A Focus Group- and Patient-Driven Study to Understand Patients' and Health Care Providers' Perspectives on Services for People with Amputation.

Purpose: This study investigates patients' and health care providers' perspectives on the services provided for people with amputation in Saskatoon. Method: We used a qualitative approach, following the Delphi method. A patient-oriented research team designed five questions and presented them to two focus groups. The discussions focused on what worked well in the health care system and what could be improved, what could be improved in the community, future research, and ways to improve specific knowledge translation regarding care of people with amputation to therapists. Results: The two focus groups consisted of 48 panellists, all community members and health care professionals. The themes that emerged included positive experiences with prosthetic care and the individual people responsible for amputee care and improvements needed to streamline the pathways of care, community support, education, and research into all aspects of amputation. Conclusions: Amputation is not just a one-time medical procedure; people with amputation need lifelong support from health care providers and the community. Clear pathways of care, access to immediate support, amputee-specific education for health care providers, better patient education, increased physical therapy, and enhanced resources and care were identified as areas in need of improvement. This study will, we hope, form the basis of future research to continually improve the quality of care and support for people living with amputation.

Objectif : explorer le point de vue des patients et des dispensateurs de soins à l'égard des services fournis aux personnes amputées de Saskatoon. Méthodologie : recherche qualitative faisant appel à la méthode Delphi. Une équipe de recherche orientée vers le patient a conçu cinq questions et les a présentées à deux groupes de travail. Les discussions ont porté sur ce qui fonctionnait bien et ce qui pouvait être amélioré dans le système de santé, ce qui pouvait être amélioré dans la communauté, les futures recherches et les moyens d'améliorer l'application des connaissances des thérapeutes sur les soins aux amputés. Résultats : les deux groupes de travail étaient composés de 48 participants, tous des membres de la communauté et des professionnels de la santé. Les thèmes qui sont ressortis étaient les expériences positives à l'égard des soins prothétiques et de la personne responsable des soins aux amputés, alors que des améliorations s'imposaient pour harmoniser la trajectoire des soins, le soutien communautaire, la formation, l'éducation et la recherche sur tous les aspects de l'amputation. Conclusion : l'amputation n'est pas une intervention ponctuelle, mais les personnes amputées ont besoin d'un soutien tout au long de leur vie de la part des dispensateurs de soins et de la communauté. Des trajectoires de soins claires, l'accès à un soutien immédiat, une formation sur les amputés destinée aux dispensateurs de soins, une meilleure éducation des patients, l'accroissement des services de physiothérapie et l'amélioration des ressources et des soins sont les secteurs à améliorer. Les auteurs espèrent que la présente étude jette les bases de futures recherches pour assurer l'amélioration continue de la qualité des soins et du soutien aux personnes amputées.

A Decade of mTBI Experience: What Have We Learned? A Summary of Proceedings From a NATO Lecture Series on Military mTBI.

Mild traumatic brain injury (mTBI, also known as a concussion) as a consequence of battlefield blast exposure or blunt force trauma has been of increasing concern to militaries during recent conflicts. This concern is due to the frequency of exposure to improvised explosive devices for forces engaged in operations both in Iraq and Afghanistan coupled with the recognition that mTBI may go unreported or undetected. Blasts can lead to mTBI through a variety of mechanisms. Debate continues as to whether exposure to a primary blast wave alone is sufficient to create brain injury in humans, and if so, exactly how this occurs with an intact skull. Resources dedicated to research in this area have also varied substantially among contributing NATO countries. Most of the research has been conducted in the US, focused on addressing uncertainties in management practices. Development of objective diagnostic tests should be a top priority to facilitate both diagnosis and prognosis, thereby improving management. It is expected that blast exposure and blunt force trauma to the head will continue to be a potential source of injury during future conflicts. An improved understanding of the effects of blast exposure will better enable military medical providers to manage mTBI cases and develop optimal protective measures. Without the immediate pressures that come with a high operational tempo, the time is right to look back at lessons learned, make full use of available data, and modify mitigation strategies with both available evidence and new evidence as it comes to light. Toward that end, leveraging our cooperation with the civilian medical community is critical because the military experience over the past 10 years has led to a renewed interest in many similar issues pertaining to mTBI in the civilian world. Such cross-fertilization of knowledge will undoubtedly benefit all. This paper highlights similarities and differences in approach to mTBI patient care in NATO and partner countries and provides a summary of and lessons learned from a NATO lecture series on the topic of mTBI, demonstrating utility of having patients present their experiences to a medical audience, linking practical clinical care to policy approaches.

A Survey of Frozen Phantom Limb Experiences: Are Experiences Compatible With Current Theories.

There are over two million individuals living with amputations in the United States. Almost all will experience the feeling of the amputated limb as still present, termed phantom limb sensation (PLS). Over 85% will also experience excruciatingly painful sensations known as phantom limb pain (PLP). Additionally some amputees also experience a sensation of the phantom limb in which the limb is immobile or stuck in a normal or abnormal anatomical position, termed frozen phantom sensations. When an amputee experiences a frozen limb they report that they are unable to move the limb, and sometimes report sensations of cramping and pain along with this immobility, fortunately not all frozen limbs are painful. Such sensations have previously been attributed to proprioceptive memories of the limb prior to amputation or a mismatch between visual feedback and proprioceptive feedback resulting from the initiation of a movement. Unfortunately there has been a dearth of research specifically focused on the frozen PLS. We conducted a survey to better elucidate and understand the characteristics and experiences of frozen PLSs. Results from the survey provided descriptions of a variety of frozen limb experiences, such as position and feelings experienced, combined with other phantom pain sensations, casting doubt on previous theories regarding frozen limbs. Further research needs to be focused on the etiology of phantom sensations and pain, which may not necessarily be maintained by the same processes, in order to understand better ways to treat PLP, increase mobility, and enhance amputees quality of life.

A review of current theories and treatments for phantom limb pain.

Following amputation, most amputees still report feeling the missing limb and often describe these feelings as excruciatingly painful. Phantom limb sensations (PLS) are useful while controlling a prosthesis; however, phantom limb pain (PLP) is a debilitating condition that drastically hinders quality of life. Although such experiences have been reported since the early 16th century, the etiology remains unknown. Debate continues regarding the roles of the central and peripheral nervous systems. Currently, the most posited mechanistic theories rely on neuronal network reorganization; however, greater consideration should be given to the role of the dorsal root ganglion within the peripheral nervous system. This Review provides an overview of the proposed mechanistic theories as well as an overview of various treatments for PLP.

Hand-to-Face Remapping But No Differences in Temporal Discrimination Observed on the Intact Hand Following Unilateral Upper Limb Amputation.

Unilateral major limb amputation causes changes in sensory perception. Changes may occur within not only the residual limb but also the intact limb as well as the brain. We tested the hypothesis that limb amputation may result in the detection of hand sensation during stimulation of a non-limb-related body region. We further investigated the responses of unilateral upper limb amputees and individuals with all limbs intact to temporally based sensory tactile testing of the fingertips to test the hypothesis that changes in sensory perception also have an effect on the intact limb. Upper extremity amputees were assessed for the presence of referred sensations (RSs)-experiencing feelings in the missing limb when a different body region is stimulated, to determine changes within the brain that occur due to an amputation. Eight of 19 amputees (42.1%) experienced RS in the phantom limb with manual tactile mapping on various regions of the face. There was no correlation between whether someone had phantom sensations or phantom limb pain and where RS was found. Six of the amputees had either phantom sensation or pain in addition to RS induced by facial stimulation. Results from the tactile testing showed that there were no significant differences in the accuracy of participants in the temporal order judgment tasks (p = 0.702), whereby participants selected the digit that was tapped first by a tracking paradigm that resulted in correct answers leading to shorter interstimulus intervals (ISIs) and incorrect answers increasing the ISI. There were also no significant differences in timing perception, i.e., the threshold accuracy of the duration discrimination task (p = 0.727), in which participants tracked which of the two digits received a longer stimulus. We conclude that many, but not all, unilateral upper limb amputees experience phantom hand sensation and/or pain with stimulation of the face, suggesting that there could be postamputation changes in neuronal circuitry in somatosensory cortex. However, major unilateral limb amputation does not lead to changes in temporal order judgment or timing perception tasks administered via the tactile modality of the intact hand in upper limb amputees.