Psychological and Physical Health in Military Amputees During Rehabilitation: Secondary Analysis of a Randomized Controlled Trial.

BACKGROUND: Service members who have experienced combat trauma with resulting amputation are at risk for compromised quality of life postamputation. Monitoring mental and physical health in amputees returning from the war is of paramount importance. This study examined changes in physical and mental health-related quality of life in service members following traumatic unilateral, transtibial amputation (TTA) during a 12-week period of rehabilitation before and after receiving a prosthesis. METHOD: This study is a secondary analysis from a randomized controlled trial (RCT) of military service members starting Military Amputee Rehabilitation Program (MARP) following a traumatic TTA. The study examined change in SF-36 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores as two aspects of health-related quality of life. Forty-four injured service members, aged 19 to 46, were recruited into the RCT. Participants were randomized into 12 weeks of MARP plus home neuromuscular electrical stimulation therapy (n = 23) or MARP alone (N = 21) and compared at baseline, 6, and 12 weeks on: SF-36 PCS and MCS scores. Linear mixed models examined time and group differences and their interaction for the MCS and PCS scores. A multivariate mixed model tested whether MCS and PCS scores differed. RESULTS: For the combined rehabilitation cohort, MCS did not differ over 12 weeks (p = 0.27) with scores at week 0 of M = 56.7 (SD = 11.9) and at week 12 of M = 52.7 (SD = 11.4), similar to healthy controls (age = 25-34, M = 51.0, SD = 7.6). Scores did not differ between treatment groups (p = 0.28) with no group by time interaction (p = 0.34). The MCS significantly declined over time (p = 0.05) after adjustment for covariates. PCS improved over 12 weeks (p < 0.0001) in the total rehabilitation group with scores at week 0 of M = 34.0 (SD = 8.1) to M = 41.8 (SD = 8.4) at week 12, significantly lower than healthy controls (age = 25-34, M = 54.1, SD = 6.6). Scores did not differ between treatment groups (p = 0.89), and there was no group by time interaction (p = 0.34). An interaction between the PCS and MCS was observed such that the PCS improved over time, whereas the MCS did not significantly change (p = 0.0005). DISCUSSION: War-injured transtibial amputees are at risk for compromised quality of life during rehabilitation. Self-perceived physical health improved as might be expected from rehabilitation. Self-perceived mental health did not. During rehabilitation, physical healing, psychological adjustment, and lifestyle adaptation are occurring simultaneously. However, more attention may need to be directed toward mental health during rehabilitation.

Effective local anesthesia for onabotulinumtoxin A injections to treat hyperhidrosis associated with traumatic amputation.

BACKGROUND: Botulinum toxin type A (BTX-A) injections are an effective treatment for controlling hyperhidrosis at sites of amputation. Hyperesthesia associated with amputated limbs is a major barrier to performing this procedure under local anesthesia. OBJECTIVE: To present a novel method for improving local anesthesia with BTX-A injections. Methods & RESULTS: A 29-year-old military veteran with a below-the-knee amputation of his right leg was suffering from amputation site hyperhidrosis, which was impeding his ability to comfortably wear a prosthesis. Prior to presenting to our clinic, the patient received one treatment of BTX-A injections to his amputation stump while under general anesthesia for surgical repair of trauma-related injuries. In our dermatology clinic, we repeated the procedure using topical lidocaine-prilocaine (30 gm total) for local anesthesia. This provided effective relief of hyperhidrosis for 6 months, but the procedure was very painful (9/10 intensity). We repeated the same procedure 6 months later, using ice in addition to topical lidocaine-prilocaine (30 gm) for local anesthesia; this resulted in reduced pain (3/10 intensity) for the patient. CONCLUSIONS: We suggest using ice in combination with a topical anesthetic as an effective method for pain control that avoids general anesthesia in treating amputation-associated hyperhidrosis.

Elution of antibiotics from poly(methyl methacrylate) bone cement after extended implantation does not necessarily clear the infection despite susceptibility of the clinical isolates.

Chronic orthopedic infections are commonly caused by bacterial biofilms, which are recalcitrant to antibiotic treatment. In many cases, the revision procedure for periprosthetic joint infection or trauma cases includes the implantation of antibiotic-loaded bone cement to kill infecting bacteria via the elution of a strong local dose of antibiotic(s) at the site. While many studies have addressed the elution kinetics of both non-absorbable and absorbable bone cements both in vitro and in vivo, the potency of ALBC against pathogenic bacteria after extended implantation time is not clear. In this communication, we use two case studies, a Viridans streptococci infected total knee arthroplasty (TKA) and a MRSA-polymicrobial osteomyelitis of a distal tibial traumatic amputation (TA) to demonstrate that an antibiotic-loaded poly(methyl methacrylate) (ALPMMA) coated intermedullary rod implanted for 117 days (TKA) and three ALPMMA suture-strung beads implanted for 210 days (TA) retained killing ability against Pseudomonas aeruginosa and Staphylococcus aureus in vitro, despite different clinical efficacies. The TKA infection resolved and the patient progressed to an uneventful second stage. However, the TA infection only resolved after multiple rounds of debridement, IV vancomycin and removal of the PMMA beads and placement of vancomycin and tobramycin loaded calcium sulfate beads.

Disordered conditioned pain modulation system in patients with posttraumatic cold intolerance.

BACKGROUND: Conditioned pain modulation (CPM) is a phenomenon of 'pain inhibiting pain' that is important for understanding idiopathic pain syndromes. Because the pathophysiology of posttraumatic cold intolerance is still unknown but it could involve similar mechanisms as idiopathic pain syndromes, we evaluated the functioning of the CPM system in patients with posttraumatic cold intolerance compared to healthy controls. METHODS: Fourteen healthy controls and 24 patients diagnosed with cold intolerance using the Cold Intolerance Symptom Severity questionnaire were included in the study. Of the 24 patients with cold intolerance, 11 had a nerve lesion and 13 an amputation of one or more digits. To quantify the CPM, pain threshold for mechanical pressure was measured at the affected region as a baseline measure. Then, the contralateral hand received a cold stimulus of ice water to evoke the noxious conditioning. After the cold stimulus, the pain threshold for mechanical pressure was determined again. RESULTS: The absolute and relative changes in algometer pressure (CPM effect) between pre- and post-conditioning were significantly smaller in the cold intolerance group compared to the control group (absolute p = 0.019, relative p = 0.004). The CPM effect was significantly different between the control group and the subgroups of nerve lesion (p = 0.003) and amputation patients (p = 0.011). CONCLUSIONS: In this study, we found a CPM effect after a cold stimulus in both controls and patients. A significant weaker CPM effect compared to the controls was found, as in other chronic pain conditions. The CPM system within patients with cold intolerance is altered.

Training with virtual visual feedback to alleviate phantom limb pain.

BACKGROUND: Performing phantom movements with visual virtual feedback, or mirror therapy, is a promising treatment avenue to alleviate phantom limb pain. However the effectiveness of this approach appears to vary from one patient to another. OBJECTIVE: To assess the individual response to training with visual virtual feedback and to explore factors influencing the response to that approach. METHODS: Eight male participants with phantom limb pain (PLP) resulting from either a traumatic upper limb amputation or a brachial plexus avulsion participated in this single case multiple baseline study. Training was performed 2 times per week for 8 weeks where a virtual image of a missing limb performing different movements was presented and the participant was asked to follow the movements with his phantom limb. RESULTS: Patients reported an average 38% decrease in background pain on a visual analog scale (VAS), with 5 patients out of 8 reporting a reduction greater than 30%. This decrease in pain was maintained at 4 weeks postintervention in 4 of the 5 participants. No significant relationship was found between the long-term pain relief and the duration of the deafferentation or with the immediate pain relief during exposure to the feedback. CONCLUSIONS: These results support the use of training with virtual feedback to alleviate phantom limb pain. Our observations suggest that between-participant differences in the effectiveness of the treatment might be related more to a difference in the susceptibility to the virtual visual feedback, than to factors related to the lesion, such as the duration of the deafferentation.

The experience of phantom limb pain in patients with combat-related traumatic amputations.

OBJECTIVES: To describe the prevalence and characteristics of phantom limb pain (PLP) and the use and perceived effectiveness of standard medical and self-treatment methods by traumatic amputees with combat-related injuries. DESIGN: A retrospective descriptive questionnaire study. SETTING: Outpatient amputee clinic at a major military medical center. PARTICIPANTS: Convenience sample of military members (N=30) with single or multiple traumatic amputations from combat and/or training. Inclusion criteria were 18 to 50 years old and amputation within 5 years of the study. Exclusion criteria were nontraumatic amputees and amputation or most recent surgical revision within 3 months before the study. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The primary dependent variables were pain and relief, as measured by an investigator-developed questionnaire. RESULTS: Seventy-seven percent of participants experienced PLP at some time since their amputation. Of those with PLP, the mean average intensity was 3.3+/-2.0 out of 10 and the mean worst intensity was 5.4+/-2.6 out of 10. The PLP was intermittent, and 78% reported episodes of PLP at least weekly. Sixty-eight percent of participants with PLP were receiving treatment from their health care providers. The most common medical treatment was gabapentin, although some patients reported greater pain relief from self-treatment methods such as distraction and relaxation techniques. CONCLUSIONS: With over 750 service members living with amputations from recent combat, PLP will continue to be a troubling problem that requires effective interventions. The discrepancy between perceived effectiveness of different treatment types supports the need for highly individualized pain management plans.

EMDR in the treatment of chronic phantom limb pain.

OBJECTIVE: Little research substantiates long-term gains in the treatment of phantom limb pain. This report describes and evaluates an eye movement desensitization and reprocessing (EMDR) treatment with extensive follow-up. DESIGN: A case series of phantom limb pain patients. Setting. In-patient hospitalization and out-patient private practice. PATIENTS: Case series of five patients with phantom limb pain ranging from 1 to 16 years. All patents were on extensive medication regimens prior to EMDR. INTERVENTIONS: Three to 15 sessions of EMDR were used to treat the pain and the psychological ramifications. OUTCOME MEASURES: Patients were measured for continued use of medications, pain intensity/frequency, psychological trauma, and depression. RESULTS: EMDR resulted in a significant decrease or elimination of phantom pain, reduction in depression and posttraumatic stress disorder (PTSD) symptoms to subclinical levels, and significant reduction or elimination of medications related to the phantom pain and nociceptive pain at long-term follow-up. CONCLUSIONS: The overview and long-term follow-up indicate that EMDR was successful in the treatment of both the phantom limb pain and the psychological consequences of amputation. The latter include issues of personal loss, grief, self-image, and social adjustment. These results suggest that (1) a significant aspect of phantom limb pain is the physiological memory storage of the nociceptive pain sensations experienced at the time of the event and (2) these memories can be successfully reprocessed. Further research is needed to explore the theoretical and treatment implications of this information-processing approach.

Pain management in the traumatic amputee.

Traumatic amputees may experience a variety of acute and chronic pain issues, including phantom limb pain and residual limb pain. Research continues to determine the causes of these problems and to find the most appropriate and effective treatments for each of these phenomena. It is important for health care providers to be knowledgeable about the variety of treatments available, including medications, surgical procedures, complementary and alternative therapies, and self-treatment methods to ensure that amputees receive the best practices for individualized, effective pain management that they deserve.

Colistin, meropenem and rifampin in a combination therapy for multi-drug-resistant Acinetobacter baumannii multifocal infection. A case report.

A 16 year-old girl underwent a multifocal (lungs, skin, soft tissues) infection due to multiresistant Acinetobacter baumannii after a car crash. To treat such a severe disease we used a combination therapy of colistin (2 millions Units twice/day), rifampicin (600 mg/day), meropenem (1 g 3 times a day) after a synergistic activity test was performed (checkerboard method on Mueller-Hinton broth and 5x10(5) cfu/mL inoculum). After 24 days, when a significant clinical improvement was gained, the 3-drugs combination therapy was replaced with i.v. levofloxacin 500 mg twice/day but, after 10 days of quinolones therapy, fever started again and the same multidrug resistant (MDR) A. baumannii was isolated from the skin grafts, central venous catheter tip and bronchial alveolar lavage. A combination therapy with colistin and meropenem was therefore started and definitive defervescence was obtained after 10 days. This therapy was continued for 70 days even if the patient was apyretic because A. baumannii was still present in the skin secretions. After 109 days of hospitalization in our intensive care unit, the patient was transferred to a rehabilitative unit. This case shows how useful is, in selected cases, rediscovering old antibiotic drugs, specially when they are adopted as a combination therapy, and highlights the importance of the clinical microbiological laboratory as it may help clinicians in choosing the best drugs combination.

The psychosocial effects of landmines in Cambodia.

The widespread use of landmines in conflict situations around the world and their continuing legacy for the civilian population in injuries, amputations, disabilities and economic costs has been recognized as a major problem. However, the psychosocial consequences for landmine victims are still to be realized. Although there are some facilities for the medical, orthopaedic and long-term rehabilitative care of landmine victims, hardly any exist for their psychosocial needs. This study considers the mental costs in terms of post-traumatic stress disorder, depression and anxiety. Individual difficulty in relationships and daily functioning is considerable, and the landmine victim faces social stigmatization, rejection and unemployment. Suggestions are made for brief training in relatively simple mental health care for staff working in already functioning programmes.

[Effect of TRH and buzhong yiqi tang on natural killer cell activity and endocrine in stress mice].

Both thyrotropin-releasing hormone (TRH) and Buzhong Yiqi tang (BZYQT) were studied on their effect on splenic natural killer (NK) activity and hypothalamic-hypophyseal-thyroid (HHT) axis of stress mice. TRH (0.2 microgram/mouse/day, ip.) and BZYQT (0.2g/mouse/day, po.) had been given for 3 days before the amputation of right hind leg of mice were performed. Result showed that the TRH and BZYQT had rarely any effect on splenic NK activity and HHT axis recovery when they were used separately, but when used in combination they could increase the NK activity of splenic cells significantly in comparing with control group (from 8.32 +/- 4.50% to 15.60 +/- 4.18%, P < 0.05), while the HHT axis recovered to normal level at 24 hours after the amputation. The result suggests that there was a synergistic effect between TRH and BZYQT, and which exerted beneficial effect to the HHT axis stabilization and splenic NK activity recovery.

Acupuncture in phantom limb pain.

A case of a 36-year-old man, with a history of traumatic amputation below the elbow on the left side, resulting in intractable phantom limb pain, is described. The patient failed to respond to a variety of medications including several analgesics, tranquilizers, and a beta-blocker. Other extended series of conventional treatment modalities, which included stellate ganglion and peripheral nerve blocks and neuromal excision with the anterior transposition of the ulnar nerve, did not relieve the pain. Acupuncture was then attempted with the subjective relief of phantom limb pain and the objective result that the patient could wear a prosthesis.

[Hyperbaric oxygenation in the prevention of wound infection in open injury to the locomotor apparatus]. / Giperbaricheskaia oksigenatsiia v profilaktike ranevoi infektsii pri otkrytoi travme oporno-dvigatel'nogo apparata.

Hyberbaric oxygenation in altitude chambers OKA-MT was used in the complex of prophylactic measures against wound infection in 91 patients with open traumas of the extremities (fractures, amputations, etc.). The effect of hyperbaric oxygenation on the external respiration was studied by the method of spirography. Tetrapolar rheography was used to follow the central hemodynamics. A number of immune parameteres were also studied. Hyperbaric oxygenation was established to abolish hyperventilation and myocardium hyperdynamia, to accelerate the recovery of the neutrophil phagocytic activity and immunoglobulin level, to contribute to the quicker diminishing of edema in the wound area and healing of the stump and open fracture without suppuration, early formation of dry necrosis with a distinct line of demarcation.