Phantom Limb Pain: Theories and Therapies

Exploring the Role of Cortical Reorganization in Postamputation Phantom Phenomena, Including Phantom Limb Pain in Lower Limb Amputees: A Cross-Sectional Study of the Patterns of Referral of Sensations into the Phantom

BACKGROUND

Cortical reorganization and pain memory are theories to explain phantom limb pain and other postamputation phantom phenomena. This study was undertaken to identify evidence of cortical reorganization in lower limb amputees and to find evidence for the pain memory theory.

METHODS

This was a qualitative interview study using structured questionnaires with lower limb amputees. Participants were asked to identify body areas and activities that stimulate postamputation phantom phenomena to confirm the cortical reorganization theory. We tested the pain memory theory by comparing traumatic amputees with surgical amputees.

RESULTS

A total of 122 participants (response rate 42%) were recruited. Prevalence of postamputation phantom phenomena was similar to previous studies with phantom pain reported as 84%. Twenty (16.3%) identified body regions that could stimulate postamputation phantom phenomena and 32 (26%) identified activities that could stimulate postamputation phantom phenomena. Not all body areas or activities were related to somatotopic regions adjacent to the leg on the sensory homunculus. Overall, 47 (38.2%) exhibited attributes suggestive of cortical reorganization into areas adjacent to the leg. No associations were found between presence of pain or length of time in pain before amputation and the presence of phantom pain (p = .1-1.0). No statistical difference was found between surgical and traumatic amputees for any postamputation phantom phenomena (p = .3-1.0).

CONCLUSIONS

The cortical reorganization and pain memory theories for the development and maintenance of postamputation phantom phenomena have only limited support from our data. Taking this into account, it may be worth reopening the debate on the mechanism for postamputation phantom phenomena, including phantom limb pain. The cortical reorganization theory and memory theory for the mechanism of phantom limb pain are questioned by these results. Both may play a role, but neither can explain the presence of postamputation phantom phenomena on their own.

Development of a Multimodal Analgesia Protocol for Perioperative Acute Pain Management for Lower Limb Amputation

Multimodal analgesia may include pharmacological components such as regional anesthesia, opioid and nonopioid systemic analgesics, nonsteroidal anti-inflammatories, and a variety of adjuvant agents. Multimodal analgesia has been reported for a variety of surgical procedures but not yet for lower limb amputation in vasculopathic patients. Perioperative pain management in these patients presents a particular challenge considering the multiple sources and pathways for acute and chronic pain that are involved, such as chronic ischemic limb pain, postoperative residual limb pain, coexisting musculoskeletal pain, phantom limb sensations, and chronic phantom limb pain. These pain mechanisms are explored and a proposed protocol for multimodal analgesia is outlined taking into account the common patient comorbidities found in this patient population.

Effectiveness of mirror therapy, motor imagery, and virtual feedback on phantom limb pain following amputation: A systematic review

BACKGROUND

Phantom limb pain is reported in 50%-85% of people with amputation. Clinical interventions in treating central pain, such as mirror therapy, motor imagery, or virtual visual feedback, could redound in benefits to amputee patients with phantom limb pain.

OBJECTIVES

To provide an overview of the effectiveness of different techniques for treating phantom limb pain in amputee patients.

STUDY DESIGN

Systematic review.

METHODS

A computerized literature search up to April 2017 was performed using the following databases: PubMed, Scopus, CINAHL, MEDLINE, ProQuest, PEDro, EBSCOhost, and Cochrane Plus. Methodological quality and internal validity score of each study were assessed using PEDro scale. For data synthesis, qualitative methods from the Cochrane Back Review Group were applied.

RESULTS

In all, 12 studies met our inclusion criteria, where 9 were rated as low methodological quality and 3 rated moderate quality. All studies showed a significant reduction in pain, but there was heterogeneity among subjects and methodologies and any high-quality clinical trial (PEDro score ≤8; internal validity score ≤5) was not found.

CONCLUSION

Mirror therapy, motor imaginary, and virtual visual feedback reduce phantom limb pain; however, there is limited scientific evidence supporting their effectiveness. Future studies should include designs with more solid research methods, exploring short- and long-term benefits of these therapies. Clinical relevance This systematic review investigates the effectiveness of mirror therapy, motor imagery, and virtual visual feedback on phantom limb pain, summarizing the currently published trials and evaluating the research quality. Although these interventions have positive benefits in phantom limb pain, there is still a lack of evidence for supporting their effectiveness.

Reaffirming the link between chronic phantom limb pain and maintained missing hand representation

Phantom limb pain (PLP) is commonly considered to be a result of maladaptive brain plasticity. This model proposes that PLP is mainly caused by reorganisation in the primary somatosensory cortex, presumably characterised by functional degradation of the missing hand representation and remapping of other body part representations. In the current study, we replicate our previous results by showing that chronic PLP correlates with maintained representation of the missing hand in the primary sensorimotor missing hand cortex. We asked unilateral upper-limb amputees to move their phantom hand, lips or other body parts and measured the associated neural responses using functional magnetic resonance imaging (fMRI). We confirm that amputees suffering from worse chronic PLP have stronger activity in the primary sensorimotor missing hand cortex while performing phantom hand movements. We find no evidence of lip representation remapping into the missing hand territory, as assessed by measuring activity in the primary sensorimotor missing hand cortex during lip movements. We further show that the correlation between chronic PLP and maintained representation of the missing hand cannot be explained by the experience of chronic non-painful phantom sensations or compensatory usage of the residual arm or an artificial arm (prosthesis). Together, our results reaffirm a likely relationship between persistent peripheral inputs pertaining to the missing hand representation and chronic PLP. Our findings emphasise a need to further study the role of peripheral inputs from the residual nerves to better understand the mechanisms underlying chronic PLP.

A Proposed Molecular Mechanism for Physical Analgesia in Chronic Pain

Although pain is indispensable for survival, chronic pain places a heavy burden on humans. As the efficacy of opioid treatment is limited, the development of alternative methods of pain relief without medication is desirable. Recently, we have developed a novel method of physical analgesia using an adhesive “pyramidal thorn patch.” When we apply about 3 trials of these patches on the skin of a pain region, the pain region moves toward the spinal cord like a “cutaneous rabbit,” and finally, the pain vanishes. In the present review, we propose a molecular mechanism for this analgesic method or pain relief following application of the pyramidal thorn patch where firstly the mechanoreceptors and their related nerves under the skin are activated in response to touch. Transient receptor potential (TRP) channels serve as mechanosensitive channels within these mechanoreceptors. We further propose that activation of the nerves connected with the mechanoreceptors releases oxytocin, which has an antinociceptive function and activates TRP channels to hyperpolarize the pain signal nerves. We believe that our system will pave the way for alternative pain treatment.

Relief from intractable phantom pain by combining psilocybin and mirror visual-feedback (MVF)

AL's leg was amputated resulting in phantom-limb pain (PLP). (1) When a volunteer placed her foot on or near the phantom - touching it evoked organized sensations in corresponding locations on AL's phantom. (2) Mirror-visual-feedback (MVF) relieved PLP, as did, "phantom massage". (3) Psilocybin-MVF pairing produced synergistic effects, complete elimination of PLP, and reduction in paroxysmal episodes. (4) Touching the volunteer's leg where AL previously had external fixators, evoked sensation of nails boring through the leg. Using a "telescoping" nail, we created the illusion of a nail being removed with corresponding pain relief. (5) Artificial flames produced warmth in the phantom.

Immersive Low-Cost Virtual Reality Treatment for Phantom Limb Pain: Evidence from Two Cases

Up to 90% of amputees experience sensations in their phantom limb, often including strong, persistent phantom limb pain (PLP). Standard treatments do not provide relief for the majority of people who experience PLP, but virtual reality (VR) has shown promise. This study provides additional evidence that game-like training with low-cost immersive VR activities can reduce PLP in lower-limb amputees. The user of our system views a real-time rendering of two intact legs in a head-mounted display while playing a set of custom games. The movements of both virtual extremities are controlled by measurements from inertial sensors mounted on the intact and residual limbs. Two individuals with unilateral transtibial amputation underwent multiple sessions of the VR treatment over several weeks. Both participants experienced a significant reduction of pain immediately after each VR session, and their pre-session pain levels also decreased greatly over the course of the study. Although preliminary, these data support the idea that VR interventions like ours may be an effective low-cost treatment of PLP in lower-limb amputees.

Phantom limb pain: a review of pharmacological management

Introduction

Phantom limb pain (PLP) is a complex condition resulting in pain in the missing limb affecting 60-80% amputees. Increasing number of patients are undergoing amputations. Approximately 1 per every 1000 people in the United Kingdom is an amputee. Incidence of PLP can be as high as 80% following amputation. PLP can be severe and difficult to treat. A range of pharmacological interventions exist yet little is known about them in respect to PLP. This article will address the effectiveness of both single pharmacological, therapy as well as drug combination therapy.

Methods

We reviewed all literature looking at the evidence for the efficacy of both single and combined pharmacological therapy in the management of phantom limb pain. Not all commonly prescribed analgesic agents have been studied in the use of PLP and in these cases, the evidence of their efficacy in neuropathic pain was reviewed.

Conclusion

It is difficult to draw definitive conclusions on the pharmacological management of PLP based on current available evidence. Most trials involved small cohorts and were not specific to the PLP. The trials which looked specifically at the PLP population gave conflicting results. Only the N-methyl-d-aspartate (NMDA) receptor antagonist class demonstrated consistent positive results. Most notably ketamine did produce a reduction in pressure pain thresholds and pain windup associated with PLP, although the numbers in these studies remain small. This benefit was not demonstrated across all NMDA receptor antagonists. Combination therapy has demonstrated effectiveness in previous studies for neuropathic pain but this has never been tested specifically against a PLP cohort. Therefore, combination treatment of agents with proven efficacy in PLP such as opioid and gabapentin deserves a closer examination in a controlled study against a placebo as well as single drug therapy.

Pregabalin as adjunct in a multimodal pain therapy after traumatic foot amputation — A case report of a 4-year-old girl

Background and purpose

The purpose of this case report is to describe a multimodal pain therapeutic concept including the adjunct use of pregabalin in a 4.5 year-old child after forefoot amputation.

Phantom limb pain and sensation is a complex pain syndrome that is difficult to treat and prevent. 70–75% of all children develop such a pain syndrome after amputation. We describe here a paediatric patient who underwent forefoot amputation following traumatic foot injury and received multimodal pain therapy including pregabalin.

The current experiment aimed at studying effects of empathic communication, and more specifically validation, on recall during a pain test and possible mediators and moderators of this effect.

Methods

A 4.5 year-old otherwise healthy girl suffered severe injuries of the right foot and lower leg during a motor vehicle accident. Due to development of severe necrosis, forefoot amputation had to be performed during the hospital stay.

Results

Initial pain therapy included paracetamol, ibuprofen, metamizol, morphine and fentanyl. With mounting pain and anxiety, regional anaesthesia of the distal sciatic nerve was administered in combination with a ketamine and morphine patient controlled analgesia pump (PCA). The peripheral blockade of the distal sciatic nerve was placed with the guidance of ultrasound and nerve stimulator. The PCA concept included a continuous basal rate combined with a bolus function. Although the regional anaesthesia was well positioned and functioning, there was inadequate pain control. The pain was described by the patient as short, highly intense and sharp sensations with intensity on the visual analogue scale (VAS) of 10 (out of 10). Furthermore, she suffered from anxiety episodes and sleep disturbance. The medical team decided to treat with pregabalin to resolve these issues while awaiting amputation (Lisfranc line). She received psychological counselling as adjunct treatment. This multimodal concept enabled an early and efficient pain reduction pre- and post-amputation and allowed for the possibility of a hospital discharge without any opioid pain medication.

Conclusion

The multimodal pain therapy including pregabalin was well tolerated, safe and highly effective in this case of traumatic limb injury and subsequent amputation. The use of pregabalin allowed significant pain and anxiety reduction for the patient.

Implications

Pregabalinis frequentlyused in adult patients for severe complex pain syndromes. There are only few reports of such adjunct medication (pregabalin) in paediatric pain syndromes. These reports focus mainly on the paediatric oncologic population. The case reported here encourages physicians to consider adjunct medications when treating complex pain, which are well established in the adult population. The benefits of such therapy in complex pain and anxiety can be extended to the paediatric population in select cases. Of course, one must always take into account that many routine medications used in children are well established but are off-label use. The authors are well aware of this problem and have conducted a critical literature review prior to pregabalin administration, including the search for randomized trials examining safety and tolerability. The parents or legal guardians of a minor must be thoroughly informed and consent to such a constellation of medical treatment.

Motor correlates of phantom limb pain

Following amputation, individuals ubiquitously report experiencing lingering sensations of their missing limb. While phantom sensations can be innocuous, they are often manifested as painful. Phantom limb pain (PLP) is notorious for being difficult to monitor and treat. A major challenge in PLP management is the difficulty in assessing PLP symptoms, given the physical absence of the affected body part. Here, we offer a means of quantifying chronic PLP by harnessing the known ability of amputees to voluntarily move their phantom limbs. Upper-limb amputees suffering from chronic PLP performed a simple finger-tapping task with their phantom hand. We confirm that amputees suffering from worse chronic PLP had worse motor control over their phantom hand. We further demonstrate that task performance was consistent over weeks and did not relate to transient PLP or non-painful phantom sensations. Finally, we explore the neural basis of these behavioural correlates of PLP. Using neuroimaging, we reveal that slower phantom hand movements were coupled with stronger activity in the primary sensorimotor phantom hand cortex, previously shown to associate with chronic PLP. By demonstrating a specific link between phantom hand motor control and chronic PLP, our findings open up new avenues for PLP management and improvement of existing PLP treatments.

A review of the management of phantom limb pain: challenges and solutions

BACKGROUND

Phantom limb pain (PLP) occurs in 50% and 80% of amputees. Although it is often classified as a neuropathic pain, few of the large-scale trials of treatments for neuropathic pain included sufficient numbers of PLP sufferers to have confidence that they are effective in this condition. Many therapies have been administered to amputees with PLP over the years; however, as of yet, there appears to be no first-line treatment.

OBJECTIVES

To comprehensively review the literature on treatment modalities for PLP and to identify the challenges currently faced by clinicians dealing with this pain.

METHOD

MEDLINE, EMBASE, CINAHL, British Nursing Index, Cochrane and psycINFO databases were searched using "Phantom limb" initially as a MeSH term to identify treatments that had been tried. Then, a secondary search combining phantom limb with each treatment was performed to find papers specific to each therapy. Each paper was assessed for its research strength using the GRADE system.

RESULTS

Thirty-eight therapies were identified. Overall, the quality of evidence was low. There was one high-quality study which used repetitive transcutaneous magnetic stimulation and found a statistical reduction in pain at day 15 but no difference at day 30. Significant results from single studies of moderate level quality were available for gabapentin, ketamine and morphine; however, there was a risk of bias in these papers. Mirror therapy and associated techniques were assessed through two systematic reviews, which conclude that there is insufficient evidence to support their use.

CONCLUSION

No decisions can be made for the first-line management of PLP, as the level of evidence is too low. Robust studies on homogeneous populations, an understanding of what amputees consider a meaningful reduction in PLP and agreement of whether pain intensity is the legitimate therapeutic target are urgently required.

[Psychotherapies for the Treatment of Phantom Limb Pain]

INTRODUCTION

The phantom limb pain has been described as a condition in which patients experience a feeling of itching, spasm or pain in a limb or body part that has been previously amputated. Such pain can be induced by a conflict between the representation of the visual and proprioceptive feedback of the previously healthy limb. The phantom limb pain occurs in at least 42 to 90% of amputees. Regular drug treatment of phantom limb pain is almost never effective.

METHODS

A systematic review of the literature was conducted in Medline and Cochrane using the MESH terms "phantom limb pain" and "psychotherapy", published in the last 10 years, in English and Spanish, finding 49 items. After reviewing the abstracts, 25 articles were excluded for not being related to the objective of the research. Additionally cross references of included articles and literature were reviewed.

OBJECTIVES

To describe the psychotherapies used in the management of phantom limb pain, their effectiveness and clinical application reported in the literature.

AIMS

The mechanisms underlying phantom limb pain were initially explained, as were the published studies on the usefulness of some psychotherapies such as mirror visual feedback and immersive virtual reality, visual imagery, desensitization and reprocessing eye movements and hypnosis.

CONCLUSIONS

The phantom limb pain is a complex syndrome that requires pharmacological and psychotherapeutic intervention. The psychotherapies that have been used the most as adjuvants in the treatment of phantom limb pain are mirror visual feedback, desensitization and reprocessing eye movements, imagery and hypnosis. Studies with more representative samples, specifically randomized trials are required.

Treating individuals with amputations in therapeutic massage and bodywork practice: A qualitative study

INTRODUCTION

Best practices for massage therapy and bodywork (TMB) treatment of individuals with amputations are not well established. Although anecdotal observations are available, they have limited applicability for informing effective massage therapy and bodywork approaches for individuals with amputations. This study is part of a multifaceted research program seeking to establish a foundation for education and investigation of TMB for amputation related conditions/symptomology. The purpose of this study was to understand how TMB practitioners approach and treat individuals with amputations and their perceptions of outcomes. The TMB practitioner perspective is important in informing the development of a TMB practice framework for people with amputation.

METHODS

The methodology of this study was informed by the phenomenological approach to qualitative inquiry. Semi-structured telephone interviews were conducted between June and September 2015, recorded and transcribed. Analysis consisted of descriptive coding and themes emerged through an iterative process. Codes and themes were discussed and verified with the research team. Participants were invited to review developed themes to indicate the extent to which results accurately encompassed their experiences as TMB practitioners.

RESULTS

Twenty-five community practicing, professional TMB practitioners from 16 states consented to participate and all completed one interview. Analysis identified four themes which indicated TMB practitioners: value touch and consider it a core aspect of treatment for individuals with amputations; operate under a core belief that individuals with amputations greatly benefit from TMB; and consider relief that stems from TMB to be multidimensional, including physical, mental, and emotional aspects; and, certain components of treatment approach are unique to amputation clients.

CONCLUSIONS

Findings support that individuals with amputation benefit from TMB, at least from the perspective of TMB practitioners. Findings of this exploratory research identify important questions regarding approaches to treatment and potential TMB effectiveness hypotheses for amputation populations. Next steps will consider TMB approach and effects from the perspective of those with amputation(s).

Association between phantom limb complex and the level of amputation in lower limb amputee

Objective

The aim of this study was to evaluate the natural course of phantom limb complex without any treatment after lower limb amputation.

Methods

The study design was consisted of a combination of retrospective review and cross-sectional interview. 101 patients with lower limb amputation were included into the study. Patients were divided into three groups according to the amputation level: i) from hip disarticulation to knee disarticulation (including knee disarticulation) (25 patients, mean age: 55.9, 19 males, 6 females) ii) transtibial amputation (below knee to ankle including ankle disarticulation) (41 patients, mean age: 58.6, 33 males, 8 females) iii) below ankle to toe amputation (35 patients, mean age: 58.7, 26 males, 9 females). The patients were evaluated on both early postoperative period (EPP) and sixth months after the surgery (ASM). The data related amputation including amputation date, level, cause, stump pain (SP), phantom limb pain (PLP), components of PLP, phantom sensation (PS) were recorded based on the information obtained from patients' and hospital files.

Results

Statistically significant differences were found for pain intensity (VAS) between groups for SP and PLP at EPP (p < 0.001, p = 0.036; respectively). The mean VAS score in Group I for SP and PLP was higher than other groups. This differences for SP and PLP did not continue at ASM assessment (p = 0.242, p = 0.580; respectively).

Conclusion

VAS scores for SP in above knee amputations and VAS scores for PLP in above knee amputations and below ankle amputations were higher at EPP. But these high scores had disappeared over time. Management strategies have to be considered particularly in the early postoperative period in patients who had undergone above knee amputation.

Level of Evidence

Level III Prognostic study.

Percutaneous Image-Guided Cryoablation for the Treatment of Phantom Limb Pain in Amputees: A Pilot Study

PURPOSE

To prospectively evaluate percutaneous image-guided nerve cryoablation for treatment of refractory phantom limb pain (PLP) in a pilot cohort for purposes of deriving parameters to design a larger, randomized, parallel-armed, controlled trial.

MATERIALS AND METHODS

From January 2015 to January 2016, 21 patients with refractory PLP underwent image-guided percutaneous cryoneurolysis procedures. Visual analog scale scores were documented at baseline and 7, 45, and 180 days after the procedure. Responses to a modified Roland Morris Disability Questionnaire were documented at baseline and 7 and 45 days after the procedure.

RESULTS

Technical success rate of the procedures was 100%. There were 6 (29%) minor procedure-related complications. Disability scores decreased from a baseline mean of 11.3 to 3.3 at 45-day follow-up (95% confidence interval 5.8, 10.3; P < .0001). Pain intensity scores decreased from a baseline mean of 6.2 to 2.0 at long-term follow-up (95% confidence interval 2.8, 5.6; P < .0001).

CONCLUSIONS

Image-guided percutaneous nerve cryoablation is feasible and safe and may represent a new efficacious therapeutic option for patients with phantom pains related to limb loss.

Phantom rectal sensations following abdominoperineal excision of the rectum (APER) and vertical rectus abdominis myocutaneous (VRAM) flap perineal reconstruction

AIM

Phantom rectum is the sensation of an intact and/or functioning rectum, despite excision at surgery. Abdominoperineal excision of the rectum (APER) may be complemented by reconstructive operations and recently it was reported that patients undergoing APER and vertical rectus abdominis myocutaneous (VRAM) flap reconstruction are more prone to develop phantom sensations at an earlier timeframe and have more persistent symptoms than those who do not have perineal repairs. The aim of this study was to determine the prevalence of phantom rectal sensations in a cohort of these patients.

METHOD

Patients who underwent APER and VRAM flap reconstruction for anorectal carcinomas were identified from May 2008 to July 2012. Patients completed a questionnaire evaluating their experience of rectal symptoms post-surgery.

RESULTS

Thirty-four of 47 eligible patients were enrolled in the study. PR sensations were experienced by 50 % of patients, the majority of which (65 %) were present for >1 year. The commonest sensation reported was the feeling of faeces in a normal rectum (24 %). Disturbances in quality of life were apparent in 44 %; notably, sleep was affected, patients expressed increased feelings of stress/sadness, heightened levels of anxiety and limitation of daily activities as consequences of PR symptoms. Few patients sought medical advice.

CONCLUSION

Fifty percent of patients experience PR sensations post-surgery, comparable with reported data for patients who have undergone APER alone. The addition of VRAM reconstruction does not significantly alter the prevalence of PR symptoms. This paper provides further evidence that phantom rectum occurs frequently and thus all patients undergoing excision of the rectum should be counselled appropriately.

A systematic review on the treatment of phantom limb pain with spinal cord stimulation

Phantom limb pain (PLP) is a challenging chronic pain syndrome to treat with pharmacologic agents being first line of management. However, when these agents fail to provide pain relief, other interventions must be considered in a clinical setting. Spinal cord stimulation (SCS) has been shown to provide analgesia in PLP, and should be considered by clinicians.

METHODS

This PRISMA systematic review analyzes the efficacy of SCS for treatment of PLP.

RESULTS

After review of 12 studies, there are mixed results to base a conclusion on.

DISCUSSION

While there is some evidence of efficacy, due to the relatively small number of patients in each study, further research is needed to demonstrate the benefits of SCS for PLP.

Cross-sectional study of alteration of phantom limb pain with visceral stimulation in military personnel with amputation

While phantom limb pain is a well-recognized phenomenon, clinical experience has suggested that the augmentation of phantom limb pain with visceral stimulation is an issue for many military personnel with amputation (visceral stimulation being the sensation of the bowel or bladder either filling or evacuating). However, the prevalence of this phenomenon is not known. The aim of this study was to investigate the prevalence of the alteration in phantom limb pain and the effect that visceral stimulation has on phantom limb pain intensity. A cross-sectional study of 75 military personnel who have lost one or both lower limbs completed a questionnaire to assess the prevalence of the alteration of phantom limb pain with visceral stimulation. Included in the questionnaire was a pain visual analog scale (VAS) graded from 0 to 10. Patients recorded the presence and intensity of phantom limb pain. They also recorded whether and how this pain altered with a need to micturate or micturition, and/or a need to defecate or defecation, again using a pain VAS. Time since amputation, level of amputation, and medications were also recorded. Patients reported a phantom limb pain prevalence of 85% with a mean VAS of 3.6. In all, 56% of patients reported a change in the severity of phantom limb pain with visceral stimuli. The mean increase in VAS for visceral stimulation was 2.5 +/- 1.6 for bladder stimulation and 2.9 +/- 2.0 for bowel stimulation. Of the patients questioned, 65% reported an improvement in symptoms over time. VAS scores were highest in the subgroup less than 6 mo postamputation. An increase in phantom limb pain with visceral stimulation is a common problem for military personnel with amputation.

Experimental tonic hand pain modulates the corticospinal plasticity induced by a subsequent hand deafferentation

Sensorimotor reorganization is believed to play an important role in the development and maintenance of phantom limb pain, but pain itself might modulate sensorimotor plasticity induced by deafferentation. Clinical and basic research support this idea, as pain prior to amputation increases the risk of developing post-amputation pain. The aim of this study was to examine the influence of experimental tonic cutaneous hand pain on the plasticity induced by temporary ischemic hand deafferentation. Sixteen healthy subjects participated in two experimental sessions (Pain, No Pain) in which transcranial magnetic stimulation was used to assess corticospinal excitability in two forearm muscles (flexor carpi radialis and flexor digitorum superficialis) before (T0, T10, T20, and T40) and after (T60 and T75) inflation of a cuff around the wrist. The cuff was inflated at T45 in both sessions and in the Pain session capsaicin cream was applied on the dorsum of the hand at T5. Corticospinal excitability was significantly greater during the Post-inflation phase (p=0.002) and increased similarly in both muscles (p=0.861). Importantly, the excitability increase in the Post-inflation phase was greater for the Pain than the No-Pain condition (p=0.006). Post-hoc analyses revealed a significant difference between the two conditions during the Post-inflation phase (p=0.030) but no difference during the Pre-inflation phase (p=0.601). In other words, the corticospinal facilitation was greater when pain was present prior to cuff inflation. These results indicate that pain can modulate the plasticity induced by another event, and could partially explain the sensorimotor reorganization often reported in chronic pain populations.

Spinal Cauda Equina Stimulation for Alternative Location of Spinal Cord Stimulation in Intractable Phantom Limb Pain Syndrome: A Case Report

Phantom limb pain is a phenomenon in which patients experience pain in a part of the body that no longer exists. In several treatment modalities, spinal cord stimulation (SCS) has been introduced for the management of intractable post-amputation pain. A 46-year-old male patient complained of severe ankle and foot pain, following above-the-knee amputation surgery on the right side amputation surgery three years earlier. Despite undergoing treatment with multiple modalities for pain management involving numerous oral and intravenous medications, nerve blocks, and pulsed radiofrequency (RF) treatment, the effect duration was temporary and the decreases in the patient's pain score were not acceptable. Even the use of SCS did not provide completely satisfactory pain management. However, the trial lead positioning in the cauda equina was able to stimulate the site of the severe pain, and the patient's pain score was dramatically decreased. We report a case of successful pain management with spinal cauda equina stimulation following the failure of SCS in the treatment of intractable phantom limb pain.

Successful Graded Mirror Therapy in a Patient with Chronic Deafferentation Pain in Whom Traditional Mirror Therapy was Ineffective: A Case Report

A 43-year-old man had deafferentation pain in his right upper extremity secondary to brachial plexus avulsion from a traffic accident 23 years previously. On our initial examination, he had severe tingling pain with numbness in the right fingers rated 10 on the numerical rating scale. The body perception of the affected third and fourth fingers was distorted in the flexed position. Although he performed traditional mirror therapy (TMT) for 4 weeks in the same methods as seen in previous studies, he could not obtain willed motor imagery and pain-alleviation effect. Therefore, we modified the task of TMT: Graded mirror therapy (GMT). GMT consisted of five stages: (1) observation of the mirror reflection of the unaffected side without imagining any movements of the affected side; (2) observation of the mirror reflection of the third and fourth fingers changing shape gradually adjusted from a flexed position to a extended position; (3) observation of the mirror reflection of passive movement; (4) motor imagery of affected fingers with observation of the mirror reflection (similar to TMT); (5) motor imagery of affected fingers without mirror. Each task was performed for 3 to 4 weeks. As a result, pain intensity during mirror therapy gradually decreased and finally disappeared. The body perception of the affected fingers also improved, and he could imagine the movement of the fingers with or without mirror. We suggested that GMT starting from the observation task without motor imagery may effectively decrease deafferentation pain compared to TMT.

Functional and Clinical Outcomes of Upper Extremity Amputation

Upper extremity amputation is an uncommon but often necessary procedure. It can be required as a result of trauma, infection, or malignancy. Amputation is a life-changing procedure. Careful planning for it must not only include the level of amputation and assurance of durable soft-tissue coverage of the amputation site, but it must also consider patients' goals and occupations, as well as social factors affecting amputees. The choice of prosthesis is an individual matter, but new technology permits lighter and more multifunctional prostheses. Targeted muscle reinnervation can be used to achieve improved myoelectric signaling and possibly decrease limb pain following amputation. Rehabilitation is crucial to achieving favorable results.

Network-level reorganisation of functional connectivity following arm amputation

One of the most striking demonstrations of plasticity in the adult human brain follows peripheral injury, such as amputation. In the primary sensorimotor cortex, arm amputation results in massive local remapping of the missing hands' cortical territory. However, little is known about the consequences of sensorimotor deprivation on global brain organisation. Here, we used resting-state fMRI to identify large-scale reorganisation beyond the primary sensorimotor cortex in arm amputees, compared with two-handed controls. Specifically, we characterised changes in functional connectivity between the cortical territory of the missing hand in the primary sensorimotor cortex ('missing hand cortex') and two networks of interest: the sensorimotor network, which is typically strongly associated with the hand cortex, and the default mode network (DMN), which is normally dissociated from it. Functional connectivity values between the missing hand cortex and the sensorimotor network were reduced in amputees, and connectivity was weaker in individuals amputated for longer periods. Lower levels of functional coupling between the missing hand cortex and the sensorimotor network were also associated with emerged coupling of this cortex with the DMN. Our results demonstrate that plasticity following arm amputation is not restricted to local remapping occurring within the sensorimotor homunculus of the missing hand but rather produces a cascade of cortical reorganisation at a network-level scale. These findings may provide a new framework for understanding how local deprivation following amputation could elicit complex perceptual experiences of phantom sensations, such as phantom pain.

Etiology of phantom limb syndrome: Insights from a 3D default space consciousness model

In this article, we examine phantom limb syndrome to gain insights into how the brain functions as the mind and how consciousness arises. We further explore our previously proposed consciousness model in which consciousness and body schema arise when information from throughout the body is processed by corticothalamic feedback loops and integrated by the thalamus. The parietal lobe spatially maps visual and non-visual information and the thalamus integrates and recreates this processed sensory information within a three-dimensional space termed the "3D default space." We propose that phantom limb syndrome and phantom limb pain arise when the afferent signaling from the amputated limb is lost but the neural circuits remain intact. In addition, integration of conflicting sensory information within the default 3D space and the loss of inhibitory afferent feedback to efferent motor activity from the amputated limb may underlie phantom limb pain.

An alternative to traditional mirror therapy: illusory touch can reduce phantom pain when illusory movement does not

OBJECTIVES

There is evidence that amputation leads to cortical reorganization, and it has been suggested that phantom pain might be related to a consequently emerging incongruence of motor intention, somatosensation and visual feedback. One therapeutic approach that has the potential to temporarily resolve this visuo-proprioceptive dissociation is mirror therapy, during which amputees typically move their intact limb while observing its reflection in a mirror, which in turn evokes the illusory perception of movement of their phantom limb. However, while the action of moving the phantom relieves pain for some patients, it can actually increase cramping sensations in others. In the current study we therefore implemented an alternative version of the mirror therapy involving a visuotactile illusion, to explore whether it might be effective with amputees for whom the action of moving the phantom increases phantom pain.

METHODS

We recruited six upper limb amputees who had been previously exposed to the classical mirror therapy with no or limited success, and exposed them to two differential experimental conditions involving visualization paired with either illusory movement or illusory touch of the phantom hand.

RESULTS

While none of the participants benefitted from the movement condition, five participants showed a significant pain reduction during the stroking condition.

DISCUSSION

Albeit preliminary, our results represent an encouraging finding of possible future clinical relevance, and indicate that the type of multisensory stimulation that most efficiently reduces phantom pain can vary in different sub-populations of amputees.

Introduction to neuropathic pain syndromes

Chronic pain impairs the quality of life for millions of individuals and therefore presents a serious ongoing challenge to clinicians and researchers. Debilitating chronic pain syndromes cost the US economy more than $600 billion per year. This article provides an overview of the epidemiology, clinical presentation, and treatment outcomes for craniofacial, spinal, and peripheral neurologic pain syndromes. Although the authors recognize that the diagnosis and treatment of the chronic forms of neuropathic pain syndromes represent a clinical challenge, there is an urgent need for standardized classification systems, improved epidemiologic data, and reliable treatment outcomes data.

Phantom limb pain: a systematic neuroanatomical-based review of pharmacologic treatment

OBJECTIVE

Review the current evidence-based pharmacotherapy for phantom limb pain (PLP) in the context of the current understanding of the pathophysiology of this condition.

DESIGN

We conducted a systematic review of original research papers specifically investigating the pharmacologic treatment of PLP. Literature was sourced from PubMed, Embase, Scopus, and the Cochrane Central Register of Controlled Trials (CENTRAL). Studies with animals, "neuropathic" but not "phantom limb" pain, or without pain scores and/or functional measures as primary outcomes were excluded. A level of evidence 1-4 was ascribed to individual treatments. These levels included meta-analysis or systematic reviews (level 1), one or more well-powered randomized, controlled trials (level 2), retrospective studies, open-label trials, pilot studies (level 3), and anecdotes, case reports, or clinical experience (level 4).

RESULTS

We found level 2 evidence for gabapentin, both oral (PO) and intravenous (IV) morphine, tramadol, intramuscular (IM) botulinum toxin, IV and epidural Ketamine, level 3 evidence for amitriptyline, dextromethorphan, topiramate, IV calcitonin, PO memantine, continuous perineural catheter analgesia with ropivacaine, and level 4 evidence for methadone, intrathecal (IT) buprenorphine, IT and epidural fentanyl, duloxetine, fluoxetine, mirtazapine, clonazepam, milnacipran, capsaicin, and pregabalin.

CONCLUSIONS

Currently, the best evidence (level 2) exists for the use of IV ketamine and IV morphine for the short-term perioperative treatment of PLP and PO morphine for an intermediate to long-term treatment effect (8 weeks to 1 year). Level 2 evidence is mixed for the efficacy of perioperative epidural anesthesia with morphine and bupivacaine for short to long-term pain relief (perioperatively up to 1 year) as well as for the use of gabapentin for pain relief of intermediate duration (6 weeks).

Sensorimotor incongruence and body perception: an experimental investigation

Objectives: Several studies have shown that mirrored arm or leg movements can induce altered body sensations. This includes the alleviation of chronic pain using congruent mirror feedback and the induction of abnormal sensation in healthy participants using incongruent mirror feedback. Prior research has identified neuronal and conceptual mechanisms of these phenomena. With the rising application of behavior-based methods for pain relief, a structured investigation of these reported effects seems necessary.

Methods: We investigated a mirror setup that included congruent and incongruent hand and arm movements in 113 healthy participants and assessed the occurrence and intensity of unusual physical experiences such as pain, the sensation of missing or additional limbs, or changes in weight or temperature. A wooden surface instead of a mirror condition served as control.

Results: As reported earlier, mirrored movements led to a variety of subjective reactions in both the congruent and incongruent movement condition, with the sensation of possessing a third limb being significantly more intense and frequent in the incongruent mirror condition. Reports of illusory pain were not more frequent during mirrored than during non-mirrored movements.

Conclusion: These results suggest that, while all mirrored hand movements induce abnormal body perceptions, the experience of an extra limb is most pronounced in the incongruent mirror movement condition. The frequent sensation of having a third arm may be related to brain processes designed to integrate input from several senses in a meaningful manner. Painful sensations are not more frequent or intense when a mirror is present.

Aluminium foil for the prevention of post-amputation pain: a randomised, double-blinded, placebo-controlled, crossover trial

INTRODUCTION

Phantom limb pain (PLP) is a painful sensation perceived in the missing limb after amputation. The underlying pathophysiology remains unclear. Until recently, only opioid analgesics have been proven to be effective in prospective studies. Anecdotally, patients with PLP employ self-help measures, sometimes including 'wrapping up' or rubbing their stump with aluminium foil for relief. Our hypothesis is that wrapping an amputation stump with aluminium foil perioperatively will prevent PLP in the postoperative period.

METHODS

From September 2007 to September 2009, 32 consecutive patients were included in a crossover, double-blinded, randomised clinical trial. Perioperative fitting of an aluminium stump bandage was compared with a placebo paper foil. Scores were noted daily in a variable diary. The observation period was 2 weeks: in the first week participants were double blinded, and in the second week there was a change of bandage from aluminium to placebo or vice versa. A visual analogue scale (VAS) score was used as primary research variable. Secondary variables were use of analgesics, VAS measures of wound pain and the incidence of wound infections. Statistical analysis was done by means of Student's t-test for non-paired observations.

RESULTS

Baseline characteristics were similar between groups. A period effect (p= 0.84) and treatment-period interaction (p = 0.79) were not present. There was no significant difference (mean difference 0.42) between both treatments in PLP VAS scores (95% CI -2.56 to -1.81, p = 0.71). VAS measure of wound pain showed no significant difference between both groups (mean difference 0.34, 95% CI -2.32 to -1.66, p = 0.72). Also, the other secondary endpoints did not differ.

CONCLUSION

Patients receiving an aluminium foil stump wrapping do not experience less phantom pain than with a placebo.