sensory function from the underlying nerve injury but also by the debilitating effects of neuropathic pain resulting from symptomatic neuromas. A wide range of surgical and therapeutic modalities have been introduced to mitigate this pain. Nevertheless, no single treatment option has been successful in completely resolving the associated constellation of symptoms. While certain novel surgical techniques have shown promising results in reducing neuroma-derived and phantom limb pain, their effectiveness and the exact mechanism behind their pain-relieving capacities have not yet been defined. Furthermore, surgery has inherent risks, may not be suitable for many patients, and may yet still fail to relieve pain. Therefore, there remains a great clinical need for additional therapeutic modalities to further improve treatment for patients with devastating injuries that lead to symptomatic neuromas. However, the molecular mechanisms and genetic contributions behind the regulatory programs that drive neuroma formation-as well as the resulting neuropathic pain-remain incompletely understood. Here, we review the histopathological features of symptomatic neuromas, our current understanding of the mechanisms that favor neuroma formation, and the putative contributory signals and regulatory programs that facilitate somatic pain, including neurotrophic factors, neuroinflammatory peptides, cytokines, along with transient receptor potential, and ionotropic channels that suggest possible approaches and innovations to identify novel clinical therapeutics.
Topics: Humans; Quality of Life; Neuroma; Neuralgia; Phantom Limb; Biology
PubMed: 37851396
DOI: 10.1097/j.pain.0000000000003055 -
Journal of Pain Research 2022Phantom limb pain (PLP) is a common condition that occurs following both upper and lower limb amputation. First recognized and described in 1551 by Ambroise Pare,... (Review)
Review
Phantom limb pain (PLP) is a common condition that occurs following both upper and lower limb amputation. First recognized and described in 1551 by Ambroise Pare, research into its underlying pathology and effective treatments remains a very active and growing field. To date, however, there is little consensus regarding the optimal management of phantom limb pain. With few large well-designed clinical trials of which to make treatment recommendations, as well as significant heterogeneity in clinical response to available treatments, the management of PLP remains challenging. Below we summarize the current state of knowledge in the field, as well as propose an algorithm for the approach to the treatment of PLP.
PubMed: 36320223
DOI: 10.2147/JPR.S355278 -
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 -
Journal of Pain Research 2023Phantom limb pain (PLP) commonly occurs post-amputation and can negatively affect the daily functioning of persons with amputation. Best practices for medication and...
BACKGROUND
Phantom limb pain (PLP) commonly occurs post-amputation and can negatively affect the daily functioning of persons with amputation. Best practices for medication and non-drug management remain unclear.
OBJECTIVE
To better understand the PLP experience and patients' familiarity with treatments, phone interviews were conducted at the Minneapolis Veterans Affairs Regional Amputation Center in Veterans with amputations.
METHODS
Fifty Veteran participants (average age 66, 96% male) with lower limb amputation were recruited for phone-based data collection of patient-reported outcomes (ie, demographics using the Trinity Amputation and Prosthesis Experience Scales-Revised (TAPES-R) and pain experience using the Phantom Phenomena Questionnaire) to characterize the population and a semi-structured interview. Notes taken during interviews were analyzed using the Krueger and Casey constant comparison analysis method.
RESULTS
Participants had an average of 15 years since amputation, and 80% reported PLP as identified with the Phantom Phenomena Questionnaire. Investigators identified several core themes from the qualitative interviews including 1) high variability in the experience of PLP, 2) acceptance and resilience, and 3) PLP treatment perceptions. The majority of participants reported trying common non-drug treatments with none endorsed consistently as highly effective.
CONCLUSION
More research is needed to inform identification and implementation of clinical best practices for non-drug interventions for PLP and understand the factors that influence engagement in non-drug interventions. The participants in this study were largely male, so these results may not be generalizable to females.
PubMed: 37138954
DOI: 10.2147/JPR.S390658