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Injury Dec 2011Lower limb amputation (LLA) is life-changing surgery. Shorter residual limbs are known to place greater physiological strain on patients than longer residual limbs;... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
Lower limb amputation (LLA) is life-changing surgery. Shorter residual limbs are known to place greater physiological strain on patients than longer residual limbs; however, there is ongoing debate as to whether through-knee amputations are preferable to above-knee amputations. This analysis aims to resolve this question by systematically collecting and pooling published and unpublished data on this subject.
METHODS
An exhaustive search of Medline, Embase and Recal databases was made for outcome studies of patients with lower limb amputations following trauma. Studies concerned with amputations of the upper limb or foot and ankle were excluded as were papers reporting outcomes in a population of mixed trauma and non-trauma patients. Authors of studies published in the last 10 years were contacted for unpublished details. Patients were then divided, according to amputation height, into four groups: below-knee amputation (BKA), through-knee amputation (TKA), above-knee amputation (AKA) and bilateral amputation. The primary outcome measure was Physical Component Score (PCS) of the short-form-36 measure of quality of life and secondary outcomes were pain, employment, ability to walk 500m and proportion of time that prosthesis is worn.
RESULTS
As many as 27 studies were included, representing a total of 3105 patients, 1855 with a BKA, 104 with a TKA, 888 with an AKA and 258 bilateral amputees. There was progressive and significant lowering of PCS (worsening outcomes) as unilateral amputation height became more proximal from BKA to TKA and AKA. A significantly greater proportion of patients with a BKA or a TKA were able to walk 500m than those with an AKA or bilateral amputation (p=0.0035). However, patients with a TKA wore their prosthesis significantly less, and had significantly more pain than those with an AKA.
CONCLUSION
This study describes the impact of LLA of different levels on patients' lives. The results indicate that patients with a TKA have a better physical quality of life than those with an AKA and, therefore, support the surgical strategy of maintaining maximum length and performing TKA in preference to AKA, where possible.
Topics: Amputation, Surgical; Amputation Stumps; Artificial Limbs; Databases, Bibliographic; Employment; Humans; Knee Joint; Leg; Leg Injuries; Lower Extremity; Military Personnel; Outcome Assessment, Health Care; Pain; Quality of Life; Walking
PubMed: 21831371
DOI: 10.1016/j.injury.2011.07.005 -
Journal of Functional Morphology and... Feb 2023Individuals with lower-limb amputations may have a significant strength deficit. This deficit may be related to the stump length and can lead to changes in gait, reduced... (Review)
Review
Individuals with lower-limb amputations may have a significant strength deficit. This deficit may be related to the stump length and can lead to changes in gait, reduced energy efficiency, walking resistance, altered joint load, and increased risk of osteoarthritis and chronic low back pain. This systematic review used the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) guidelines to examine the effects of resistance training in lower limb amputees. Interventions with resistance training and other training methods were sufficient to achieve muscle strength gain in muscles of the lower limbs, improved balance, and improvements in gait pattern and speed when walking. However, it was impossible to determine from the results whether resistance training was mainly responsible for these benefits or even whether the positive effects presented would be observed with only this training method. When combined with other exercises, interventions with resistance training made possible gains for this population. Accordingly, it is noteworthy that the main finding of this systematic review is that the effects may be different according to the level of amputation, with mainly transtibial and transfemoral amputations studied.
PubMed: 36810507
DOI: 10.3390/jfmk8010023 -
PloS One 2020Phantom limb pain (PLP)-pain felt in the amputated limb-is often accompanied by significant suffering. Estimates of the burden of PLP have provided conflicting data. To... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Phantom limb pain (PLP)-pain felt in the amputated limb-is often accompanied by significant suffering. Estimates of the burden of PLP have provided conflicting data. To obtain a robust estimate of the burden of PLP, we gathered and critically appraised the literature on the prevalence and risk factors associated with PLP in people with limb amputations.
METHODS
Articles published between 1980 and July 2019 were identified through a systematic search of the following electronic databases: MEDLINE/PubMed, PsycINFO, PsycArticles, Cumulative Index to Nursing and Allied Health Literature, Africa-Wide Information, Health Source: Nursing/Academic Edition, SCOPUS, Web of Science and Academic Search Premier. Grey literature was searched on databases for preprints. Two reviewers independently conducted the screening of articles, data extraction and risk of bias assessment. The meta-analyses were conducted using the random effects model. A statistically significant level for the analyses was set at p<0.05.
RESULTS
The pooling of all studies demonstrated a prevalence estimate of 64% [95% CI: 60.01-68.05] with high heterogeneity [I2 = 95.95% (95% CI: 95.10-96.60)]. The prevalence of PLP was significantly lower in developing countries compared to developed countries [53.98% vs 66.55%; p = 0.03]. Persistent pre-operative pain, proximal site of amputation, stump pain, lower limb amputation and phantom sensations were identified as risk factors for PLP.
CONCLUSION
This systematic review and meta-analysis estimates that six of every 10 people with an amputation report PLP-a high and important prevalence of PLP. Healthcare professionals ought to be aware of the high rates of PLP and implement strategies to reduce PLP by addressing known risk factors, specifically those identified by the current study.
Topics: Amputation, Surgical; Clinical Decision-Making; Humans; Phantom Limb; Prevalence; Risk Factors
PubMed: 33052924
DOI: 10.1371/journal.pone.0240431 -
The Cochrane Database of Systematic... Apr 2019Chronic pain, considered to be pain lasting more than three months, is a common and often difficult to treat condition that can significantly impact upon function and... (Review)
Review
BACKGROUND
Chronic pain, considered to be pain lasting more than three months, is a common and often difficult to treat condition that can significantly impact upon function and quality of life. Treatment typically includes pharmacological and non-pharmacological approaches. Transcutaneous electrical nerve stimulation (TENS) is an adjunct non-pharmacological treatment commonly recommended by clinicians and often used by people with pain.
OBJECTIVES
To provide an overview of evidence from Cochrane Reviews of the effectiveness of TENS to reduce pain in adults with chronic pain (excluding headache or migraine).To provide an overview of evidence from Cochrane Reviews of the safety of TENS when used to reduce pain in adults with chronic pain (excluding headache or migraine).To identify possible sources of inconsistency in the approaches taken to evaluating the evidence related to TENS for chronic pain (excluding headache or migraine) in the Cochrane Library with a view to recommending strategies to improve consistency in methodology and reporting.To highlight areas of remaining uncertainty regarding the effectiveness of TENS for chronic pain (excluding headache or migraine) with a view to recommending strategies to reduce any uncertainty.
METHODS
Search methodsWe searched the Cochrane Database of Systematic Reviews (CDSR), in the Cochrane Library, across all years up to Issue 11 of 12, 2018.Selection of reviewsTwo authors independently screened the results of the electronic search by title and abstract against inclusion/exclusion criteria. We included all Cochrane Reviews of randomised controlled trials (RCTs) assessing the effectiveness of TENS in people with chronic pain. We included reviews if they investigated the following: TENS versus sham; TENS versus usual care or no treatment/waiting list control; TENS plus active intervention versus active intervention alone; comparisons between different types of TENS; or TENS delivered using different stimulation parameters.Data extraction and analysisTwo authors independently extracted relevant data, assessed review quality using the AMSTAR checklist and applied GRADE judgements where required to individual reviews. Our primary outcomes included pain intensity and nature/incidence of adverse effects; our secondary outcomes included disability, health-related quality of life, analgesic medication use and participant global impression of change.
MAIN RESULTS
We included nine reviews investigating TENS use in people with defined chronic pain or in people with chronic conditions associated with ongoing pain. One review investigating TENS for phantom or stump-associated pain in people following amputation did not have any included studies. We therefore extracted data from eight reviews which represented 51 TENS-related RCTs representing 2895 TENS-comparison participants entered into the studies.The included reviews followed consistent methods and achieved overall high scores on the AMSTAR checklist. The evidence reported within each review was consistently rated as very low quality. Using review authors' assessment of risk of bias, there were significant methodological limitations in included studies; and for all reviews, sample sizes were consistently small (the majority of studies included fewer than 50 participants per group).Six of the eight reviews presented a narrative synthesis of included studies. Two reviews reported a pooled analysis.Primary and secondary outcomes One review reported a beneficial effect of TENS versus sham therapy at reducing pain intensity on a 0 to 10 scale (MD -1.58, 95% CI -2.08 to -1.09, P < 0.001, I² = 29%, P = 0.22, 5 studies, 207 participants). However the quality of the evidence was very low due to significant methodological limitations and imprecision. A second review investigating pain intensity performed a pooled analysis by combining studies that compared TENS to sham with studies that compared TENS to no intervention (SMD -0.85, 95% CI -1.36 to -0.34, P = 0.001, I² = 83%, P < 0.001). This pooled analysis was judged as offering very low quality evidence due to significant methodological limitations, large between-trial heterogeneity and imprecision. We considered the approach of combining sham and no intervention data to be problematic since we would predict these different comparisons may be estimating different true effects. All remaining reviews also reported pain intensity as an outcome measure; however the data were presented in narrative review form only.Due to methodological limitation and lack of useable data, we were unable to offer any meaningful report on the remaining primary outcome regarding nature/incidence of adverse effects, nor for the remaining secondary outcomes: disability, health-related quality of life, analgesic medication use and participant global impression of change for any comparisons.We found the included reviews had a number of inconsistencies when evaluating the evidence from TENS studies. Approaches to assessing risk of bias around the participant, personnel and outcome-assessor blinding were perhaps the most obvious area of difference across included reviews. We also found wide variability in terms of primary and secondary outcome measures, and inclusion/exclusion criteria for studies varied with respect to including studies which assessed immediate effects of single interventions.
AUTHORS' CONCLUSIONS
We found the methodological quality of the reviews was good, but quality of the evidence within them was very low. We were therefore unable to conclude with any confidence that, in people with chronic pain, TENS is harmful, or beneficial for pain control, disability, health-related quality of life, use of pain relieving medicines, or global impression of change. We make recommendations with respect to future TENS study designs which may meaningfully reduce the uncertainty relating to the effectiveness of this treatment in people with chronic pain.
Topics: Chronic Pain; Humans; Pain Management; Pain Measurement; Systematic Reviews as Topic; Transcutaneous Electric Nerve Stimulation; Treatment Outcome
PubMed: 30941745
DOI: 10.1002/14651858.CD011890.pub3 -
Prosthetics and Orthotics International Apr 2005In order to achieve stump healing after trans-tibial amputation, various methods are applied, such as soft dressings followed by elastic wrapping of the stump, rigid... (Review)
Review
In order to achieve stump healing after trans-tibial amputation, various methods are applied, such as soft dressings followed by elastic wrapping of the stump, rigid dressings, semi-rigid dressings, and more recently the application of silicon or gel-liners. A systematic literature search was performed to identify the optimal post-amputation management. The methodological quality of the studies was systematically evaluated by using a predefined list of criteria. Only 11 controlled studies were identified and evaluated for their methodological quality. From these studies, no studies were classified as A-level studies, whereas three were classified as B-level, and 8 were classified as C-level studies. Relevant literature appears heterogeneous with respect to patient selection, intervention and outcome measures. Despite the large variability of included studies, this review reveals a trend in favour of rigid and semi-rigid dressings for achieving stump healing and reduction of stump volume. No conclusions can be drawn with regard to the effect on functional outcome. The literature is not conclusive on the effects of early weight bearing on stump healing, volume reduction, and functional outcome. More research is needed for the development of evidence-based clinical practice guidelines concerning management after transtibial amputation.
Topics: Amputation, Surgical; Amputation Stumps; Artificial Limbs; Bandages; Equipment Design; Humans; Leg; Prosthesis Fitting; Tibia; Wound Healing
PubMed: 16180374
DOI: 10.1080/17461550500066832 -
European Journal of Vascular and... Aug 2015The aim of this systematic review and meta-analysis was to evaluate the effects of using an intraoperatively placed perineural catheter (PNC) with a postoperative local... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
The aim of this systematic review and meta-analysis was to evaluate the effects of using an intraoperatively placed perineural catheter (PNC) with a postoperative local anaesthetic infusion on immediate and long-term outcomes after lower limb amputation.
METHODS
A systematic review of key electronic journal databases was undertaken from inception to January 2015. Studies comparing PNC use with either a control, or no PNC, were included. Meta-analysis was performed for postoperative opioid use, pain scores, mortality, and long-term incidence of stump and phantom limb pain. Sensitivity analysis was performed for opioid use. Quality of evidence was assessed using the GRADE system.
RESULTS
Seven studies reporting on 416 patients undergoing lower limb amputation with PNC usage (n = 199) or not (n = 217) were included. Approximately 60% were transtibial amputations PNC use reduced postoperative opioid consumption (standardised mean difference: -0.59, 95% CI -1.10 to -0.07, p = .03), maintained on sensitivity analysis for large (p = .03) and high-quality (p = .003) studies, but was marginally lost (p = .06) on studies enrolling patients with peripheral arterial disease only. PNC treatment did not affect postoperative pain scores (p = .48), in-hospital mortality (p = .77), phantom limb pain (p = .28) or stump pain (p = .37). GRADE quality of evidence for all outcomes was very low.
CONCLUSION
There is poor-quality evidence that PNC usage significantly reduces opioid consumption following lower limb amputation, without affecting other short- or long-term outcomes. Well-performed randomised studies are required.
Topics: Amputation, Surgical; Analgesics, Opioid; Anesthetics, Local; Catheterization; Catheters, Indwelling; Chi-Square Distribution; Humans; Infusions, Parenteral; Lower Extremity; Odds Ratio; Pain Measurement; Pain, Postoperative; Phantom Limb; Time Factors; Treatment Outcome
PubMed: 26067167
DOI: 10.1016/j.ejvs.2015.04.030 -
The Cochrane Database of Systematic... Aug 2015This is the first update of a Cochrane review published in Issue 5, 2010 on transcutaneous electrical nerve stimulation (TENS) for phantom pain and stump pain following... (Review)
Review
BACKGROUND
This is the first update of a Cochrane review published in Issue 5, 2010 on transcutaneous electrical nerve stimulation (TENS) for phantom pain and stump pain following amputation in adults. Pain may present in a body part that has been amputated (phantom pain) or at the site of amputation (stump pain), or both. Phantom pain and stump pain are complex and multidimensional and the underlying pathophysiology remains unclear. The condition remains a severe burden for those who are affected by it. The mainstay treatments are predominately pharmacological, with increasing acknowledgement of the need for non-drug interventions. TENS has been recommended as a treatment option but there has been no systematic review of available evidence. Hence, the effectiveness of TENS for phantom pain and stump pain is currently unknown.
OBJECTIVES
To assess the analgesic effectiveness of TENS for the treatment of phantom pain and stump pain following amputation in adults.
SEARCH METHODS
For the original version of the review we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, AMED, CINAHL, PEDRO and SPORTDiscus (February 2010). For this update, we searched the same databases for relevant randomised controlled trials (RCTs) from 2010 to 25 March 2015.
SELECTION CRITERIA
We only included RCTs investigating the use of TENS for the management of phantom pain and stump pain following an amputation in adults.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed trial quality and extracted data. We planned that where available and appropriate, data from outcome measures were to be pooled and presented as an overall estimate of the effectiveness of TENS.
MAIN RESULTS
In the original review there were no RCTs that examined the effectiveness of TENS for the treatment of phantom pain and stump pain in adults. For this update, we did not identify any additional RCTs for inclusion.
AUTHORS' CONCLUSIONS
There were no RCTs to judge the effectiveness of TENS for the management of phantom pain and stump pain. The published literature on TENS for phantom pain and stump pain lacks the methodological rigour and robust reporting needed to confidently assess its effectiveness. Further RCT evidence is required before an assessment can be made. Since publication of the original version of this review, we have found no new studies and our conclusions remain unchanged.
Topics: Adult; Amputation Stumps; Humans; Pain Management; Phantom Limb; Transcutaneous Electric Nerve Stimulation
PubMed: 26284511
DOI: 10.1002/14651858.CD007264.pub3 -
The Cochrane Database of Systematic... May 2010Amputee pain may present in a body part that has been amputated (phantom pain) or at the site of amputation (stump pain), or both. Phantom pain and stump pain are... (Review)
Review
BACKGROUND
Amputee pain may present in a body part that has been amputated (phantom pain) or at the site of amputation (stump pain), or both. Phantom pain and stump pain are complex and multidimensional and the underlying pathophysiology remains unclear. The mainstay treatments for phantom pain and stump pain are predominately pharmacological. The condition remains a severe burden for those who are affected by it. There is increasing acknowledgement of the need for non-drug interventions and Transcutaneous Electrical Nerve Stimulation (TENS) may have an important role to play. TENS has been recommended as a treatment option for phantom pain and stump pain. To date there has been no systematic review of available evidence and the effectiveness of TENS for phantom pain and stump pain is currently unknown.
OBJECTIVES
To assess the analgesic effectiveness of TENS for the treatment of phantom pain and stump pain following amputation in adults.
SEARCH STRATEGY
We searched MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, PsycINFO, AMED, CINAHL, PEDRO and SPORTDiscus (February 2010).
SELECTION CRITERIA
Only randomised controlled trials (RCTs) investigating the use of TENS for the management of phantom pain and stump pain following an amputation in adults were included.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed trial quality and extracted data. It was planned that where available and appropriate, data from outcome measures were to be pooled and presented as an overall estimate of the effectiveness of TENS.
MAIN RESULTS
No RCTs that examined the effectiveness of TENS for the treatment of phantom pain and stump pain in adults were identified by the searches.
AUTHORS' CONCLUSIONS
There were no RCTs on which to judge the effectiveness of TENS for the management of phantom pain and stump pain. The published literature on TENS for phantom pain and stump pain lacks the methodological rigour and robust reporting needed to confidently assess its effectiveness. Further RCT evidence is required before such a judgement can be made.
Topics: Adult; Amputation Stumps; Humans; Pain Management; Phantom Limb; Transcutaneous Electric Nerve Stimulation
PubMed: 20464749
DOI: 10.1002/14651858.CD007264.pub2 -
Annals of Vascular Surgery Oct 2014To investigate whether application of a rigid dressing (RD) to the residual limb soon after transtibial amputation reduces the time from amputation to the first... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To investigate whether application of a rigid dressing (RD) to the residual limb soon after transtibial amputation reduces the time from amputation to the first prosthetic casting/fitting compared with the residual limb managed with a soft dressing (SD).
DATA SOURCES
Studies in humans were identified by a systematic search of MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials to December 2013. Search terms were based on appropriate medical subject headings and other free-text headings combining the following key words: "amputation," "amputation stumps," "transtibial," "lower limb," "post operative dressing," "removable rigid dressing," "rigid dressing," "wound healing," "rehabilitation," and "prosthetic." Reference lists of the relevant retrieved studies were checked for further studies. Papers could be published in English or other languages.
STUDY SELECTION
Randomized controlled trials (RCT) and cross-sectional studies that included adults who had an amputation of the lower limb were included. Initial literature search identified 356 potentially relevant articles. Review of abstracts and subsequently full text identified 6 studies included in the meta-analysis. Of these studies, 2 were RCT and 4 were retrospective cross-sectional studies.
DATA EXTRACTION
Data were extracted by one reviewer and then checked by another reviewer.
DATA SYNTHESIS
The use of RD resulted in significantly shorter time from amputation to casting or fitting of the prosthesis. Pooled standardized mean difference (SMD) from meta-analysis using DerSimonian and Laird random effect model was 0.46 (95% confidence interval: 0.19-0.73; P = 0.001), with 54% variation in SMD attributable to heterogeneity (I(2) = 0.539, P = 0.06). No evidence of small study effect has been found. The quality of reporting of the results varied, with some important elements omitted in the publications.
CONCLUSIONS
Patients who are fitted with RD post transtibial amputation commence prosthetic management sooner than those managed with SD.
Topics: Amputation, Surgical; Artificial Limbs; Bandages; Humans; Leg; Time Factors
PubMed: 24911808
DOI: 10.1016/j.avsg.2014.05.002 -
Pain Jul 2021Residual limb pain (RLP) is associated with (partial) extremity amputations and is defined as pain felt in the remaining part of the amputated limb. A common cause of... (Meta-Analysis)
Meta-Analysis
Residual limb pain (RLP) is associated with (partial) extremity amputations and is defined as pain felt in the remaining part of the amputated limb. A common cause of RLP is neuroma formation after nerve transections. Neuromas can be very painful and severely debilitating pathologies, preventing prosthetic use, reducing quality of life, and requiring medication. Residual limb pain and symptomatic neuromas are often not properly recognized by physicians explaining the varying prevalence in the literature. This systematic review and meta-analysis aim to provide a comprehensive overview of published literature on the prevalence of RLP and symptomatic neuroma after lower extremity amputation. Studies reporting the prevalence of RLP and symptomatic neuroma pain in patients who have had a lower extremity amputation published between 2000 and 2020 were identified in PubMed and Embase. Random-effects meta-analyses of proportions were performed to quantify the prevalence of RLP and symptomatic neuroma. Subgroups were identified and analysed. For RLP, the pooled prevalence was 59% (95% CI: 51-67). For symptomatic neuromas, the pooled prevalence was 15% (95% CI: 7-28). Residual limb pain subgroup analysis showed statistically significant higher prevalence in patients aged >50 years, follow-up >2 years, and in studies using a self-administered questionnaire for data collection. The prevalence of RLP and symptomatic neuroma in patients who have had a lower extremity amputation is 59% and 15%, respectively. Knowledge of their high prevalence may result in better awareness among physicians, in turn providing timely and adequate management.
Topics: Amputation, Surgical; Amputation Stumps; Humans; Lower Extremity; Neuroma; Pain; Prevalence; Quality of Life; Retrospective Studies
PubMed: 33470746
DOI: 10.1097/j.pain.0000000000002202