Missing Limb Research Articles

A retrospective study of duloxetine for phantom limb pain post lower‐limb amputation

AbstractBackgroundPhantom limb pain (PLP) refers to the painful sensory perception of a missing limb after amputation, which can have physical and psychological impacts.AimTo determine the effectiveness of duloxetine for pain management in PLP by the reduction of opioid doses and other neuropathic analgesics when introduced into multimodal pain management strategies in the subacute rehabilitation setting.MethodThis was a retrospective observational case‐matched cohort study of patients who were admitted to a geriatric and rehabilitation unit at a tertiary Australian hospital from January 2005–December 2017 with PLP after lower‐limb amputation. Patients were included if they had a new amputation and experienced PLP. The primary outcome was a difference in oxycodone dose equivalents at discharge between the two cohorts. Univariable analysis was used to compare groups. Ethical approval was granted by the Metro South Low Negligible Risk Ethics Committee (Reference no: LNR/2018/QMS/47370) and the study conforms with the National statement on ethical conduct in human research.ResultsThirty patients from the duloxetine treatment cohort and 57 patients from the non‐duloxetine cohort were identified. Participants were predominantly male (81%) and had a median age of 63 years (interquartile range = 10.7). Both populations showed a similar rate of opioid dose reduction comparing doses at admission with those at discharge. There were no significant differences in absolute oxycodone equivalent doses at the two observed check points: admission and discharge.ConclusionThis study demonstrated that opioid consumption in post‐surgical lower‐limb amputees reporting PLP was not significantly different between populations that used and did not use duloxetine. Future research should evaluate the efficacy of duloxetine in PLP pain management using a multisite prospective study design.

About a person with a missing limb and a clubfoot in one of their legs (congenital talipes equinovarus, or CTEV)

The Ponseti technique has a higher success rate than any other method now used in physiotherapy practice for the treatment of congenital talipes equinovarus or clubfoot. The study’s objective was to discover proof that using the Ponseti approach for clubfoot challenging functional results and missing limb by prosthetic shoes. A baby girl who was 1 month and 6 days old and had no prior history of complications for either her mother or herself visited Centre for the Rehabilitation of the Paralysed (CRP). We identified her as having unilateral normal clubfeet (left) and missing limb in right, and throughout the casting process, her midfoot scored higher than her hindfoot. On the first casting day, feet had a total Pirani score (PS) of 5.5. Total casting was necessary, and the right feet’s PSs were 1.5 and 1, respectively. Just before the casting, she had manipulation (exercise therapy). After nine casting, Pirani’s score was zero. Afterward, the patient was given the brace and prosthetic in the 4 size. This study’s findings suggest that using the Ponseti approach yields comprehensive clinical and functional results and missing limb by prosthetic shoes.

A chromatin code for limb segment identity in axolotl limb regeneration

The salamander limb correctly regenerates missing limb segments because connective tissue cells have segment-specific identities, termed "positional information". How positional information is molecularly encoded at the chromatin level has been unknown. Here, we performed genome-wide chromatin profiling in mature and regenerating axolotl limb connective tissue cells. We find segment-specific levels of histone H3K27me3 as the major positional mark, especially at limb homeoprotein gene loci but not their upstream regulators, constituting an intrinsic segment information code. During regeneration, regeneration-specific regulatory elements became active prior to the re-appearance of developmental regulatory elements. In the hand, the permissive chromatin state of the homeoprotein gene HoxA13 engages with the regeneration program bypassing the upper limb program. Comparison of regeneration regulatory elements with those found in other regenerative animals identified a core shared set of transcription factors, supporting an ancient, conserved regeneration program.

Phantom Limb Pain Improvement Post Right Lower Extremity Amputation With a Liner-type Prosthesis and Pharmacotherapy Combination: A Case Report

BACKGROUND: Phantom limb pain is pain in a missing limb postamputation. There is no sufficient evidence for an effective drug therapy, even though various treatment methods have been tried. Apart from drug therapy, mirror therapy, proprioceptive training, and virtual reality, as well as rehabilitation with appropriate orthotics have been tried. Liner-type prostheses use a silicone liner to reduce shear forces between the skin and the orthosis and to maintain suspension function, thereby relieving pain and improving comfort and functionality for the user. CASE REPORT: A 65-year-old man underwent amputation of his right thigh. On the 10th postoperative day, he complained of phantom limb pain centered on the amputation site. Pregabalin was started but did not alleviate his symptoms. After consultation with a physical therapist, the patient began using a liner prosthesis on the 33rd postoperative day. Symptoms gradually lessened, and positive comments were heard from the patient. Pregabalin and duloxetine were administered for a time but were soon reduced. Due to good pain control, the patient was discharged on the 46th postoperative day. After discharge from the hospital, the patient was able to continue treatment as an outpatient without his symptoms worsening, using a liner prosthesis as needed. CONCLUSION: Right thigh amputation is a very physically and emotionally taxing operation for the patient. Phantom limb pain is a difficult symptom to manage, but it must be adequately controlled for the patient. We have achieved phantom limb pain improvement with a combination of pharmacotherapy and a liner prosthesis. We feel a great need for close collaboration with other professions and for a nonpharmacologic approach in addition to pharmacotherapy. KEY WORDS: Phantom limb pain, amputation, pregabalin, duloxetine, liner type prosthesis

Comparison of quality and interpretation of newborn ultrasound screening examinations for developmental dysplasia of the hip by basically trained nurses and junior physicians with no previous ultrasound experience.

We are obliged to give babies the chance to profit from a nationwide screening of developmental dysplasia of the hip in very rural areas of Mongolia, where trained physicians are scarce. This study aimed to compare the quality and interpretation of hip ultrasound screening examinations performed by nurses and junior physicians. A group of 6 nurses and 6 junior physician volunteers with no previous ultrasound experience underwent Graf's standard training in hands-on practice. Newborns were examined before discharge from the hospital, according to the national guideline. Two standard documentation images of each hip were saved digitally. The groups were compared on the proportion of good quality of sonograms and correct interpretation. Two Swiss supervisors' agreed diagnosis according to Graf was considered the final reference for the study purposes. A total of 201 newborns (402 hips or 804 sonograms) were examined in the study, with a mean age of 1.3±0.8 days at examination. Junior physicians examined 100 newborns (200 hips or 400 sonograms), while nurses examined 101 newborns (202 hips or 404 sonograms). The study subjects of the two groups were well balanced for the distribution of baseline characteristics. The study observed no statistically significant difference in the quality of Graf's standard plane images between the providers. Eventually, 92.0% (92) of the physician group and 89.1% (90) of the nurse group were correctly diagnosed as "Group A" (Graf's Type 1 hip) or "Non-Group A" hips (p = 0.484). The most common errors among the groups were a missing lower limb, wrong measurement lines, and technical problems. Our study provides evidence that while there might be a trend of slightly more technical mistakes in the nurse group, the overall diagnosis accuracy is similar to junior physicians after receiving standard training in Graf's hip ultrasound method. However, after basic training, regular quality control is a must and all participants should receive refresher trainings. More specifically, nurses need training in the identification of anatomical structures.

Human image animation via semantic guidance

Image animation creates visually compelling effects by animating still source images according to driving videos. Recent work performs animation on arbitrary objects using unsupervised methods and can relatively robustly perform motion transfer on human bodies. However, the complex representation of motion and unknown correspondence between human bodies often lead to issues such as distorted limbs and missing semantics, which make human animation challenging. In this paper, we propose a semantically guided, unsupervised method of motion transfer, which uses semantic information to model motion and appearance. Specifically, we use a pre-trained human parsing network to encode the rich and diverse foreground semantic information, thus generating fine details. Secondly, we use a cross-modal attention layer to learn the semantic region’s correspondence between human bodies to guide the network in selecting appropriate input features, prompting the network to generate accurate results. Experiments demonstrate that our method outperforms state-of-the-art methods in motion-related metrics, while effectively addressing the problems of semantic missing and unclear limb structures prevalent in human motion transfer. These improvements can facilitate its applications in various fields, such as education and entertainment.

The Coevolution of the Understanding and Treatment Modalities for Phantom Limb Pain

Phantom Limb Pain (PLP), an inappropriate sensation in a missing limb, is a post-amputation phenomenon that occurs in up to 80% of amputees. The specific sensations vary from person to person, but some common reported sensations include warmth or coldness, itching, tingling, and electric shock. Some patients also perceive a specific position or movement of the phantom limb. Most amputees experience PLP with varying degrees of intensity, frequency, and duration. About 5-10% of amputees continue to have severe PLP for many years after amputation. As technology and scientific understanding have evolved, phantom limb pain has become better understood over the centuries, from its first mention from Ambroise Pare in the 1600s to the usage of a variety of medication, medical therapy, and surgery options available today. Although the field of medicine does not yet have a curative treatment for PLP, treatment modalities have advanced from the use of wooden pegs to the latest and advanced prosthetics. By summarizing the growing understanding and evolution of treatment modalities for the medical condition from its first mention in the 16th century to the current 21st century, we can begin to appreciate the years of study and collaboration to current knowledge of phantom limb pain.

First Archaeological Record of the Torture and Mutilation of Indigenous Mapuche During the “War of Arauco,” Sixteenth Century

Abstract Newen Antug is a multicomponent (residential and funerary) archaeological site located in the Lácar basin south of Neuquén, Argentina, in the east Andean section of the binational basin of the Valdivia River. Two human skeletons were discovered during the excavation of the site. Based on radiocarbon dating and associated material contexts, the burials can be associated with the period of first contact between the indigenous people of the region with the Spanish. Based on the analysis of historical sources, bioanthropological studies, and forensic data, we postulate that these individuals were tortured victims of the war waged by the Spaniards against the indigenous inhabitants. The skeletal remains present various perimortem trauma. The left hand and distal end of the left forearm was absented in situ and which are discussed as being possible form of mutilations of the upper limbs. Individual 1♀ had a horse (Equus caballus) leg replacing or symbolising the missing left limb. The mutilation practice is recorded as part of the power devices characteristic of the Warfare Phase (1536–1655) of the conquest, when the Spanish were attempting to establish a pre-disciplinary machinery of their “Sovereign Power” in the south-central Chile. The findings reported here extend this process to Northeastern Patagonia in Argentina.

Design and manufacture of a forelimb prosthesis prototype for a dog

The objective of this writing is to develop a methodology for the design and selection of materials that allows for the manufacturing of a canine prosthesis prototype based on anthropometric measurements, element simulation, and finite analysis. The canine prosthesis aims to restore mobility to a missing limb of a dog due to amputation and/or congenital malformation. The methodological approach for this study has been determined based on the analysis of a series of parameters, such as the dimensions of the animal leg, as well as its weight and the location of the amputation, to mention just a few points. As a contribution, a prototype of an exoprosthesis is proposed for a missing front limb, where it should fit within the range of the leg length, from 35 cm to 45 cm, and its weight should range between 30 kg and 40 kg. Additionally, the amputation should be located starting from the elbow region, and the optimal design should be able to adapt to different anthropometric measurements and the needs of the dogs.

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

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

When proprioceptive feedback enhances visual perception of self-body movement: rehabilitation perspectives.

Rehabilitation approaches take advantage of vision's important role in kinesthesia, using the mirror paradigm as a means to reduce phantom limb pain or to promote recovery from hemiparesis. Notably, it is currently applied to provide a visual reafferentation of the missing limb to relieve amputees' pain. However, the efficiency of this method is still debated, possibly due to the absence of concomitant coherent proprioceptive feedback. We know that combining congruent visuo-proprioceptive signals at the hand level enhances movement perception in healthy people. However, much less is known about lower limbs, for which actions are far less visually controlled in everyday life than upper limbs. Therefore, the present study aimed to explore, with the mirror paradigm, the benefit of combined visuo-proprioceptive feedback from the lower limbs of healthy participants. We compared the movement illusions driven by visual or proprioceptive afferents and tested the extent to which adding proprioceptive input to the visual reflection of the leg improved the resulting movement illusion. To this end, 23 healthy adults were exposed to mirror or proprioceptive stimulation and concomitant visuo-proprioceptive stimulation. In the visual conditions, participants were asked to voluntarily move their left leg in extension and look at its reflection in the mirror. In the proprioceptive conditions, a mechanical vibration was applied to the hamstring muscle of the leg hidden behind the mirror to simulate an extension of the leg, either exclusively or concomitantly, to the visual reflection of the leg in the mirror. (i) Visual stimulation evoked leg movement illusions but with a lower velocity than the actual movement reflection on the mirror; (ii) proprioceptive stimulation alone provided more salient illusions than the mirror illusion; and (iii) adding a congruent proprioceptive stimulation improved the saliency, amplitude, and velocity of the illusion. The present findings confirm that visuo-proprioceptive integration occurs efficiently when the mirror paradigm is coupled with mechanical vibration at the lower limbs, thus providing promising new perspectives for rehabilitation.

Ensuring wholeness: Using Code Biology to overcome the autonomy-heteronomy divide

This paper presents an alternative to Autopoietic Enactivism in the form of a Code Biology-informed account on human sense-making. It demonstrates the possibility of avoiding a dualism between, on the one hand, the autonomy of individual sense-makers and, on the other, the heteronomy of social facts. This is possible because code biological principles are pertinent to different levels of biological and non-biological organization and cut across the organismic self—non-self border. Analytically, one can maintain the overall integrity of an agent as a separable unit of (inter)action while also avoiding an autonomy-heteronomy divide. We therefore emphasise the constitutive role of codified relations that, while irreducible to operational closure, connect the sense-making agent's social interactions to those of other agents. The move grants a central, constitutive role to external norms (or, heteronomy) as altering the internal, embodied integrity of an autonomous agent. Drawing on the case of prosthetics use in amputees, we show that successful integration of a prothesis cannot be reduced to the substitution of a missing limb. Rather, it demands experienced bodily wholeness on the part of the agent which can only be achieved by attuning and adapting to use of a prosthesis while also internalizing social norms and values. It is concluded that many aspects of the living actualize codified relations which incorporate both heteronomous and autonomous traits.

Hukum Pidana Terkait Tes DNA Korban dalam Rangka Pembuktian terhadap Kejahatan Mutilasi

The occurrence of murder accompanied by the mutilation of the victim basically requires adequate evidence so that the crime is proven, as one of the efforts to prove it requires certainty that the victim has been mutilated and if there is a missing limb it is necessary to find his identity. Often perpetrators try to eliminate evidence. DNA testing is an option, including if suspicious items are found that are suspected of being a tool to commit crimes. The blood attached to the found items was carried out. The purpose of this study was to find out how the law regulates the use of DNA testing by investigators to identify victims in uncovering the crime of murder by mutilating the body parts of the victim in a murder case accompanied by mutilation. This study uses a qualitative research type. In conducting the analysis, the juridical-normative research method used a law approach. The data analysis technique in examining the problems in this research is the statute approach, which is carried out on the rule of law in the legislation and relates it to the entire existing legal system. While the types and sources of data are primary data and secondary data. Conclusions from the results of the study: 1) There is still uncertainty regarding clear legal arrangements for mutilation murder cases both in the Criminal Code and other regulations for the crime of mutilation. 2. There is no legal regulation that explicitly regulates the crime of mutilation. 3. Regarding the DNA test as evidence of the criminal act of mutilation, it has not been recognized as independent evidence, so it cannot yet become binding evidence for judges in court, because DNA tests are only as evidence, so judges can consider others and are not bound by evidence. 4. Related to this, a special regulation in the Criminal Code should be made to regulate evidence with the results of DNA tests against victims of the crime of mutilation.

A Review of some Characteristics of a Composite Hybrid Socket for Prosthetics Derived from Plant Fibers

According to the ICF (International Classification of Functioning, Disability, and Health), a prosthetic is a device used to restore or replace the function of a missing limb as a result of a rare genetic defect, dangerous incident, surgical trauma, or disease that limits the amputee's ability to participate in daily life. Prosthetic limb sockets were formerly made out of a wide variety of materials before the development of thermoplastics and composites. Plant fibers are favored due to their low density. Both their strength and rigidity are remarkably high considering their low weight and inexpensiveness. Plant fiber is one of the most popular ways to give polymer composites more strength because of its low production costs and stretchability. Following a brief introduction to the many types of natural fibers (both plant and animal), this article provides a comprehensive assessment of the literature from the past decade that focuses on the mechanical characteristics of plant materials. Reinforced polymers are made with fibers. This literature study will focus on the mechanical properties and behavior of plant fibers used to create sockets for prosthetic limbs. If an article is written about the overall features of composites made with fibers made from the plant, it is expected to be of great use to the research community in the field of composites.

Times and Seasons

Times and Seasons

Open-Source 3D Printing in the Prosthetic Field—The Case of Upper Limb Prostheses: A Review

Upper limb loss alters individuals’ private and professional life. Prosthetic devices are thus a solution to supply the missing upper limb segments. Nevertheless, commercial prostheses are often unaffordable, or inaccessible, to underprivileged individuals (e.g., no health insurance, low incomes, warzone). Among potential affordable alternatives, additive manufacturing, commonly “3D printing”, has been increasingly employed. This technology offers higher availability and accessibility, and can produce complex geometrical and highly customized products, which are essential features for prostheses manufacturing. Therefore, this study aims to portray an overview of reliable open-source upper limb 3D-printed prostheses currently available. We thus searched the scientific literature and online repositories hosting 3D-printable designs. We extracted data relative to mechanical and kinematic properties, 3D printing process and efficacy for each device. We found six studies implementing open-source 3DP upper limb prostheses and twenty-five open-source designs from online databases meeting selection criteria. Devices’ technical specifications were not systematically reported. In conclusion, though open-source 3D-printed upper limb prostheses can perform some functional tasks and grasps, and are widely employed to supply limb differences, further research is mandatory to validate their usage and to prove their clinical efficacy. More guidelines are required to unify contributions from private makers and non-governmental organizations with scientific groups.

Nerves, Pain and Consciousness

We all experience pain at one time or another. Pain is an essential “alarm bell” that tells us that something is wrong, and a “teacher” that reminds us not to do that same thing again. Usually, pain is felt when a stimulus, such as a pinch or an injury, causes electrical pulses to run along one of the cables of nerve fibers in our body and into the brain where they generate an unpleasant sensory and emotional experience. Sometimes pain occurs without any actual stimulus, such as when nerve fibers have been damaged. An example is the phantom pain that amputees sometimes feel in their missing limb. Certain drugs can stop pain by blocking the electrical pulses before they reach the brain. Other drugs stop pain in a different way, by preventing the brain from reading the pain message carried by the electrical pulses. This article explains what happens in the body when we are hurt, how the brain causes this to be felt as pain and how certain drugs can stop pain.

Association of Peripheral Serum MicroRNAs With Persistent Phantom Limb Pain in Individuals With Amputation.

Individuals with major limb amputation(s) frequently experience phantom limb sensations, which are described as vivid impressions of either parts or entire missing limb(s). Despite the high incidence and prevalence of phantom limb pain, the underlying pathophysiology of phantom limb pain remains poorly understood. The objective of this study was to evaluate a possible role of microRNAs in the pathophysiology of phantom limb pain. Adults with acquired limb amputation and varying degrees of phantom limb pain consented to provide clinical data and blood samples. One hundred forty participants with single or multiple limb amputation(s) were enrolled. The Visual analog scale and neuropathic pain symptom inventory were administered to evaluate the pain. Serum samples were analyzed for microRNA expression and bioinformatic analysis was performed. Sixty-seven participants did not experience phantom limb pain, whereas 73 participants experienced varying severities of phantom limb pain measured on a pain scale. Linear regression analysis suggested that the time since amputation is inversely related to severity of the pain. A significantly increased expression of 16 microRNAs was observed in participants experiencing phantom limb pain. Bioinformatic analysis shows a possible role of these microRNAs in regulating genes expressed in peripheral neuropathy. This study provides the first evidence of association of microRNA in phantom limb pain.

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.

Limb loss experience evoked by electric cortical stimulation.

Limb loss experience is a type of body illusion characterized by the sensation of a missing limb or body part. We aimed to investigate the brain areas involved in this unusual somatosensory experience evoked by electric cortical stimulation with stereo-electroencephalography electrodes. We retrospectively reviewed the data of patients with medical intractable epilepsy, from October 2015 to December 2020, who underwent stereo-electroencephalography implantation and electric cortical stimulation in order to locate the epileptogenic zone and obtain a functional map. We included patients who reported experiences of limb loss during the process of electric cortical stimulation for functional mapping. Three patients reported experiences of limb loss in the process of electric cortical stimulation. Limb loss experience (including the right hand, right upper limb and right side of the body) occurred when the cortex of the left posterior insula, posterior dorsal cingulate and parietal operculum were stimulated. Limb loss experience can be evoked by electric cortical stimulation of the posterior insula, parietal operculum, and posterior cingulate cortex, and provides additional evidence that these cortices play a role in the integration of body sensory perception.