Peripheral Nerve Stimulation for the Treatment of Postamputation Pain—A Case Report

Many amputees suffer from postamputation pain, which can be extremely debilitating, decrease quality of life, increase the risk of depression, and negatively affect interpersonal relationships and the ability to work. Present methods of treatment, including medications, are often unsatisfactory in reducing postamputation pain. Electrical stimulation of the nerve innervating the painful area could reduce the pain, but peripheral nerve stimulation is rarely used to treat postamputation pain because present methods require invasive surgical access and precise placement of the leads in close proximity (≤ 2 mm) with the nerve. The present study investigated a novel approach to peripheral nerve stimulation in which a lead was placed percutaneously a remote distance (> 1 cm) away from the femoral nerve in a patient with severe residual limb pain (RLP) 33 years following a below‐knee amputation. Electrical stimulation generated ≥ 75% paresthesia coverage, reduced RLP by > 60%, and improved quality of life outcomes as measured by the pain interference scale of the Brief Pain Inventory‐Short Form (100% reduction in pain interference), Pain Disability Index (74% reduction in disability), and the Patient Global Impression of Change (very much improved) during a 2‐week home trial. There were no adverse events. The ability to generate significant paresthesia coverage and pain relief with a single lead inserted percutaneously and remotely from the target nerve holds promise for providing relief of postamputation pain.     

Pain Management in Four‐Limb Amputation: A Case Report

Acute pain following amputation can be challenging to treat due to multiple underlying mechanisms and variable clinical responses to treatment. Furthermore, poorly controlled preoperative pain is a risk factor for developing chronic pain. Evidence suggests that epidural analgesia and peripheral nerve blockade may decrease the severity of residual limb pain and the prevalence of phantom pain after lower extremity amputation. We present the perioperative analgesic management of a patient with gangrene of the bilateral upper and lower extremities as a result of septic shock and prolonged vasopressor administration who underwent four‐limb amputation in a single procedure. A multimodal analgesic regimen was utilized, including titration of preoperative opioid and neuropathic pain agents, perioperative intravenous, epidural and peripheral nerve catheter infusions, and postoperative oral medication titration. More than 8 months postoperatively, the patient has satisfactory pain control with no evidence for phantom limb pain. To our knowledge, there have been no publications to date concerning analgesic regimens in four‐limb amputation.     

Phantom Limb Pain Treatment with Mirtazapine: A Case Series

Objectives: To pilot the efficacy of mirtazapine for relief of phantom limb pain (PLP); to correlate the putative drug mechanism with theoretical PLP mechanisms; and to develop a rationale for further study of mirtazapine in this population. Design: Open‐label case series. Subjects/Patients: Four individuals with PLP for at least 3 months after amputation. Methods: All subjects received oral mirtazapine between 7.5 and 30 mg/day. An 11‐point numeric rating scale (0 to 10) measured pain intensity and relief during monitored outpatient follow‐up visits. Results/Discussion: Mirtazapine use improved the PLP experienced by these subjects by at least 50%. Subjects with PLP‐related sleeping difficulties reported the greatest pain relief concomitant with improved sleep quality. One subject was able to eliminate the use of a selective serotonin reuptake inhibitor antidepressant while using mirtazapine for PLP and depression without change in mood or affect. Mirtazapine enhances noradrenergic and serotonergic activity and may modulate PLP by central mechanisms. Current concepts of the proposed pathophysiology of PLP and the hypothetical impact of mirtazapine are discussed. Conclusion: Mirtazapine may be an effective treatment for PLP that can also potentially enhance sleep and mood. This information provides preliminary reinforcement for more formal, controlled studies concerning mirtazapine use in PLP.     

Pulsed Radiofrequency Ablation for Residual and Phantom Limb Pain: A Case Series

Residual limb pain (RLP) and phantom limb pain (PLP) can be debilitating and can prevent functional gains following amputation. High correlations have been reported between RLP and the stump neuromas following amputation. Many treatment methods including physical therapy, medications, and interventions, have been used with limited success. Pulsed radiofrequency ablation (PRFA) has shown promise in treating neuropathic pain because of the inhibition of evoked synaptic activity. We present 4 amputees who were treated with PRFA after failing conservative management for their RLP and PLP. All 4 patients underwent PRFA and demonstrated at least 80% relief of RLP for over 6 months. One patient reported a complete resolution of phantom sensation while another patient had significantly decreased frequency of spontaneous PLP and resolution of evoked PLP. In addition, all patients reported improved overall function including increased prosthetic tolerance and decreased oral pain medications. This case series suggests that PRFA is a viable treatment option which might be used for long‐term relief of intractable RLP and/or PLP.     

Intrathecal Morphine and Bupivacaine for Phantom Limb Pain: A Case Report

Abstract:   Besides the causes and prevention issues, chronic nonmalignant pain must be considered as a combination of multidimensional disorder of neurophsiology, behavior, culture, social, economic aspects.     

改良强制性诱导运动治疗儿童偏瘫个案报道

目的为儿童偏瘫患者的上肢功能康复训练提供一种可资借鉴的模式。方法选择1例5岁的脑外伤后遗右侧偏瘫患儿,监护人知情同意。主要参照强制性诱导运动疗法的基本原则,限制健侧上肢活动,集中、反复、大量地对患肢进行训练。包括针对性推拿和作业治疗(30 min/次)、家庭功能性、文娱性活动训练,1次/d,5次/周,3周为1个疗程。治疗期间用低温板塑的限制性器具限制左上肢(健侧),10 h/d。采用Peabody运动发育量表(PDMS-2)、上田敏偏瘫上肢功能评价表、Brunnstrom偏瘫手功能评价、治疗师日志并参考家长反应来评估疗效。结果治疗后患肢的主动性有明显提高,PDMS-2评定明显提高,上田敏偏瘫上肢功能评价表、Brunnstrom偏瘫手功能评价均有改善。结论改良强制性诱导运动疗法对偏瘫儿童患侧上肢的功能恢复有积极的影响。     

Hypovitaminosis D Presenting as Diffuse Myalgia in a 22-Year-Old Woman: A Case Report

Background

Caused predominantly by insufficient conversion of vitamin D precursors by sunlight, hypovitaminosis D is an issue of increasing importance worldwide. Although it has been associated with a range of diseases, musculoskeletal effects dominate the clinical picture and can lead to significant physical debility, whether acute or chronic. Although diagnosis of vitamin D deficiency typically occurs in the outpatient setting, it is an easily treatable condition, and timely intervention can dramatically improve one's quality of life. As highlighted by this case report, hypovitaminosis D may be an important but underappreciated etiology of undifferentiated myalgia that, when present, warrants initiation of vitamin D repletion therapy even from the emergency department (ED).

Case Report

A 22-year-old African-American female presented to our ED with diffuse myalgia for 4 months. She reported significant debility from these symptoms with difficulty ambulating and performing activities of daily living. There had been no upper respiratory infection symptoms. The patient had discussed all of this with her primary care physician who, despite an extensive laboratory work-up, had not identified a definitive etiology.

Why Should an Emergency Physician Be Aware of This?

Chronic pain has stricken the ED patient population across the board. Studies demonstrate that the myalgia caused by hypovitaminosis D can have a profound and negative impact on an individual's lifestyle. Our patient was found to have hypovitaminosis D and had substantial improvement with her myalgia and quality of life after treatment. The purpose of this report is to help the emergency physician appreciate this disease and consider it when clinically appropriate.     

ICF-CY理论与方法在脑性瘫痪康复中的应用

目的探讨基于《国际功能、残疾和健康分类(儿童和青少年版)》(ICF-CY)架构开展脑瘫儿童康复。方法报道1 例以ICF-CY理论与方法为基础的功能障碍评定与干预。结果和结论ICF-CY的理论模式可以应用于脑瘫儿童的康复。     

Adults with congenital limb deficiency in Norway: demographic and clinical features,pain and the use of health care and welfare services. A cross-sectional study

Abstract

Purpose: To describe an adult population with congenital limb deficiency (CLD) recruited through the National Resource Centre for Rare Disorders (TRS) in Norway: (1) demographic factors, (2) clinical features, (3) pain and (4) use of health care and welfare services. Methods: Cross-sectional study. In 2012, a postal questionnaire was sent to 186 eligible persons with CLD, age 20 years and older. Results: Ninety-seven respondents, median-age 39 years (range: 20–82); 71% were women. The population was divided into two subgroups: (1) unilateral upper-limb deficiency (UULD) n?=?77, (2) multiple and/or lower-limb deficiency (MLD/LLD). About 40% worked full-time, 18% received disability pensions and 64% reported chronic pain, mostly bilateral pain. Grip-improving devices were used more often than prostheses; 23% were previous prosthesis users. Use of health care and welfare services are described. No significant differences were found between the subgroups regarding pain or employment status. Conclusions: Persons with CLD reported increased prevalence of chronic pain, mostly bilateral, and increased prevalence of early retirement. A greater focus on the benefits of the use of assistive devices, the consequences of overuse and vocational guidance may moderate pain and prevent early retirement. Further studies of more representative samples should be conducted to confirm our findings.

• Implications for Rehabilitation

• Most adults with congenital limb deficiency (CLD) live ordinary lives and experience normal life events. However, several report chronic pain and retire before normal retirement age.

• In spite of free and accessible prosthetic services, a large fraction chooses not to use prosthesis, more use grip-improving devices for specific activities. These preferences should be acknowledged by rehabilitation specialists.

• Focus on individually adapted environments, more information about the consequences of overuse, and vocational guidance may moderate pain and prevent early retirement.

     

Successful Graded Mirror Therapy in a Patient with Chronic Deafferentation Pain in Whom Traditional Mirror Therapy was Ineffective: A Case Report

A 43‐year‐old man had deafferentation pain in his right upper extremity secondary to brachial plexus avulsion from a traffic accident 23 years previously. On our initial examination, he had severe tingling pain with numbness in the right fingers rated 10 on the numerical rating scale. The body perception of the affected third and fourth fingers was distorted in the flexed position. Although he performed traditional mirror therapy (TMT) for 4 weeks in the same methods as seen in previous studies, he could not obtain willed motor imagery and pain‐alleviation effect. Therefore, we modified the task of TMT: Graded mirror therapy (GMT). GMT consisted of five stages: (1) observation of the mirror reflection of the unaffected side without imagining any movements of the affected side; (2) observation of the mirror reflection of the third and fourth fingers changing shape gradually adjusted from a flexed position to a extended position; (3) observation of the mirror reflection of passive movement; (4) motor imagery of affected fingers with observation of the mirror reflection (similar to TMT); (5) motor imagery of affected fingers without mirror. Each task was performed for 3 to 4 weeks. As a result, pain intensity during mirror therapy gradually decreased and finally disappeared. The body perception of the affected fingers also improved, and he could imagine the movement of the fingers with or without mirror. We suggested that GMT starting from the observation task without motor imagery may effectively decrease deafferentation pain compared to TMT.