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)

Abstract

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 - LTh) 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 value was < 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

LTh 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.