Phantom Limb Pain Insights

Amputations

• Amputation is surgery to remove all or part of a body appendage, commonly a limb or extremity (arm, leg, hand, or foot).

Types of Amputations

• Upper Body: Shoulder disarticulation, elbow disarticulation, hip disarticulation, knee disarticulation, ankle disarticulation, partial foot.
• Lower Body: Forequarter, above elbow, below elbow, partial hand (transcarpal), hand and wrist disarticulation, hemipelvectomy, above knee (transfemoral), below knee (transtobial), Syme's.

Etiology

• Diabetes and other vascular diseases (peripheral artery disease)
• Traumatic incidents
• Congenital limb deformities
• Cancer (bone cancer)
• In Canada, diabetes is the primary cause of lower limb amputations.

Prevalence of Lower Limb Amputations (LLA)

• Between 2006 and 2011, 44,430 amputations were performed in Canada.
• Little variation in LLA numbers year to year.
• Average age of LLA patients is 65, with 54.9% between 50 and 74 years old
• 68.8% of those undergoing LLA were male.
• Transtibial amputations make up 30.9% of all LLA.
• LLA in BC represent 10% of all cases in Canada.
• Upper limb amputations are much less prevalent and studied compared to lower limb amputations.

Case Study: Jim

• 68-year-old African American male
• Low-income, limited access to healthcare
• Diagnosed with Type 2 diabetes
• Peripheral artery disease
• Peripheral neuropathy
• Long history of smoking
• Minimal physical activity
• Infected ulcer
• Undergone surgical removal

Research Informed Timeline

• Rehabilitation stages are broken down into weeks based on research.
• The ICF model, exercise interventions, physical, mental, and social characteristics are addressed according to their prominence at each stage.
•  Stages: Acute post-operative, pre-prosthetic phase, prosthetic training phase, and advanced mobility/community reintegration.

Stage 1: Acute Post-Operative

• Focuses on the immediate recovery period immediately after amputation.
• Identifying goals for this stage is important.
• Time line is crucial.

Medications

• Various medications are applied for pain relief, including NMDA-antagonists, antidepressants, opioids, anticonvulsants, hormones, and antihypertensives.
• Different mechanisms of actions and potential benefits and side effects are described.
• Medications specific for Jim are explored.
• Types of pain experienced are noted

Stage 2: Pre-Prosthetic Training (Weeks 4 - 8)

• Communication, goal planning, teamwork with the patient
• Specific, tested training plans aimed at improving muscle strength and range of motion.
• Preparing the patient for prosthesis use.
• Improving capacity for day-to-day tasks.
• Goals, expectations and anticipated difficulties are laid out.

Exercises

• Many different exercises are listed for strengthening muscles, promoting mobility and balance, performing gait training, maintaining posture and increasing endurance.
• Detailed procedures for many exercises.

ICF Model

• A model for understanding how health conditions affect activities and participation.
• The model is applied to help Jim with his amputation.
• Includes health conditions, body functions, activities and participation, environmental and personal factors relevant to his case.

Decrease in Health-Related Quality of Life

• Onset of depression, low self-esteem, decreasing motivation, hopelessness and other mental factors.
• Associated with: prosthesis use/availability, perceived social support, and functionality levels

Duration, Frequency and Factors Associated With Prosthesis Use

• Decreased symptoms of depression.
• Improved self-esteem.
• Beliefs that physical symptoms are stable, and treatment will be successful.
• Better prosthesis use scores relate to better mental health.
• Stronger positive correlation between mobility and well-being.
• Prosthesis use can prevent sedentary lifestyle and obesity.

Quality of Life Following a Lower Limb Amputation in Diabetic Patients

• 86-person study group, with diabetes and a diabetic foot ulcer
• 73.3% male patients, mean age of 63
• Hospital Anxiety and Depression Scale, Barthel Index, Satisfaction with Social Support Scale, and Short Form Health Survey results used to evaluate quality of life after amputation.
• Perceived social support and functionality have effects on patients.
• Early untreated anxiety can impact rehabilitation.
• Trauma can affect the physical component score.
• Appropriate psychological support from professionals in the area with amputees is crucial.
• Exercise interventions should be goal-oriented.

Stage 3: Initial Prosthetic Training (Weeks 8-12)

• Gait training, weight-bearing, functional movement.
• Mirror therapy to treat phantom limb pain.
• Client gains additional independence and incorporates prosthesis into daily life.
• Different types of lower limb prostheses are listed, including hemipelvectomy, hip disarticulation, transfemoral, transtibial and Syme's.

Transtibial or Below-Knee Prosthesis

•  Image of a transtibial or below-knee prosthesis is included.

Strengthening, Gait and Balance, and Functional Mobility and Endurance

• Detailed description of strengthening exercises (core, oblique twists, lower body, etc.).
• Detailed description of gait and balance training (weight shifting, heel-to-toe walking, uneven surfaces etc).
• Detailed description of functional mobility and endurance (walking with assistive devices, stair climbing, etc.).

Phantom Limb Pain

• Phantom Limb Pain is a type of pain felt in a limb that's been amputated, with sensations described as crushing, burning, tingling, or shooting.

Mirror Therapy and Phantom Limb Pain

• Mirror therapy can help reduce phantom limb pain, by giving a low cost, alternative form of pain relief.
• There is a lack of understanding of the mechanisms underlying the therapy.
• Significant relief from phantom limb pain, and increased motor control is noted in some case studies.

Stage 4: Advanced Mobility and Community Reintegration (Weeks 17+)

• Achieves independence in daily tasks.
• Enhances community participation.
• Continues long-term health management.

Advanced Rehabilitation

• Lifestyle adjustments, emphasizing diabetes and PAD management, and seeking support from community.
• Advanced gait training involving obstacle courses, uneven surfaces.
• Cardiovascular and endurance training (stationary cycling, swimming).
• Strength training for core, legs, and upper body.

ICF Model Development

• Muscle atrophy has improved considerably.
• Significant improvement in mobility, activities, participation and independent living in many ways.

Research

• Weight-bearing and walking training improves functional performance.
• Dynamic activities with prosthesis improve balance reaction.
• Physiotherapy rehabilitation plans restore strength, range of motion and improved surrounding systems.

Continual Safety Considerations

• Cardiovascular endurance, pain, and balance remain limitations despite functional progress, hence safety measures may need to be considered.
• Alternative exercise methods (harness-supported treadmills) provide safer cardiovascular option compared to unsupervised methods.

Physiotherapy Intervention

• Explains the holistic treatment approach for patients.
• Programs focus on strengthening exercises, gait training, and functional activities.

Stage 3: Initial Prosthetic Training (Weeks 8-12)

• Focused on gait, weight bearing, and functional movement
• Mirror Therapy for Phantom Limb Pain
• Develops independence and incorporates prosthesis into daily activities

Other Important Considerations

• Manual muscle testing results showing improved strength in the affected limb.
• Significant improvements in range of motion in the affected limb.
• Describes practical applications and specific exercises for these phases.

Test your knowledge on Phantom Limb Pain, including its definition, occurrence rates, risk factors, and therapeutic approaches. This quiz also explores findings from case studies, such as the effects of Mirror Therapy on management of this condition.