Phantom Limb Pain

wafflejourneyAI and Robotics

Nov 14, 2013 (3 years and 10 months ago)

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Treatment Options for
Phantom Limb Pain

By: Sara Walsh, SPT

Ithaca College

Objectives

O
Background information on phantom pain

O
Mirror Therapy

O
Virtual Reality Therapy

O
Current Evidence

O
Speculations

What exactly is phantom limb
pain?

O
Any painful sensation perceived in the
missing part of the limb after amputation

O
Not to be confused with phantom sensation
or residual limb pain

O
Stabbing, cramping, burning




1

Why do we care about
phantom limb pain?

O
Chronic phantom limb pain is present in 80% of
individuals with partial or total limb loss.

O
156,000 new amputations per year

O
156,000 x 0.80 = 124,800





1,2

Why does phantom pain
occur?

O
Historically: psychological origins


O
Overall abnormal overload of input to the spinal
cord and
brain




1

3,1



Why does phantom pain
occur?

O
Peripheral
Mechanism

O
Many theories

O
Pain from neuroma increases the amount of central map
reorganization; reorganization=pain

O
Enhanced sensitivity of afferent
fibers (toward CNS)

O
Local changes at site of remaining nerve

O
Enhanced sensitivity

O
Sprouting of injured axon: neuroma

O
Spinal cord forming new neural connections with sprouts
(contributes to sensitization of pain transmission neurons)

O
Reduction of local
inter
-
segmental
inhibitory mechanisms:
spinal
dis
-
inhibition
and enhanced
supra
-
spinal
input to
nociceptive
centers

1


Why does phantom limb pain
occur?

O
Central Mechanism

O
Changes in neuronal excitability (
motor activation
without sensory feedback to dampen motor
commands verifying that movement has taken place

O
Somatotopic reorganization in cortical and
subcortical areas

O
Neuroimaging studies reveal that a reversal of these
neuroplastic changes are associated with phantom
limb pain remission

1, 3

3

Pharmacological Treatment

O
NSAIDS

O
Most evidence based

O
Anti
-
depressants

O
Anticonvulsants

O
Sodium Channel blockers

O
NMDA receptor antagonists (anesthesia)

O
Opioids

4

Invasive Treatments

O
Must consider possible side effects of neurosurgery
(wound infection, device failure, wire migration,
anesthesia, stroke, death)

O
Invasive
Neuromodulation

(last resort)

O
Deep brain stimulation (stimulate thalamus)

O
<25% success rate

O

Motor Cortex stimulation

O
Precentral

gyrus

O
53% success rate

O

Spinal Cord Stimulation

O
Electrodes in epidural space

O
39% success rate

5,6,7



Non
-
Invasive Treatments

(low levels of evidence)

O
Trans
-
cranial magnetic stimulation (TMS)

O
Electrical currents due to magnetic coil over scalp

O

Electrical Stimulation

O
Psychotherapeutic approaches

O
Reflexology

O
Hypnosis

O
Motor Imagery (moderate levels of evidence)

O
Myoelectric Prosthesis

O
Expansion of representation zone

4




Mirror Therapy

How does it work?

O
Mirror Neuron System

O
Neurons are active during execution of tasks
and during observation of tasks

O
Imagined movements share the same cortical
pathways as executed motor tasks

O

Visual feedback dominates somatosensory
feedback

O
Sensory experiences can be evoked by visual
information

O
Visual system enhances tactile sensitivity

8,9

Mirror Therapy

O
Current Evidence:


O
3

case reports on pts. with UE amputations

O
Kawashima 2009

O
Wilcher

2011

O
2 case studies on p.t with LE amputation

O
MacLauchlan 2004

O
Darnall

2009

O
Darnall

2012

O
2 RCTs on pts. with LE amputations

O
Chan 2007

O
Brodie

2003

O
1 quasi
-
experimental study on pt. with LE amputation

O
Seidel 2011

10
-
16

Mirror Therapy

O
Subjects:

O
Males and females

O
24
-
83 y/o

O
Mechanism of Injury

O
Trauma

O
UE caught in machine at work

O
Motorcycle accident

O

Necrotizing Fasciitis

O
DM

O
Vascular disease

10
-
16



Mirror Therapy

O
Typical Protocol

O
Pt. is seated with mirror oriented to pt.’s sagittal plane so that pt.
can see sound limb’s reflection in mirror (resembles phantom limb)

O
Synchronous movements

O
Elbow, Wrist flex/extension

O
Opening/closing fist

O
Pronating/supinating

O
Clapping (with someone else making “clapping noise”)

O
Hip, Knee flex/extension

O
DF/PF, inversion/eversion, circumduction ankle

O
Seated marches

O
Flex/extension toes

O
Spread toes/relax toes, Ext great toe while flexing other toes

O
Hip abduction/adduction, Hip ER/IR

O
15 minutes 2x/day to 1 hour/week

O
1 month
-

3 months




10
-
16

Mirror Therapy

O
Results:

O
Metal bar grasped by phantom limb with severe pain …did not feel existence of
phantom (Kawashima
-
case study UE amp)



…EMG modulations in residual wrist mm. (
pt

able to re
-
activate commands to
phantom limb

O
Naproxin
, tramadol, morphine, acetaminophen,
lidocaine
, gabapentin…all pain
meds except gabapentin discontinued and blood pressure decreased (as a sign of
decreased pain) (
Wilcher
-
case study UE amp)

O
5
-
9/10 pain…0
-
1/10 with 0 % control over phantom limb to 25
-
30% control over
phantom limb (
MacLaughlen
-
case study LE amp)

O
After 4
wks
, 100% of
pts

in mirror group had decreased pain and phantom limb
pain decreased in 8/9
pts

who switched to mirror therapy from covered mirror of
mental visualization (Chan
-
UE and LE RCT)

O
3 fold increase in amount of movement perceived vs. control group, but no
decrease in pain b/c all but one
pt

was not in pain at the time of the study (
Brodie
-
UE and LE amps RCT)

O
6/10


0/10 pain with increased control of phantom (
Darnall
-
case study LE amp)

O
15 % pain reduction in 2 months (
Darnall
-
Case study LE amp)

O
4.6/10 pain…1.8/10 pain (statistically significant)

O
No consistent pattern of cortical reorganization (Seidel
-
quasi LE)


10
-
16

Mirror Therapy 13,14

Criteria

Chan

Brodie

Did the investigators

randomly assign subjects to
groups?

Yes

Yes

Was each group assignment

concealed from the people
enrolling individuals in the study?

No

No

Were the subjects masked?

No

No

Were

the clinicians masked?

No

No

Did the investigators manage all subjects

the same
way?

Yes

Yes

Was data collected

from all subjects over a long enough
time frame for outcomes to occur?

Yes
(4wks)

Unknown

Did attrition occur?

No

No

If attrition occurred
, was an intention to treat analysis
performed?

---

---

Were findings confirmed with a new

set of subjects?

No

No

Do you have enough confidence to use this

evidence
with your patients?

?

?

Trivia Question for Candy #1


O
Mirror therapy has been proven to be
effective in:

O
A) the clinic

O
B) the home setting

O
C) both the clinic and the home setting

Answer:

O
C) both the clinic and the home setting


Mirror Therapy

Conclusions

O
Mirror therapy is a non
-
expensive (third party
payer,) noninvasive option for phantom limb pain
management

O
S
tatistically significant reductions in pain

O
Mirror therapy can be used on UE and LE
amputees

O
Increased control of phantom = decrease in pain

O
Use with patients who are currently having pain

O
Home PT

O
***More high quality evidence is needed***

10
-
15

Virtual Reality Therapy

O
Limited quantity of evidence (2 studies)


O
Case Study/Quasi
-
experimental Murray


O
Quasi
-
experimental (1 group pretest post
-
test)

O
Subjects
-
>pre
-
test measurement
-
>intervention
-
> post test measurement
-
Cole


O
Qualitative component


O
Unable to rate on hierarch, but resembles a 2b for quasi
-
experimental (on a scale
of 1a
-
5)


O
3B
-
case study


O
Lacks randomization and control group

17,18

Virtual Reality Therapy

O
Based on principles of mirror therapy


O
Addresses limitation of mirror therapy

O
Narrow spatial dimension

O
Patient in fixed space

O
Patient must ignore intact limb providing the
reflection

17,18


Virtual Reality Therapy

O
Murray
-
2007 and Cole
-
2009

O
Quasi
-
experimental studies

O
Murray: 3
pts

in their 60’s (2 UE amps and 1 LE
amp)

O
Cole: 14
pts

ages 27
-
82 (7 UE amps and 7 LE
amps)

O
Inclusion Criteria (Murray):

O
Has phantom limb
pain

O
Adults without any major visual or cognitive
deficits

O
Minimum 12
months post

amp


17, 18


Virtual Reality Therapy

O
Murray Protocol:

O
2
-
5 immersive virtual reality
sessions (30
mins

each)

O
V6 virtual reality head
-
mounted display, 5DT
-
14 data
glove and sensors with UE amp and just sensors for
LE amps (sensors attached to elbow, wrist, knee,
ankle)

O
four
tasks in repetition

O
placing
virtual limb onto colored tiles which light up in
sequence

O
batting
or kicking a virtual
ball

O
tracking
the motion of a moving virtual
stimulus

O
directing
a virtual stimulus toward a
target 17


How does it work? 17


Virtual Reality Therapy

O
Cole Protocol:

O
UE: seen twice, several weeks apart

O
LE: seen once

O
60
-
90
mins

O
Motion capture device respond to electro
magnetic
sensors
attached to arm/leg of user

O
Calibrate system through set of
residual limb
movements

O
Grasp apple on surface of a table

O
Bass drum: LE

18



17

17

Virtual Reality Therapy

O
Outcome measures:

O
Short form McGill Pain Questionnaire (Murray
and Cole)

O
VAS pain scale (Murray and Cole)

O
Pain diaries (Murray)

O
Drug use (Cole)

O
Qualitative
component: semi
-
structured
interview before and after each
session
(Murray and Cole) 17,18


Virtual Reality Therapy

O
Results

O
8.3/10
-
> 6.8/10 Murray

O
5
-
6
hrs

of sleep compared to
2
-
3 Murray

O
7/10 to 3/10 at third
session Murray







17, 18

Virtual Reality Therapy

O
Testimonials: UE

O
Reported decrease in pain, but then it would come back with
“a bit of a vengeance” within a few hours

O
“I actually felt as if it was my left arm that was doing the work
and chasing the ball. My actual phantom arm rather than my
right…and was more like reality than virtual reality.”

O
“If I could harness that movement in my phantom limb maybe I
could open my fingers and ease the cramping pain a little.”

O
“I’ve actually been sleeping a little better over the last few
days…I’m getting about 5
-
6 hours of sleep as opposed to 2
-
3
hours and I’m doing nothing else different in my life except
coming here

O
“It’s funny, one of my fingers is coming out, sort of pointing out
now versus:
the nails of my fingers are digging into my
palm”

O
“Now when I move the fingers there is still pressure but there
is no pain, they are not being ripped off or squashed.”

O
“When I move my arm, it does not tingle; pain disappears into
the background and merges into the movement sensations

O
“The arm is now a gentle presence.”

17, 18


Virtual Reality Therapy

O
Testimonials: LE

O

I can feel the movement in the missing leg and maybe
feel touch too. Once I am on the pedal I relax and feel
my foot coming off it. It is second
nature
as though
moving my full leg. The prosthesis is always a
prosthesis; this is different. Here I am moving the foot.
And at
the moment the toes have sensation and though
there is slight cramping in
the
toes there is no pain
.”
(pain went from 7
-
0
)


O

It is no longer a constant throbbing.
When I stop
moving the pain returns within a second or two , but
equally when I move and feel it is me, the pain reduces.
(LE
)

17, 18


Virtual Reality Therapy 17, 18

O
Should we consider using this evidence with our
pts
?

Item

Murray

Cole

Did the investigators randomly assign subjects to groups

No

No

Was each group assignment

concealed from the people
enrolling individuals in the study?

No

No

Were the subjects masked?

No

No

Were

the clinicians masked?

No

No

Did the investigators manage all subjects

the same way?

No

Yes

Was data collected

from all subjects over a long enough time
frame for outcomes to occur?

Yes

Yes

Did attrition occur?

No

Yes

If attrition occurred
, was an intention to treat analysis
performed?

---

No

Were findings confirmed with a new

set of subjects?

No

No

Do you have enough confidence to use this

evidence with
your patients?

No

No

Trivia Question for candy # 2

O
Name 2 evidence based outcome measures
you could use if you were treating a patient
with virtual reality therapy……


Possible Answers:

O
Short form McGill Pain questionnaire

O
VAS scale

O
Pain diaries

O
Medication dosages

Virtual Reality Therapy

O
Conclusions:

O
Expensive (third party payer)

O
Decrease in pain

O
Lack of carryover

O
Patient satisfaction

O
Need for increased research

O
Promising starting point

O
Look for future research 17, 18

Trivia Question #3 for candy:

O
There is a specific protocol to follow for
mirror therapy and virtual reality therapy

O
True or False


Answer:

O
False

Speculations

O
Virtual reality/mirror therapy with prosthetic
training

O
Virtual Reality Therapy vs. Mirror Therapy vs.
Control Group

O
Large Sample Sizes

O
High Quality RCT

Thank You!

O
Any questions?





O
Please fill out my survey


Works Cited

1.
Flor

H. Phantom
-
limp pain: characteristics, causes and treatments.
Lancet Neurol
. 2002;1(3):
182
-
189

2.
American Amputee Foundation, Inc. AAF. http://www.americanamputee.org/.
Accessed
August 26,
2012

3.
Maclver

K, Lloyd M, Kelly S,
Nurmikko

T. Phantom limb pain, cortical reorganization and the therapeutic
effect of mental imagery.
Brain
. 2008;131:2181
-
2191.

4.
Knotkova

H,
Cruciani

R,
Tronnier

V,
Rasche

D. Current and future options for the management of phantom
-
limb pain.

Journal Of Pain Research

2012;5:39
-
49. Available from: MEDLINE, Ipswich, MA. Accessed July
22,
2012

5.
Rasche

D,
Ruppolt

M,
Stippich

C, Unterberg A,
Tronnier

VM. Motor cortex stimulation for long
-
term relief of
chronic neuropathic pain: a 10 year experience. Pain 2006;121(2):43
-
52

6.
Nguyen JP,
Nizard

J,
Keravel

Y,
Lefaucheur

JP. Invasive brain stimulation for the treatment of neuropathic
pain. Nat Rev Neurol. 2011;7(12):699
-
709

7.
Krainick

JU,
Thoder

U. Spinal cord stimulation in post
-
amputation pain. In: Siegfried J, Zimmerman M,
editors. Phantom and Stump Pain. Berlin, Germany: Springer
-
Verlag
; 2002:527
-
535

8.
Cole J,
Crowle

S,
Austwick

G, Slater D. Exploratory findings with virtual reality for phantom limb pain; from stump motion
to agency and analgesia.

Disability And Rehabilitation
[serial online]. 2009;31(10):846
-
854. Available from: MEDLINE,
Ipswich, MA. Accessed August 26, 2012

9.
Diers

M,
Christmann

C,
Koeppe

C,
Ruf

M,
Flor

H.
Morrored
, imagined and executed movements differentially
activate sensorimotor cortex in amputees with and without phantom limb pain. Pain. 2010;149(2):296
-
304

10.
Kawashima N,
Mita

T. Metal bar prevents phantom limb motion: case study of an amputation patient who
showed a profound change in the awareness of his phantom
limb.
Neurocase

[serial online]. December
2009;15(6):478
-
484. Available from: MEDLINE, Ipswich, MA. Accessed August 26, 201

11.
Wilcher

D,
Chernev

I, Yan K. Combined mirror visual and auditory feedback therapy for upper limb phantom pain: a case
report.

Journal Of Medical Case Reports

[serial online]. January 27, 2011;5:41. Available from: MEDLINE, Ipswich, MA.
Accessed August 26, 2012

Works Cited

11.
MacLachlan

M, McDonald D,
Waloch

J. Mirror treatment of lower limb phantom pain: a case
study.

Disability And Rehabilitation

[serial online]. 2004 Jul 22
-
Aug 5 2004;26(14
-
15):901
-
904.
Available from: MEDLINE, Ipswich, MA. Accessed August 26, 201

12.
Chan B, Witt R,
Tsao

J, et al. Mirror therapy for phantom limb pain.

The New England Journal Of
Medicine

[serial online]. November 22, 2007;357(21):2206
-
2207. Available from: MEDLINE,
Ipswich, MA. Accessed August 26, 2012

13.
Brodie

E, Whyte A, Waller B. Increased motor control of a phantom leg in humans results from the
visual feedback of a virtual leg.

Neuroscience Letters

[serial online]. May 1, 2003;341(2):167
-
169.
Available from: MEDLINE, Ipswich, MA. Accessed August 26, 2012

14.
Seidel S,
Kasprian

G, Prayer D, et al. Mirror therapy in lower limb amputees
--
a look beyond primary
motor cortex reorganization.

Röfo
:
Fortschritte

Auf Dem
Gebiete

Der
Röntgenstrahlen

Und Der
Nuklearmedizin

[serial online]. November 2011;183(11):1051
-
1057. Available from: MEDLINE,
Ipswich, MA. Accessed July 22,
2012

15.
Darnall
, BD. Self
-
delivered home
-
based mirror therapy for lower limb phantom pain.
American
Journal of Physical Medicine and Rehabilitation
. 2009;88:78
-
81.

16.
Darnall
, B, Li H. Home based self delivered mirror therapy for phantom pain: a pilot study.
J
Rehabil

Med
. 2012; 44: 254
-
260

17.
Murray
C,
Pettifer

S,
Bamford

C, et al. The treatment of phantom limb pain using immersive virtual
reality: three case studies.

Disability And Rehabilitation

[serial online]. September 30,
2007;29(18):1465
-
1469. Available from: MEDLINE, Ipswich, MA. Accessed August 26, 2012

18.
Cole
J,
Crowle

S,
Austwick

G, Slater D. Exploratory findings with virtual reality for phantom limb
pain; from stump motion to agency and analgesia.

Disability And Rehabilitation
[serial online].
2009;31(10):846
-
854. Available from: MEDLINE, Ipswich, MA. Accessed August 26, 2012