Postamputation pain and sensory changes in treatment-naive patients: characteristics and responses to treatment with tramadol, amitriptyline, and placebo.
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BACKGROUND: Pain after amputation is common but difficult to treat, and few controlled treatment studies exist. METHODS: In the current study, 94 treatment-naive posttraumatic limb amputees with phantom pain (intensity: mean visual analog scale score [0-100], 40 [95% confidence interval, 38-41]) were randomly assigned to receive individually titrated doses of tramadol, placebo (double-blind comparison), or amitriptyline (open comparison) for 1 month. Nonresponders were crossed over to the alternative active treatment. RESULTS: After 1 month, phantom pain intensity was 1 (0-2) in the 48 tramadol responders (mean dose, 448 mg [95% confidence interval, 391-505 mg]), 0 (0-0) in the 40 amitriptyline responders (55 [50-59] mg), and 0 (0-0) in the 2 placebo responders, with similar effects on stump pain. Cytochrome P-450 2D6 slow metabolizers derived greater analgesia from tramadol and less from amitriptyline compared with fast metabolizers in the first treatment week (P < 0.01). Electrical pain thresholds increased and pain during suprathreshold stimulation decreased markedly on the stump and, to a lesser extent, on the contralateral limb after 1 month of treatment with amitriptyline or tramadol. Adverse effects were minor in all groups, but more common with tramadol. CONCLUSIONS: In treatment-naive patients, both amitriptyline and tramadol provided excellent and stable phantom limb and stump pain control with no major adverse events. Both drugs demonstrated consistent and large antinociceptive effects on both the stump and the intact limbs. (+info)
Spasms of amputation stumps.
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Two patients are presented with muscle spasms in an amputation stump. Neither patient experienced neuropathic pain nor phantom sensations, though phantom sensory phenomena, severe pain, and lack of response to treatment is characteristic of reported cases. One patient, a 75 year old man, has had myoclonic activity of the stump for more than two years, and the other, a 79 year old woman, recovered spontaneously after three months and is symptom free after a one year follow up. We emphasise the lack of association with pain and the need to consider spontaneous improvement when therapy is evaluated. (+info)
Efficacy of shock-absorbing versus rigid pylons for impact reduction in transtibial amputees based on laboratory, field, and outcome metrics.
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Prosthetic manufacturers have marketed shock-absorbing pylons (SAPs) for attenuation of injurious loads from foot-ground contact. In this study, we compared a commonly prescribed SAP with a conventional rigid pylon, using a within-subject design (n = 15 unilateral transtibial amputees), to assess effect on gait mechanics, measure transmitted accelerations in situ, and determine functional outcomes using step counts and questionnaires. No differences were found across pylons for self-selected walking speed, prosthetic-side step length, prosthetic-side loading rate and decelerative peak of the vertical ground reaction force, peak pylon acceleration, step count per week, or questionnaire results that examined pylon performance and subjects' pain and fatigue levels. The only statistically significant finding was for the prosthetic-side knee angle at initial contact, where subjects displayed an average of 2.6 degrees more flexion with the rigid pylon than the SAP while walking at a controlled speed (p = 0.004); this result indicates that transtibial amputees are able to modulate the effective stiffness of their residual limb in response to changes in prosthetic component stiffness. The results from the laboratory, field, and subjective outcome measurements suggest that the SAP in this study is as effective as a rigid pylon for unilateral transtibial amputees. (+info)
The Krukenberg hand.
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Little has been published about the Krukenberg operation, which has been regarded as primarily indicated for the blind patient with bilateral hand amputations. Of the 35 Krukenberg cineplasty operations I have performed in the last 36 years, only two have been on blind patients. The operation provides forearm amputees with pincers which allow them to perform tasks without a prosthesis, but does not preclude the use of any type of aid. The author's operative procedure is described and the results illustrate its practical application for most patients. (+info)
Persistent hand motor commands in the amputees' brain.
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The loss of a limb leads to sensorimotor modifications that are frequently accompanied by the vivid experience that the missing limb is still present, and that it can be moved at will. Furthermore, amputees can clearly distinguish between phantom movements of the fingers and of more proximal joints, like movements of the elbow. This phenomenon raises the question of whether these specific phantom movement experiences are translated into differentiated activity within the remaining muscles. We recorded stump muscle activity when above-elbow amputees voluntarily moved their phantom limb. Voluntary movements of the phantom hand triggered specific patterns of stump muscle activity, which differed from activity recorded in the same muscle groups during movements of the proximal limb. This result indicates that the brain's motor areas can be differentially activated according to the phantom movement the patient intends to perform, and suggests that hand motor commands are preserved after amputation. To further understand the interaction between central commands and sensory feedback in the perception of phantom movement we also measured stump muscle EMG activity in an amputee experiencing a frozen phantom limb, and in three below-elbow amputees with vivid phantom movements after inducing an ischaemic block. Failed attempts to move the paralysed phantom limb always resulted in the same EMG pattern, no matter what type of phantom movement was attempted, while ischaemic nerve block reduced or eliminated the ability to voluntarily move the phantom limb and produced a dramatic reduction in the amplitude of stump muscle EMG activity. Our data suggest that the experience of phantom hand movement involves the activation of hand motor commands. We propose that preserved hand movement representations re-target the stump muscles to express themselves and that when these representations are voluntarily accessible they can instruct the remaining muscles to move in such a way as if the limb is still there. (+info)
Mapping phantom movement representations in the motor cortex of amputees.
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Limb amputation results in plasticity of connections between the brain and muscles, with the cortical motor representation of the missing limb seemingly shrinking, to the presumed benefit of remaining body parts that have cortical representations adjacent to the now-missing limb. Surprisingly, the corresponding perceptual representation does not suffer a similar fate but instead persists as a phantom limb endowed with sensory and motor qualities. How can cortical reorganization after amputation be reconciled with the maintenance of a motor representation of the phantom limb in the brain? In an attempt to answer this question we explored the relationship between the cortical representation of the remaining arm muscles and that of phantom movements. Using transcranial magnetic stimulation (TMS) we systematically mapped phantom movement perceptions while simultaneously recording stump muscle activity in three above-elbow amputees. TMS elicited sensations of movement in the phantom hand when applied over the presumed hand area of the motor cortex. In one subject the amplitude of the perceived movement was positively correlated with the intensity of stimulation. Interestingly, phantom limb movements that the patient could not produce voluntarily were easily triggered by TMS, suggesting that the inability to voluntarily move the phantom is not equivalent to a loss of the corresponding movement representation. We suggest that hand movement representations survive in the reorganized motor area of amputees even when these cannot be directly accessed. The activation of these representations is probably necessary for the experience of phantom movement. (+info)
Prognostic factors in prosthetic rehabilitation of bilateral dysvascular above-knee amputee: is the stump condition an influencing factor?
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AIM: The aim of this study was to evaluate the prognostic factors for rehabilitation outcome in bilateral dysvascular lower limb amputees, specifically to ascertain how the stump condition can influence the mobility outcome. METHODS: A retrospective study of 30 selected bilateral above-knee amputees for vascular disease was carried out. Barthel Index (BI) was given and stump condition was assessed at admission and at discharge. Influence of age, comorbidities and stump condition on effectiveness of BI was evaluated. Locomotor Capability Index (LCI) was performed at discharge. Influence of stump problems (pain, flexion, pain with flexion) on LCI was evaluated. RESULTS: At discharge, 25 patients were able to ambulate. Age and pathological conditions of stumps correlated negatively with BI effectiveness. LCI values were higher for patients with ideal stumps and lower for patients with combined stump pain and flexion deformities. Post hoc analysis showed that the principal factor negatively influencing the LCI score was the presence of stump flexion deformities. CONCLUSIONS: In our homogeneous group of bilateral amputees, age reduced the possibility of improving the level of autonomy. Good stump quality is one of the major determinants of mobility outcome. Efforts should be made to minimize stump complications. In particular, incorrect positioning of the stump, which is responsible for hip flexor retraction, should be avoided after surgery. (+info)
A randomized study of the effects of gabapentin on postamputation pain.
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BACKGROUND: Pain after amputation is common but difficult to treat. Therefore, the authors examined whether postoperative treatment with gabapentin could reduce postamputation stump and phantom pain. METHODS: Forty-six patients scheduled to undergo lower limb amputation were randomly assigned to receive oral gabapentin or placebo. Treatment was started on the first postoperative day and continued for 30 days. The daily dose of gabapentin or placebo was gradually increased to 2,400 mg/day. The intensity of stump and phantom pain was recorded every day on a numeric rating scale (0-10) during the 30-day treatment period. Five interviews were performed after 7, 14, and 30 days and after 3 and 6 months. RESULTS: Results from 41 patients were included in the data analysis. The risk of phantom pain (gabapentin vs. placebo) was 55.0% versus 52.6% (risk difference, 2.4%; 95% confidence interval, -28.9 to 33.7%; P = 0.88; 30 days) and 58.8% versus 50.0% (risk difference, 8.8%; 95% confidence interval, -23.3 to 40.9%; P = 0.59; 6 months). The median intensity of phantom pain (gabapentin vs. placebo) was 1.5 (range, 0-9.0) versus 1.2 (range, 0-6.6) (P = 0.60; 30 days) and 1.0 (range, 0-6.0) versus 0.5 (range, 0-5.0) (P = 0.77; 6 months). The median intensity of stump pain was 0.85 (range, 0-8.2) versus 1.0 (range, 0-5.4) (P = 0.68; 30 days) and 0 (range, 0-8.0) versus 0 (range, 0-5.0) (P = 0.58; 6 months). CONCLUSION: Gabapentin administered in the first 30 postoperative days after amputation does not reduce the incidence or intensity of postamputation pain. (+info)