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Plastic Surgery (Oakville, Ont.) May 2024Painful neuromas are a common postoperative complication of limb amputation often treated with secondary reinnervation. Surgical reinnervation include Targeted Muscle...
Targeted Muscle Reinnervation and Regenerative Peripheral Nerve Interfaces Versus Standard Management in the Treatment of Limb Amputation: A Systematic Review and Meta-Analysis.
Painful neuromas are a common postoperative complication of limb amputation often treated with secondary reinnervation. Surgical reinnervation include Targeted Muscle Reinnervation (TMR) and Regenerative Peripheral Nerve Interface (RPNI), and can be primary and secondary. The aim of this review is to assess the effects of primary TMR/RPNI at the time of limb amputation on the incidence and intensity of post-operative neuroma and pain. This review was registered on PROSPERO (CRD42021264360). A search of the following databases was performed in June 2021: Medline, EMBASE, and CENTRAL. Unpublished trials were searched using clinicaltrials.gov. All randomized and non-randomized studies assessing amputation with a reinnervation strategy (TMR, RPNI) were included. Outcomes evaluated included the incidences of painful neuroma, phantom limb pain (PLP), residual limb pain (RLP), as well as severity of pain, and Pain intensity, behavior, and interference (PROMIS). Eleven studies were included in this systematic review, and five observational studies for quantitative synthesis. Observational study evidence suggests that TMR/RPNI results in a statistically significant reduction in incidence, pain scores and PROMIS scores of PLP and RLP. Decreased incidence of neuromas favored primary TMR/RPNI, but this did not achieve statistical significance (p = 0.07). Included studies had moderate to critical risk of bias. The observational data suggests that primary TMR/RPNI reduces incidence, pain scores and PROMIS scores of PLP and RLP. Going forward, randomized trials are warranted to evaluate this research question, particularly to improve the certainty of evidence.
PubMed: 38681253
DOI: 10.1177/22925503221107462 -
Journal of Plastic, Reconstructive &... May 2024Globally, over 1 million lower limb amputations are performed annually, with approximately 75% of patients experiencing significant pain, profoundly impacting their... (Review)
Review
BACKGROUND
Globally, over 1 million lower limb amputations are performed annually, with approximately 75% of patients experiencing significant pain, profoundly impacting their quality of life and functional capabilities. Targeted muscle reinnervation (TMR) has emerged as a surgical solution involving the rerouting of amputated nerves to specific muscle targets. Originally introduced to enhance signal amplification for myoelectric prosthesis control, TMR has expanded its applications to include neuroma management and pain relief. However, the literature assessing patient outcomes is lacking, specifically for lower limb amputees. This systematic review aims to assess the effectiveness of TMR in reducing pain and enhancing functional outcomes for patients who have undergone lower limb amputation.
METHODS
A systematic review was performed by examining relevant studies between 2010 and 2023, focusing on pain reduction, functional outcomes and patient-reported quality of life measures.
RESULTS
In total, 20 studies were eligible encompassing a total of 778 extremities, of which 75.06% (n = 584) were lower limb amputees. Average age was 46.66 years and patients were predominantly male (n = 70.67%). Seven studies (35%) reported functional outcomes. Patients who underwent primary TMR exhibited lower average patient-reported outcome measurement information system (PROMIS) scores for phantom limb pain (PLP) and residual limb pain (RLP). Secondary TMR led to improvements in PLP, RLP and general limb pain as indicated by average numeric rating scale and PROMIS scores.
CONCLUSION
The systematic review underscores TMR's potential benefits in alleviating pain, fostering post-amputation rehabilitation and enhancing overall well-being for lower limb amputees.
Topics: Humans; Quality of Life; Amputation, Surgical; Lower Extremity; Nerve Transfer; Muscle, Skeletal; Phantom Limb; Patient Reported Outcome Measures; Pain Management; Amputees
PubMed: 38599000
DOI: 10.1016/j.bjps.2024.03.013 -
Prosthetics and Orthotics International Mar 2024Chronic pain following amputation is debilitating. Due to its mechanisms in modulating muscle contraction and pain, botulinum toxin has been investigated as a treatment...
Chronic pain following amputation is debilitating. Due to its mechanisms in modulating muscle contraction and pain, botulinum toxin has been investigated as a treatment option for phantom limb pain (PLP) and residual limb pain (RLP). The objective of this study was to determine the efficacy of botulinum toxin injection in the management of PLP and RLP following major limb amputation using a systematic review of the literature. The databases Medline, CINAHL, EMBASE, Scopus, Web of Science, and Cochrane were searched from inception through October 30, 2023. The search identified 50 articles; 37 underwent full-text review, and 11 were included in the final review. Eighty-nine individuals with pain were investigated by the included studies; 53 had RLP and 63 had PLP. There was significant variation in botulinum toxin type, injection method, and dosage. Twenty-one (53.9%) and 27 (64.3%) participants had improvement in PLP and RLP following botulinum toxin injection, respectively. Therefore, there is potential for use of botulinum toxin for the treatment of PLP and RLP. However, due to the minimal number of studies, small sample sizes, and heterogenous methodologies, our ability to conclude with certainty the efficacy of botulinum toxin injection on the treatment of PLP and RLP following amputation is limited.
PubMed: 38517393
DOI: 10.1097/PXR.0000000000000344 -
Injury Jun 2024Globally, severe lower limb injuries (SLLIs) are the predominant cause of long-term injury related disability and poor functional outcomes. Chronic pain is a major... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Globally, severe lower limb injuries (SLLIs) are the predominant cause of long-term injury related disability and poor functional outcomes. Chronic pain is a major source of this morbidity, but the magnitude of the contribution is not clearly understood. The aim of this systematic review and meta-analysis was to determine the prevalence of chronic pain following SLLIs in civilian and military patients.
METHOD
This systematic review was prospectively registered with The International Prospective Register of Systematic Reviews (PROSPERO) with study ID CRD42022313615. A systematic literature search (Medline, Embase, Ovid, and Web of Science) was performed to identify original studies that reported chronic pain outcomes for adults who underwent surgical treatment for SLLIs in a civilian or military setting. Risk of bias in included studies was assessed using the ROBINS-E tool, and quality assessment was reported at study level using the Newcastle-Ottawa Scale, and at outcome-level using the GRADE framework. Absolute (proportional) and relative (odds ratio) outcome measures were calculated and pooled using a random effects model.
RESULTS
Forty-three studies reporting the outcomes of 5601 patients were included. Estimated overall prevalence of pain was 63 % (CI 55-70 %). The prevalence of chronic pain in amputees (64 % (CI 55-73 %)) was similar to those who underwent limb salvage (56 % (CI 44-67 %)). The prevalence of chronic pain in civilian populations was 70 % (CI 63-77 %) compared to military populations (51 % (CI 35-66 %)). In amputees, the prevalence of residual limb pain was similar to phantom limb pain (OR 1.06 [0.64-1.78], p = 0.81, I = 92 %).
CONCLUSION
Most people who sustain a SLLI will suffer from chronic pain. Healthcare systems must continue to research interventions that can reduce the incidence and severity of long-term pain and ensure adequate resources are allocated for this common and debilitating complication.
Topics: Humans; Chronic Pain; Prevalence; Leg Injuries; Lower Extremity; Amputees
PubMed: 38490051
DOI: 10.1016/j.injury.2024.111495 -
British Journal of Pain Feb 2024To evaluate the efficacy of conventional and novel non-pharmacologic, non-invasive therapeutic interventions in physiotherapy for the treatment of phantom limb pain...
OBJECTIVE
To evaluate the efficacy of conventional and novel non-pharmacologic, non-invasive therapeutic interventions in physiotherapy for the treatment of phantom limb pain (PLP) in post-amputee patients.
METHODS
A systematic search for the articles was conducted in multiple electronic databases such as PUBMED, Google Scholar, EMBASE, Cochrane library and Physiotherapy Evidence Database (PEDro), following the PRISMA method and only published articles from the last 12 years (2010-2022) evaluating the efficacy of different physiotherapy interventions for the treatment of PLP in post-amputee patients were included. The methodological quality and risk of bias of the articles were assessed and evaluated by two independent reviewers using the PEDro scale, Methodological index for non-randomized studies scale (MINORS), and Cochrane collaboration's assessment tool.
RESULT
A total of 1840 articles were identified, out of which 17 articles (11 RCTs and 6 pilot studies) were ultimately chosen after the full-text screening. After reviewing the articles, evidence identified in RCTs and pilot studies indicates towards significant improvement in reducing the severity of PLP in post-amputee patients by using different physiotherapy interventions.
CONCLUSION AND DISCUSSION
Physiotherapy interventions with advance modalities and exercises can be used to increase the overall effectiveness of the treatment and to reduce the severity of phantom limb pain in post-amputee patients. However, due to the lack of consistent evidence for a given intervention, it becomes even more difficult to reach a majority consensus as to which intervention better assess all the mechanism of PLP thereby alleviating the problem of PLP in post-amputee patients. Therefore, more rigorous randomized controlled trials will be required in the future to reach a conclusion.
PubMed: 38344263
DOI: 10.1177/20494637231197002 -
BMC Neurology Feb 2024We previously performed a systematic review and meta-analysis which revealed a Phantom Limb Pain (PLP) prevalence estimate of 64% [95% CI: 60.01-68.1]. The prevalence... (Meta-Analysis)
Meta-Analysis
BACKGROUND
We previously performed a systematic review and meta-analysis which revealed a Phantom Limb Pain (PLP) prevalence estimate of 64% [95% CI: 60.01-68.1]. The prevalence estimates varied significantly between developed and developing countries. Remarkably, there is limited evidence on the prevalence of PLP and associated risk factors in African populations.
METHODS
Adults who had undergone limb amputations between January 2018 and October 2022 were recruited from healthcare facilities in the Western and Eastern Cape Provinces. We excluded individuals with auditory or speech impairments that hindered clear communication via telephone. Data on the prevalence and risk factors for PLP were collected telephonically from consenting and eligible participants. The prevalence of PLP was expressed as a percentage with a 95% confidence interval. The associations between PLP and risk factors for PLP were tested using univariate and multivariable logistic regression analyses. The strength of association was calculated using the Odds Ratio where association was confirmed.
RESULTS
The overall PLP prevalence was 71.73% [95% CI: 65.45-77.46]. Persistent pre-operative pain, residual limb pain, and non-painful phantom limb sensations were identified as risk factors for PLP.
CONCLUSION
This study revealed a high prevalence of PLP. The use of effective treatments targeting pre-amputation pain may yield more effective and targeted pre-amputation care, leading to improved quality of life after amputation.
Topics: Humans; Cross-Sectional Studies; Phantom Limb; Prevalence; Quality of Life; Risk Factors
PubMed: 38321380
DOI: 10.1186/s12883-024-03547-w -
Arquivos de Neuro-psiquiatria Jan 2024Phantom limb pain (PLP) occurs after amputations and can persist in a chronic and debilitating way. Repetitive transcranial magnetic stimulation (rTMS) is a...
BACKGROUND
Phantom limb pain (PLP) occurs after amputations and can persist in a chronic and debilitating way. Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive neuromodulation method capable of influencing brain function and modulating cortical excitability. Its effectiveness in treating chronic pain is promising.
OBJECTIVE
To evaluate the evidence on the efficacy and safety of using rTMS in the treatment of PLP, observing the stimulation parameters used, side effects, and benefits of the therapy.
METHODS
This is a systematic review of scientific articles published in national and international literature using electronic platforms.
RESULTS
Two hundred and fifty two articles were identified. Two hundred and forty six publications were removed because they were duplicated or met the exclusion criteria. After selection, six studies were reviewed, those being two randomized clinical trials and four case reports. All evaluated studies indicated some degree of benefit of rTMS to relieve painful symptoms, even temporarily. Pain perception was lower at the end of treatment when compared to the period prior to the sessions and remained during patient follow-up. There was no standardization of the stimulation parameters used. There were no reports of serious adverse events. The effects of long-term therapy have not been evaluated.
CONCLUSION
There are some benefits, even if temporary, in the use of rTMS to relieve painful symptoms in PLP. High-frequency stimulation at M1 demonstrated a significant analgesic effect. Given the potential that has been demonstrated, but limited by the paucity of high-quality studies, further controlled studies are needed to establish and standardize the clinical use of the method.
Topics: Humans; Transcranial Magnetic Stimulation; Phantom Limb; Chronic Pain
PubMed: 38286434
DOI: 10.1055/s-0044-1779051 -
Pain Apr 2024Combat trauma can lead to widespread tissue damage and limb loss. This may result in chronic neuropathic and post amputation pain, including phantom limb pain (PLP) and... (Meta-Analysis)
Meta-Analysis
Combat trauma can lead to widespread tissue damage and limb loss. This may result in chronic neuropathic and post amputation pain, including phantom limb pain (PLP) and residual limb pain (RLP). The military population is distinct with respect to demographic, injury, and social characteristics compared with other amputation and trauma cohorts. We undertook a systematic review of studies of military personnel, with a history of combat injury, that reported a prevalence of any type of postamputation pain or chronic neuropathic pain, identified from Embase and MEDLINE databases.Using the inverse variance method with a random-effects model, we undertook a meta-analysis to determine an overall prevalence and performed exploratory analyses to identify the effect of the type of pain, conflict, and time since injury on prevalence. Pain definitions and types of pain measurement tools used in studies were recorded. Thirty-one studies (14,738 participants) were included. The pooled prevalence of PLP, RLP, and chronic neuropathic pain were 57% (95% CI: 46-68), 61% (95% CI: 50-71), and 26% (95% CI: 10-54), respectively. Between-study heterogeneity was high (I 2 : 94%-98%). Characterisation of duration, frequency, and impact of pain was limited. Factors reported by included studies as being associated with PLP included the presence of RLP and psychological comorbidity. The prevalence of postamputation pain and chronic neuropathic pain after combat trauma is high. We highlight inconsistency of case definitions and terminology for pain and the need for consensus in future research of traumatic injury.
Topics: Humans; Military Personnel; Prevalence; Pain Measurement; Neuralgia; Phantom Limb
PubMed: 38112578
DOI: 10.1097/j.pain.0000000000003094 -
Explore (New York, N.Y.) 2024Phantom limb pain (PLP) is a distressing consequence commonly encountered by individuals who have undergone amputations. The efficacy of treatment options for PLP is...
Phantom limb pain (PLP) is a distressing consequence commonly encountered by individuals who have undergone amputations. The efficacy of treatment options for PLP is limited. In this study, we present a case of a 64-year-old male who suffered from PLP for a duration of 10 years following an above-the-knee amputation. Despite unsuccessful attempts with painkillers and neurotrophic drugs over the course of a decade, the patient sought relief through Fu's Subcutaneous Needling (FSN), an innovative acupuncture therapy that specifically targets the subcutaneous tissue for pain management. Remarkably, the patient experienced a significant reduction in PLP and subsequently decreased his reliance on medication, as well as experiencing improved sleep after undergoing one session of FSN per day for four consecutive days. A follow-up conducted three years later demonstrated positive treatment outcomes. FSN demonstrated a significant influence on PLP, resulting in reduced analgesic requirements and enhanced quality of life. Therefore, FSN may be recommended as an additional treatment option for PLP. In order to gain a comprehensive understanding of the effects of acupuncture on PLP, a systematic review of relevant literature was conducted in PubMed, Embase, Cochrane Library and Web of Science in recent 20 years (from January 1, 2003 to October 16, 2023), using different combinations of the following terms: (phantom acrodynia), (residual limb pain), (phantom limb pain), (acupuncture), (electroacupuncture), (auriculoacupuncture), and (needling). 9 articles with 18 cases including one randomized controlled trial (n = 8) were obtained. This review provided additional evidence supporting the efficacy and safety of needling therapies for PLP. This systematic review offers additional evidence supporting the effectiveness and safety of needling therapies for PLP. However, there were no precedent reports using FSN treatment for PLP. Hence, this case may provide some implications for clinicians in practice.
Topics: Humans; Male; Phantom Limb; Middle Aged; Acupuncture Therapy; Pain Management; Quality of Life; Amputation, Surgical; Treatment Outcome
PubMed: 38008590
DOI: 10.1016/j.explore.2023.11.011 -
Zeitschrift Fur Orthopadie Und... Nov 2023Up 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...
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.
PubMed: 37967831
DOI: 10.1055/a-2188-3565