Background Although many treatments exist for phantom limb pain (PLP), the evidence supporting them is limited and there are no guidelines for PLP management. Brain and spinal cord neurostimulation therapies are targeted at patients with chronic PLP but have yet to be systematically reviewed. Objective To determine which types of brain and spinal stimulation therapy appear to be the best for treating chronic PLP. Design Systematic reviews of effectiveness and epidemiology studies, and a survey of NHS practice. Population All patients with PLP. Interventions Invasive interventions – deep brain stimulation (DBS), motor cortex stimulation (MCS), spinal cord stimulation (SCS) and dorsal root ganglion (DRG) stimulation. Non-invasive interventions – repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS). Main outcome measures Phantom limb pain and quality of life. Data sources Twelve databases (including MEDLINE and EMBASE) and clinical trial registries were searched in May 2017, with no date limits applied. Review methods Two reviewers screened titles and abstracts and full texts. Data extraction and quality assessments were undertaken by one reviewer and checked by another. A questionnaire was distributed to clinicians via established e-mail lists of two relevant clinical societies. All results were presented narratively with accompanying tables. Results Seven randomised controlled trials (RCTs), 30 non-comparative group studies, 18 case reports and 21 epidemiology studies were included. Results from a good-quality RCT suggested short-term benefits of rTMS in reducing PLP, but not in reducing anxiety or depression. Small randomised trials of tDCS suggested the possibility of modest, short-term reductions in PLP. No RCTs of invasive therapies were identified. Results from small, non-comparative group studies suggested that, although many patients benefited from short-term pain reduction, far fewer maintained their benefits. Most studies had important methodological or reporting limitations and few studies reported quality-of-life data. The evidence on prognostic factors for the development of chronic PLP from the longitudinal studies also had important limitations. The results from these studies suggested that pre-amputation pain and early PLP intensity are good predictors of chronic PLP. Results from the cross-sectional studies suggested that the proportion of patients with severe chronic PLP is between around 30% and 40% of the chronic PLP population, and that around one-quarter of chronic PLP patients find their PLP to be either moderately or severely limiting or bothersome. There were 37 responses to the questionnaire distributed to clinicians. SCS and DRG stimulation are frequently used in the NHS but the prevalence of use of DBS and MCS was low. Most responders considered SCS and DRG stimulation to be at least sometimes effective. Neurosurgeons had mixed views on DBS, but most considered MCS to rarely be effective. Most clinicians thought that a randomised trial design could be successfully used to study neurostimulation therapies. Limitation There was a lack of robust research studies. Conclusions Currently available studies of the efficacy, effectiveness and safety of neurostimulation treatments do not provide robust, reliable results. Therefore, it is uncertain which treatments are best for chronic PLP. Future work Randomised crossover trials, randomised N-of-1 trials and prospective registry trials are viable study designs for future research. Study registration The study is registered as PROSPERO CRD42017065387. Funding The National Institute for Health Research Health Technology Assessment programme.
This project is highly useful for professionals in a clinic setting to aid in appropriate patient selection and to justify the cost of prescribing microprocessor-controlled prosthetic knees.
Abstract-Advances associated in terms of cost and quality in virtual reality have brought new paradigms to help with rehabilitation in a vast range of areas. Previous systems have focused on visual based only paradigms with varied results. The system described in this paper draw not only from visual based approaches but also adding elements of haptics to increase the level of immersion but in combination also invoke the sense of agency in patients with phantom limb pain. This paper presents three case studies of an on-going clinical study. The initial results suggest an increased sense of embodiment of the virtual limb promotes a decrease in perceived levels of pain. The results strengthen the view that the cortical map does not fully "disappear" yet lays dormant.
The most common reason for lower limb amputations in the UK is peripheral arterial disease. A thoughtful approach to surgery, with consideration of optimal amputation level and residual limb shape, can improve prosthetic use and functional outcomes. Prosthesis socket design and fit, as well as use of appropriate components, must be considered in accordance with the patient's activity level and potential. Major developments in prosthetics over the past 20 years, particularly in the area of joint design, including microprocessor knees, have increased options to improve ambulation. This is particularly significant among those with more proximal amputations, for whom energy expenditure on walking is even greater. Management of post-amputation pain syndromes including phantom limb pain can prove challenging, although there are novel options for pain control. Long-term care of both the residual and contralateral limbs is paramount to reduce risk of further amputation surgery, and optimize longer term function and quality of life.
PurposeComplete fibula absence often presents with significant lower-limb deformity. Parental counselling regarding management is paramount in achieving the optimum functional outcome. Amputation offers a single surgical event with minimal complications. This study compares outcomes with an amputation protocol to those using an extension prosthesis.MethodThirty-two patients were identified. Nine patients (2 males, 7 females; median age at assessment of 23.5 years) used an extension prosthesis. Twenty-three patients (16 males, 7 females; median age at assessment of eight years) underwent 25 amputations during childhood. Mobility was assessed using SIGAM and K scores. Quality of life was assessed using the PedsQL inventory questionnaire; pain by a verbal severity score.ResultsThe 19 Syme and one Boyd amputation in 19 patients were performed early (mean age 15 months). Four Syme and one trans-tibial amputation in four patients took place in older children (mean age 6.6 years). Only two underwent tibial kyphus correction to aid prosthetic fitting. K scores were significantly higher (mean 4 vs 2) and pain scores lower in the amputation group allowing high impact activity compared with community ambulation with an extension prosthesis. The SIGAM and PedsQL scores were all better in the amputation group, but not significantly so.ConclusionChildhood amputation for severe limb length inequality and foot deformity in congenital fibula absence offers excellent short-term functional outcome with prosthetic support. The tibial kyphus does not need routine correction and facilitates prosthetic suspension. Accommodative extension prostheses offer reasonable long-term function but outcome scores are lower.
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