Self-Reported Treatments Used for Lower-Limb Phantom Pain: Descriptive Findings (original) (raw)
Related papers
PM&R, 2021
Background: Phantom limb pain (PLP) is common and often accompanied by serious suffering. Current systematic-review evidence suggests that recommended treatments are no more effective than placebo for reducing PLP. Given the difficulty in conducting a meta-analysis for nonpharmacological treatments and the weak evidence for pharmacological treatments for PLP, consensus on the first-line management of PLP needs to be reached using alternative methods. Objective: To reach expert consensus and make recommendations on the effective management of PLP. Design: A three-round Delphi design was used. Setting: The study was conducted using e-mail and Google survey tool as the main methods of communication and providing feedback. Participants: The study included 27 clinicians and researchers from various health disciplines who are experts in PLP management. Method: Data were collected using three sequential rounds of anonymous online questionnaires where experts proposed and ranked the treatments for PLP. A consensus was reached on the treatments that were endorsed by 50% or more of the experts. Results: Thirty-seven treatments were proposed for the management of PLP at the beginning of the study. Consensus was reached on seven treatments that were considered effective for managing PLP and on two treatments that were considered ineffective. Graded motor imagery, mirror therapy, amitriptyline, sensory discrimination training, and use of a functional prosthesis were endorsed by most experts because of the available backing scientific evidence and their reported efficacy in clinical practice. Cognitive behavioral therapy and virtual reality training were endorsed by most experts because of their reported efficacy in clinical practice despite indicating a dearth of scientific evidence to support their ranking. Citalopram and dorsal root ganglion pulsed radiofrequency were rejected owing to a lack of relevant scientific evidence. Conclusion: The results of this study suggest that the nonpharmacological treatments endorsed in this study may have an important role in the management of PLP.
Anesthesiology. 2011 May;114(5):1144-54, 2011
BACKGROUND: Severe preamputation pain is associated with phantom limb pain (PLP) development in limb amputees. We investigated whether optimized perioperative analgesia reduces PLP at 6-month follow-up. METHODS: A total of 65 patients underwent lower-limb amputation and were assigned to five analgesic regimens: (1) Epi/Epi/Epi patients received perioperative epidural analgesia and epidural anesthesia; (2) PCA/Epi/Epi patients received preoperative intravenous patient-controlled analgesia (PCA), postoperative epidural analgesia, and epidural anesthesia; (3) PCA/Epi/PCA patients received perioperative intravenous PCA and epidural anesthesia; (4) PCA/GA/PCA patients received perioperative intravenous PCA and general anesthesia (GA); (5) controls received conventional analgesia and GA. Epidural analgesia or intravenous PCA started 48 h preoperatively and continued 48 h postoperatively. The results of the visual analog scale and the McGill Pain Questionnaire were recorded perioperatively and at 1 and 6 months. RESULTS: At 6 months, median (minimum-maximum) PLP and P values (intervention groups vs. control group) for the visual analog scale were as follows: 0 (0-20) for Epi/Epi/Epi (P = 0.001), 0 (0-42) for PCA/Epi/Epi (P = 0.014), 20 (0-40) for PCA/Epi/PCA (P = 0.532), 0 (0-30) for PCA/GA/PCA (P = 0.008), and 20 (0-58) for controls. The values for the McGill Pain Questionnaire were as follows: 0 (0-7) for Epi/Epi/Epi (P < 0.001), 0 (0-9) for PCA/Epi/Epi (P = 0.003), 6 (0-11) for PCA/Epi/PCA (P = 0.208), 0 (0-9) for PCA/GA/PCA (P = 0.003), and 7 (0-15) for controls. At 6 months, PLP was present in 1 of 13 Epi/Epi/Epi, 4 of 13 PCA/Epi/Epi, and 3 of 13 PCA/GA/PCA patients versus 9 of 12 control patients (P = 0.001, P = 0.027, and P = 0.009, respectively). Residual limb pain at 6 months was insignificant. CONCLUSIONS: Optimized epidural analgesia or intravenous PCA, starting 48 h preoperatively and continuing for 48 h postoperatively, decreases PLP at 6 months.
Phantom Limb Pain in Daily Practice-Still a Lot of Work to Do!
Pain Medicine, 2012
Objectives. Effective treatment of phantom limb pain (PLP, pain felt in the part of the body of an amputated limb) is still difficult to achieve, and improved treatment is needed. It is therefore of paramount interest to understand the current practice of PLP therapy outside pain centers. Design. As a part of a nationwide survey, 537 amputees were asked 11 questions related to their treatment experiences and the pain relief. Furthermore, the patients' opinion about the quality of medical care was also asked. Results. Five hundred thirty-seven out of 1088 amputees returned the questionnaire (49.4%). Four hundred (74.5%) suffered from PLP. The patients rated their caregivers' knowledge about PLP lower than their own. Many (41.6%) of PLP patients had never been informed about the possibility of occurrence and mechanisms of PLP. The vast majority of the PLP patients did not try any treatment. Among those treated, more than 30% consulted more than three physicians for beneficial treatment. A >50% pain reduction was achieved in only 12.7% of PLP patients. The most successful treatments were opioids (67.4%) and anticonvulsants (51.7%). Surgery was performed in 46.4% of all PLP patients and in 29.7% due to a clinically suspected neuroma. After surgery, pain was worse or unchanged in 50% and improved in 41.6%, and 7.4% were pain-free. Conclusions. Our results suggest that there are primary needs for better information about PLP pathophysiology and treatment not only for patients but also for caregivers. Limited therapeutic success reveals a further need for increased research in PLP management.
Strategies for prevention of lower limb post-amputation pain: A clinical narrative review
Journal of Anaesthesiology Clinical Pharmacology
Postamputation limb pain or phantom limb pain (PLP) develops due to the complex interplay of peripheral and central sensitization. The pain mechanisms are different during the initial phase following amputation as compared with the chronic PLP. The literature describes extensively about the management of established PLP, which may not be applicable as a preventive strategy for PLP. The novelty of the current narrative review is that it focuses on the preventive strategies of PLP. The institution of preoperative epidural catheter prior to amputation and its continuation in the immediate postoperative period reduced perioperative opioid consumption (Level II). Optimized preoperative epidural or intravenous patient-controlled analgesia starting 48 hours and continuing for 48 hours postoperatively decreased PLP at 6 months (Level II). Preventive role of epidural LA with ketamine (Level II) reduced persistent pain at 1 year and LA with calcitonin decreased PLP at 12 months (Level II). Peripheral nerve catheters have opioid sparing effect in the immediate postoperative period in postamputation patients (Level I), but evidence is low for the prevention of PLP (Level III). Gabapentin did not reduce the incidence or intensity of postamputation pain (Level II). The review in related context mentions evidence regarding therapeutic role of gabapentanoids, peripheral nerve catheters, and psychological therapy in established PLP. In future, randomized controlled trials with long-term follow-up of patients receiving epidural analgesia, perioperative peripheral nerve catheters, oral gabapentanoids, IV ketamine, or mechanism-based modality for prevention of PLP as primary outcome are required.
Background. There is currently no reliable treatment for phantom limb pain (PLP). Chronic PLP and asso- ciated cortical abnormalities may be maintained from abnormal peripheral input, raising the possibility that a continuous peripheral nerve block (CPNB) of extended duration may permanently reorganize cor- tical pain mapping, thus providing lasting relief. Methods. Three men with below-the-knee (2) or -elbow (1) amputations and intractable PLP received femoral/sciatic or infraclavicular perineu- ral catheter(s), respectively. Subjects were random- ized in a double-masked fashion to receive perineural ropivacaine (0.5%) or normal saline for over 6 days as outpatients using portable elec- tronic infusion pumps. Four months later, subjects returned for repeated perineural catheter insertion and received an ambulatory infusion with the alter- nate solution (“crossover”). Subjects were fol- lowed for up to 1 year. Results. By chance, all three subjects received saline during their initial infusion and reported little change in their PLP. One subject did not receive crossover treatment, but the remaining two sub- jects reported complete resolution of their PLP during and immediately following treatment with ropivacaine. One subject experienced no PLP recur- rence through the 52-week follow-up period and the other reported mild PLP occurring once each week of just a small fraction of his original pain (pretreat- ment: continuous PLP rated 10/10; posttreatment: no PLP at baseline with average of one PLP episode each week rated 2/10) for 12 weeks (lost to follow-up thereafter). Conclusions. A prolonged ambulatory CPNB may be a reliable treatment for intractable PLP. The results of this pilot study suggest that a large, randomized clinical trial is warranted. Key Words. Persistent Pain; Chronic Pain; Per- sistent Postsurgical Pain; Persistent Post-Surgical Pain
Systematic Reviews, 2019
Background: The prevalence of phantom limb pain (PLP) in people with amputations is unclear because of the conflicting reports across the literature. It is proposed that the conflicting reports on the prevalence of PLP are a consequence of variations in the time period during which the studies were undertaken, countries in which the studies were conducted and recruitment processes implemented during collection of epidemiological data. In consideration of these factors, we aim to gather and critically appraise relevant literature to determine the prevalence estimate of and risk factors for PLP in people with amputations. Methods: We will use a customised search strategy containing relevant words and terms to search the following databases: MEDLINE/PubMed (via EBSCOhost), PsycINFO (via EBSCOhost), PsycArticles, Cumulative Index to Nursing and Allied Health Literature (CINAHL) (via EBSCOhost), Africa-Wide Information (via EBSCOhost), Health Source: Nursing/Academic Edition (via EBSCOhost) SCOPUS, Web of Science and Academic Search Premier (via EBSCOhost). The risk of bias assessment will be conducted using a risk of bias assessment tool for prevalence studies, and data will be extracted using a piloted customised data extraction sheet. Data extracted from individual studies will be entered into Review Manager 5 and assessed for clinical and statistical heterogeneity. Studies will be pooled for meta-analysis using the random-effects model to determine a summary estimate of the prevalence of PLP across included studies. A statistically significant level will be set at p < 0.05. Discussion: As far as we know, a systematic review and meta-analysis on the prevalence of, and risk factors for PLP in people with amputations has not been conducted. Given the varying reports in the literature, it is necessary to determine an estimate of the prevalence of PLP to generate an informed conclusion on this subject. The results of this review will be published in an internationally accredited journal and used to inform researchers, clinicians, policy-makers and the public about the burden of, and risk factors for PLP. This will be done with a further aim to improve the quality of pain management in society. Systematic review registration: PROSPERO CRD42018094821
Management of Phantom Limb Pain: A Review
International Journal of Medical Reviews and Case Reports, 2018
There are two types of pain after limb amputation, residual limb pain (RLP) that is pain localised on the stump, and pain perceived by the patient on the area of the missing limb which is called phantom limb pain (PLP). The prevalence of phantom limb pain remain high; several studies reported 50%-80% of amputated patients experienced PLP. Phantom limb pain therapy is challenging because its mechanism is not precise yet. In recent years, many therapies are being studied; they are divided into pharmacologic and nonpharmacologic therapy. Pharmacologic treatment such as BoNT/A injection, antidepressants (amitriptyline), anticonvulsants (pregabalin and gabapentin), opioids, NMDA receptor antagonists (memantine and ketamine), and capsaicin 8% patch. Nonpharmacologic therapy such as mirror therapy, transcutaneous electrical stimulation (TENS), spinal cauda equina stimulation, cryoneurolysis, and acupuncture. However, from all those studies, they conclude that there is no first-line treatment. In this review, modalities for PLP treatment over the past few years will be discussed. KEYWORDS phantom limb pain, management of phantom limb pain, pharmacologic therapy, nonpharmacologic therapy 1.Introduction The sensation of pain, experienced in the area of the missing body part is called phantom limb pain (PLP) [1,2]. It has to be distinguished from residual limb pain (RLP), formerly known as "stump pain" [3]. PLP first describe by Ambroise Paré in 1552 [4] and named by Silas Weir Mitchell [2,5]. PLP is very frequent in post-amputated patients, and the prevalence may be as high as 50% to 80% [2,6-8]. In 92% of PLP patients, the pain occurs in the first-week post-amputation, and 65% occur in the first sixmonth post-amputation [3,9]. Phantom limb pain is classified as neuropathic pain and associated with differentiation and cortical reorganisation mechanism in the somatosensory system. From all those treatments that are being studied, no one shows significant effectiveness [7].
Evidence for the Optimal Management of Acute and Chronic Phantom Pain: A Systematic Review
The Clinical Journal of Pain, 2002
Objectives: The objective was to examine the evidence to determine the optimal management of phantom limb pain in the preoperative and postoperative phase of amputations. Methods: Trials were identified by a systematic search of MEDLINE, review articles, and references of relevant trials from the period 1966-1999, including only English-language articles. Included trials involved a control group, any intervention, and reported phantom pain as an outcome. Results: Twelve trials were identified, including 375 patients whose follow-ups ranged in duration from 1 week to 2 years. Only three randomized, controlled studies with parallel groups and three randomized crossover trials were identified. Eight trials examined treatment of acute phantom pain, including epidural treatments (three trials), regional nerve blocks (three trials), treatment with calcitonin (one trial), and transcutaneous electrical nerve stimulation (one trial). Three trials demonstrated a positive impact of the intervention on phantom limb pain, but the remainder demonstrated no difference between the intervention and control groups. Four trials examined late postoperative interventions, including transcutaneous electrical nerve stimulation (two trials) and the use of Farabloc (a metal threaded sock) and ketamine (one trial each). With regard to late postoperative interventions, three of the four trials showed modest short-term reduction of phantom limb pain. There was no relation between the quality of the trial and a positive result of the intervention. Conclusions: Although up to 70% of patients have phantom limb pain after amputation, there is little evidence from randomized trials to guide clinicians with treatment. Evidence on preemptive epidurals, early regional nerve blocks, and mechanical vibratory stimulation provides inconsistent support for these treatments. There is currently a gap between research and practice in the area of phantom limb pain.