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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 -
Archives of Physical Medicine and... May 2022To evaluate the effectiveness of mirror therapy (MT) for phantom limb pain (PLP). (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To evaluate the effectiveness of mirror therapy (MT) for phantom limb pain (PLP).
DATA SOURCES
PubMed, EMBASE, Ovid MEDLINE, Scopus, Cochrane Library, Physiotherapy Evidence Database, CNKI, and WanFang Data were used to search for studies published up to March 31, 2021.
STUDY SELECTION
Randomized controlled trials (RCTs) comparing the pain intensity of MT for PLP were performed. A total of 2094 articles were found. Among them, 10 were eligible for the final analysis.
DATA EXTRACTION
The quality of the RCTs was assessed using the Physiotherapy Evidence Database (PEDro) scale by 2 independent reviewers. Outcome data were pooled according to follow-up intervals (1, 3, 6, and 12mo). Duration times were used as a basis for distinguishing subgroups. The primary evaluation was by visual analog scale. The PEDro scale was used to assess the methodological quality of studies.
DATA SYNTHESIS
Meta-analysis revealed a statistically significant decrease in pain in the MT group vs the control group within 1 month (I=0%; standardized mean difference [SMD]=-0.46, 95% confidence interval [CI], -0.79 to -0.13; P = .007). The patients with pain for longer than 1 year benefited more from MT (I=0%; SMD=-0.46; 95% CI, -0.85 to -0.07; P = .02).
CONCLUSIONS
MT has beneficial effects for patients with PLP in the short-term, as evidenced by their improved pain scores. There was no evidence that MT had a long-term effect, but that may be a product of limited data. For patients with long-term PLP, MT may be an effective treatment.
Topics: Humans; Mirror Movement Therapy; Pain Measurement; Phantom Limb; Physical Therapy Modalities; Treatment Outcome
PubMed: 34461084
DOI: 10.1016/j.apmr.2021.07.810 -
Clinical Rehabilitation Dec 2021This systematic review and meta-analysis aimed to evaluate the effects of mirror therapy on phantom limb sensation and phantom limb pain in amputees. (Meta-Analysis)
Meta-Analysis
OBJECTIVE
This systematic review and meta-analysis aimed to evaluate the effects of mirror therapy on phantom limb sensation and phantom limb pain in amputees.
DATA SOURCES
Nine electronic databases (PubMed, EMBASE, MEDLINE, Web of Science, the Cochrane Library, CINAHL, PsycInfo, PreQuest, PEDro) were searched from their inception to May 10th, 2021.
METHODS
Two authors independently selected relevant studies and extracted the data. The effect sizes were calculated under a random-effects model meta-analysis, and heterogeneity was assessed using the test. The risk of bias was evaluated by the Cochrane risk of bias tool, and the methodological quality was appraised by the PEDro scale. The GRADE approach was applied to assess the confidence of the effect.
RESULTS
A total of 11 RCTs involving 491 participants were included in this review and nine RCTs involving 372 participants were included in meta-analysis. The quality of these studies was from poor to good with scores ranging from 2 to 8 points according to PEDro scale. The pooled SMD showed that mirror therapy reduced the pain with a large effect size (-0.81; 95% CI = -1.36 to -0.25; = 0.005; = 82%; = 372) compared with other methods (four covered mirror, one phantom exercise, three mental visualization, one sensorimotor exercise, one transcutaneous electrical nerve stimulation, one tactile stimuli). The quality of evidence for the outcome pain intensity was determined to be fair according to GRADE approach.
CONCLUSION
There is fair-quality evidence that MT is beneficial for reducing phantom limb pain.
Topics: Amputees; Humans; Phantom Limb; Randomized Controlled Trials as Topic; Sensation; Transcutaneous Electric Nerve Stimulation
PubMed: 34308686
DOI: 10.1177/02692155211027332 -
Disability and Rehabilitation Sep 2022Phantom limb pain (PLP) is a chronic neuropathic pain condition of a missing limb following amputation. Pain management is multi-modal, including various... (Review)
Review
PURPOSE
Phantom limb pain (PLP) is a chronic neuropathic pain condition of a missing limb following amputation. Pain management is multi-modal, including various non-pharmacological therapies. The purpose of this scoping review was to investigate the evidence surrounding current non-pharmacological treatment modalities for PLP and provide insight into their clinical feasibility.
METHOD
A systematic search was conducted using four databases (Medline, Embase, PsychInfo, and CINAHL) following the PRISMA-ScR method. Results from papers meeting the inclusion criteria were charted to summarize findings, demographics, and use of neuroimaging.
RESULTS
A total of 3387 papers were identified, and full texts of 142 eligible papers were assessed. Eleven treatment modalities for PLP were identified with varying levels of evidence. Overall, there were 25 RCTs, 58 case reports, and 59 a combination of pilot, quasi-experimental, observational, and other study designs.
CONCLUSIONS
Currently, the evidence surrounding most treatment modalities is limited and only a fraction of studies are supported by strong evidence. The findings of this review demonstrated a clear need to conduct more rigorous research with diverse study designs to better understand which modalities provide the most benefit and to incorporate neuroimaging to better determine the neural correlates of PLP and mechanisms of various treatments.Implications for RehabilitationPhantom limb pain (PLP) is a prevalent and debilitating condition following amputation and health care professionals should incorporate an evidence-based pain management protocol into their rehabilitation program.There exist a number of different non-pharmacological therapies to address PLP, however the scientific rigor and levels of evidence vary across modalities.Prescription of interventions for PLP should consider individual patient differences, accessibility to the patient, and quite possibly, a multi-modal approach, particularly for those who also experience residual limb pain.Imagery-based therapies provide the highest level of current evidence based on robust and large randomized control trials, are readily accessible, and are thus most recommended for relief of PLP.
Topics: Amputation, Surgical; Amputees; Humans; Imagery, Psychotherapy; Pain Management; Phantom Limb
PubMed: 34293999
DOI: 10.1080/09638288.2021.1948116 -
Annals of Plastic Surgery May 2022Neuromata developed after major extremity amputation can cause pain, limit the use of prosthetics, and negatively affect the quality of life. The frequency of... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Neuromata developed after major extremity amputation can cause pain, limit the use of prosthetics, and negatively affect the quality of life. The frequency of postamputation neuroma varies widely. The objective of this study was to determine the incidence of patients who developed symptomatic neuromata after lower-limb amputation through a systematic review and meta-analysis.
METHODS
A systematic review of the literature was performed on 4 major databases. Studies that reported the incidence of symptomatic neuroma in lower-limb amputees were included. A meta-analysis was performed to calculate the pooled incidence of neuromata.
RESULTS
Thirteen studies consisting of 1329 patients were included in this meta-analysis. The reported incidence of patients who developed symptomatic neuromata ranged between 4% and 49%. The median duration of follow-up was 8.6 years (interquartile range, 2.0-17.4 years). The pooled percentage (95% confidence interval [CI]) of lower-limb amputees who developed symptomatic neuromata was 19% (12%-29%). In studies with a duration of follow-up at least 3 years, the pooled percentage (95% CI) of lower-limb amputees who developed symptomatic neuromata was 30% (22%-40%). In studies with a follow-up period of fewer than 3 years, the pooled percentage (95% CI) of neuroma incidence was 3% (2%-6%).
CONCLUSIONS
In summary, the overall incidence of patients who developed symptomatic neuromata was 19% or approximately 1 in 5 lower-limb amputees. Symptomatic neuromata are more commonly diagnosed when the follow-up period is longer than 3 years. These findings suggest that neuroma after amputation might be underestimated in studies with a short duration of follow-up.
Topics: Amputation, Surgical; Amputation Stumps; Humans; Incidence; Lower Extremity; Neuroma; Phantom Limb; Quality of Life
PubMed: 34270470
DOI: 10.1097/SAP.0000000000002946 -
Neural Regeneration Research Jan 2022Phantom limb pain is a chronic pain syndrome that is difficult to cope with. Despite neurostimulation treatment is indicated for refractory neuropathic pain, there is...
Phantom limb pain is a chronic pain syndrome that is difficult to cope with. Despite neurostimulation treatment is indicated for refractory neuropathic pain, there is scant evidence from randomized controlled trials to recommend it as the treatment choice. Thus, a systematic review was performed to analyze the efficacy of central nervous system stimulation therapies as a strategy for pain management in patients with phantom limb pain. A literature search for studies conducted between 1970 and September 2020 was carried out using the MEDLINE and Embase databases. Principles of The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline were followed. There were a total of 10 full-text articles retrieved and included in this review. Deep brain stimulation, repetitive transcranial magnetic stimulation, transcranial direct current stimulation, and motor cortex stimulation were the treatment strategies used in the selected clinical trials. Repetitive transcranial magnetic stimulation and transcranial direct current stimulation were effective therapies to reduce pain perception, as well as to relieve anxiety and depression symptoms in phantom limb pain patients. Conversely, invasive approaches were considered the last treatment option as evidence in deep brain stimulation and motor cortex stimulation suggests that the value of phantom limb pain treatment remains controversial. However, the findings on use of these treatment strategies in other forms of neuropathic pain suggest that these invasive approaches could be a potential option for phantom limb pain patients.
PubMed: 34100428
DOI: 10.4103/1673-5374.314288 -
European Journal of Vascular and... Aug 2021Controlling pain after major lower limb amputation (MLLA) is of critical importance to patients and clinicians. The aim of this systematic review and meta-analysis was... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
Controlling pain after major lower limb amputation (MLLA) is of critical importance to patients and clinicians. The aim of this systematic review and meta-analysis was to assess the effect of perineural catheters (PNCs) on post-operative pain, post-operative morphine requirement, in-hospital mortality, long term phantom limb pain, and chronic stump pain.
METHODS
A systematic review using PubMed, EMBASE via OVID and the Cochrane library from database inception (1946) to 20 October 2020 was performed according to PRISMA guidelines. Studies involving patients undergoing MLLA which reported on post-operative morphine requirement, pain scores, in-hospital mortality, phantom limb pain (PLP), and chronic stump pain were included. Studies comparing PNC use with epidural or wound site local anaesthetic infusions were excluded. Outcome data were extracted from individual studies and meta-analysis was performed using a random effects (Mantel-Haenszel) model for dichotomous data using an odds ratio (OR) summary statistic with 95% confidence intervals (CI), and with an inverse variance random effects model for continuous data using a standardised mean difference (SMD) summary statistic with 95% CIs. Sensitivity analyses were performed for post-operative pain scores and post-operative morphine requirement. Study quality was assessed using the Downs and Black score, and outcomes were assessed using the GRADE tool.
RESULTS
Ten studies reporting on 731 patients were included, with 350 patients receiving a PNC and 381 receiving standard care. PNC use is associated with a reduction in post-operative pain (SMD -0.30, 95% CI -0.58 - -0.01, p = .040, I = 54%, GRADE quality of evidence: low) and post-operative morphine requirements (SMD -0.63, 95% CI -1.03 - -0.23, p = .002, I = 75%, GRADE quality of evidence: moderate), although the effect of PNC on reduced post-operative morphine requirements is lost on sensitivity analysis of randomised trials only (p = .40). No demonstrable effect was found on in-hospital mortality, PLP, or chronic stump pain (GRADE quality of evidence: low).
CONCLUSION
PNC use in amputees is associated with a significant reduction in post-operative pain scores and post-operative morphine requirements, although this latter finding is lost on sensitivity analysis of randomised trials only.
Topics: Amputation, Surgical; Amputation Stumps; Analgesics, Opioid; Anesthetics, Local; Catheters; Hospital Mortality; Humans; Lower Extremity; Morphine; Pain Measurement; Pain, Postoperative; Peripheral Nerves; Phantom Limb
PubMed: 34088614
DOI: 10.1016/j.ejvs.2021.03.008