Potential of Physical Analgesia in the Complex Rehabilitation of Patients with Stump Pain and Phantom Pain After Lower Limb Amputation (A Double-blind Randomised Controlled Trial of Efficacy of Deep Oscillation, Laser Therapy and Paravertebral Infiltrations)

Introduction: Most of amputees feel residual limb (stump) pain, phantom sensations and phantom pain. Our purpose was to remind the wide public of the impact of rehabilitation (including the modern physical  modalities  Deep  Oscillation – DO  and  Laser  therapy –L Th)  in  the  pain  management  of amputees. According the medical definitions the amputation is ‘’the intentional surgical removal of a limb  or  body  part;  performed  for  the  following  reasons:  to  remove  malignant  tumors,  after  severe trauma, and to remove tissues without adequate blood supply, because of injury to the blood vessel, hardening of the arteries, arterial embolism, impaired circulation, repeated severe infection that leads to gangrene, severe frostbite, Raynaud’s disease, or Buerger’s disease’’.

Aims: Comparative evaluation of drug, physical (including DO and LTh) and combined analgesia in the complex rehabilitation of patients after trans-femoral amputation suffering from stump pain and phantom pain. In the current chapter, we tested the hypothesis that  some  modern  preformed modalities (Deep Oscillation and Laser therapy) in combination with paravertebral infiltrations have the capacity to provide an analgesic effect, to relieve reactive depression and to ameliorate the quality of life of amputees.

Materials and Methods: During last years a total of 105 amputees with stump pain and phantom pain were  observed  and  investigated.  The  investigation  was  conducted  with  consideration  for  the protection of patients, as outlined in the Declaration of Helsinki, and was approved by the appropriate institutional review boards and ethic commissions. All patients gave written informed consent before undergoing any examination or study procedure. A  simple  randomization  was  used.  Patients  were  sequentially  numbered  and  randomized  into  five treatment groups of 21 each one. All  patients  received  a  complex  rehabilitation  programme  including  physical  therapy  and  patients’ education. In group 1 we applied too drug therapy – paravertebral infiltrations with steroids, lidocaine and B vitamins. Patients of group 2 received a complex rehabilitation programme, including DO. In group 3 we applied drug and physical analgesia techniques (infiltrations and DO). Patients of group 4 received  a  complex  rehabilitation  programme,  including  LaserTh.  In  group  5  we  applied  drug  and physical analgesia techniques (infiltrations and LTh). For statistical evaluation we used t-test (ANOVA) and Wilcoxon rank test (non-parametrical correlation analysis), performed using SPSS package. The treatment difference was considered as statistically significant if the P valuewas < 0.05.

Results: The comparative analysis of results shows a significant improvement of the symptoms of the patients,  concerning: pain  relief  (visualized  by  the  analysis  of  results  of  Visual  analogue  scale, evaluation  of  stump  tenderness),  and  depression  (scales  of  Zung  and  McGill  Quality  of  life questionnaire). In all cases we detected reduction of pain sensation and depression; amelioration of the independence in ADL.  The  drug  analgesia  in  group  1 was  fast,  but  short;  the  efficacy in physiotherapy groups 2 & 4 was slow, but stable, and durable. We received best results in combined groups 3 & 5.

Discussion: The drug therapy is efficient but with short duration. The physical analgesia with DO and L Th initiates  its  effect  slowly,  but  the  results  are  stable.  Best  efficacy  was  observed  in  case  of combination  of medication  with physical  modalities – in  the  beginning  due  to the  steroid  injection, toward the moment of effective «input» of the physical modalities. Current  paper  proposes  personal  opinions  on  some  contemporaneous  theories  of  pain  and therapeutic concepts of analgesia, including physical analgesia. We mentioned principal natural and preformed physical modalities, with effectiveness in clinical practice. Authors suggest a conception of mechanisms  of  physical  analgesia, especially  in  case of  application  of  Deep oscillation  and  Laser therapy.

Conclusion: We  consider  most  effective  the  combination  of  drug  and  non-drug  analgesia  in  all patients after lower limb amputation. We could recommend the complex program for treatment of the pain in amputees. Pain management is an important part of the rehabilitation algorithms in amputated patients with stump and phantom limb pain. The efficacy of Deep Oscillation is probably due to a block of  nociceptors. The application  of  Laser  therapy  is  most  effective  in  cases  with  trophic alterations.

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