Exploring the Role of Cortical Reorganization in Postamputation Phantom Phenomena, Including Phantom Limb Pain in Lower Limb Amputees: A Cross-Sectional Study of the Patterns of Referral of Sensations into the Phantom.

BACKGROUND: Cortical reorganization and pain memory are theories to explain phantom limb pain and other postamputation phantom phenomena. This study was undertaken to identify evidence of cortical reorganization in lower limb amputees and to find evidence for the pain memory theory. METHODS: This was a qualitative interview study using structured questionnaires with lower limb amputees. Participants were asked to identify body areas and activities that stimulate postamputation phantom phenomena to confirm the cortical reorganization theory. We tested the pain memory theory by comparing traumatic amputees with surgical amputees. RESULTS: A total of 122 participants (response rate 42%) were recruited. Prevalence of postamputation phantom phenomena was similar to previous studies with phantom pain reported as 84%. Twenty (16.3%) identified body regions that could stimulate postamputation phantom phenomena and 32 (26%) identified activities that could stimulate postamputation phantom phenomena. Not all body areas or activities were related to somatotopic regions adjacent to the leg on the sensory homunculus. Overall, 47 (38.2%) exhibited attributes suggestive of cortical reorganization into areas adjacent to the leg. No associations were found between presence of pain or length of time in pain before amputation and the presence of phantom pain (p = .1-1.0). No statistical difference was found between surgical and traumatic amputees for any postamputation phantom phenomena (p = .3-1.0). CONCLUSIONS: The cortical reorganization and pain memory theories for the development and maintenance of postamputation phantom phenomena have only limited support from our data. Taking this into account, it may be worth reopening the debate on the mechanism for postamputation phantom phenomena, including phantom limb pain. The cortical reorganization theory and memory theory for the mechanism of phantom limb pain are questioned by these results. Both may play a role, but neither can explain the presence of postamputation phantom phenomena on their own.

Therapeutic opportunities when using vapocoolants for cannulation in children.

How nurses make a difference and influence outcome has been the subject of much debate over many years and is perhaps more relevant now owing to healthcare funding being a scarce commodity. Nurses need justification and validation of what they do. Nursing therapeutics is a relatively new term that can help nurses and others to appreciate the multifariousness, complexity and value of what they do. It encapsulates the means by which a nurse delivers care that is both evidence based and beneficial to his or her patients. This article highlights how nurses can make use of common nursing interventions to ensure that the full impact of their skills is embedded in their care-using the administration of vapocoolants as the focus of the discussion. It will be illustrated that through each patient contact, a nurse can establish therapeutic principles that can positively influence health outcomes.

A Clinical Evaluation of Postamputation Phenomena Including Phantom Limb Pain after Lower Limb Amputation in Dysvascular Patients.

To explore the effects of phantom phenomena on a group of dysvascular lower limb amputees. This was a cross-sectional study of dysvascular lower limb amputees. A modified version of the phantom phenomena questionnaire was used to measure the prevalence of phantom phenomena and the effects of those phenomena on daily life. Eighty-nine amputees were recruited. The majority were inpatients (72%) and male (72%). Most had pain before amputation (83%). Sixty-three percent had phantom limb pain. No associations were found between phantom limb pain and preamputation pain (p = .397). Phantom limb pain was present immediately on waking from amputation in 23%. Phantom limb pain is highly fluctuant. It is more likely that phantom limb pain was present with more time passed since amputation (p = .002). Outpatients with unhealed wounds were less likely to have phantom limb pain (p = .007). The effects of postamputation phenomena include sleep loss and social restrictions. These results challenge the belief that phantom limb pain reduces over time as more outpatients reported phantom limb pain than inpatients. Preamputation pain is not linked to the presence of phantom limb pain. The fluctuant nature of phantom limb pain makes its treatment complex. Some may wish intensity to reduce, whereas others may prefer to reduce the number of episodes or duration of each episode instead. More research is needed to clarify the needs of amputees in relation to the postamputation phenomena.

Making pain visible: an audit and review of documentation to improve the use of pain assessment by implementing pain as the fifth vital sign.

Pain has been promoted as the fifth vital sign for a decade, but there is little empirical evidence to suggest that doing so has affected the care of individuals suffering pain. This was a three-stage audit of pain assessment in one large teaching hospital in the Northwest of England. Stage one measured the baseline pain assessment activity on surgical and medical wards and identified that the pain assessment tool was not visible to nurses. Stage two redesigned the patient observation charts held at the end of the bed and piloted two versions for clinical utility. Version 2 which had pain assessment alongside the early warning score was adopted and introduced throughout the hospital. Stage three audited pain assessment and management 8 months after the introduction of the new charts. Pain was assessed more regularly at the stage three audit than at the baseline audit. On average, pain was assessed alongside other routine observations 70% of the time across surgical and medical wards. Medical wards appeared to improve their pain assessment using the philosophy of pain being the fifth vital sign better than surgical wards, because they assessed pain alongside routine observations in >90% of cases. Stage three identified that where a high pain score was recorded, analgesia was delivered in the majority of cases (88%). Introducing the philosophy of pain as the fifth vital sign and making pain assessment more visible on the patient observation chart improved the uptake of pain assessment. Pain management strategies were stimulated when high pain scores were identified.

Exploring the experiences of community first responders working in a UK ambulance service.

Background: Community first responders (CFRs) work voluntarily to support UK ambulance services by responding to emergencies. They are dispatched via the local 999 call centre and details of incidents in their local area are sent to their mobile phone. They have emergency equipment with them, including a defibrillator and oxygen, and attend a range of incidents, including cardiac arrests. Previous research has looked at the impact the CFR role has had on patient survival, but there is no previous research looking at the experiences of the CFRs while working in a UK ambulance service. Method: This study involved 10 semi-structured interviews, which took place in November and December 2018. One researcher interviewed all the CFRs using a pre-defined interview schedule. The findings of the study were analysed using thematic analysis. Results: The main themes from the study are 'relationships' and 'systems'. The sub-themes of relationships are the relationship between CFRs; the relationship between CFRs and ambulance service staff; and the relationship between CFRs and patients. The sub-themes of systems are call allocation; technology; and reflection and support. Conclusions: CFRs support one another and are encouraging with new starting members. Their relationships with ambulance service staff have improved since CFRs first became active, but there is still room for improvement. The calls that CFRs attend are not always within their scope of practice, but the rate of this occurring is unclear. CFRs are frustrated with the level of technology involved in their role and feel it impacts them attending incidents quickly. CFRs reported attending cardiac arrests on a regular basis and the support that they receive afterwards. Further research should use a survey approach to further explore the experiences of the CFRs based on the themes raised in this study. Using this methodology would identify if these themes are unique to the one ambulance service where this was conducted, or if they are relevant to all UK CFRs.

Patient satisfaction with pain relief following major abdominal surgery is influenced by good communication, pain relief and empathic caring: a qualitative interview study.

BACKGROUND: Monitoring and improving the quality of care is an ever increasing concern for health care organisations. Measuring the effectiveness of clinical outcomes is done by looking at specific markers of high quality care. Pain management is considered one of the markers of high quality care and satisfaction with pain management is a crucial and important quality assurance marker; yet, we know little about what contributes to a patient's decision about satisfaction. METHODS: A qualitative study drawing on phenomenological approach aiming to evaluate the perspective of patients experiencing post-operative pain. Patients undergoing major abdominal surgery were recruited from a Renal Transplant and Urology ward in the North of England, UK. Data were collected using in-depth semi-structured interviews and were analysed using Colaizzi's approach. RESULTS: Ten patients participated in the study and three themes emerged from the analysis. The findings of this study revealed that in order to achieve satisfaction with the management of pain, patient care has to include information delivery which is timely and adequate according to a patient's individual needs, nurses should have a caring attitude and pain should be well controlled. CONCLUSION: Satisfaction with pain management is influenced by good communication and information transfer, appropriate pain management and an empathic presence throughout.

An investigation into the effects of a virtual reality system on phantom limb pain: a pilot study.

BACKGROUND: There is no first-line treatment available for phantom limb pain (PLP). For some years, there has been interest in the use of mirrors and other techniques based on visual feedback. Unfortunately, up until now, all published studies have had methodological weaknesses with two recent systematic reviews concluding that therapies of this kind need more evidence to support their use. AIM: To evaluate the effects of a virtual reality (VR) activity on PLP. METHODS: This was a prospective pilot study of upper limb amputees using questionnaires to evaluate a VR system. Eleven participants were recruited, with nine completing all three sessions of VR. Participants undertook three sessions of VR, one a month for 3 months. Outcome measures were PLP pain intensity using an 11-point numerical rating scale (NRS), number of PLP episodes and duration of the PLP episodes. All participants were also asked for their judgement of change. Open-ended questions captured the qualitative experience of all aspects of the VR experience. RESULTS: The mean PLP pain score following three VR sessions reduced (6.11 v 3.56) but this was not a statistical difference (t = 2.1, df = 8, p = 0.07). No statistical difference was found for the number of PLP episodes (Pearson chi-square = 3.43, df = 2, p = 0.18) or the duration of each PLP episode (Pearson chi-square = 22.50, df = 16, p = 0.13). Three groups emerged: those whose pain reduced (the majority), those whose pain remained the same (small number) and one those whose pain increased slightly. DISCUSSION: There is insufficient evidence from these results to identify an effect of VR on PLP; however, this is a small group and qualitatively most were content with the treatment and wanted a longer trial.

Nursing aspects of phantom limb pain following amputation.

Phantoms (painless and painful) occur following the removal of virtually all body parts. Phantoms of the limbs, including phantom limb pain (PLP), are the most studied. As yet there is no agreed theory to explain phantom limb pain but the neuromatrix and cortical reorganization theories have come to prominence over recent years. Multiple treatment strategies have been applied to PLP; however, none of these strategies have been proven to be effective for the majority of amputees. As a result of knowledge acquired through the cortical reorganization theory, new avenues for treatment have opened up. These include pre-emption and normalization strategies which have significant nursing aspects. This article explores all of these issues and identifies the implications that they have for the nursing treatment of patients with PLP and those that are expected to develop it. This involves the care of people pre-, peri- and post-amputation. All aspects of phantoms and phantom pain need to be taken into account by nurses and other healthcare workers when planning rehabilitation packages for this group.

Introducing nursing practice to student nurses: How can we promote care compassion and empathy.

To the population nursing and caring are synonymous. Empathy and using therapeutic relationships are ways that nurses can utilise care and compassion in their practice. However health care delivery needs to be led by evidence and one way to ensure evidence-based care is delivered compassionately and with empathy is to utilise the principles of nursing therapeutics. Nursing therapeutics allows a nurse to understand how care should be delivered as well as why. This discussion paper explores the use of therapeutic relationship building, nursing therapeutics and compassionate nursing and how neophyte student nurses can be introduced into these concepts during their first practice exposure. Using clinical case-studies, role-play and reflective discussion, student nurses explore and re-evaluate assumptions, to apprise and consider their beliefs and their impulse to care. Educational dialogue encourages a connection with the patient, to the person and their humanity. The implementation of this approach is facilitated by the use of newly devised learning resources which have been formulated to frame the encounter and to enable the student to look at their interaction and develop their therapeutic approach.

A prospective study of factors associated with the presence of phantom limb pain six months after major lower limb amputation in patients with peripheral vascular disease.

UNLABELLED: Because of a lack of evidence to support any treatment for phantom limb pain (PLP), interest has turned to preventing it instead. However, like other areas of PLP research, there is little consensus regarding factors that may be associated with the development of PLP. This study was devised to identify physical and psychological factors associated with PLP development and maintenance. It was a prospective study of 59 patients listed for amputation of a lower limb due to peripheral vascular disease. Each was interviewed before amputation, and the survivors were reinterviewed 6 months afterward. Pain and coping style were the primary outcome measures. The use of high levels of passive coping strategies (P = .001), especially catastrophizing (P = .02) before amputation, were found to be associated with PLP development. Pain was only weakly associated with the presence of PLP 6 months after amputation. The ability to move the phantom (P = .01) and stump pain (P = .01) were postamputation factors associated with PLP. The complexity of the relationship between previous pain and coping style and the development of PLP is discussed alongside aspects of pain memory. Pre-emptive treatment of PLP will need to include psychological as well as physical interventions. PERSPECTIVE: During this study, preamputation passive coping (especially catastrophizing) was found to be associated with the development of PLP. This knowledge will help researchers and clinicians to identify future targets for pre-emption of this condition because once established, PLP is difficult to treat.

A review of the management of phantom limb pain: challenges and solutions.

BACKGROUND: Phantom limb pain (PLP) occurs in 50% and 80% of amputees. Although it is often classified as a neuropathic pain, few of the large-scale trials of treatments for neuropathic pain included sufficient numbers of PLP sufferers to have confidence that they are effective in this condition. Many therapies have been administered to amputees with PLP over the years; however, as of yet, there appears to be no first-line treatment. OBJECTIVES: To comprehensively review the literature on treatment modalities for PLP and to identify the challenges currently faced by clinicians dealing with this pain. METHOD: MEDLINE, EMBASE, CINAHL, British Nursing Index, Cochrane and psycINFO databases were searched using "Phantom limb" initially as a MeSH term to identify treatments that had been tried. Then, a secondary search combining phantom limb with each treatment was performed to find papers specific to each therapy. Each paper was assessed for its research strength using the GRADE system. RESULTS: Thirty-eight therapies were identified. Overall, the quality of evidence was low. There was one high-quality study which used repetitive transcutaneous magnetic stimulation and found a statistical reduction in pain at day 15 but no difference at day 30. Significant results from single studies of moderate level quality were available for gabapentin, ketamine and morphine; however, there was a risk of bias in these papers. Mirror therapy and associated techniques were assessed through two systematic reviews, which conclude that there is insufficient evidence to support their use. CONCLUSION: No decisions can be made for the first-line management of PLP, as the level of evidence is too low. Robust studies on homogeneous populations, an understanding of what amputees consider a meaningful reduction in PLP and agreement of whether pain intensity is the legitimate therapeutic target are urgently required.

Nurses' in the multi-professional pain team: a study of attitudes, beliefs and treatment endorsements.

BACKGROUND AND AIM: It is widely accepted that chronic pain is best treated by a multidisciplinary team. Team approaches are best facilitated if all members understand their own and each others role. Roles and responsibilities have inherent values and beliefs which need to be understood if the team is going to function optimally. Little is known about the attitudes and beliefs of the pain team or the individual professionals within it. All members of the pain team therefore need to critically examine the values and beliefs they bring to these teams. The aim of this study was to start this process for nurses. This was done uniquely by: finding out what components of pain management nurses endorse as important; investigating their beliefs about pain management; and exploring whether nurses' beliefs differ in relation to other service providers. METHOD: Data from 103 nurses was extracted from a wider research study of the congruence between what service providers and service users believe to be important treatments for chronic pain. Nurses were surveyed regarding their opinions about which specific treatments or treatment components they would endorse for people with chronic pain. Skevington's Beliefs About Pain Control Questionnaire (BPCQ) was also included. This measured beliefs in three crucial areas; the internal or personal control of pain, beliefs that powerful others (doctors) control pain and beliefs that pain is controlled by chance events. Statistical comparisons were made between nurses who endorsed particular treatments and their belief pattern. Differences between nurses and other professionals and service users were explored. RESULTS: The study showed that nurses were high treatment endorsers. There was universal agreement to the importance of 'The nurse', 'The multidisciplinary team', 'relaxation', and 'psychological assessment' for chronic pain management'. Nurses' endorsement patterns were different to the other professionals, because they endorsed more treatments. BPCQ scores were consistently lower than the other professionals and the service users. CONCLUSIONS: The findings of this study are congruent with emerging literature highlighting the complexity of health care. The high endorsement patterns seen in this study could be taken as support that nurses are, either tacitly or overtly, aware of this need to approach pain management in an open-minded and flexible manner.

Incidence of phantom phenomena including phantom limb pain 6 months after major lower limb amputation in patients with peripheral vascular disease.

OBJECTIVES: Contentions exist regarding the true incidence of phantom limb pain (PLP) and other associated post-amputation phenomena. Recognizing and understanding these phenomena would assist in the rehabilitation of amputees. This study was designed to investigate all post-amputation phenomena in a homogenous group of amputees. METHODS: Prospective amputees were recruited prior to amputation of a lower limb due to peripheral vascular disease. All survivors were followed 6 months after surgery and interviewed to identify post-amputation phenomena, including phantom sensations, PLP, and stump pain. RESULTS: Sixty amputees were recruited and 52 survived until the 6-month interview. Phantom sensations were universal, and aspects of the non-painful phenomena, including kinetic, kinesthetic, and exteroceptive components, were identified at varying rates within the sample. PLP was found in 78.8% of the survivors, and 51.2% had stump pain. Super-added phenomena occurred in 15.4%. Links were found between PLP and stump pain (P=0.01) and PLP and the ability to move the phantom (P=0.01). No link was found between PLP and telescoping of the phantom (P=0.47). CONCLUSIONS: Phantom phenomena are associated with many myths. This study starts to unravel myth from fact, but further study is required before this enigmatic condition and its influence on rehabilitation are fully understood.

Nursing therapeutics: Teaching student nurses care, compassion and empathy.

BACKGROUND: Debate continues regarding whether humanitarian values such as care and compassion can be taught or are innate in individuals who wish to become nurses. OBJECTIVES: To undertake a discursive review of the literature on caring, compassion and empathy. To understand the teaching and learning issues associated with these concepts. To design and implement an Undergraduate Unit of study which addresses the development of caring, compassion and empathy in student nurses. METHODS/DATA SOURCES: MEDLINE, CINAHL, and a wide range of literature including books and governmental reports were used for a discursive narrative review. RESULTS: Caring, compassion and empathy are ill-defined; however healthcare users are clear that they know when nurses use skills and attitudes associated with these concepts. Evidence is available to show that caring, compassion and empathy can be taught and there are tools available to measure them in neophytes through their training. Central to the androgogical embedding of these concepts into nursing curricula is the development of therapeutic relationships. CONCLUSIONS: It is possible to develop materials to enable student nurses to learn how to care using compassion and empathy. Nursing therapeutics is a term devised to describe how student nurses can exploit the therapeutic potential of any patient contact especially when related to specific and routine nursing interventions. Muetzel's model for understanding therapeutic relationships is one framework that can be adopted to help student nurses to appreciate how to build patient relationships and encourage them to move towards therapeutic advantage using care, compassion and empathy.

Adherence to ocular hypotensive therapy: patient health education needs and views on group education.

BACKGROUND: In this study the authors sought both to understand the health education needs of patients with glaucoma, with particular regard to adherence to glaucoma treatment, and to examine these patients' views of group education. METHODS: Using a health promotion approach to health education, 27 qualitative interviews with new and established patients receiving glaucoma treatment were conducted. Health promotion is defined as a way of strengthening people's capacities to control and optimize their own health. The interviews were transcribed and were then analyzed thematically RESULTS: NINE CATEGORIES OF HEALTH EDUCATION NEEDS WERE IDENTIFIED FROM THE TRANSCRIPTS: (1) to understand glaucoma; (2) to understand their diagnosis or understand the difficulties in giving a diagnosis; (3) to understand the implications of eye drops, their side effects, and how to renew the eye drops; (4) to feel confident to put in eye drops; (5) to put the condition into perspective - to know how to manage their risk; (6) to be able to ask questions of clinicians; (7) to be able to navigate the health care system; (8) to understand and be able to manage own adherence behavior; and (9) to know where to access other sources of information. The majority of patients had something positive to say about group education, and about half of the patients said they would attend group education if they were offered the opportunity. CONCLUSION: A health promotion approach identified a wide range of patient-centered health education needs regarding adherence to glaucoma treatment. Group education will be attractive to some patients. Clinicians could use the health education needs identified in this study to guide the development of either individual or group-based educational intervention to improve adherence to glaucoma treatment. However, clinicians need to be aware that when developing a group intervention, attention will need to be given to making the education relevant to the circumstances of each patient.

A study to assess the feasibility of undertaking a randomized controlled trial of adherence with eye drops in glaucoma patients.

BACKGROUND: Adherence with therapy could influence the progression of glaucoma and ultimately affect the onset of visual impairment in some individuals. This feasibility study evaluated the measures to be used for a future randomized controlled trial assessing the effects of group-based education on adherence with eye drops. METHODS: People diagnosed with glaucoma within the previous 12 months attending a regional ophthalmology clinic in the North West of England were recruited. A two-session education program delivered one week apart had been devised as part of a previous project. A combined adult learning and health needs approach to education was taken. Outcomes measured were knowledge of glaucoma, self-report of adherence, illness perception, beliefs about medicines, patient enablement, and general health (Short Form-12). Adherence was also measured objectively using a Medical Events Monitoring System device. RESULTS: Twenty-six participants consented to undertake the educational program and 19 produced analyzable data. Knowledge of glaucoma, illness perception, beliefs about medicine, and patient enablement all showed statistically significant improvements after education. Mean adherence with eye drops was maintained above 85% before and for 3 months after attendance at the educational program. Self-report exaggerated adherence by at least 10% when compared with the objective Medical Events Monitoring System data, and in fact the kappa agreement was zero. CONCLUSION: All questionnaires other than the Short Form-12 were considered to be valuable measures and use of a Medical Events Monitoring System device was considered to be an objective surrogate measure for adherence with eye drops. A multicenter, randomized, controlled equivalence trial of group versus individualized education using adherence as the primary outcome is the next step.

Re-thinking pain educational strategies: Pain a new model using e-learning and PBL.

Despite some high profile reorganisation including the introduction of acute pain teams, many patients still experience unnecessary pain. Traditional teaching and learning strategies seem to have made little impact in clinical practice. This paper explores the possible reasons for this and identifies the need to help postregistration students transfer (re-contextualise) what they are learning to practice. A new, more flexible pain management module utilising a blended face to face/e-learning approach within a problem-based learning philosophy was introduced to increase knowledge in pain management whilst also attempting to overcome the barriers to knowledge transfer into practice. This is done by challenging attitudes and encouraging students to explore their clinical practice alongside theoretical concepts.

Sucrose analgesia: identifying potentially better practices.

OBJECTIVE: The objectives of this study were to review the use of oral sucrose for procedural pain management in NICUs, develop potentially better practice guidelines that are based on the best current evidence, and provide ideas for the implementation of these potentially better practices. METHODS: A collaboration of 12 centers of the Vermont Oxford Network worked together to review the strength of the evidence, clinical indications, dosage, administration, and contraindications and identify potential adverse effects for the use of sucrose analgesia as the basis of potentially better practices for sucrose analgesia guidelines. Several units implemented the guidelines. RESULTS: Through reviews and inputs from all centers of the evidence, consensus was reached and guidelines that included indication, dosage per painful procedure, age-related dosage over 24 hours, method of delivery, and contraindications were developed. CONCLUSIONS: Guidelines now are available from a consensus group, and suggestions for implementation of guidelines, based on implementation of other pain management strategies, were developed.