Limb Pain Patients Research Articles

An Evaluation of Phantom Pain among Traumatic Lower Limb Amputees in Lahore

Background: Amputation is the surgical removal of all or part of an irreparably damaged limb due to injury or disease. Trauma is the leading cause of lower limb amputation in Pakistan. Phantom limb pain (PLP) is a common and distressing complication following amputation, affecting the quality of life and functional outcomes. Objective: The primary objective of this study was to assess the occurrence and intensity of phantom limb pain in patients who had undergone lower limb amputation due to traumatic causes in Pakistan. Methods: A descriptive cross-sectional study was conducted over six months, involving 73 patients who had undergone lower limb amputation due to trauma. The study was carried out in Ghurki Trust Teaching Hospital, Sheikh Zayed Hospital, and Mayo Hospital. Patients aged 20-45 years, with amputations performed within one year, were included. Exclusion criteria were non-traumatic amputations and amputations older than one year. Non-probability convenience sampling was used. Participants were divided into three groups based on the level of amputation: hip disarticulation (n=12), transfemoral (n=28), and transtibial (n=33). Phantom limb pain was assessed using the Numeric Pain Rating Scale (NRPS), an 11-item scale ranging from 0 (no pain) to 10 (severe pain). Data were analyzed using SPSS version 25, and descriptive statistics were presented in tables and graphs. Ethical approval was obtained from the Ethics Committee of Lahore College of Physical Therapy (ERC-LCPT/298/2019). Written informed consent was obtained from all participants. Results: The study found that 83.6% of the participants experienced phantom limb pain. Among the hip disarticulation group, 91.7% reported PLP, with a mean NRPS score of 7.3. In the transfemoral group, 89.3% experienced PLP, with a mean NRPS score of 6.8. In the transtibial group, 75.8% reported PLP, with a mean NRPS score of 5.4. The association between the level of amputation and the presence of PLP was significant, with p-values of 0.003 for hip disarticulation, 0.000 for transfemoral, and 0.001 for transtibial amputations. Conclusion: Phantom limb pain is a prevalent and significant issue among patients with traumatic lower limb amputations in Pakistan, with varying intensity across different levels of amputation. These findings underscore the need for targeted pain management strategies and comprehensive rehabilitation programs to address PLP and improve the quality of life for amputees.

Charcot Neuroarthropathy Is Associated With Higher Rates of Phantom Limb After Lower Extremity Amputation.

The incidence of phantom limb pain in patients with Charcot neuroarthropathy who undergo major amputation is not well described. The purpose of this study was to determine whether patients with Charcot neuroarthropathy and diabetes who underwent either a below-knee amputation (BKA) or above-knee amputation (AKA) had an increased rate of phantom limb pain compared with those with a diagnosis of diabetes alone. Using international classification of disease (ICD) and common procedural terminology (CPT) codes, the TriNetX research database identified 10 239 patients who underwent BKA and 6122 who underwent AKA between 2012 and 2022. Diabetic patients with and without Charcot neuroarthropathy were compared in terms of demographics and relative risk of developing phantom limb pain after AKA or BKA. Age, sex, ethnicity, and race did not significantly differ between groups. Charcot neuroarthropathy was associated with significantly increased risk of phantom limb pain following both BKA (risk ratio [RR]: 1.2, 95% confidence interval [CI]: 1.1-1.3, P < .01) and AKA (RR: 1.6, 95% CI: 1.2-2.3, P < .0068). Our results indicate that patients with a coexisting diagnosis of Charcot neuroarthropathy who require BKA or AKA may have an increased risk of developing phantom limb pain. Level III.

Risk Factors Analysis of Phantom Limb Pain in Amputees with Malignant Tumors.

Postamputation neuropathic pain is a common disease in patients with malignant tumor amputation, seriously affecting amputees' quality of life and mental health. The objective of this study was to identify independent risk factors for phantom limb pain in patients with tumor amputation and to construct a risk prediction model. Patients who underwent amputation due to malignant tumors from 2013 to 2023 were retrospectively analyzed and divided into phantom limb pain group and non-phantom limb pain group. To determine which preoperative factors would affect the occurrence of phantom limb pain, we searched for candidate factors by univariate analysis and used multivariate logistic regression analysis to identify independent factors and construct a predictive model. The receiver operating characteristic curve (ROC) was drawn to further evaluate the accuracy of the prediction model in evaluating the phantom limb pain after amputation of bone and soft tissue tumors. Multivariate analysis showed that age (OR, 1.054; 95% CI, 1.027 to 1.080), preoperative pain (OR, 5.773; 95% CI, 2.362 to 14.104), number of surgeries (OR, 3.425; 95% CI, 1.505 to 7.795), amputation site (OR, 5.848; 95% CI, 1.837 to 18.620), amputation level (OR, 8.031; 95% CI, 2.491 to 25.888) were independent risk factors for phantom limb pain for bone and soft tissue tumors. The the area under the curve (AUC) of this model was 0.834. Risk factors for postoperative phantom limb pain were the site of amputation, proximal amputation, preoperative pain, multiple amputations, and older age. These factors will help surgeons to individualize and stratify phantom limb pain and help patients with risk counseling. In particular, an informed clinical decision targeting those modifiable factors can be considered when needed.

Is mirror therapy associated with progressive muscle relaxation more effective than mirror therapy alone in reducing phantom limb pain in patients with lower limb amputation?: Erratum.

Is mirror therapy associated with progressive muscle relaxation more effective than mirror therapy alone in reducing phantom limb pain in patients with lower limb amputation?: Erratum.

Targeted Muscle Reinnervation for Limb Amputation to Avoid Neuroma and Phantom Limb Pain in Patients Treated at a Pediatric Hospital.

Patients undergoing major limb amputation with TMR were included with minimum one year follow-up and completed questionnaires. Primary clinical outcomes included incidence of symptomatic neuromas, PLP, residual limb pain, narcotic use, and neuromodulator use. A follow-up phone survey was conducted assessing five pediatric Patient Reported Outcomes Measurement Information System (PROMIS) metrics adapted to assess residual limb and PLP. Nine patients (seven male and two female patients, avg. age = 16.83 ± 7.16 years) were eligible. Average time between surgery and phone follow-up was 21.3 ± 9.8 months. Average PROMIS Pediatric t-scores for measures of pain behavior, interference, quality-affective, and quality-sensory for both PLP and residual limb pain were nearly 1 standard deviation lower than the United States general pediatric population. One patient developed a symptomatic neuroma 1 year after surgery. Compared with an adult patient sample reported by Valerio et al, our TMR patients at Nationwide Children's Hospital (NCH) showed similar PLP PROMIS t-scores in pain behavior (50.1 versus 43.9) and pain interference (40.7 versus 45.6). Both pediatric and adult populations had similar residual limb pain including PROMIS pain behavior (36.7 adult versus 38.6 pediatric) and pain interference (40.7 adult versus 42.7 pediatric). TMR at the time of amputation is feasible, safe, and should be considered in the pediatric population.

Assessment of efficiency of mirror therapy in preventing phantom limb pain in patients undergoing below-knee amputation surgery-a randomized clinical trial.

Phantom limb pain (PLP) is a major cause of physical limitation and disability accounting for about 85% of amputated patients. Mirror therapy is used as a therapeutic modality for patients with phantom limb pain. Primary objective was to study the incidence of PLP at 6months following below-knee amputation between the mirror therapy group and control group. Patients posted for below-knee amputation surgery were randomized into two groups. Patients allocated to group M received mirror therapy in post-operative period. Two sessions of therapy were given per day for 7days and each session lasted for 20min. Patients who developed pain from the missing portion of the amputated limb were considered to have PLP. All patients were followed up for six months and the time of occurrence of PLP and intensity of the pain were recorded among other demographic factors. A total of 120 patients completed the study after recruitment. The demographic parameters were comparable between the two groups. Overall incidence of phantom limb pain was significantly higher in the control group (Group C) when compared to the mirror therapy (Group M) group [Group M = 7 (11.7%) vs Group C = 17 (28.3%); p = 0.022]. Intensity of PLP measured on the Numerical Rating Scale (NRS) was significantly lower at 3months in Group M compared to Group C among patients who developed PLP [NRS-median (Inter quartile range): Group M 5 (4,5) vs Group C 6 (5,6); p 0.001]. Mirror therapy reduced the incidence of phantom limb pain when administered pre-emptively in patients undergoing amputation surgeries. The severity of the pain was also found to be lower at 3months in patients who received pre-emptive mirror therapy. This prospective study was registered in the clinical trial registry of India. CTRI/2020/07/026488.

Efficacy of combined application of traditional Chinese medicine foot bath and mild moxibustion in the treatment o f limb pain in diabetic peripheral neuropathy patients

Purpose: To determine the efficacy of the combination of traditional Chinese medicine (TCM) foot bath and mild moxibustion in the treatment of limb pain in patients with diabetic peripheral neuropathy (DPN).&#x0D; Methods: A total of 120 patients with symptoms of DPN-induced pain who were hospitalized at the Department of Endocrinology in the 903rd Hospital of PLA, from January 2020 to June 2021, were included in this study. They were randomly assigned to a study group and a control group, with 60 patients in each group. Patients in both groups received conventional treatments and nursing care, while those in study group were additionally treated with a combination of TCM foot bath and mild moxibustion. Treatment efficacy in the patients was evaluated using Short-Form McGill Pain Questionnaire (SF-MPQ), pain rating index (PRI), visual analogue scale (VAS), TCM symptom score (TCMSS), and Toronto Clinical Scoring System (TCSS).&#x0D; Results: Compared with control group, there were significant improvements in pain-related scores, namely, SF-MPQ, (p ˂ 0.05); PRI, (p &lt; 0.01); VAS, (p &lt; 0.05); as well as overall efficacy (p &lt; 0.05). Similar improvements were also observed with regard to TCMSS (p &lt; 0.001) and TCSS (p &lt; 0.001) in the study group. However, there were no significant changes in Adjusted Diabetes Quality of Life (A-DQOL) score and blood glucose control in both groups.&#x0D; Conclusion: Relative to the conventional treatment for DPN, limb pain and disease score of patients are significantly reduced by the combination of TCM foot bath and mild moxibustion treatments. Further clinical trials would be required prior to application in clinical practice.

Incidence and Nerve Distribution of Symptomatic Neuromas and Phantom Limb Pain after Below-Knee Amputation.

Patients with major lower limb amputations suffer from symptomatic neuromas and phantom-limb pain due to their transected nerves. Peripheral nerve surgery techniques, such as targeted muscle reinnervation and regenerative peripheral nerve interface, aim to physiologically prevent this nerve-specific pain. No studies have specifically reported on which nerves most frequently cause chronic pain. The authors studied the nerve-specific incidence of symptomatic neuroma formation and phantom limb pain in patients undergoing a below-knee amputation, to better tailor use of targeted muscle reinnervation and regenerative peripheral nerve interface. This was a retrospective review of all patients undergoing a below-knee amputation from January 1, 2013, to December 31, 2018, at MedStar Georgetown University Hospital. All below-knee amputations were performed with a posterior skin flap, myotenodesis, and traction neurectomies of all nerves. Postoperative notes were reviewed for the presence of a symptomatic neuroma, defined as localized pain and a Tinel sign over a known sensory nerve, and nerve-specific phantom limb pain, defined as pain of the missing limb corresponding to a known dermatome. One hundred ninety-eight patients were included in this study. The rate of symptomatic neuroma formation was 14.6 percent (29 of 198), with the superficial peroneal and saphenous nerves most often involved. Diabetes and obesity were protective against symptomatic neuroma formation. The rate of nerve-specific phantom limb pain was 12.6 percent (25 of 198) and highly correlated with the presence of a symptomatic neuroma. To optimize outcomes for amputees, it is critical that surgeons best understand what nerves are more likely to form symptomatic neuromas and lead to nerve-specific phantom limb pain, so that surgeons can best tailor primary or secondary management of the major sensory nerves. Risk, III.

Development and Validation of a Graded Motor Imagery Intervention for Phantom Limb Pain in Patients with Amputations (GraMI Protocol): A Delphi Study.

Background: Phantom limb pain can be defined as discomfort or pain in a missing part of the limb. The aims of this study were to develop and validate, through a Delphi methodology, a graded motor imagery protocol in order to reduce phantom limb pain. Method: Physiotherapists and/or occupational therapists with experience in research and a minimum clinical experience of five years in the field of neurorehabilitation and/or pain were recruited by part of a group of experts to assess the intervention. The study was conducted through an online questionnaire, where experts assessed each aspect of the intervention through a Likert scale. As many rounds as necessary were carried out until consensus was reached among experts. Results: A total of two rounds were required to fully validate the intervention. During the second round, the relative interquartile range of all aspects to be assessed was less than 15%, thus showing a consensus among experts and with good concordance (Kappa index of 0.76). Conclusion: Experts validated a graded motor imagery intervention of phantom limb pain in patients with amputations (GraMi protocol). This intervention can help to homogenize the use of graded motor imagery in future studies and in clinical practice.

Central nervous system stimulation therapies in phantom limb pain: a systematic review of clinical trials.

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.

Examination of the regression model to quantify the degree of low back pain and lower limb symptoms in patients with lumbar disc herniation by the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ).

The Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ) was created to evaluate specific treatment outcomes in terms of physical functioning, social ability, and mental health in patients with back pain-related diseases. In this study, we investigated whether the JOABPEQ could be used to construct a regression model to quantify low back pain and lower limb symptoms in patients with lumbar disc herniation (LDH). We reviewed 114 patients with LDH scheduled to undergo surgery at our hospital. We measured the degrees of 1) lower back pain, 2) lower limb pain, and 3) lower limb numbness using the visual analog scale before the surgery. All answers and physical function data were subjected to partial least squares regression analysis. The degrees of lower back and lower limb pain could be used as a regression model from the JOABPEQ and had a significant causal relationship with them. However, the degree of lower limb numbness could not be used for the same. Based on our results, the questions of the JOABPEQ can be used to multilaterally understand the degree of lower back pain and lower limb pain in patients with LDH. However, the degree of lower limb numbness has no causal relationship, so actual measurement is essential.

Below-the-Knee Amputation With Targeted Muscle Reinnervation: Operative Technique and Technical Pearls of an Interfascicular Superficial Peroneal Nerve Targeted Muscle Reinnervation

INTRODUCTION: Targeted muscle reinnervation (TMR) is a nerve transfer technique by which the severed ends of sensory nerves are transferred to expendable donor motor nerves to minimize pain. TMR has successfully been used to reduce residual limb and phantom limb pain in patients with upper and lower extremity amputations. For patients with below-the-knee amputations (BKAs), the tibial nerve and superficial peroneal nerve (SPN) are the most common sensory nerves addressed with TMR. Although the tibial nerve coaptation is well-protected by the deep posterior musculature, the SPN coaptation is commonly positioned at the weight-bearing portion of the stump without significant soft tissue padding. This study details a novel interfascicular SPN TMR technique performed through a proximal incision at the fibular head. TECHNIQUE: TMR performed primarily at time of BKA is offered to all patients preoperatively to prophylactically reduce pain. TMR is also offered secondarily to patients who develop severe neuroma or phantom limb pain after their amputation. When performed primarily, TMR is performed on the SPN and tibial nerve. When performed secondarily, TMR is performed on the involved nerves based on clinical exam. The SPN TMR is performed through an approach to the common peroneal nerve (CPN) at the fibular head. Accessing the CPN at this level allows for complete decompression of the CPN through the peroneal tunnel. An internal neurolysis is performed, and a nerve stimulator is used to map the motor fascicles to identify an expendable target. The extensor digitorum longus is preferentially selected since it is not critical to tibial padding. The SPN is then translocated from the distal wound into the peroneal tunnel incision and an antegrade nerve transfer is performed to the motor target, typically with a close size match (Video). RESULTS: This technique for primary TMR for BKAs was performed in 109 patients over a 2-year period from January 1, 2018 to December 31, 2019. The SPN was transferred to the extensor digitorum longus 78.5% of the time, peroneus brevis 9.3%, redundant branch of tibialis anterior 6.5%, and peroneus longus 5.6%. The tibial nerve was transferred to the tibialis posterior 66.7% of the time, soleus 10.0%, flexor digitorum longus 8.3%, flexor hallucis longus 8.3%, and unspecified muscle of the deep flexor compartment 6.7%. No primary DPN, sural, or saphenous TMRs were performed. There were no added surgical complications attributable to the TMR portion of the case: no surgical site infections at the fibular head incision or reoperation for seromas or hematomas. If patients developed pain in the saphenous or sural distributions a secondary TMR was performed, but this was only required in 2 patients. CONCLUSIONS: TMR has been demonstrated to greatly improve amputees’ pain and ambulation following a major lower extremity amputation. This article provides insight into the technical pearls of the unique interfascicular SPN TMR, which places the coaptation away from the weight-bearing stump and allows for a close size match. This technique has been used with excellent clinical outcomes and no procedure-specific complications in over 100 patients.

Increased white matter diffusivity associated with phantom limb pain.

BackgroundWe utilized diffusion tensor imaging (DTI) to evaluate the cerebral white matter changes that are associated with phantom limb pain in patients with unilateral arm amputation. It was anticipated that this would complement previous research in which we had shown that changes in cerebral blood volume were associated with the cerebral pain network.MethodsTen patients with phantom limb pain due to unilateral arm amputation and sixteen healthy age-matched controls were enrolled. The intensity of phantom limb pain was measured by the visual analogue scale (VAS) and depressive mood was assessed by the Hamilton depression rating scale. Diffusion tensor-derived parameters, including fractional anisotropy, mean diffusivity, axial diffusivity (AD), and radial diffusivity (RD), were computed from the DTI.ResultsCompared with controls, the cases had alterations in the cerebral white matter as a consequence of phantom limb pain, manifesting a higher AD of white matter in both hemispheres symmetrically after adjusting for individual depressive moods. In addition, there were associations between the RD of white matter and VAS scores primarily in the hemispheres related to the missing hand and in the corpus callosum.ConclusionsThe phantom limb pain after unilateral arm amputation induced plasticity in the white matter. We conclude that loss of white matter integrity, particularly in the hemisphere connected with the missing hand, is significantly correlated with phantom limb pain.

Factors affecting phantom limb pain in patients undergoing amputation: retrospective study.

The efficacy of preemptive analgesia for prevention of phantom limb pain has been controversial although pain management before amputation is empirically important. The aim of this study was to determine the associated factors with perioperative phantom limb pain. Following approval by the Medical Ethics Committee in our university, medical records of patients receiving limb amputation surgery in our hospital between April 1, 2013 and October 31, 2017 were retrospectively reviewed. To determine which pre-operative factors could affect the development of phantom limb pain, we performed univariate analysis to find candidate factors (p < 0.05), and then did multivariate regression analysis. Incidence of phantom limb pain was 50% (22/44). There was no difference between the groups in types of anesthesia and post-operative pain levels. The multivariate logistic regression including possible confounders suggested that diabetes mellitus and uncontrollable preoperative pain with non-steroidal anti-inflammatory drugs (NSAIDs) were independently associated with the development of phantom limb pain (Adjusted odds ratio (OR) 0.238 [95% confidential interval (CI) 0.0643-0.883], p = 0.032, Adjusted OR 6.360 [95% CI 1.280-31.50], p = 0.024, respectively). The types of anesthesia and the degree of postoperative pain were not related to the development of phantom limb pain. The present data suggest that insufficient preoperative pain with NSAIDs and diabetes mellitus would give an impact on the development of phantom limb pain.

Targeted Muscle Reinnervation Technique in Below-Knee Amputation.

Approximately 25 percent of major limb amputees will develop chronic localized symptomatic neuromas and phantom limb pain in the residual limb. A method to treat and possibly prevent these pain symptoms is targeted reinnervation. Previous studies prove that targeted reinnervation successfully treats and, in some cases, resolves peripheral neuropathy and phantom limb pain in patients who have undergone previous amputation (i.e., secondary targeted reinnervation). This article seeks to share the authors' clinical indications and surgical technique for targeted muscle reinnervation in below-knee amputation, a surgical description currently absent from our literature. Targeted reinnervation for the below-knee amputee has been performed on 22 patients at the authors' institution. Each patient has been followed on an outpatient basis for 1 year to evaluate symptoms of neuroma or phantom limb pain, patient satisfaction, and functionality. All subjects have denied neuroma pain following amputation. The majority of subjects reported phantom pain at 1 month. However, at 3 months, all patients reported resolution of this pain. Dumanian et al. first noted the improvement of symptomatic neuroma and phantom limb pain in patients undergoing targeted reinnervation to provide intuitive control of upper limb prostheses. These findings have been substantiated by multiple previous studies at various amputation levels. This study extends the success of targeted muscle reinnervation to below-knee amputations and provides a description for this technique.

Prevalence and correlates of psychiatric comorbidity in chronic pain patients: A hospital-based study

Background: There is a paucity of information on psychiatric comorbidity in chronic pain patients in developing countries like India. The present study was undertaken in this context. Aim: The aim of this study is to assess the psychiatric comorbidity in chronic pain patients. Materials and Methods: Fifty adult chronic pain patients without organic cause of more than 6 months duration attending outpatient departments were included in the study with their informed consent. Psychiatric comorbidity was assessed by the Schedules for Clinical Assessment in Neuropsychiatry. Results: Majority (80%) of patients was between 18 and 50 years of age, came from nuclear families (88%), and was married (82%). Majority (76%) of patients had pain <2 years; 56% had moderate pain severity and 54% had moderate functional impairment due to pain. In chronic pain patients, 78% had psychiatric comorbidity; the most common disorder was depression (36%) followed by generalized anxiety disorder (18%), somatoform disorder (16%), and panic disorder (8%) patients indicating that patients with chronic pain are more likely to have mood disorder than other psychiatric disorders. A significant association was seen between psychiatric comorbidity and pain severity but not with sociodemographic characteristics. Psychiatric comorbidity was associated with severity of pain. Head and neck and back pain patients reported high prevalence of depression (39.5% and 36%), while chest pain and limb pain patients had high prevalence of generalized anxiety disorder (45.5% and 33.3%). There was high prevalence of nonspecific symptoms such as localized tension pain (90%) and worry (82%) in chronic pain patients. Conclusion: The high prevalence of psychiatric comorbidity in patients suffering from chronic pain disorders emphasize the need to screen these patients for psychiatric disorders, particularly depression and anxiety. Diagnosis and treatment of comorbid psychiatric disorders will greatly improve the management of chronic pain patients.

Bloodletting puncture and cupping as an adjuvant therapy for breast cancer-related lymphedema in female adults: A non-randomized controlled pragmatic trial

Abstract Objective To evaluate the effectiveness of bloodletting puncture and cupping in relieving breast cancer-related lymphedema. Methods We conducted a non-randomized controlled study at the Galactophore Department of the 3rd Affiliated Hospital of Beijing University of Chinese Medicine from March 2013 to December 2014. Seventy-five patients undergoing treatment for breast cancer-related lymphedema were divided into two groups in accordance with the patients’ treatment choices: the treatment group (n = 50) underwent bloodletting puncture and cupping every 5 days for 15 min/session (one session per day) combined with exercise training once a day for 30 minutes; the control group (n = 25) underwent the same exercise training alone. Evaluation indexes were measured before and after treatment; these included arm circumference (at the wrist crease, 10 cm distal to the wrist crease, the elbow crease, and 10 cm distal to the elbow crease) and visual analogue scale (VAS) score for pain. The safety of the treatment was also evaluated. Results The treatment period was 50 days for all 75 patients. At the end of the treatment period, the mean reduction in arm circumference was 1.21 (0.65) cm the treatment group, and 0.58 (0.78) cm in the control group. Compared with the control group, the treatment group had a significantly greater reduction in arm circumference (P = .03) and a significantly lower VAS score for pain (P = .01). No patient in either group experienced any adverse events. Conclusion Bloodletting puncture and cupping effectively reduces arm circumference and relieves upper limb pain in patients with breast cancer-related lymphedema. Our results provide sufficient basis for exploring cupping as long-term therapy for managing breast cancer-related lymphedema.

Preliminary Evidence for Training-Induced Changes of Morphology and Phantom Limb Pain.

The aim of this study was to investigate whether a special prosthetic training in phantom limb pain patients aimed at increasing the functional use of the prosthesis leads to neural morphological plasticity of brain structures and a reduction in phantom limb pain. For chronic pain disorders, it was shown that morphological alterations due to pain might become at least partially reversed by pain therapies. Phantom limb pain is a chronic pain disorder that is frequently followed by neural plasticity of anatomical brain structures. In our study, 10 patients with amputation of the upper limb participated in a two-week training with a myoelectric prosthesis with somatosensory feedback. Grip strength was fed back with electrocutaneous stimulus patterns applied to the stump. Phantom limb pain was assessed before and after the two-week training. Similarly, two T1 weighted MRI scans were conducted for longitudinal thickness analyses of cortical brain structures. As result of this treatment, patients experienced a reduction in phantom limb pain and a gain in prosthesis functionality. Furthermore, we found a change of cortical thickness in small brain areas in the visual stream and the post-central gyrus ipsilateral to the amputation indicating morphological alterations in brain areas involved in vision and pain processing.

Monitoring of Gait Quality in Patients With Chronic Pain of Lower Limbs.

Severe injuries of lower extremities often lead to chronic pain and reduced walking abilities. We postulated that measuring free-living gait can provide further information about walking ability in complement to clinical evaluations. We sought to validate a method that characterizes free gaits with a wearable sensor. Over one week, 81 healthy controls (HC) and 66 chronic lower limb pain patients (CLLPP) hospitalized for multidisciplinary rehabilitation wore a simple accelerometer (Actigraph). In the acceleration signals, steady 1-min walks detected numbered 7,835 (5,085 in CLLPP and 2,750 in HC). Five gait quality measures were assessed: movement intensity, cadence, stride regularity, and short-term and long-term local dynamic stability. Gait quality variables differed significantly between CLLPP and HC (4%-26%). Intraclass correlation coefficients revealed moderate to high repeatability (0.71-0.91), which suggests that seven days of measurement are sufficient to assess average gait patterns. Regression analyses showed significant association (R2 = 0.44) between the gait quality variables and a clinical evaluation of walking ability, i.e., the 6-min walk test. Overall, the results show that the method is easy to implement, valid (high concurrent validity), and reliable to assess walking abilities ecologically.

Functional Reorganization of the Primary Somatosensory Cortex of a Phantom Limb Pain Patient

Functional reorganization of the somatosensory system was widely observed in phantom limb pain patients. Whereas some studies demonstrated that the primary somatosensory cortex (S1) of the amputated limb was engaged with the regions around it, others showed that phantom limb pain was associated with preserved structure and functional organization in the former brain region. However, according to the law of use and disuse, the sensitivity of S1 of the amputated limb to pain-related context should be enhanced due to the adaptation to the long-lasting phantom limb pain experience. Here, we collected neurophysiological data from a patient with 21-year phantom limb pain using electroencephalography (EEG) and functional magnetic resonance imaging (fMRI) techniques. EEG data showed that both laser-evoked potentials (LEPs) and tactileevoked potentials (TEPs) were clearly presented only when radiant-heat laser pulses and electrical pulses were delivered to the shoulder of the healthy limb, but not of the amputated limb. This observation suggested the functional deficit of somatosensory pathways at the amputated side. FMRI data showed that significant larger brain activations by painful rather than non-painful stimuli in video clips were observed not only at visual-related brain areas and anterior/mid-cingulate cortex, but also at S1 contralateral to the amputated limb. This observation suggested the increased sensitivity of S1 of the amputated limb to the pain-related context. In addition, such increase of sensitivity was significantly larger if the context was associated with the amputated limb of the patient. In summary, our findings provided novel evidence for a possible neuroplasticity of S1 of the amputated limb: in an amputee with long-lasting phantom limb pain, the sensitivity of S1 to pain-related and amputated-limb-related context was greatly enhanced. Key words: Phantom limb pain, primary somatosensory cortex (S1), functional reorganization, sensory deficit, neuroplasticity, functional sensitivity, electroencephalography (EEG), functional magnetic resonance imaging (fMRI)