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European Journal of Pain (London,... Jan 2023Phantom limb pain (PLP) concerns >50% of amputees and has a negative impact on their rehabilitation, mental health and quality of life. Mirror therapy (MT) is a... (Review)
Review
Effect of mirror therapy in the treatment of phantom limb pain in amputees: A systematic review of randomized placebo-controlled trials does not find any evidence of efficacy.
BACKGROUND AND OBJECTIVE
Phantom limb pain (PLP) concerns >50% of amputees and has a negative impact on their rehabilitation, mental health and quality of life. Mirror therapy (MT) is a promising strategy, but its effectiveness remains controversial. We performed a systematic review to: (i) evaluate the effectiveness of MT versus placebo in reducing PLP, and (ii) determine MT effect on disability and quality of life.
DATABASES AND DATA TREATMENT
We selected randomized-controlled trials in five databases (Medline, Cochrane Library, CINAHL, PEDro and Embase) that included patients with unilateral lower or upper limb amputation and PLP and that compared the effects on PLP of MT versus a placebo technique. The primary outcome was PLP intensity changes and the secondary outcomes were PLP duration, frequency, patients' disability and quality of life.
RESULTS
Among the five studies included, only one reported a significant difference between the MT group and control group, with a positive MT effect at week 4. Only one study assessed MT effect on disability and found a significant improvement in the MT group at week 10 and month 6.
CONCLUSIONS
Our systematic review did not allow concluding that MT reduces PLP and disability in amputees. This lack of strong evidence is probably due to (i) the low methodological quality of the included studies, and (ii) the lack of statistical power. Future trials should include a higher number of patients, increase the number and frequency of MT sessions, have a long-term follow-up and improve the methodological quality.
SIGNIFICANCE
Recent meta-analyses concluded that MT is effective for reducing phantom limb pain. Conversely, the present systematic review that included only studies with the best level of evidence did not find any evidence about its effectiveness for this condition. We identified many ways to improve future randomized-controlled trials on this topic: increasing the number of participants, reducing the intra-group heterogeneity, using a suitable placebo and intensifying the MT sessions and frequency.
Topics: Humans; Phantom Limb; Quality of Life; Mirror Movement Therapy; Amputees; Pain Management; Randomized Controlled Trials as Topic
PubMed: 36094758
DOI: 10.1002/ejp.2035 -
Journal of Neural Engineering Sep 2022Electrical stimulation can induce sensation in the phantom limb of individuals with amputation. It is difficult to generalize existing findings as there are many... (Review)
Review
Electrical stimulation can induce sensation in the phantom limb of individuals with amputation. It is difficult to generalize existing findings as there are many approaches to delivering stimulation and to assessing the characteristics and benefits of sensation. Therefore, the goal of this systematic review was to explore the stimulation parameters that effectively elicited referred sensation, the qualities of elicited sensation, and how the utility of referred sensation was assessed.We searched PubMed, Web of Science, and Engineering Village through January of 2022 to identify relevant papers. We included papers which electrically induced referred sensation in individuals with limb loss and excluded papers that did not contain stimulation parameters or outcome measures pertaining to stimulation. We extracted information on participant demographics, stimulation approaches, and participant outcomes.After applying exclusion criteria, 49 papers were included covering nine stimulation methods. Amplitude was the most commonly adjusted parameter (= 25), followed by frequency (= 22), and pulse width (= 15). Of the 63 reports of sensation quality, most reported feelings of pressure (= 52), paresthesia (= 48), or vibration (= 40) while less than half (= 29) reported a sense of position or movement. Most papers evaluated the functional benefits of sensation (= 33) using force matching or object identification tasks, while fewer papers quantified subjective measures (= 16) such as pain or embodiment. Only 15 studies (36%) observed percept intensity, quality, or location over multiple sessions.Most studies that measured functional performance demonstrated some benefit to providing participants with sensory feedback. However, few studies could experimentally manipulate sensation location or quality. Direct comparisons between studies were limited by variability in methodologies and outcome measures. As such, we offer recommendations to aid in more standardized reporting for future research.
Topics: Amputees; Artificial Limbs; Feedback, Sensory; Humans; Phantom Limb; Sensation
PubMed: 36001115
DOI: 10.1088/1741-2552/ac8c38 -
Journal of Reconstructive Microsurgery Mar 2023Targeted muscle reinnervation (TMR) is growing in popularity; however, literature evaluating patient characteristics and outcomes is limited.
BACKGROUND
Targeted muscle reinnervation (TMR) is growing in popularity; however, literature evaluating patient characteristics and outcomes is limited.
METHODS
The EMBASE database was queried with the search terms "targeted muscle reinnervation" OR "TMR" AND "outcomes" OR "patient outcomes." Clinical human studies in English were eligible for inclusion, yielding 89 articles. After rigorous exclusion criteria, a total of 13 articles were included in this review. Study data including geographic location, patient demographics, TMR indication, amputation level, number of nerve transfers performed, length of follow-up, and reported outcomes were extracted and analyzed.
RESULTS
The included articles represent 338 patients (341 limbs). Average patient age was 47.4 years. Indication for amputation included trauma ( = 125), infection ( = 76) cancer/tumor resection ( = 71), ischemia ( = 18), failed Charcot reconstruction ( = 15), failed hardware ( = 9), burn ( = 4), and CRPS ( = 4). Five studies included upper extremity TMR only, two included lower extremity TMR only, and six included both upper and lower extremity TMR. TMR was performed in an immediate or delayed fashion, with an average of 2.2 nerve transfers performed per limb overall. Average length of follow-up was 22.3 months. In three studies, patients with phantom limb pain undergoing delayed TMR were found to have significant or trending toward significant reduction in pain after TMR using numeric rating scale and patient-reported outcomes measurement information system scales. One article reported 9/10 patients with improved or complete resolution of phantom limb pain after delayed TMR. Three studies found that patients undergoing immediate TMR had lower pain scores compared with non-TMR controls.
CONCLUSION
While there is evidence that TMR reduces neuroma-related pain and improves the quality of life for amputees, further outcomes studies are needed to study the patient experience with TMR on a larger scale. Establishing standardized, validated patient-reported outcomes assessment tools is critical to future investigation in this field.
Topics: Humans; Middle Aged; Phantom Limb; Quality of Life; Muscle, Skeletal; Amputation, Surgical; Neoplasms; Upper Extremity
PubMed: 35988579
DOI: 10.1055/s-0042-1755262 -
European Journal of Physical and... Oct 2022Phantom limb pain (PLP) after amputation is a frequent entity that conditions the life of those who suffer it. Current treatment methods are not sufficiently effective...
INTRODUCTION
Phantom limb pain (PLP) after amputation is a frequent entity that conditions the life of those who suffer it. Current treatment methods are not sufficiently effective for PLP management. We aim to analyze the clinical application of transcranial direct current (tDCS) in people with amputation suffering from PLP.
EVIDENCE ACQUISITION
The following databases were consulted in September 2021: MEDLINE, EMBASE, The Web of Science, PEDro, SCOPUS and SciELO. Randomized controlled trials investigating the use of tDCS in people with amputation undergoing PLP were selected. Demographic data, type and cause of amputation, time since amputation, stimulation parameters, and outcomes were extracted.
EVIDENCE SYNTHESIS
Six articles were included in this review (seven studies were considered because one study performed two individual protocols). All included studies evaluated PLP; six evaluated the phantom limb sensations (PLS) and two evaluated the psychiatric disorders. In all included studies the intensity and frequency of PLP was reduced, in three PLS were reduced, and in none study psychiatric symptoms were modified.
CONCLUSIONS
Anodic tDCS over the contralateral M1 to the affected limb, with an intensity of 1-2 mA, for 15-20 minutes seems to significantly reduce PLP in people with amputation. Single-session treatment could modify PLP intensity for hours, and multi-session treatment could modify PLP for months. Limited evidence suggests that PLS and psychiatric disorders should be treated with different PLP electrode placements. Further studies with larger sample size and longer follow-up times are needed to establish the priority of tDCS application in the PLP management.
Topics: Humans; Amputation, Surgical; Phantom Limb; Randomized Controlled Trials as Topic; Sensation; Transcranial Direct Current Stimulation
PubMed: 35758072
DOI: 10.23736/S1973-9087.22.07439-1 -
Journal of Personalized Medicine Apr 2022Autologous fillet flaps are a common reconstructive option for large defects after forequarter amputation (FQA) due to advanced local malignancy or trauma. The inclusion... (Review)
Review
Autologous fillet flaps are a common reconstructive option for large defects after forequarter amputation (FQA) due to advanced local malignancy or trauma. The inclusion of osseous structures into these has several advantages. This article therefore systematically reviews reconstructive options after FQA, using osteomusculocutaneous fillet flaps, with emphasis on personalized surgical technique and outcome. Additionally, we report on a case with an alternative surgical technique, which included targeted muscle reinnervation (TMR) of the flap. Our literature search was conducted in the PubMed and Cochrane databases. Studies that were identified were thoroughly scrutinized with regard to relevance, resulting in the inclusion of four studies (10 cases). FQA was predominantly a consequence of local malignancy. For vascular supply, the brachial artery was predominantly anastomosed to the subclavian artery and the brachial or cephalic vein to the subclavian or external jugular vein. Furthermore, we report on a case of a large osteosarcoma of the humerus. Extended FQA required the use of the forearm for defect coverage and shoulder contour reconstruction. Moreover, we performed TMR. Follow-up showed a satisfactory result and no phantom limb pain. In case of the need for free flap reconstruction after FQA, this review demonstrates the safety and advantage of osteomusculocutaneous fillet flaps. If the inclusion of the elbow joint into the flap is not possible, we recommend the use of the forearm, as described. Additionally, we advocate for the additional implementation of TMR, as it can be performed quickly and is likely to reduce phantom limb and neuroma pain.
PubMed: 35455676
DOI: 10.3390/jpm12040560 -
Therapeutic Advances in Chronic Disease 2022To evaluate the effectiveness of any form of physiotherapy intervention for the management of central neuropathic pain (cNeP) due to any underlying cause.
OBJECTIVES
To evaluate the effectiveness of any form of physiotherapy intervention for the management of central neuropathic pain (cNeP) due to any underlying cause.
METHODS
Multiple databases were searched from inception until August 2021. Randomised controlled trials evaluating physiotherapy interventions compared to a control condition on pain among people with cNeP were included. Methodological quality and the quality of evidence were assessed using the Physiotherapy Evidence Database Scale and the Grading of Recommendations, Assessment, Development, and Evaluation tool, respectively.
RESULTS
The searches yielded 2661 studies, of which 23 randomised controlled trials met the inclusion criteria and were included in the meta-analyses. Meta-analyses of trials examining non-invasive neurostimulation revealed significant reductions in pain severity due to spinal cord injury (SCI; standardised mean difference (SMD): -0.59 (95% confidence interval [CI]: -1.07, -0.11), = 0.02) and phantom limb pain (weighted mean difference (WMD): -1.57 (95% CI: -2.85, -0.29), = 0.02). The pooled analyses of trials utilising acupuncture, transcutaneous electrical nerve stimulation (TENS), and mirror therapy showed significant reductions in pain severity among individuals with stroke (WMD: -1.46 (95% CI: -1.97, -0.94), < 0.001), multiple sclerosis (SMD: -0.32 (95% CI: -0.57, -0.06), = 0.01), and phantom limb pain (SMD: -0.74 (95% CI: -1.36, -0.11), = 0.02), respectively. Exercise was also found to significantly reduce pain among people with multiple sclerosis (SMD: -1.58 (95% CI: -2.85, -0.30), = 0.02).
CONCLUSION
Evidence supports the use of non-invasive neurostimulation for the treatment of pain secondary to SCI and phantom limb pain. Beneficial pain management outcomes were also identified for acupuncture in stroke, TENS in multiple sclerosis, and mirror therapy in phantom limb pain.
PubMed: 35356293
DOI: 10.1177/20406223221078672 -
BMJ Military Health Apr 2022Amputations result from trauma, war, conflict, vascular diseases and cancer. Phantom limb pain (PLP) is a potentially debilitating form of chronic pain affecting around... (Meta-Analysis)
Meta-Analysis
INTRODUCTION
Amputations result from trauma, war, conflict, vascular diseases and cancer. Phantom limb pain (PLP) is a potentially debilitating form of chronic pain affecting around 100 million amputees across the world. Mirror therapy and virtual reality (VR) are two commonly used treatments, and we evaluated their respective success rates.
METHODS
A meta-analysis and systematic review was undertaken to investigate mirror therapy and VR in their ability to reduce pain levels. A mean difference (MD) model to compare group pain levels pretreatment and post-treatment via aggregating these results from numerous similar studies was employed. Meta-analysis was conducted using RevMan (V.5.4) and expressed in MD for visual analogue scale (VAS) score.
RESULTS
A total of 15 studies met our search criteria; they consisted of eight mirror therapy with 214 participants and seven VR including 86 participants, totalling 300 participants. Mean age ranged from 36 to 63 years, 77% male, of which 61% were lower body amputees. Both led to a VAS reduction (mirror therapy mean reduction VAS score was 2.54, 95% CI 1.42 to 3.66; p<0.001; VR 2.24, 95% CI 1.28 to 3.20; p<0.001). There was no statistically significant difference in pain alleviation between mirror therapy and VR (p=0.69).
CONCLUSIONS
Mirror therapy and VR are both equally efficacious in alleviating PLP, but neither is more effective than the other. However, due to small sample size and limited number of studies, factors such as gender, cause of amputation, site of limb loss or length of time from amputation, which may influence treatment success, could not be explored.
Topics: Adult; Amputees; Female; Humans; Male; Middle Aged; Mirror Movement Therapy; Phantom Limb; Virtual Reality; Virtual Reality Exposure Therapy
PubMed: 35042760
DOI: 10.1136/bmjmilitary-2021-002018 -
Journal of Plastic, Reconstructive &... Mar 2022Pain after amputation can be known as residual limb pain (RLP) or phantom limb pain (PLP); however, both can be disabling in daily life with reported incidences of 8%... (Review)
Review
BACKGROUND
Pain after amputation can be known as residual limb pain (RLP) or phantom limb pain (PLP); however, both can be disabling in daily life with reported incidences of 8% for finger amputations and up to 85% for major limb amputations. The current treatment is focused on reducing the pain after neuropathic pain occurs. However, surgical techniques to prevent neuropathic pain after amputation are available and effective, but they are underutilized. The purpose of the review is to investigate the effects of techniques during amputation to prevent neuropathic pain.
METHODS
A systematic review was performed in multiple databases (Embase, Medline, Web of Science, Scopus, Cochrane, and Google Scholar) and following the PRISMA guidelines. Studies that reported surgical techniques to prevent neuropathic pain during limb amputation were included.
RESULTS
Of the 6188 selected studies, 13 eligible articles were selected. Five articles reported techniques for finger amputation: neurovascular island flap, centro-central union (CCU), and epineural ligatures, and flaps. For finger amputations, the use of prevention techniques resulted in a decrease of incidences from 8% to 0-3% with CCU being the most beneficial. For major limb amputations, the incidences for RLP were decreased to 0 to 55% with TMR and RPNI and compared to 64-91% for the control group. Eight articles reported techniques for amputations on major limbs: targeted muscle reinnervation (TMR), targeted nerve implantation, concomitant nerve coaptation, and regenerative peripheral nerve interface (RPNI).
CONCLUSIONS
Based on the current literature, we state that during finger and major limb amputation, the techniques to prevent neuropathic pain and PLP should be performed.
Topics: Amputation, Surgical; Humans; Muscle, Skeletal; Neuralgia; Phantom Limb; Upper Extremity
PubMed: 34955394
DOI: 10.1016/j.bjps.2021.11.076 -
JMIR Serious Games Dec 2021Augmented reality (AR) is a rapidly expanding technology; it comprises the generation of new images from digital information in the real physical environment of a... (Review)
Review
BACKGROUND
Augmented reality (AR) is a rapidly expanding technology; it comprises the generation of new images from digital information in the real physical environment of a person, which simulates an environment where the artificial and real are mixed. The use of AR in physiotherapy has shown benefits in certain areas of patient health. However, these benefits have not been studied as a whole.
OBJECTIVE
This study aims to ascertain the current scientific evidence on AR therapy as a complement to physiotherapy and to determine the areas in which it has been used the most and which variables and methods have been most effective.
METHODS
A systematic review registered in PROSPERO (International Prospective Register of Systematic Reviews) was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) recommendations. The search was conducted from July to August 2021 in the PubMed, PEDro, Web of Science, Scopus, and Cochrane Library scientific databases using the keywords augmented reality, physiotherapy, physical therapy, exercise therapy, rehabilitation, physical medicine, fitness, and occupational therapy. The methodological quality was evaluated using the PEDro scale and the Scottish Intercollegiate Guidelines Network scale to determine the degree of recommendation. The Cochrane Collaboration tool was used to evaluate the risk of bias.
RESULTS
In total, 11 articles were included in the systematic review. Of the 11 articles, 4 (36%) contributed information to the meta-analysis. Overall, 64% (7/11) obtained a good level of evidence, and most had a B degree of recommendation of evidence. A total of 308 participants were analyzed. Favorable results were found for the Berg Balance Scale (standardized mean change 0.473, 95% CI -0.0877 to 1.0338; z=1.65; P=.10) and the Timed Up and Go test (standardized mean change -1.211, 95% CI -3.2005 to 0.7768; z=-1.194; P=.23).
CONCLUSIONS
AR, in combination with conventional therapy, has been used for the treatment of balance and fall prevention in geriatrics, lower and upper limb functionality in stroke, pain in phantom pain syndrome, and turning in place in patients with Parkinson disease with freezing of gait. AR is effective for the improvement of balance; however, given the small size of the samples and the high heterogeneity of the studies, the results were not conclusive. Future studies using larger sample sizes and with greater homogeneity in terms of the devices used and the frequency and intensity of the interventions are needed.
TRIAL REGISTRATION
PROSPERO International Prospective Register of Systematic Reviews CRD42020180766; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=180766.
PubMed: 34914611
DOI: 10.2196/30985 -
Clinical Neurology and Neurosurgery Nov 2021Different Dorsal root entry zone (DREZ) lesion techniques have been reported as effective treatment for intractable painful conditions, though with contradictory...
BACKGROUND
Different Dorsal root entry zone (DREZ) lesion techniques have been reported as effective treatment for intractable painful conditions, though with contradictory results. Overall, good results were reported especially in specific conditions, such as pain due to brachial plexus avulsion, spinal cord injuries and oncological pain management. However, data on long term results in different clinical conditions are still missing.
OBJECTIVE
This study aims to systematically review the pertinent literature to evaluate indications, clinical outcomes, and complications of DREZ lesion (DREZotomy), in chronic pain management.
METHODS
A systematic literature review was conducted according to the PRISMA statement. Papers on DREZotomy for chronic pain in cancer, brachial plexus avulsion, spinal cord injury, post herpetic neuralgia, and phantom limb pain were considered for eligibility. For each category we further identified two sub-group according to the length of follow up: medium term and long term follow up (more than 3 years) respectively.
RESULTS
46 papers, and 1242 patients, were included in the present investigation. When considering long term results DREZotomy provided favorable clinical outcomes in brachial plexus avulsion and spinal cord injury, in 60.8% and 55.8% of the cases respectively. Conversely, the success rate was 35.3% in phantom limb pain and 28.2% in post herpetic neuralgia. A poor clinical outcome was reported in over than 25% of the patients suffering from phantom limb pain, post herpetic neuralgia and spinal cord injury. The mean complications rate was 23.58%. While BPA and SCI patients presented stable improvement over time, good outcomes among PHN and PLP groups dropped by - 46.2%; and - 14.7% at long term follow up respectively.
CONCLUSION
DREZotomy seems to be an effective treatment for chronic pain conditions, especially for brachial plexus avulsion, spinal cord injury and intractable cancer/post-radiation pain. According to the low level of evidence of the pertinent literature, further studies are strongly recommended, to better define potential benefits and limitations of this technique.
Topics: Humans; Pain, Intractable; Spinal Nerve Roots; Treatment Outcome
PubMed: 34739884
DOI: 10.1016/j.clineuro.2021.107004