Managing acute phantom limb pain with transcutaneous electrical nerve stimulation: a case report.

INTRODUCTION: Phantom limb pain is characterized by painful sensations in the amputated limb. The clinical presentation of acute phantom limb pain may differ from that of patients with chronic phantom limb pain. The variation observed implies that acute phantom limb pain may be driven by peripheral mechanisms, indicating that therapies focused on the peripheral nervous system might be successful in reducing pain. CASE PRESENTATION: A 36-year-old African male with acute phantom limb pain in the left lower limb, was treated with transcutaneous electrical nerve stimulation. CONCLUSION: The assessment results of the presented case and the evidence on acute phantom limb pain mechanisms contribute to the current body of literature, indicating that acute phantom limb pain presents differently to chronic phantom limb pain. These findings emphasize the importance of testing treatments that target the peripheral mechanisms responsible for phantom limb pain in relevant individuals with acquired amputations.

Treatment Recommendations for Phantom Limb Pain in People with Amputations: An Expert Consensus Delphi Study.

BACKGROUND: Phantom limb pain (PLP) is common and often accompanied by serious suffering. Current systematic-review evidence suggests that recommended treatments are no more effective than placebo for reducing PLP. Given the difficulty in conducting a meta-analysis for nonpharmacological treatments and the weak evidence for pharmacological treatments for PLP, consensus on the first-line management of PLP needs to be reached using alternative methods. OBJECTIVE: To reach expert consensus and make recommendations on the effective management of PLP. DESIGN: A three-round Delphi design was used. SETTING: The study was conducted using e-mail and Google survey tool as the main methods of communication and providing feedback. PARTICIPANTS: The study included 27 clinicians and researchers from various health disciplines who are experts in PLP management. METHOD: Data were collected using three sequential rounds of anonymous online questionnaires where experts proposed and ranked the treatments for PLP. A consensus was reached on the treatments that were endorsed by 50% or more of the experts. RESULTS: Thirty-seven treatments were proposed for the management of PLP at the beginning of the study. Consensus was reached on seven treatments that were considered effective for managing PLP and on two treatments that were considered ineffective. Graded motor imagery, mirror therapy, amitriptyline, sensory discrimination training, and use of a functional prosthesis were endorsed by most experts because of the available backing scientific evidence and their reported efficacy in clinical practice. Cognitive behavioral therapy and virtual reality training were endorsed by most experts because of their reported efficacy in clinical practice despite indicating a dearth of scientific evidence to support their ranking. Citalopram and dorsal root ganglion pulsed radiofrequency were rejected owing to a lack of relevant scientific evidence. CONCLUSION: The results of this study suggest that the nonpharmacological treatments endorsed in this study may have an important role in the management of PLP.

The effectiveness of graded motor imagery for reducing phantom limb pain in amputees: a randomised controlled trial.

OBJECTIVE: To investigate whether graded motor imagery (GMI) is effective for reducing phantom limb pain (PLP) in people who have undergone limb amputations. DESIGN: A single-blinded randomised, controlled trial. SETTING: Physiotherapy out-patient departments in three secondary level hospitals in Cape Town, South Africa. PARTICIPANTS: Twenty-one adults (≥18 years) who had undergone unilateral upper or lower limb amputations and had self-reported PLP persisting beyond three months. INTERVENTIONS: A 6-week GMI programme was compared to routine physiotherapy. The study outcomes were evaluated at baseline, 6 weeks, 3 months and 6 months. OUTCOME MEASURES: The pain severity scale of the Brief Pain Inventory (BPI) was used to assess the primary outcome - PLP. The pain interference scale of the BPI and the EuroQol EQ-5D-5L were used to assess the secondary outcomes - pain interference with function and health-related quality of life (HRQoL) respectively. RESULTS: The participants in the experimental group had significantly greater improvements in pain than the control group at 6 weeks and 6 months. Further, the participants in the experimental group had significantly greater improvements than the control group in pain interference at all follow-up points. There was no between-group difference in HRQoL. CONCLUSION: The results of the current study suggest that GMI is better than routine physiotherapy for reducing PLP. Based on the significant reduction in PLP and pain interference within the participants who received GMI, and the ease of application, GMI may be a viable treatment for treating PLP in people who have undergone limb amputations. CLINICAL TRIAL REGISTRATION NUMBER: (PACTR201701001979279).

The effects of graded motor imagery and its components on phantom limb pain and disability in upper and lower limb amputees: a systematic review protocol.

BACKGROUND: Phantom limb pain (PLP) is characterized by the anatomical shifting of neighbouring somatosensory and motor areas into a deafferented cortical area of the brain contralateral to the amputated limb. It has been shown that maladaptive neuroplasticity is positively correlated to the perception of PLP in amputees. Recent studies support the use of graded motor imagery (GMI) and its component to alleviate the severity of PLP and disability. However, there is insufficient collective empirical evidence exploring the effectiveness of these treatment modalities in amputees with PLP. This systematic review will therefore explore the effects of GMI and its individual components on PLP and disability in upper and lower limb amputees. METHODS: We will utilize a customized search strategy to search PubMed, Cochrane Central register of Controlled Trials, MEDLINE, Embase, PsycINFO, PEDro, Scopus, CINAHL, LILACS, DARE, Africa-Wide Information and Web of Science. We will also look at clinicaltrials.gov ( http://www.clinicaltrials.gov/ ), Pactr.gov ( http://www.pactr.org/ ) and EU Clinical trials register ( https://www.clinicaltrialsregister.eu/ ) for ongoing research. Two independent reviewers will screen articles for methodological validity. Thereafter, data from included studies will be extracted by two independent reviewers through a customized pre-set data extraction sheet. Studies with a comparable intervention and outcome measure will be pooled for meta-analysis. Studies with high heterogeneity will be analysed through random effects model. A narrative data analysis will be considered where there is insufficient data to perform a meta-analysis. DISCUSSION: Several studies investigating the effectiveness of GMI and its different components on PLP have drawn contrasting conclusions regarding the efficacy and applicability of GMI in clinical practice. This systematic review will therefore gather and critically appraise all relevant data, to generate a substantial conclusion and recommendations for clinical practice and research on this subject. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016036471.