A review of current theories and treatments for phantom limb pain

Collins, Kassondra; Russell, Hannah G.; Schumacher, Patrick J.; Robinson-Freeman, Katherine E.; O’Conor, Ellen C.; Gibney, Kyla D.; Yambem, Olivia; Dykes, Robert W.; Waters, Robert S.; Tsao, Jack W.

doi:10.1172/jci94003

Cited by 123 publications

(114 citation statements)

References 89 publications

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“…TMS assessment of cortical reorganization provides insights into PLP underlying mechanisms. Understanding the mechanisms of central reorganization can be used to explain the potential pain modulation effects of neuromodulation techniques, such as non-invasive brain stimulations (Collins et al, 2018;Meeker et al, 2019). Regarding the previous studies showing the top-down motor cortex modulation of pain networks through thalamocortical connections (Garcia-Larrea et al, 1999;Miranda et al, 2006;Yoon et al, 2014), the motor cortex can be a potential treatment target to decrease PLP.…”

Section: The Intensity Of Pain Is Associated With the Level Of Reorgamentioning

confidence: 99%

Motor Cortex Reorganization in Limb Amputation: A Systematic Review of TMS Motor Mapping Studies

et al. 2020

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Purpose: The purpose of this systematic review is to evaluate motor cortex reorganization in amputees as indexed by transcranial magnetic stimulation (TMS) cortical mapping and its relationship with phantom limb pain (PLP).Methods: Pubmed database were systematically searched. Three independent researchers screened the relevant articles, and the data of motor output maps, including the number of effective stimulation sites, center of gravity (CoG) shift, and their clinical correlations were extracted. We calculated a pooled CoG shift for motor cortex TMS mapping.Results: The search yielded 468 articles, 11 were included. Three studies performed correlation between the cortical changes and PLP intensity, and only one study compared cortical mapping changes between amputees with pain and without pain. Results showed (i) enlarged excitable area and a shift of CoG of neighboring areas toward the deafferented limb area; (ii) no correlation between motor cortex reorganization and level of pain and (iii) greater cortical reorganization in patients with PLP compared to amputation without pain.Conclusion: Our review supports the evidence for cortical reorganization in the affected hemisphere following an amputation. The motor cortex reorganization could be a potential clinical target for prevention and treatment response of PLP.

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Section: The Intensity Of Pain Is Associated With the Level Of Reorgamentioning

confidence: 99%

Motor Cortex Reorganization in Limb Amputation: A Systematic Review of TMS Motor Mapping Studies

et al. 2020

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“…The authors concluded that cortical disinhibition seems to be disassociated with mirror pain. However, acquired mirror pain likely has different mechanisms ( 2 ) compared to PLP.…”

Section: Discussionmentioning

confidence: 99%

“…After amputation, cortex's afferent inputs from amputated limb are interrupted, resulting in decreased cortical excitation, affecting local inhibitory drive (1). Decreased cortical inhibition seems to be maladaptive and can be related with other dysfunctional behaviors, like PLP (2,3).…”

Section: Introductionmentioning

confidence: 99%

Intracortical Inhibition in the Affected Hemisphere in Limb Amputation

Santos

Gushken²,

Gadotti³

et al. 2020

Front. Neurol.

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Phantom limb pain (PLP) affects up to 80% of amputees. Despite the lack of consensus about the etiology and pathophysiology of phantom experiences, previous evidence pointed out the role of changes in motor cortex excitability as an important factor associated with amputation and PLP. In this systematic review, we investigated changes in intracortical inhibition as indexed by transcranial magnetic stimulation (TMS) in amputees and its relationship to pain. Four electronic databases were screened to identify studies using TMS to measure cortical inhibition, such as short intracortical inhibition (SICI), long intracortical inhibition (LICI) and cortical silent period (CSP). Seven articles were included and evaluated cortical excitability comparing the affected hemisphere with the non-affected hemisphere or with healthy controls. None of them correlated cortical disinhibition and clinical parameters, such as the presence or intensity of PLP. However, most studies showed decreased SICI in amputees affected hemisphere. These results highlight that although SICI seems to be changed in the affected hemisphere in amputees, most of the studies did not investigate its clinical correlation. Thus, the question of whether they are a valid diagnostic marker remains unanswered. Also, the results were highly variable for both measurements due to the heterogeneity of study designs and group comparisons in each study. Although these results underscore the role of inhibitory networks after amputation, more studies are needed to investigate the role of a decreased inhibitory drive in the motor cortex to the cause and maintenance of PLP.

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“…Unfortunately, commonly used treatments for PN and PLP are currently diverse, unreliable, and without standardization. 19 , 37 – 39 Although respondents were familiar with most treatments in our comprehensive list, clear, distinct patterns of preferred management strategies for PN and PLP emerged. Injection, topical and surgical treatments were more commonly used for PN.…”

Section: Discussionmentioning

confidence: 99%

Managing Neuroma and Phantom Limb Pain in Ontario: The Status of Targeted Muscle Reinnervation

Letourneau

Hendry

2020

Plastic and Reconstructive Surgery - Global Open

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Background: Painful neuromas (PN) and phantom limb pain (PLP) are common following amputation and are unreliably treated, which impacts quality of life. Targeted muscle reinnervation (TMR) is a microsurgical technique that repairs the severed proximal nerve end to a redundant motor nerve in the amputated stump. Evidence supports TMR as effective in treating PN and PLP; however, its adoption has been slow. This study aimed to characterize: (1) the populations experiencing post-amputation PN/PLP; (2) current trends in managing PN/PLP; and (3) attitudes toward routine use of TMR to manage PN/PLP. Methods: A cross-sectional survey was distributed to all orthopedic surgeons, plastic surgeons, and physiatrists practicing in Ontario, via publicly available emails and specialty associations. Data were collected on demographics, experience with amputation, managing post-amputation pain, and attitudes toward routine use of TMR. Results: Sixty-six of 698 eligible participants submitted complete surveys (9.5% response rate). Respondents had a greater experience with surgical management of PN (71% PN versus 10% PLP). However, surgery was considered a 3rd-line option for PN and not an option for PLP in 57% and 59% of respondents, respectively. Thirty participants (45%) were unaware of TMR as an option, and only 8 respondents have currently incorporated TMR into their practice. Many (76%) would be willing to incorporate TMR into their practice as either an immediate or delayed surgical technique. Conclusions: Despite its promise in managing post-amputation pain, awareness of TMR as a surgical option is generally poor. Several barriers to the widespread adoption of this technique are defined.

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A review of current theories and treatments for phantom limb pain

Cited by 123 publications

References 89 publications

Motor Cortex Reorganization in Limb Amputation: A Systematic Review of TMS Motor Mapping Studies

Motor Cortex Reorganization in Limb Amputation: A Systematic Review of TMS Motor Mapping Studies

Intracortical Inhibition in the Affected Hemisphere in Limb Amputation

Managing Neuroma and Phantom Limb Pain in Ontario: The Status of Targeted Muscle Reinnervation

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