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Geriatric Nursing (New York, N.Y.) 2024The aim of this study was to evaluate the prevalence of, and explore factors related to, prescription of potentially inappropriate medications (PIMs) among older adults...
OBJECTIVE
The aim of this study was to evaluate the prevalence of, and explore factors related to, prescription of potentially inappropriate medications (PIMs) among older adults with lower-limb loss (LLL).
METHODS
This was a secondary analysis of a cross-sectional dataset collected through an interdisciplinary limb loss clinic between September 2013 and November 2022. Self-report medication lists were reviewed during in-clinic face-to-face interviews and compared to the American Geriatrics Society Beers Criteria corresponding to the patient's evaluation year.
RESULTS
Of 82 participants (72.9 ± 6.6 years-old; 78.0 % male), n = 41 (50.0 %) reported using one or more PIM. PIM prescription was significantly associated with presence of phantom limb pain, history of upper gastrointestinal issues, and a greater number of medications.
DISCUSSION
Polypharmacy and PIM use are common among older adults with LLL. Greater attention should be paid to medications post-amputation, especially pain management medications, to minimize potential adverse side-effects.
Topics: Humans; Male; Aged; Female; Potentially Inappropriate Medication List; Inappropriate Prescribing; Cross-Sectional Studies; Geriatrics; Polypharmacy
PubMed: 38367544
DOI: 10.1016/j.gerinurse.2024.02.018 -
The Journal of Hand Surgery, European... Jun 2024Selective nerve transfers are used in the setting of upper limb amputation to improve myoelectric prosthesis control. This surgical concept is referred to as targeted... (Review)
Review
Selective nerve transfers are used in the setting of upper limb amputation to improve myoelectric prosthesis control. This surgical concept is referred to as targeted muscle reinnervation (TMR) and describes the rerouting of the major nerves of the arm onto the motor branches of the residual limb musculature. Aside from providing additional myosignals for prosthetic control, TMR can treat and prevent neuroma pain and possibly also phantom limb pain. This article reviews the history and current applications of TMR in upper limb amputation, with a focus on practical considerations. It further explores and identifies technological innovations to improve the man-machine interface in amputation care, particularly regarding implantable interfaces, such as muscle electrodes and osseointegration. Finally, future clinical directions and possible scientific avenues in this field are presented and critically discussed.
Topics: Humans; Nerve Transfer; Upper Extremity; Artificial Limbs; Muscle, Skeletal; Bionics; Amputation, Surgical
PubMed: 38366374
DOI: 10.1177/17531934241227795 -
A new perspective on positive symptoms: expression of damage or self-defence mechanism of the brain?Neurological Sciences : Official... May 2024Usually, positive neurological symptoms are considered as the consequence of a mere, afinalistic and abnormal increase in function of specific brain areas. However,...
Usually, positive neurological symptoms are considered as the consequence of a mere, afinalistic and abnormal increase in function of specific brain areas. However, according to the Theory of Active Inference, which argues that action and perception constitute a loop that updates expectations according to a Bayesian model, the brain is rather an explorer that formulates hypotheses and tests them to assess the correspondence between internal models and reality. Moreover, the cerebral cortex is characterised by a continuous "conflict" between different brain areas, which constantly attempt to expand in order to acquire more of the limited available computational resources, by means of their dopamine-induced neuroplasticity. Thus, it has recently been suggested that dreams, during rapid eye movement sleep (REMS), protect visual brain areas (deprived of their stimuli during rest) from being conquered by other normally stimulated ones. It is therefore conceivable that positive symptoms also have a functional importance for the brain. We evaluate supporting literature data of a 'defensive' role of positive symptoms and the relevance of dopamine-induced neuroplasticity in the context of neurodegenerative and psychiatric diseases. Furthermore, the possible functional significance of idiopathic REMS-related behavioural disorder as well as phantom limb syndrome is examined. We suggest that positive neurological symptoms are not merely a passive expression of a damage, but active efforts, related to dopamine-induced plasticity, to maintain a correct relationship between the external world and its brain representation, thus preventing healthy cortical areas from ousting injured ones.
Topics: Humans; Dopamine; Bayes Theorem; Brain; Sleep, REM; REM Sleep Behavior Disorder
PubMed: 38353846
DOI: 10.1007/s10072-024-07395-x -
Plastic and Reconstructive Surgery.... Feb 2024Targeted muscle reinnervation offers an approach to regain use of the affected extremity through electronic prosthesis while limiting phantom pain and neuroma limb...
Targeted muscle reinnervation offers an approach to regain use of the affected extremity through electronic prosthesis while limiting phantom pain and neuroma limb production or pain. In this case report, we present the first reported case of leveraging the rectus flap for targeted muscle reinnervation. The case herein is of a 28-year-old woman who sustained a severe right upper extremity crush injury while being involved in a vehicular roll-over collision requiring right transhumeral amputation. Plastic surgery, orthopedic surgery, and vascular surgery were consulted to manage the right upper extremity injury.
PubMed: 38348459
DOI: 10.1097/GOX.0000000000005574 -
JBJS Essential Surgical Techniques 2024A neuroma occurs when a regenerating transected peripheral nerve has no distal target to reinnervate. Symptomatic neuromas are a common cause of postamputation pain that...
BACKGROUND
A neuroma occurs when a regenerating transected peripheral nerve has no distal target to reinnervate. Symptomatic neuromas are a common cause of postamputation pain that can lead to substantial disability. Regenerative peripheral nerve interface (RPNI) surgery may benefit patients through the use of free nonvascularized muscle grafts as physiologic targets for peripheral nerve reinnervation for mitigation of neuroma and postamputation pain.
DESCRIPTION
An RPNI is constructed by implanting the distal end of a transected peripheral nerve into a free nonvascularized skeletal muscle graft. The neuroma or free end of the affected nerve is identified, transected, and skeletonized. A free muscle graft is then harvested from the donor thigh or from the existing amputation site, and the distal end of each transected nerve is implanted into the center of the free muscle graft with use of 6-0 nonabsorbable suture. This can be done acutely at the time of amputation or as an elective procedure at any time postoperatively.
ALTERNATIVES
Nonsurgical treatments of neuromas include desensitization, chemical or anesthetic injections, biofeedback, transcutaneous electrical nerve stimulation, topical lidocaine, and/or other medications (e.g., antidepressants, anticonvulsants, and opioids). Surgical treatment of neuromas includes neuroma excision, nerve capping, excision with transposition into bone or muscle, nerve grafting, and targeted muscle reinnervation.
RATIONALE
Creation of an RPNI is a simple and reproducible surgical option to prevent neuroma formation that leverages several biologic processes and addresses many limitations of existing neuroma-treatment strategies. Given the understanding that neuromas will form when regenerating axons are not presented with end organs for reinnervation, any strategy that reduces the number of aimless axons within a residual limb should serve to reduce symptomatic neuromas. The use of free muscle grafts offers a vast supply of denervated muscle targets for regenerating nerve axons and facilitates the reestablishment of neuromuscular junctions without sacrificing denervation of any residual muscles.
EXPECTED OUTCOMES
Articles describing RPNI surgery for postamputation pain have shown favorable outcomes, with significant reduction in neuroma pain and phantom pain scores at approximately 7 months postoperatively. Neuroma pain scores were reduced by 71% and phantom pain scores were reduced by 53%. Prophylactic RPNI surgery is also associated with substantially lower incidence of symptomatic neuromas (0% versus 13.3%) and a lower rate of phantom limb pain (51.1% versus 91.1%) compared with the rates in patients who did not undergo RPNI surgery.
IMPORTANT TIPS
Ask the patient preoperatively to point at the site of maximal tenderness, as this can serve as a guide for where the symptomatic neuroma may be located. The incision can be made either through the previous site of the amputation or directly over the site of maximal tenderness longitudinally. The pitfall of incising directly over the site is creating another incision with its attendant risk of wound infection.Excise the terminal neuroma with a knife until healthy-appearing axons are visualized.The free nonvascularized skeletal muscle graft can be obtained from local muscle (preferred) or from a separate donor site. A separate donor site can introduce donor-site morbidity and complications, including hematoma and pain.The harvested skeletal muscle graft should ideally be approximately 35 mm long, 20 mm wide, and 5 mm thick in order to ensure survivability and to prevent central necrosis. The harvesting can be performed with curved Mayo scissors.The peripheral nerve should be implanted parallel to the direction of the muscle fibers, and the epineurium should be secured to the free muscle graft at 1 or 2 places. One suture should be utilized to tack the distal end of the epineurium to the middle of the bed of the muscle graft. Another suture should be utilized to start the wrapping of the muscle graft around the nerve using a bite through the muscle, a bite through the epineurium of the proximal end of the nerve, and another bite through the other muscle edge in order to form a cylindrical wrap around the nerve.Wrap the entire muscle graft by taking only bites of muscle graft around the nerve to secure the muscle graft in a cylindrical structure using 2 to 4 more sutures.Avoid locating the RPNI near weight-bearing surfaces of the residual limb when closing. The RPNI should be in the muscular tissue, deep to the subcutaneous tissue and dermis.Do perform intraneural dissection for large-caliber nerves to create several (normally 2 to 4) distinct RPNIs, to avoid too many regenerating axons in a single free muscle graft.
PubMed: 38348364
DOI: 10.2106/JBJS.ST.23.00009 -
Foot & Ankle Specialist Feb 2024The incidence of phantom limb pain in patients with Charcot neuroarthropathy who undergo major amputation is not well described. The purpose of this study was to...
BACKGROUND
The incidence of phantom limb pain in patients with Charcot neuroarthropathy who undergo major amputation is not well described. The purpose of this study was to determine whether patients with Charcot neuroarthropathy and diabetes who underwent either a below-knee amputation (BKA) or above-knee amputation (AKA) had an increased rate of phantom limb pain compared with those with a diagnosis of diabetes alone.
METHODS
Using international classification of disease (ICD) and common procedural terminology (CPT) codes, the TriNetX research database identified 10 239 patients who underwent BKA and 6122 who underwent AKA between 2012 and 2022. Diabetic patients with and without Charcot neuroarthropathy were compared in terms of demographics and relative risk of developing phantom limb pain after AKA or BKA.
RESULTS
Age, sex, ethnicity, and race did not significantly differ between groups. Charcot neuroarthropathy was associated with significantly increased risk of phantom limb pain following both BKA (risk ratio [RR]: 1.2, 95% confidence interval [CI]: 1.1-1.3, P < .01) and AKA (RR: 1.6, 95% CI: 1.2-2.3, P < .0068).
CONCLUSION
Our results indicate that patients with a coexisting diagnosis of Charcot neuroarthropathy who require BKA or AKA may have an increased risk of developing phantom limb pain.
LEVELS OF EVIDENCE
Level III.
PubMed: 38344975
DOI: 10.1177/19386400241230597 -
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 -
Med (New York, N.Y.) Feb 2024Recently, we reported the presence of phantom thermal sensations in amputees: thermal stimulation of specific spots on the residual arm elicited thermal sensations in...
BACKGROUND
Recently, we reported the presence of phantom thermal sensations in amputees: thermal stimulation of specific spots on the residual arm elicited thermal sensations in their missing hands. Here, we exploit phantom thermal sensations via a standalone system integrated into a robotic prosthetic hand to provide real-time and natural temperature feedback.
METHODS
The subject (a male adult with unilateral transradial amputation) used the sensorized prosthesis to manipulate objects and distinguish their thermal properties. We tested his ability to discriminate between (1) hot, cold, and ambient temperature objects, (2) different materials (copper, glass, and plastic), and (3) artificial versus human hands. We also introduced the thermal box and block test (thermal BBT), a test to evaluate real-time temperature discrimination during standardized pick-and-place tasks.
FINDINGS
The subject performed all three discrimination tasks above chance level with similar accuracies as with his intact hand. Additionally, in all 15 sessions of the thermal BBT, he correctly placed more than half of the samples. Finally, the phantom thermal sensation was stable during the 13 recording sessions spread over 400 days.
CONCLUSION
Our study paves the way for more natural hand prostheses that restore the full palette of sensations.
FUNDING
This work was funded by the Bertarelli Foundation (including the Catalyst program); the Swiss National Science Foundation through the National Centre of Competence in Research (NCCR) Robotics; the European Union's Horizon 2020 research and innovation program; the Horizon Europe Research & Innovation Program; the Ministry of University and Research (MUR), National Recovery and Resilience Plan (NRRP); and the Tuscany Health Ecosystem.
Topics: Adult; Humans; Male; Artificial Limbs; Feedback; Hand; Phantom Limb; Sensation
PubMed: 38340707
DOI: 10.1016/j.medj.2023.12.006 -
Brain and Cognition Mar 2024Among other bodily signals, the perception of sensations arising spontaneously on the skin with no external triggers contributes to body awareness. The topic of...
Among other bodily signals, the perception of sensations arising spontaneously on the skin with no external triggers contributes to body awareness. The topic of spontaneous sensations (SPS) being quite recent in the literature, there is still a debate whether this phenomenon is elicited by peripheral cutaneous units' activity underlying tactile perception or originates directly from central mechanisms. In a first experiment, we figured that, if SPS depended on peripheral afferents, their perception on the glabrous hand should relate to the hand tactile sensitivity. On the contrary, we found no relationship at all, which led us to envisage the scenario of SPS in the absence of cutaneous units. In a second experiment, we present the case of Julie, a right-hand amputee that could perceive and report SPS arising on her phantom limb syndrome. We found that SPS distribution on the phantom limb followed the same gradient as that observed in control participants, unlike SPS perceived on the intact left hand. Those findings are crucial to the understanding of neural factors determining body awareness through SPS perception and provide insights into the existence of a precise neural gradient underlying somesthesis.
Topics: Female; Humans; Phantom Limb; Sensation; Hand; Touch Perception; Awareness
PubMed: 38335922
DOI: 10.1016/j.bandc.2024.106138 -
Games For Health Journal Feb 2024Lower limb amputation is an emotionally devastating condition that causes a complete change in the quality of life, may lead to phantom limb pain in most of the cases,...
Effect of Adding Virtual Reality Training to Traditional Exercise Program on Pain, Mental Status and Psychological Status in Unilateral Traumatic Lower Limb Amputees: A Randomized Controlled Trial.
Lower limb amputation is an emotionally devastating condition that causes a complete change in the quality of life, may lead to phantom limb pain in most of the cases, and puts the individual in a high risk of developing psychological disorders. The objective of this study is to evaluate the consequence of adding virtual reality (VR) to a traditional exercise program on pain, mental status, and psychological status in traumatic unilateral lower limb amputees (LLAs). Thirty-two traumatic LLAs were randomly assigned into two equal groups in this randomized control trial. Participants did accomplish a postfitting exercise program at least 6 months before enrolment; the control group (CG) underwent a traditional rehabilitation program, and experimental group (EG) had the same program, in addition to VR training. Data were collected before and after 6 weeks of intervention using visual analog scale (VAS) for pain, Beck's depression inventory (BDI) for depression, and 12-item short form survey for mental health summary (MHS) and physical health summary (PHS). Thirty-two amputees (29 males and 3 females) were included with mean age in CGs and EG (27.6 ± 4) and (27.6 ± 7.6) years, respectively. Postintervention, the VAS score was significantly reduced only in EG ( = 0.003). Both groups showed significant improvement in BDI, MHS, and PHS ( < 0.05). However, the EG showed a superior significance in BDI and MHS scores ( < 0.05). There was no significance between groups in PHS score. Adding VR to conventional training is beneficial in decreasing pain and in improving depression and MHS of traumatic unilateral LLAs.
PubMed: 38324006
DOI: 10.1089/g4h.2023.0164