The profile of people undergoing lower limb amputations at Groote Schuur Hospital.

Background: The annual incidence of lower limb amputations (LLA) at Groote Schuur Hospital is rising gradually. However, little is known about the sociodemographic and clinical profiles of people undergoing these limb amputations. Objectives: To collect and analyse data to describe the sociodemographic, health and amputation profiles of people who have undergone LLA at Groote Schuur Hospital. Method: A descriptive retrospective chart review was conducted using a sample of 107 participants who had undergone LLA at Groote Schuur Hospital between January 2019 and July 2020. A customised assessment tool was used to extract data on the sociodemographic, health and amputation profiles of patients who had LLA. Data were analysed descriptively. Results: Sixty per cent of the patients who had undergone LLA at Groote Schuur Hospital were women. Most of the patients were over the age of 60 years and had not completed school and were pensioners or unemployed, with very low income and multiple co-morbidities including poorly controlled diabetes. Conclusions: Complications because of uncontrolled diabetes were the primary indication for LLAs at Groote Schuur Hospital. Therefore, health literacy projects are indicated to address chronic diseases of lifestyle, which, in turn, may reduce the overall burden of LLA, particularly on the South African under-resourced healthcare system. Contribution: The results of this study may help us identify key factors that predispose patients to LLAs. Consequently, this may help us identify key areas for prevention and better management of diseases that can result in complications that indicate the need for amputation.

The prevalence and risk factors for phantom limb pain: a cross-sectional survey.

BACKGROUND: We previously performed a systematic review and meta-analysis which revealed a Phantom Limb Pain (PLP) prevalence estimate of 64% [95% CI: 60.01-68.1]. The prevalence estimates varied significantly between developed and developing countries. Remarkably, there is limited evidence on the prevalence of PLP and associated risk factors in African populations. METHODS: Adults who had undergone limb amputations between January 2018 and October 2022 were recruited from healthcare facilities in the Western and Eastern Cape Provinces. We excluded individuals with auditory or speech impairments that hindered clear communication via telephone. Data on the prevalence and risk factors for PLP were collected telephonically from consenting and eligible participants. The prevalence of PLP was expressed as a percentage with a 95% confidence interval. The associations between PLP and risk factors for PLP were tested using univariate and multivariable logistic regression analyses. The strength of association was calculated using the Odds Ratio where association was confirmed. RESULTS: The overall PLP prevalence was 71.73% [95% CI: 65.45-77.46]. Persistent pre-operative pain, residual limb pain, and non-painful phantom limb sensations were identified as risk factors for PLP. CONCLUSION: This study revealed a high prevalence of PLP. The use of effective treatments targeting pre-amputation pain may yield more effective and targeted pre-amputation care, leading to improved quality of life after amputation.

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.

The Efficacy of Graded Motor Imagery and Its Components on Phantom Limb Pain and Disability: A Systematic Review and Meta-Analysis.

Introduction: Graded Motor Imagery (GMI) is a non-invasive and inexpensive therapy used to treat Phantom Limb Pain (PLP) by sequentially activating motor networks in such a way that movement and pain are unpaired. The objective of this systematic review was to critically appraise relevant data on the efficacy of GMI and its components for reducing PLP and disability in amputees. Methods: We searched 11 electronic databases for controlled trials investigating GMI and its components in amputees with PLP from inception until February 2023. Two reviewers independently screened studies and extracted relevant data. Study-level data were entered using the inverse variance function of the Review Manager 5 and pooled with the random effects model. Results: Eleven studies with varying risk of bias were eligible. No eligible study considered left/right judgement tasks in isolation. Studies showed no effect for imagined movements, but positive effects were seen for GMI [weighted mean difference: -21.29 (95%CI: -31.55, -11.02), I2= 0%] and mirror therapy [weighted mean difference: -8.55 (95%CI: -14.74, -2.35, I2= 61%]. A comparison of mirror therapy versus sham showed no difference [weighted mean difference: -4.43 (95%CI: -16.03, 7.16), I2= 51%]. Conclusion: Our findings suggest that GMI and mirror therapy may be effective for reducing PLP. However, this conclusion was drawn from a limited body of evidence, and the certainty of the evidence was very low. Therefore, rigorous, high-quality trials are needed to address the gap in the literature and inform practice.

Contexte: L'imagerie motrice graduelle (IMG) est un traitement non invasif et peu coûteux utilisé pour traiter la douleur du membre fantôme par activation séquentielle des réseaux moteurs de manière à ce que le mouvement et la douleur soient dissociés. L'objectif de cette revue systématique était d'évaluer de manière critique les données sur l'efficacité de l'IMG et de ses composantes pour réduire la douleur du membre fantôme et l'invalidité chez les amputés.Méthodes: Nous avons effectué des recherches dans 11 bases de données électroniques afin d'y repérer des essais contrôlés portant sur l'utilisation de l'IMG et de ses composantes auprès des amputés atteints de douleur du membre fantôme depuis le début jusqu'en février 2023. Deux évaluateurs indépendants ont examiné les études et extrait les données pertinentes Les données au niveau de l'étude ont été saisies à l'aide de la fonction de variation inverse de Review Manager 5 et regroupées selon un modèle à effets aléatoires.Résultats: Onze études présentant un risque de biais variable ont été retenues. Aucune étude admissible ne se penchait sur les tâches de jugement gauche/droite de manière isolée. Les études n'ont montré aucun effet pour les mouvements imaginés, mais des effets positifs ont été observés pour l'IMG [différence moyenne pondérée : -21,29 (IC à 95 % : -31,55, -11,02), I2 = 0 %] et la thérapie miroir [différence moyenne pondérée: -8,55 (IC 95% : -14,74, -2,35, I2 = 61%]. La comparaison de la thérapie miroir à une thérapie factice n'a montré aucune différence [différence moyenne pondérée : -4,43 (IC à 95 % : -16,03, 7.16), I2 = 51 %].Conclusion: Nos résultats indiquent que l'IMG et la thérapie miroir peuvent être efficaces pour réduire la douleur du membre fantôme. Cependant, cette conclusion a été tirée à partir d'un ensemble limité de données probantes, et la certitude de ces dernières était très faible. Par conséquent, des essais rigoureux et de haute qualité sont nécessaires pour combler les lacunes dans la littérature et éclairer la pratique.

Making sense of phantom limb pain.

Phantom limb pain (PLP) impacts the majority of individuals who undergo limb amputation. The PLP experience is highly heterogenous in its quality, intensity, frequency and severity. This heterogeneity, combined with the low prevalence of amputation in the general population, has made it difficult to accumulate reliable data on PLP. Consequently, we lack consensus on PLP mechanisms, as well as effective treatment options. However, the wealth of new PLP research, over the past decade, provides a unique opportunity to re-evaluate some of the core assumptions underlying what we know about PLP and the rationale behind PLP treatments. The goal of this review is to help generate consensus in the field on how best to research PLP, from phenomenology to treatment. We highlight conceptual and methodological challenges in studying PLP, which have hindered progress on the topic and spawned disagreement in the field, and offer potential solutions to overcome these challenges. Our hope is that a constructive evaluation of the foundational knowledge underlying PLP research practices will enable more informed decisions when testing the efficacy of existing interventions and will guide the development of the next generation of PLP treatments.

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 prevalence and risk factors for phantom limb pain in people with amputations: A systematic review and meta-analysis.

BACKGROUND: Phantom limb pain (PLP)-pain felt in the amputated limb-is often accompanied by significant suffering. Estimates of the burden of PLP have provided conflicting data. To obtain a robust estimate of the burden of PLP, we gathered and critically appraised the literature on the prevalence and risk factors associated with PLP in people with limb amputations. METHODS: Articles published between 1980 and July 2019 were identified through a systematic search of the following electronic databases: MEDLINE/PubMed, PsycINFO, PsycArticles, Cumulative Index to Nursing and Allied Health Literature, Africa-Wide Information, Health Source: Nursing/Academic Edition, SCOPUS, Web of Science and Academic Search Premier. Grey literature was searched on databases for preprints. Two reviewers independently conducted the screening of articles, data extraction and risk of bias assessment. The meta-analyses were conducted using the random effects model. A statistically significant level for the analyses was set at p<0.05. RESULTS: The pooling of all studies demonstrated a prevalence estimate of 64% [95% CI: 60.01-68.05] with high heterogeneity [I2 = 95.95% (95% CI: 95.10-96.60)]. The prevalence of PLP was significantly lower in developing countries compared to developed countries [53.98% vs 66.55%; p = 0.03]. Persistent pre-operative pain, proximal site of amputation, stump pain, lower limb amputation and phantom sensations were identified as risk factors for PLP. CONCLUSION: This systematic review and meta-analysis estimates that six of every 10 people with an amputation report PLP-a high and important prevalence of PLP. Healthcare professionals ought to be aware of the high rates of PLP and implement strategies to reduce PLP by addressing known risk factors, specifically those identified by the current study.

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 prevalence of phantom limb pain and associated risk factors in people with amputations: a systematic review protocol.

BACKGROUND: The prevalence of phantom limb pain (PLP) in people with amputations is unclear because of the conflicting reports across the literature. It is proposed that the conflicting reports on the prevalence of PLP are a consequence of variations in the time period during which the studies were undertaken, countries in which the studies were conducted and recruitment processes implemented during collection of epidemiological data. In consideration of these factors, we aim to gather and critically appraise relevant literature to determine the prevalence estimate of and risk factors for PLP in people with amputations. METHODS: We will use a customised search strategy containing relevant words and terms to search the following databases: MEDLINE/PubMed (via EBSCOhost), PsycINFO (via EBSCOhost), PsycArticles, Cumulative Index to Nursing and Allied Health Literature (CINAHL) (via EBSCOhost), Africa-Wide Information (via EBSCOhost), Health Source: Nursing/Academic Edition (via EBSCOhost) SCOPUS, Web of Science and Academic Search Premier (via EBSCOhost). The risk of bias assessment will be conducted using a risk of bias assessment tool for prevalence studies, and data will be extracted using a piloted customised data extraction sheet. Data extracted from individual studies will be entered into Review Manager 5 and assessed for clinical and statistical heterogeneity. Studies will be pooled for meta-analysis using the random-effects model to determine a summary estimate of the prevalence of PLP across included studies. A statistically significant level will be set at p < 0.05. DISCUSSION: As far as we know, a systematic review and meta-analysis on the prevalence of, and risk factors for PLP in people with amputations has not been conducted. Given the varying reports in the literature, it is necessary to determine an estimate of the prevalence of PLP to generate an informed conclusion on this subject. The results of this review will be published in an internationally accredited journal and used to inform researchers, clinicians, policy-makers and the public about the burden of, and risk factors for PLP. This will be done with a further aim to improve the quality of pain management in society. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018094821.

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.