Reduce Phantom Limb Pain Research Articles

Targeted Muscle Reinnervation Compared to Standard Peripheral Nerve Management Following Amputation: A Systematic Review and Meta-Analysis.

Chronic pain remains a significant challenge for individuals following limb amputation, with incidence of painful neuromas, phantom limb pain (PLP), and residual limb pain (RLP). Targeted muscle reinnervation (TMR) is a surgical technique designed to restore motor control information lost during amputation by redirecting residual nerves to new muscle targets. This systematic review and meta-analysis aims to compare patient-reported and functional outcomes following amputation with either TMR or standard neurological treatment (SNT). The study also includes an examination of primary versus secondary TMR and explores outcomes in highly comorbid patient populations. A search of central databases was performed, and meta-analysis was completed on extracted data where possible. Eleven studies were identified. Results indicate a significant reduction in PLP and RLP in patients undergoing TMR compared to SNT using various pain scores. TMR also demonstrates improved functional outcomes and decreased opioid use. Furthermore, results indicated patients who underwent TMR at the time of amputation (primary TMR) had improved pain scores compared with those who had TMR performed later (secondary TMR). The review emphasizes the benefits of TMR as a valuable surgical adjunct for amputee patients, while also highlighting the need for further research, especially in comorbid populations.

Reducing phantom limb pain using phantom motor execution enabled by augmented and virtual reality: participants’ perspectives on an innovative treatment

Purpose Phantom limb pain (PLP) is a condition that greatly diminishes quality of life. Phantom motor execution (PME), enabled by myoelectric pattern recognition combined with virtual and augmented reality, is a novel treatment for PLP. Here we, aimed to describe patients’ experiences of this treatment. Material and Methods Qualitative, using semi-structured interviews one month after completed PME treatment. Twenty-one Swedish and Dutch patients (mean age 57, 16 males, 16 lower limb amputations) participated. The analysis followed the framework approach. Results The main themes were 1) treatment effects on the perception of the phantom limb, 2) living with PLP before and after treatment, and 3) facilitators and barriers to treatment. Most participants learned to control their phantom limb, perceived it more positively and as more complete. This control over the phantom limb became a tool for managing PLP. Most participants’ outlook on life and energy levels improved after treatment. Being mentally focused during treatment was important. Therapists were pivotal to the success of the treatment. Conclusion Controlling the phantom limb improved their perception of it and pain management, self-agency, and quality of life. The therapists’ role was invaluable. We suggest training for patients in phantom limb control before and after amputation.

The home-based mirror therapy in the reduction of phantom limb pain in unilateral below-knee amputees

The home-based mirror therapy in the reduction of phantom limb pain in unilateral below-knee amputees

Acute versus non-acute targeted muscle reinnervation for pain control following major limb amputation: A comparative study

BackgroundTargeted muscle reinnervation (TMR) has been shown to reduce phantom limb pain (PLP) and residual limb pain (RLP) after major limb amputation. However, the effect of the timing of surgery on pain control and quality of life outcomes is controversial. We conducted a retrospective study to compare the outcomes of acute TMR for pain prevention with non-acute TMR for the treatment of established pain. MethodsAll patients treated with TMR in our institution between January 2018 and December 2021 were evaluated at 6, 12, 18 and 24 months post-operatively. Pain intensity and quality of life outcomes were assessed using the Brief Pain Inventory (Pain Severity and Pain Interference scales) and Pain Catastrophizing Scale. Outcomes were compared between acute and non-acute TMR using the Wilcoxon ranked-sum test or Fisher’s exact test as appropriate. Multilevel mixed-effects linear regression was used to account for repeat measures and potential pain confounders. ResultsThirty-two patients with 38 major limb amputations were included. Acute TMR patients reported significantly lower RLP and PLP scores, pain interference and pain catastrophisation at all time points (p < 0.05). Acute TMR was significantly associated with lower pain severity and pain interference in a linear mixed-effects model accounting for patient age, gender, amputation indication, amputation site, time post-TMR and repeated surveys (p < 0.05). There was no significant difference in the complication rate (p = 0.51). ConclusionAcute TMR was associated with clinically and statistically significant pain outcomes that were better than that in non-acute TMR. This suggests that TMR should be performed with preventative intent, when possible, as part of a multidisciplinary approach to pain management, rather than deferred until the development of chronic pain.

Development of a Device for Mirror Therapy

Previous research on the interconnections between brain activity and actions had led to the discovery of mirror neurons, neurons that have two particularly important roles: they mediate the imitation of movements based on visual information, and they underlie the understanding of actions. Mirror therapy is a relatively new, non-invasive therapy based on the use of visual feedback in recovery. Since 1996, it has been introduced in medical rehabilitation programmes, targeting conditions such as: hemiplegia after stroke, gait recovery after stroke, improvement of finger coordination in Parkinson's patients, reduction of phantom limb pain after amputations, and chronic pain from hand osteoarthritis, fibromyalgia, and complex regional pain syndrome. The device that is the subject of the present work presents a new constructive variant of the mirror box, which offers a much more efficient method of applying mirror therapy in various conditions, both at the level of the upper and lower limbs. The results of two assessments on the effectiveness of visual stimulation in recovery, carried out with the help of this device, first on the recovery of the hand functionality in subjects with hemiparesis after ischemic stroke and second assessment in the treatment of chronic pain of subjects with hand osteoarthritis will also be presented. Keywords: mirror therapy, visual feedback, neuroplasticity, kinesthetic memory, stroke, phantom limb pain

Restoration of sensory feedback from the foot and reduction of phantom limb pain via closed-loop spinal cord stimulation.

Restoring somatosensory feedback in individuals with lower-limb amputations would reduce the risk of falls and alleviate phantom limb pain. Here we show, in three individuals with transtibial amputation (one traumatic and two owing to diabetic peripheral neuropathy), that sensations from the missing foot, with control over their location and intensity, can be evoked via lateral lumbosacral spinal cord stimulation with commercially available electrodes and by modulating the intensity of stimulation in real time on the basis of signals from a wireless pressure-sensitive shoe insole. The restored somatosensation via closed-loop stimulation improved balance control (with a 19-point improvement in the composite score of the Sensory Organization Test in one individual) and gait stability (with a 5-point improvement in the Functional Gait Assessment in one individual). And over the implantation period of the stimulation leads, the three individuals experienced a clinically meaningful decrease in phantom limb pain (with an average reduction of nearly 70% on a visual analogue scale). Our findings support the further clinical assessment of lower-limb neuroprostheses providing somatosensory feedback.

Ten-year phantom limb pain with only four sessions of Fu's subcutaneous needling: A case report and systematic review

Phantom limb pain (PLP) is a distressing consequence commonly encountered by individuals who have undergone amputations. The efficacy of treatment options for PLP is limited. In this study, we present a case of a 64-year-old male who suffered from PLP for a duration of 10 years following an above-the-knee amputation. Despite unsuccessful attempts with painkillers and neurotrophic drugs over the course of a decade, the patient sought relief through Fu's Subcutaneous Needling (FSN), an innovative acupuncture therapy that specifically targets the subcutaneous tissue for pain management. Remarkably, the patient experienced a significant reduction in PLP and subsequently decreased his reliance on medication, as well as experiencing improved sleep after undergoing one session of FSN per day for four consecutive days. A follow-up conducted three years later demonstrated positive treatment outcomes. FSN demonstrated a significant influence on PLP, resulting in reduced analgesic requirements and enhanced quality of life. Therefore, FSN may be recommended as an additional treatment option for PLP. In order to gain a comprehensive understanding of the effects of acupuncture on PLP, a systematic review of relevant literature was conducted in PubMed, Embase, Cochrane Library and Web of Science in recent 20 years (from January 1, 2003 to October 16, 2023), using different combinations of the following terms: (phantom acrodynia), (residual limb pain), (phantom limb pain), (acupuncture), (electroacupuncture), (auriculoacupuncture), and (needling). 9 articles with 18 cases including one randomized controlled trial (n = 8) were obtained. This review provided additional evidence supporting the efficacy and safety of needling therapies for PLP. This systematic review offers additional evidence supporting the effectiveness and safety of needling therapies for PLP. However, there were no precedent reports using FSN treatment for PLP. Hence, this case may provide some implications for clinicians in practice.

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.

A service evaluation of the newly introduced sciatic nerve local anaesthetic infusion catheters for acute pain management of major lower limb amputations

Background: Patients who undergo lower limb amputations experience severe acute postoperative pain. Despite having no strong evidence for the efficacy of peripheral nerve blocks in reducing phantom limb pain, the reduction in acute postoperative pain and opioid-sparing effect1 make these techniques important to consider. Acute pain management has been identified as a key priority in the management of patients undergoing amputation.2 An initial audit, in October 2021, found that postoperative pain scores and opiate use were high. In April 2022, postoperative local anaesthetic nerve catheters for major lower limb amputations were introduced at our institution. The aim of this service evaluation was to ascertain the postoperative pain scores and analgesic consumption for patients having undergone a lower limb amputation and who subsequently received a continuous postoperative local anaesthetic infusion (levobupivacaine 0.125%, at 6–10 ml h−1 for up to 5 days) via a sciatic nerve catheter. Methods: A retrospective audit was undertaken between July and September 2022 at Birmingham Heartlands Hospital. We included patients having undergone a lower limb amputation with a sciatic nerve catheter placed intraoperatively by surgeons under direct vision and left along the nerve in the cut nerve sheath. Data collected included patient characteristics, postoperative pain scores days 1–5, postoperative opioid use including opioid side-effects, postoperative neuropathic pain, and block related complications. Results: We collected data for 24 patients. Compared with the period before the introduction of sciatic nerve catheters, we observed that the mean pain scores on the numeric rating scale (NRS) decreased. This was particularly evident on day 1 postoperatively when the mean pain scores decreased from the moderate to mild range. On days 1–5 of the postoperative period, the mean immediate-release opioid consumption was 16.1 mg day−1 and mean prolonged-release opioid consumption was 11.6 mg day−1. This was in comparison to the audit in October 2021 that found mean opioid use of 24.1 mg day−1 and 21 mg day−1, respectively. Opioid side-effects reported were sedation (18%), constipation (13%), and nausea or vomiting (8%). Fifty percent of patients reported neuropathic pain. Conclusion: The postoperative pain scores improved and the postoperative opioid consumption reduced slightly with the addition of a sciatic nerve catheter. Opioid side-effects and acute neuropathic pain remain an issue for this group of patients postoperatively. Overall, the introduction of a continuous local anaesthetic infusion via a sciatic nerve catheter after major lower limb amputations in our hospital has been a success and the technique is likely to play a significant future role as part of our multi-modal analgesia regimen for these patients. The Acute Pain Team at University Hospitals Birmingham NHS Foundation Trust. 1.Ilfeld BM. Anesth Analg 2011; 113: 904–252.Gough MJ, Juniper M, Freeth H, Butt A, Mason M. Lower limb amputation: Working together. A report by the National Confidential Enquiry into Patient Outcome and Death, 2014. https://www.hqip.org.uk/wp-content/uploads/2018/02/lower-limb-amputation-report.pdf (accessed 20/03/23)

Pre-operative sciatic nerve block vs postoperative surgeon-placed perineural stump catheter for prevention of phantom limb pain after below-knee amputation.

Pre-operative sciatic nerve block vs postoperative surgeon-placed perineural stump catheter for prevention of phantom limb pain after below-knee amputation.

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.

Brain-computer interface applications to decrease phantom limb pain

Phantom limb pain is mainly experienced in people who have suffered limb amputation, its study and analysis are relevant to know the causes and help patients to reduce pain. On the other hand, brain-computer interfaces encode brain signals and decode them for communication with a device. Through the motor imagination of the movement of the amputated limb and with the help of a brain-computer interface, an amputee patient can reduce or eliminate pain. The objective of this paper is to give an introduction to brain-computer interfaces as a tool for the reduction of phantom limb pain. Therefore, the applications of interfaces in relation to pain are highlighted, some related studies are discussed, and their benefits and disadvantages are analyzed. Finally, it is established that phantom limb pain research benefits from incorporating brain-computer interfaces as part of non-pharmaceutical therapy because it is a tool that provides feedback on the reconfiguration of the cerebral cortex in relation to pain.

Evolving techniques for reducing phantom limb pain.

At least two million people in the United States of America live with lost limbs, and the number is expected to double by 2050, although the incidence of amputations is significantly greater in other parts of the world. Within days to weeks of the amputation, up to 90% of these individuals develop neuropathic pain, presenting as phantom limb pain (PLP). The pain level increases significantly within one year and remains chronic and severe for about 10%. Amputation-induced changes are considered to underlie the causation of PLP. Techniques applied to the central nervous system (CNS) and peripheral nervous system (PNS) are designed to reverse amputation-induced changes, thereby reducing/eliminating PLP. The primary treatment for PLP is the administration of pharmacological agents, some of which are considered but provide no more than short-term pain relief. Alternative techniques are also discussed, which provide only short-term pain relief. Changes induced by various cells and the factors they release are required to change neurons and their environment to reduce/eliminate PLP. It is concluded that novel techniques that utilize autologous platelet-rich plasma (PRP) may provide long-term PLP reduction/elimination.

What is the Most Effective, Non-Pharmacological, and Non-Invasive Treatment Mechanism for Reducing Phantom Limb Pain in Amputees?

Phantom limb pain (PLP) is characterized by pain deposited in non-existent extremities. Although present in those born without limbs, nearly 90% of amputees experience PLP. Unfortunately, the causal mechanism of PLP is unknown, making it difficult to treat. Researchers are striving to find the most efficacious treatment as 25–50% of patients report severe pain, which reduces their quality of life. Currently, there is an immense list of treatments all with various degrees of success. This article explores some of these potential treatments.

Targeted Muscle Reinnervation of the brachial plexus region: A cadaveric study and case series

Targeted Muscle Reinnervation (TMR) has been shown to prevent and treat neuropathic pain as well as enhance bioprosthetic function. A paucity of data and anatomical description exist regarding TMR in the setting of proximal amputations at the level of the brachial plexus region. In this work, the technique and anatomical description of TMR for proximal amputations at the shoulder level and above, with the corresponding brachial plexus nerve transfers and reconstruction, will be described as an anatomic reference and operative guide. Cadaveric dissections of four shoulder and forequarter level amputations were performed. Major mixed motor and sensory nerve branches were identified, dissected, and tagged. Amputated peripheral nerves were then transferred to identified and labeled target motor nerves within the shoulder and chest levels via direct end-to-end coaptations per traditional TMR technique. A retrospective review was completed by our multi-institutional team including clinical case correlates for TMR performed at the described levels. A total of 8 TMR brachial plexus clinical cases were performed between 2016 and 2020 in a primary or secondary setting following oncologic resection or traumatic injuries. Follow-up ranged from 18 to 58 months, mean follow-up of 34.6 months. Six out of 8 patients require no narcotics, while 2 require supplemental narcotic use. One patient requires no pain medication. Four of the 7 patients utilize an EMG enhanced bioprosthetic. The eighth patient died from tumor recurrence. Technical considerations for brachial plexus TMR surgery have been outlined with early follow-up data showing beneficial pain control and prosthetic outcomes. • TMR transfers transected peripheral nerve stumps to redundant motor nerves to prevent formation of symptomatic neuroma. • TMR has been shown to effectively reduce phantom limb pain (PLP) and phantom limb syndrome (PLS). • TMR can be performed on the brachial plexus to act as a bio-amplifier for advanced myoelectric prosthetic use. • With well-performed TMR, minimal re-training is required for use of a future myoelectric prosthesis.

Correlation between kinesthetic motor imagery of an amputated limb and phantom limb pain.

Phantom limb pain (PLP) is a frequent painful sensation in amputees, and motor imagery (MI) is a useful approach for the treatment of this type of pain. However, it is not clear regarding the best MI modality for PLP. The purpose of this study was to investigate the relationship between the PLP and MI modality in upper limb amputees. Observational study. Eleven patients who underwent unilateral upper limb amputation participated in this study. The MI modality (kinesthetic and visual) and PLP intensity were evaluated using the Kinesthetic and Visual Imagery Questionnaire (KVIQ)-20 and a visual analog scale. MI ability was also assessed during the hand mental rotation task. We examined the correlation between MI modalities, ability, and pain intensity. The total KVIQ kinesthetic score was negatively correlated with pain intensity (r = -0.71, P < 0.01): the more vivid the kinesthetic imagery, the weaker the pain. In particular, the reduction in pain intensity was associated with strong kinesthetic imagery of opposing movements of the deficient thumb (r = -0.81, P < 0.01). The KVIQ visual score and MI ability were not associated with pain intensity. Our data showed that the reduction of PLP could be associated with the kinesthetic modality of MI but not with visual modality or MI ability. In other words, it was suggested that the more vivid the sensation of moving muscles and joints in the defect area, the lower the PLP intensity. To reduce PLP, clinicians may prefer interventions using the kinesthetic modality.

Sensory Feedback for Upper-Limb Prostheses: Opportunities and Barriers

The addition of sensory feedback to upper-limb prostheses has been shown to improve control, increase embodiment, and reduce phantom limb pain. However, most commercial prostheses do not incorporate sensory feedback due to several factors. This paper focuses on the major challenges of a lack of deep understanding of user needs, the unavailability of tailored, realistic outcome measures and the segregation between research on control and sensory feedback. The use of methods such as the Person-Based Approach and co-creation can improve the design and testing process. Stronger collaboration between researchers can integrate different prostheses research areas to accelerate the translation process.

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.

Pain relief by movement representation strategies: An umbrella and mapping review with meta‐meta‐analysis of motor imagery, action observation and mirror therapy

AbstractObjectiveTo develop a mapping and umbrella review with a meta‐meta‐analysis (MMA) to critically evaluate the current evidence of motor imagery (MI), action observation and mirror therapy (MT) on pain intensity.MethodsThe study involved a systematic search of PubMed, PEDro, Scielo, EBSCO and Google Scholar.ResultsTen systematic reviews were included in the qualitative synthesis, 70% of which showed high methodological quality. Three reviews found a significant reduction in chronic musculoskeletal pain as the result of applying movement representation methods (MRM) plus usual‐care (UC), with a large clinical effect (standardized mean difference [SMD] of −1.47; 95% CI −2.05 to −0.88; heterogeneity Q = 1.66; p = 0.44; I2 = 0%). However, two reviews showed no statistically significant reduction in acute and postsurgical pain as a result of applying MI plus UC. Four reviews showed no significant reduction in phantom limb pain (PLP) as a result of applying MT plus UC interventions. In four reviews, the MMA showed a significant reduction in complex regional pain syndrome (CRPS) as a result of applying MT plus UC, with a large clinical effect (SMD −1.27; 95% CI −1.87 to −0.67; heterogeneity Q = 3.95; p = 0.27; I2 = 24%). In two reviews, the MMA showed no significant differences in poststroke pain as a result of applying MT plus UC.ConclusionResults show that MRM could be effective for chronic musculoskeletal pain, with low to moderate‐quality evidence. The results also show a reduction in pain intensity through MT interventions in patients with CRPS, although these results were not found in patients with PLP or poststroke pain.SignificanceThis umbrella review analysed systematic reviews evaluating movement representation techniques, with the aim of synthesizing the available evidence regarding motor imagery, action observation and mirror therapy on pain. The results provide relevant information about the potential clinical use of movement representation techniques in different types of patients with painful conditions.

Reduction of Phantom Limb Pain and Improved Proprioception through a TSR-Based Surgical Technique: A Case Series of Four Patients with Lower Limb Amputation.

Four patients underwent targeted sensory reinnervation (TSR), a surgical technique in which a defined skin area is first selectively denervated and then surgically reinnervated by another sensory nerve. In our case, either the area of the lateral femoral cutaneous nerve or the saphenous nerve was reinnervated by the sural nerve. Patients were then fitted with a special prosthetic device capable of transferring the sense of pressure from the sole of the prosthesis to the newly wired skin area. Pain reduction after TSR was highly significant in all patients. In three patients, permanent pain medication could even be discontinued, in one patient the pain medication has been significantly reduced. Two of the four patients were completely pain-free after the surgical intervention. Surgical rewiring of existing sensory nerves by TSR can provide the brain with new afferent signals seeming to originate from the missing limb. These signals help to reduce phantom limb pain and to restore a more normal body image. In combination with special prosthetic devices, the amputee can be provided with sensory feedback from the prosthesis, thus improving gait and balance.