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Phantom limb treatment

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Presentation on Phantom Limb treatment.
"PLP"

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Phantom limb treatment

  1. 1. Phantom Limb Pain Treatment By: R A Candra Putra (5718035) Auntouch T (5718036) Harashdeep Grover (5718037) Rina F Rahmawati (5718038)
  2. 2. Contents • Introduction • Causes • Treatment – Pharmacological Treatment – Nonpharmacological Treatment – Surgical Treatment • Conclusion
  3. 3. The concept of Phantom Limb Pain as being in pain that feels like it's coming from a body part that's no longer there. Doctors once believed this post-amputation phenomenon was a psychological problem, but experts now recognize that these real sensations originate in the spinal cord and brain. The concept of Phantom Limb Pain as being in pain that feels like it's coming from a body part that's no longer there. Doctors once believed this post-amputation phenomenon was a psychological problem, but experts now recognize that these real sensations originate in the spinal cord and brain. Introduction
  4. 4. •The exact cause of phantom pain is unclear, but it appears to originate in the spinal cord and brain. •During imaging scans — such as magnetic resonance imaging (MRI) or positron emission tomography (PET) — portions of the brain that had been neurologically connected to the nerves of the amputated limb show activity when the person feels phantom pain. •A number of other factors are believed to contribute to phantom pain, including damaged nerve endings, scar tissue at the site of the amputation and the physical memory of pre-amputation pain in the affected area. •The exact cause of phantom pain is unclear, but it appears to originate in the spinal cord and brain. •During imaging scans — such as magnetic resonance imaging (MRI) or positron emission tomography (PET) — portions of the brain that had been neurologically connected to the nerves of the amputated limb show activity when the person feels phantom pain. •A number of other factors are believed to contribute to phantom pain, including damaged nerve endings, scar tissue at the site of the amputation and the physical memory of pre-amputation pain in the affected area. Causes
  5. 5. PHARMACOLOGICAL TREATMENT
  6. 6. PreEmptive Analgesia and Anesthesia absence of sensibility to pain,  particularly the relief of pain without loss  of consciousness;   or noxious stimulation. absence of sensibility to pain,  particularly the relief of pain without loss  of consciousness;   or noxious stimulation. Lack of feeling or sensationLack of feeling or sensation AdvantagesAdvantages •Stable intraoperative conditions (e.g.  Cardiovascular) •Effective •Reduced nausea and vomiting •No effect on urinary function. •Improved early mobilization of major  joints. •Stable intraoperative conditions (e.g.  Cardiovascular) •Effective •Reduced nausea and vomiting •No effect on urinary function. •Improved early mobilization of major  joints. •Time consuming –takes around 15-30   minutes to be effective •Failure rate about 5% even in the  best hands. •Inadequate training of consultants  and trainees. •Time consuming –takes around 15-30   minutes to be effective •Failure rate about 5% even in the  best hands. •Inadequate training of consultants  and trainees. Disadvantage s Disadvantage s
  7. 7. Acetaminophen and Nonsteroidal Anti-Inflammatory Drugs ( NSAIDs )    A cross sectional study found that acetaminophen and NSAIDs were the most common medications used in the treatment of PLP .  The analgesic mechanism of acetaminophen is not clear but serotonergic and multiple other central nervous system pathways are likely to be involved.  NSAIDs inhibit the enzymes needed for the synthesis of prostaglandin and decrease the nociception peripherally and centrally.  One of the major side effects is that they decrease the effect of the normal blood clotting factors in blood.  A cross sectional study found that acetaminophen and NSAIDs were the most common medications used in the treatment of PLP .  The analgesic mechanism of acetaminophen is not clear but serotonergic and multiple other central nervous system pathways are likely to be involved.  NSAIDs inhibit the enzymes needed for the synthesis of prostaglandin and decrease the nociception peripherally and centrally.  One of the major side effects is that they decrease the effect of the normal blood clotting factors in blood.
  8. 8. Opioids (Morphine) • Bind to CNS and PNS • Provide analgesia without loss of touch, proprioception, or conciousness • Effective for treatment neuropathic pain including PLP, Diminish cortical reorganization (Huse E 2001) • Controversial and their use is limited due to the side effects and potential for
  9. 9. Tricyclic Antidepressant (TCAs) • Commonly used for neuropathic pain • Analgesic – inhibition of serotonin-norephineprine uptake blockade • Average dose of 55mg of amitriptyline is effective to control PLP • Nortryptyline and desipramine equally effective with less side effects • Side effects - cardiotoxicity, orthostasis, tachycardia, arrhythmias, insomnia, dizziness, weight gain, and anticholinergic effects
  10. 10. Anticonvulsants • Anticonvulsants - prevent or reduce the severity and frequency of seizures in various types of epilepsy but which are also effective for pain. They work in a number of different ways, all of which have relevance to their effect on pain. • Gabapentin – show positive result in controlling PLP by inhibitory action at voltage-gated calcium channels The most common side effects were dizziness and somnolence, but weight gain, nausea, abdominal pain, asthenia, • Carbamazepine has been reported to reduce pain associated with PLP • Oxcarbazepine and pregabalin – need further studies
  11. 11.  NMDA receptors play a role in sensitization at the spinal cord level  memantine produce an analgesic effect that may be beneficial in the treatment of PLP  it may be successful in treating PLP if initiated in early post-amputation period(Hackworth, et al 2008) Calcitonin NMDA receptor antagonists Calcitonin is a peptide with high a molecular weight.  The exact mechanism of action is still unclear (Eichenberger, et al 2008)  But it leads to decreased formation of local cytokines and prostaglandin  It may reduce the intensity and frequency of pain; however, a more recent randomized, controlled trial showed that calcitonin alone was ineffective against PLP
  12. 12. Other medications • The beta blocker propanolol and the Ca channel blocker nifedipine - used for treatment PLP. However their effectiveness is still unclear
  13. 13. NONPHARMALOGICAL TREATMENT
  14. 14. Treatment of Phantom pain (PLP) • Nonpharmacological treatment • Transcutaneous Electrical Never Stimulation (TENS) - Standard device , inexpensive - Safe and easy to use - Using battery to control - Generates to the skin to activate the effected nerves.
  15. 15. Mirror Therapy • was first introduced by Ramachandran in 1996 • persons with amputated limb use either a mirror or mirror box to reflect an image of the intact limb. It is hypothesized that this works by preventing cortical restructuring • patients with PLP showed a decrease in pain at the 6-month follow-up (Diers, 2010) • mechanisms underlying the effects of mirror training or motor imagery, are still unclear
  16. 16. Biofeedback – It can help to reduce muscle tension and increase blood flow. – by using visual or other sensory stimuli to retrain the brain to stop sending pain signals Prosthesis - Help to regain the feeling of loosing limb - An electrical prosthetic limb moved by signals. Prosthesis - Help to regain the feeling of loosing limb - An electrical prosthetic limb moved by signals.
  17. 17. SURGICAL INTERVENTION • Should be avoided • Stump Revision – Patients with continued phantom limb pain – Stump with vascular insufficiency – Infection – Neuromas may undergo stump revision
  18. 18. Surgical Remove the nerve sending the pain signals • Neurectomy : Nerve removal • Rhizotomy : sever nerve roots in the spinal cord • Cordotomy : sever nerve cord in the spinal cord • Lobectomy • Patient experience numbness, tingling or impairment of the surrounding nerves • May provide short term relief but pain commonly reappears
  19. 19. Surgical Dorsal Root Entry Zone • Phantom pain because of brachial plexus avulsion, sacral plexus avulsion or Spinal Cord Injury • Dorsal root : nerve fibers send the brain messages about sensations and pain • Destroying the area where damaged nerves join the central nervous system. This intercepts pain messages from nerves to the brain • Most patients experience relief of pain immediately after surgery • Sustain good pain relief over the long term
  20. 20. Conclusion • Multidisciplinary approach, tailored to the individual needs of the patient, has the best chance of improving the symptoms of phantom limb pain and the functional outcome TENS Acupuncture Bio-feedback Hypnosis Massage Ultrasound ECT Nerve blocks Neurectomy Stump revision Rhizotomy Cordotomy Lobectomy Sympathectomy Spinal cord stim Brain stimulation TCA Anticonvulsants Lidocaine Opioids NMDA antagonists clonidine
  21. 21. THANK YOU FOR YOUR ATTENTION

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