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Phantomschmerz nach Extremittenamputation: Diagnostik und Biofeedback-Behandlung

Phantom pain after limb amputation: diagnostic and biofeedback treatment English abstract

Fakultt fr Sozia-und Verhaltenswissenschaften der Ruprecht-Karls-Universitt Heidelberg

von Dipl.-Psych. Cornelia Winter-Barnstedt

Abstract Phantom limb pain is a multicausal pain syndrom that is still lacking effective treatment. Study 1 of the present work evaluated the psychometric properties of a diagnostic interview for phantom and stump phenomena. As in other pain syndromes, an effective and a sensory pain dimension could be identified in phantom and stump pain. Study 2, a comparison between upper and lower limb amputees with phantom pain was conducted. A reorganization of the representation zones in primary somatosensory cortex was observed in both groups, but was more variable in lower limb amputees. The latter also showed a higher usage of prostheses. In study 3, five arm or leg amputees participated in ten sessions of biofeedback training. This led to a significant reduction in phantom limb pain. The hightest treatment gains were obtained in patients who showed concurrent stump pain, a high reagibility of stump EMG and a episodic pain occurrence.

Study 1 results The structural model with two factors, affective experience of pain and sensory Pain experience was for all pain scales confirm high quality of fit. The 2-indices and RMSEA values were all in inconspicuous area. For the Phantom pain scale the two-factor model found with regard that is a very good

index of the goodness of fit (Goodness of Fit Index, GFI) of 0970 (2 = 35.80, p = 1.00). The standardized residuals ranged from | 0.00 | (= median) and a maximum of | 2.57 | and remained so all below the significance threshold of | 2.58 | delivered, thus no evidence of misspecification in the model. The same was found for the analog scale retrospective, phantom pain after amputation with a

Goodness of fit of 0987 (2 = 13.24, p = 1.00) and a maximum standard Residuum of the confirmatory analysis of the two-factor model, stump pain now revealed an even higher quality of fit (GFI) of 0991 (2 = 9.64, p = 1.00), the standardized Residuals were up 0.00 to | 1:08 | well below the significance threshold. The same was true for the scale retrospective, after the amputation stump pain 'with a GFI of 0994 (2 = 6.46, p = 1.00) and a maximum standardized residual of | 0.74 |. Also for the Amputate member pain scale and wound pain, which do not complement, but it reduced the original SES had been made, resulted in a

good fit between data and model at the Amputate member pain scale with a Model fit (GFI) of 0991 (2 = 9.57, p = 1.00, maximum residual | 1.12 |), in which Scale of pain with a fit of 0988 (2 = 8.45, p = 1.00, maximum

Residual | 0.94 |). The two-factor solution proved to be so in all cases as appropriate and sufficient to explain the data structure of pain-related

Adjective scales. The details of means, standard deviations and covariances of the Input variables are listed in Appendix 2.









now 'as a path model (here with the non-standardized variables). To the left of the manifest variables (= single item), the error values, the right of them, the charges of latent factors on the manifest variables.

Study 2 results Regarding the intensity and frequency of occurrence of the phantom and stump phenomena were generally no group differences between leg and arm amputees, patients determine. The results are shown in Table 5.3.1 for the larger sample of 24 arm and leg amputees represented.

Overall, the above table shows 5.3.1, that the affective dimension of phantom limb pain of the patients was more heavily weighted than the sensory, where typically only a few specific descriptors were selected. When stump pain was the difference

not to the same extent. In the description of phantom pain was the most common leg amputees, Pungent 'as specified sensory quality (n = 8 patients), less tense,', 'hot'










Most amputees, severe '(n = 9), followed by, unnerving' (n = 8), terrible (n = 6), intolerable ',' horrible '(n = 5), distressing' and 'exhaustive' (n = 4). The six Leg amputee who suffered alongside the Phantom and stump pain describes these as well as a pungent, (n = 6) and also as tearing '(n = 4), tense,

burning and hammering (n = 3). Regarding the affective quality of the selected five six patients the same descriptors as for the phantom pain ('violent', 'distressing' , Unnerving ',' disgusting '), the sixth person who was suffering from a weak stump pain was, no affective descriptors. The arm amputees surveyed patients characterized their pain sensory most respects than tense '(n = 9 patients) and relatively frequently as pungent (n = 5) or hot (n = 4). Regarding the affective dimension called the most patients, the terms, agonizing, violent (n = 9), unnerving (n = 8), Intolerable (n = 7), hideous and terrible (n = 5). Six of the arm amputees patients also suffered from stump pain, and five of them chose to describe the sensory quality descriptors same as for the phantom pain (tense,

burning, cutting), a person described the stump pain differently (stabbing in contrast to cramped phantom pain). Also regarding the emotional color have often chosen the same descriptions.

Study 3 results Initial findings and training success in learning the feedback control

Output values: Since the indication for biofeedback training and the choice of feedback parameter from the physiological baseline of the patient was discharged, they were initially in Overview presented (Table 6.3.1).

Looking at the skin temperature the table shows the average percentage of Points per subject, where the stump temperature significantly (at least 1 C) reduced compared to the corresponding point of the contralateral limb was. In four of the six patients had such a reduction of at least 20% of the measurement points determine what was chosen as indication criterion for temperature feedback. The above is also shown EMG stress reactivity in the treatment group was very varies. The single data set are as follows (Figure 6.3.1):

Two patients (B18 and B19) were given an EMG biofeedback training. The patient B18 was still a strong EMG stress reactivity, same time they found little difference between the temperature of the stump and the intact leg (percentage of colder Measuring points on the stump: 8.3%). The second patient, B19, was a borderline case with only 20% measuring points on the stump and a colder moderate EMG responsiveness. When he was first an experiment with temperature feedback and made only during the Training Phantom episodes the pain, of EMG which, pain added. inter some Both alia, relief patients as by suffered from and attacks could like be the


tense, or



Limb muscles reach. Training effects: In four of the six patients focused on the biofeedback training, the Influence of skin temperature, and so a group presentation of the training effects can take place (Figure 6.3.2).

It can be seen that the training in the group means better control of its purpose Skin temperature reached at the stump. Succeeded to the participants during the first session a temperature increase by an average of 0.2 C, they reached in the last Treatment session, an increase of 1.0 C. The baseline skin temperature changed does not. Breaking down the group result after individual cases, it appears however, that a patient (B09), who suffered from circulatory problems, the temperature control in during the training did not learn (Figures 6.3.3 and 6.3.4). In Figure 6.3.3 Besides the four patients treated with temperature feedback (TH05, PS11, B09, TH10) for comparison, the data of the two patients (B18, B19) shown, which means EMG Feedback were treated.

Figure 6.3.4 shows the appropriation of the temperature control as a process of meetings per patient. It is situated only 9 sessions, as in the first hour to introduce the Method, first temperature feedback was given by the index finger. In patient TH05 was clarity possible for technical were preferred reasons 8 in and Session 9 in 7, no recording, the figure. the The


Figure shows that the acquisition of the temperature control was not linear, but - depending on the tried and tested techniques, introduced the stressors, but also the Outside temperature - with significant changes from session to session was connected.

The training results of the two patients treated with EMG biofeedback in the Figures 6.3.5, 6.3.6 and 6.3.7 rendered.











recognize the decreased EMG responsiveness to stress stimuli can be personally relevant. The course of training is shown in the figure 6.3.6. The increased values in Session 4 are due to a change in attitude of the stump.

B19 in the patient, the presentation of the training course more difficult. as above, the EMG feedback was introduced here only in the course of training (Session 6) after the very agile and restless, 79-year old patient with learning difficulties the Temperature control - and with a total relaxation on the basis of self-suggestion or imagination - showed. The concrete feedback and influence on the often very high muscle tension proved to be more suitable for him as a feedback method, using which he in his sporadic violent attacks of stump and phantom pain (to Home and twice during the training sessions) reached an immediate improvement. Since the patient but reached only a very brief periods of relaxation, reflected the training effects in this case (see Figure 6.3.7) is not a general change the EMG values against. The ninth session is not shown in the figure, because here - may in Combined with high restlessness of the patient because of stomach pain

- Occurred distinctive artifacts and recording the data were not evaluated. the generally unusually high level of tension in this patient is in addition to the

spontaneous EMG spikes also increased by a resting tone and motor restlessness the patient's reason for which it was a total hard to sit quietly for several minutes. Verbal-subjective data: Table 6.3.1 shows the means and standard deviations of Treatment and control groups in terms of different dimensions for phantom pain intensity, the results of the two-factorial, univariate analyzes of variance with repeated measurements and the effect sizes.

According to hypothesis shows a significant interaction effect between the factors Group and time in terms of pain scale (total) and their

affective subscale, a trend towards significant interaction also in terms of scale , Phantom pain intensity 'of the MPI-D. In contrast, the changes can be in the visual analog scale and in the sensory subscale of the pain scale (SES) not significantly protect against the control group. There are, however, with respect to all noted above dimensions for phantom pain intensity large effect sizes (d

= 0.80 or greater). Before the therapy, none of these scales had a significant Group difference between treatment and control groups demonstrated (p 0.20). A similar picture emerges when only the values of the treatment group pre and post therapy are compared using t tests for dependent samples. With regard to the scale of , Pain intensity 'of the MPI-D, the reduction is significant (t 4 = 2.8, p = 0.049), as well as in the affective subscale of the SES (t4 = 2.91, p = 0.044). A trend toward significance arises in the SES total score (t 4 = 2.63, p = 0.058) and also in the visual analogue scale (t 4 = 2:18, p = 0.095). Not significant is the change in the sensory subscale of the SES (T4 = 1.92, P = 0.128). A statistically significant difference between treatment group and control group shows in the post-time in the phantom pain intensity according to the MPI-D (t 8 = -2.33, p = 0.048) and as a trend in the affective subscale (t 8 = -1.88, p = 0.097) and total score (t 8 = - 1.96, P = 0.086) of the SES. Not significant, however, the group differences in the sensory SES subscale and the VAS after therapy.

With regard to the clinical importance of pain reduction achieved Table 6.3.2 shows the improvement rates in the treatment group. Here there are clear discrepancies between each phantom pain dimensions. While the MPI-D only in one patient

clinically relevant improvement by at least 30% was achieved, these are three or four of the five patients, when the VAS and the SES takes the measure.

The results for the other, in addition to the pure intensity of pain recorded variables in Table 6.3.3 gives an overview.

There are no resulting effects that are significantly different from purely random or timeChanges in the control group take off (no significant interaction of group x time). In the variable affected by the pain '(MPI-D) shows, however - compares If the post-values of both groups - a reduction in the therapy group having an average exhibits to high effect size. This change in the treatment group achieved but also in the pre-post comparison using t tests for dependent samples not

Significance level (t4 = 1.19, ns). The reduction of the residual limb pain in the treatment group was - because of unequal variances - is also investigating using the Wilcoxon test,

Here too the group difference was not significant (MPI-D: Z = -1.34, ns). Follow-up. The results of the investigation catamnestic after three months and the statistical effects in comparison to the pre-examination are placed in table 6.3.4; Table 6.3.5 shows the rates of clinical improvement after three months. With respect to the Effect sizes is (limiting) taken into account that this in turn based on the data the control group for post-time was calculated as a measurement for catamnesis The control group was not available. The results show that the achieved Treatment effects in the course of three months remained essentially stable.