Pain Support for Adults with a Diabetes-Related Lower Limb Amputation: an Empirical Phenomenology Study

The experiences and needs of people with dysvascular lower extremity amputations: a qualitative systematic review and meta-synthesis

PURPOSE

The aim of this review is to synthesise the experiences and needs of people who had undergone dysvascular lower extremity amputations. Given the increasing global prevalence of vascular diseases like diabetes mellitus and peripheral arterial disease, the risk of requiring an amputation remains high.

MATERIALS AND METHODS

This systematic review follows the PRISMA and ENTREQ reporting guidelines. Seven databases were searched for qualitative studies from January 2011 to October 2023. In total 6435 studies were obtained, where 1146 were duplicates and 5271 studies failed to meet the eligibility criteria. The remaining 18 studies were synthesised using Sandelowski and Barroso's approach and appraised using the CASP checklist.

RESULTS

Four themes emerged from the meta-synthesis: (1) making the decision to amputate, (2) difficulties in the physical adaptation to limb loss, (3) psychosocial consequences of living with an amputation, and (4) regaining control and building hope.

CONCLUSIONS

Having dysvascular lower extremity amputations is a complicated experience as not only was the pre-amputation pain relieved, but a new set of physical, emotional and social challenges would surface after the amputation. These synthesised findings serve as a platform to explore the factors behind the various experiences faced by these people and how healthcare professionals can help them in their adjustment.

Development of the ECLIPSE model of meaningful outcome domains following lower limb amputation and prosthetic rehabilitation, through systematic review and best fit framework synthesis

BACKGROUND

Little is known about which outcome domains characterise meaningful recovery following prosthetic rehabilitation and should be measured. Our previous qualitative work developed a conceptual model of outcome domains which are meaningful to patients. This qualitative synthesis aims to develop that model by exploring views and experiences of recovery captured in the limb loss literature, and use these to produce a second iteration of the model describing outcome domains of importance following prosthetic rehabilitation from the patient's perspective.

METHODS

Systematic searches were conducted using CINAHL, Psychinfo and Web of Science from 2011 to early 2023. Studies with a qualitative design focusing on views and experiences of lower limb prosthetic users were eligible for inclusion. Quality was assessed using the CASP tool. 'Best Fit' framework synthesis was used to synthesise the evidence and develop the conceptual model.

RESULTS

40 studies were included, describing the experiences of 539 participants. Data supported the pre-existing conceptual model and led to development of four of the five domains. The newly named ECLIPSE model describes meaningful outcome domains as 1) Being able to participate in important activities and roles, 2) Participating in the way I want to, 3) My prosthesis works for me, 4) If I am in pain, I can manage it, and 5) I am able to accept my new normal. Studies came from 15 countries showing good coverage of high-income settings. Few participants from low-and-middle-income countries were included, it is unclear if the ECLIPSE model describes outcome domains of importance in these settings.

CONCLUSIONS

This synthesis provides a rigorous foundation for understanding outcome domains of importance following lower limb prosthetic rehabilitation from the patient's perspective. The ECLIPSE model is an accessible representation of recovery which could direct rehabilitation programmes, as well as inform the evaluation of prosthetic care through the selection of outcome measures.

Thoughts and experiences regarding leg amputation among patients with diabetic foot ulcers: A phenomenological study

Despite lower-limb amputation being common among patients with diabetic foot ulcers, few studies have qualitatively investigated the patients' perspectives. Therefore, this study aimed to explore the thoughts and experiences of patients with diabetic foot ulcers regarding lower-limb amputation in Hong Kong. A phenomenological study using individual, semi-structured interviews was conducted with 18 participants with foot ulcers recruited in Hong Kong between July and September 2022. The interviews were audio-recorded, transcribed verbatim, and analysed using an interpretative phenomenological approach and a constant comparison strategy. The results highlighted four substantial themes: (a) coping or being alone and taciturn, (b) altered appearance impacting one's sense of maintaining social relations, (c) thoughts about self-efficacy and encountering a new normal, and (d) the possibility of a reduced gap in physical consequences between the old and new self. This study provided different perspectives of patients with a history of diabetic foot ulcers, even in cases where lower-limb amputation has not yet been performed. The results demonstrate that lower-limb amputation is considered a forbidden topic. This makes it culturally difficult for Chinese patients to discuss the matter with healthcare authorities and family members. Healthcare workers should be aware of how they communicate regarding lower-limb amputation.

A novel mixed reality system to manage phantom pain in-home: results of a pilot clinical trial

Introduction

Mirror therapy for phantom limb pain (PLP) is a well-accepted treatment method that allows participants to use a mirror to visually perceive the missing limb. Mixed reality options are now becoming increasingly available, but an in-home virtual mirror therapy option has yet to be adequately investigated.

Methods

We had previously developed a mixed reality system for Managing Phantom Pain (Mr. MAPP) that registers the intact limb and mirrors it onto the amputated limb with the system's visual field, allowing the user to engage with interactive games targeting different large lower limb movements. Feasibility and pilot outcomes of treating patients with lower extremity PLP by using Mr. MAPP at home for 1 month were evaluated in this study. Pain intensity and interference were assessed using the McGill Pain Questionnaire, Brief Pain Inventory, and a daily exercise diary. Function was assessed using the Patient Specific Functional Scale (PSFS). The clinical trial registry number for this study is NCT04529083.

Results

This pilot study showed that it was feasible for patients with PLP to use Mr. MAPP at home. Among pilot clinical outcomes, statistically significant differences were noted in mean current pain intensity [1.75 (SD = 0.46) to 1.125 (SD = 0.35) out of 5, P = .011] and PSFS goal scores [4.28 (SD = 2.27) to 6.22 (SD = 2.58) out of 10, P = .006], with other outcome measures showing non-significant trends towards improvement.

Discussion

This pilot study revealed that in-home use of Mr. MAPP has potential to provide pain relief and improve function in patients with lower extremity PLP and is feasible. Each scale used provided unique perspective on the functional impact of PLP. Further expanded studies and investigation, including a fully powered clinical trial, with these scales are warranted.

Clinical Trial Registration

https://www.clinicaltrials.gov/ct2/show/NCT04529083, Identifier: NCT04529083.

Veteran Perspectives on Phantom Limb Pain and Non-Drug Interventions

Background

Phantom limb pain (PLP) commonly occurs post-amputation and can negatively affect the daily functioning of persons with amputation. Best practices for medication and non-drug management remain unclear.

Objective

To better understand the PLP experience and patients' familiarity with treatments, phone interviews were conducted at the Minneapolis Veterans Affairs Regional Amputation Center in Veterans with amputations.

Methods

Fifty Veteran participants (average age 66, 96% male) with lower limb amputation were recruited for phone-based data collection of patient-reported outcomes (ie, demographics using the Trinity Amputation and Prosthesis Experience Scales-Revised (TAPES-R) and pain experience using the Phantom Phenomena Questionnaire) to characterize the population and a semi-structured interview. Notes taken during interviews were analyzed using the Krueger and Casey constant comparison analysis method.

Results

Participants had an average of 15 years since amputation, and 80% reported PLP as identified with the Phantom Phenomena Questionnaire. Investigators identified several core themes from the qualitative interviews including 1) high variability in the experience of PLP, 2) acceptance and resilience, and 3) PLP treatment perceptions. The majority of participants reported trying common non-drug treatments with none endorsed consistently as highly effective.

Conclusion

More research is needed to inform identification and implementation of clinical best practices for non-drug interventions for PLP and understand the factors that influence engagement in non-drug interventions. The participants in this study were largely male, so these results may not be generalizable to females.

The Development and Pilot Study of a Multiple Criteria Decision Analysis (MCDA) to Compare Patient and Provider Priorities around Amputation-Level Outcomes

Background. Patients with chronic limb-threatening ischemia who are facing a lower-limb amputation often require a transmetatarsal amputation (TMA) or a transtibial amputation (TTA). A TMA preserves more of the patient's limb and may provide better mobility but has a lower probability of primary wound healing relative to a TTA and may result in additional amputation surgeries. Understanding the differences in how patients and providers prioritize key outcomes may enhance the amputation decisional process. Purpose. To develop and pilot test a multiple criteria decision analysis (MCDA) tool to elicit patient values around amputation-level selection and compare those with provider perceptions of patient values. Methods. We conducted literature reviews to identify and measure the performance of criteria important to patients. Because the quantitative literature was sparse, we developed a Sheffield elicitation framework exercise to elicit criteria performance from subject matter experts. We piloted our MCDA among patients and providers to understand tool acceptability and preliminarily assess differences in patient and provider priorities. Results. Five criteria of importance were identified: ability to walk, healing after amputation surgery, rehabilitation intensity, limb length, and prosthetic/orthotic device ease. Patients and providers successfully completed the MCDA and identified challenges in doing so. We propose potential solutions to these challenges. The results of the pilot test suggest differences in patient and provider outcome priorities. Limitations. The pilot test study enrolled a small sample of providers and patients. Conclusions. We successfully implemented the pilot study to patients and providers, received helpful feedback, and identified solutions to improve the tool. Implications. Once modified, our MCDA tool will be suitable for wider rollout.

Highlights

Patients and providers have successfully completed our MCDA, and patients feel the MCDA may be useful in clinical practice.We encountered several methodologic challenges and identified approaches to ease participant burden.When data are sparse, using the Sheffield elicitation framework is helpful in creating a performance matrix, although patients relied largely on their amputation experiences to complete the exercise. Blinding the alternatives may help patients better understand the process.

Evaluation of the quality of life in individuals with amputations in relation to the etiology of their amputation. A case-control study

Objectives: Several studies indicate that limb amputations have a negative influence in the quality of life of those individuals who underwent amputation surgery. The aims of this study were to evaluate the quality of life in Mexican individuals with limb amputations compared with a control group, to identify demographic and clinical differences related to the etiology of the amputation, and to determine if they are associated with the quality of life observed in these patients. Methods: All participants were recruited from the Hospital "Dr Gustavo A. Rovirosa Pérez". The quality of life of all participants was evaluated using SF-36. Results: Individuals with amputations of vascular or trauma etiology, showed a diminished health-related quality of life when compared with the control group (p < .001). We observed that individuals with amputations due to trauma were younger, mostly single, with more upper limb amputations and with a shorter period since amputation at the current assessment in comparison to individuals with amputations. Conclusions: Although limb amputation represents a surgical procedure necessary to preserve the life of a person, our results support that it negatively impacts the health-related quality of life of these individuals. Regardless of the etiology of the amputation, rehabilitation programs are primarily focused on reintegrating individuals to their everyday life. However, these programs may have poor results when patients have a poor quality of life. Therefore, quality of life assessment and early inclusion in programs that aim to improve the quality of life of individuals with amputations should be always taken into consideration.

Recent advances in understanding and managing phantom limb pain

Post-amputation phantom limb pain (PLP) is highly prevalent and very difficult to treat. The high-prevalence, high-pain intensity levels, and decreased quality of life associated with PLP compel us to explore novel avenues to prevent, manage, and reverse this chronic pain condition. This narrative review focuses on recent advances in the treatment of PLP and reviews evidence of mechanism-based treatments from randomized controlled trials published over the past 5 years. We review recent evidence for the efficacy of targeted muscle reinnervation, repetitive transcranial magnetic stimulation, imaginal phantom limb exercises, mirror therapy, virtual and augmented reality, and eye movement desensitization and reprocessing therapy. The results indicate that not one of the above treatments is consistently better than a control condition. The challenge remains that there is little level 1 evidence of efficacy for PLP treatments and most treatment trials are underpowered (small sample sizes). The lack of efficacy likely speaks to the multiple mechanisms that contribute to PLP both between and within individuals who have sustained an amputation. Research approaches are called for to classify patients according to shared factors and evaluate treatment efficacy within classes. Subgroup analyses examining sex effects are recommended given the clear differences between males and females in pain mechanisms and outcomes. Use of novel data analytical approaches such as growth mixture modeling for multivariate latent classes may help to identify sub-clusters of patients with common outcome trajectories over time.