Richardson Cliff, Kulkarni Jai
University of Manchester, Division of Nursing Midwifery and Social Work, Manchester, UK.
Specialized Ability Centre (Manchester), University Hospitals of South Manchester NHS Foundation Trust, Manchester, UK.
J Pain Res. 2017 Aug 7;10:1861-1870. doi: 10.2147/JPR.S124664. eCollection 2017.
Phantom limb pain (PLP) occurs in 50% and 80% of amputees. Although it is often classified as a neuropathic pain, few of the large-scale trials of treatments for neuropathic pain included sufficient numbers of PLP sufferers to have confidence that they are effective in this condition. Many therapies have been administered to amputees with PLP over the years; however, as of yet, there appears to be no first-line treatment.
To comprehensively review the literature on treatment modalities for PLP and to identify the challenges currently faced by clinicians dealing with this pain.
MEDLINE, EMBASE, CINAHL, British Nursing Index, Cochrane and psycINFO databases were searched using "Phantom limb" initially as a MeSH term to identify treatments that had been tried. Then, a secondary search combining phantom limb with each treatment was performed to find papers specific to each therapy. Each paper was assessed for its research strength using the GRADE system.
Thirty-eight therapies were identified. Overall, the quality of evidence was low. There was one high-quality study which used repetitive transcutaneous magnetic stimulation and found a statistical reduction in pain at day 15 but no difference at day 30. Significant results from single studies of moderate level quality were available for gabapentin, ketamine and morphine; however, there was a risk of bias in these papers. Mirror therapy and associated techniques were assessed through two systematic reviews, which conclude that there is insufficient evidence to support their use.
No decisions can be made for the first-line management of PLP, as the level of evidence is too low. Robust studies on homogeneous populations, an understanding of what amputees consider a meaningful reduction in PLP and agreement of whether pain intensity is the legitimate therapeutic target are urgently required.
50%至80%的截肢者会出现幻肢痛（PLP）。尽管它通常被归类为神经性疼痛，但很少有针对神经性疼痛的大规模治疗试验纳入足够数量的PLP患者，以使人们确信这些治疗方法在这种情况下是有效的。多年来，许多疗法已应用于患有PLP的截肢者；然而，截至目前，似乎尚无一线治疗方法。
全面回顾关于PLP治疗方式的文献，并确定临床医生在应对这种疼痛时目前面临的挑战。
使用“幻肢”作为医学主题词（MeSH），首先在MEDLINE、EMBASE、CINAHL、英国护理索引、Cochrane和psycINFO数据库中进行检索，以确定已尝试的治疗方法。然后，进行二次检索，将幻肢与每种治疗方法相结合，以查找特定于每种疗法的论文。使用GRADE系统评估每篇论文的研究强度。
共确定了38种疗法。总体而言，证据质量较低。有一项高质量研究使用了重复经皮磁刺激，发现第15天时疼痛有统计学意义的减轻，但第30天时无差异。加巴喷丁、氯胺酮和吗啡的单项中等质量水平研究有显著结果；然而，这些论文存在偏倚风险。镜像疗法及相关技术通过两项系统评价进行评估，其结论是没有足够证据支持其使用。
由于证据水平过低，无法就PLP的一线管理做出决策。迫切需要对同质人群进行有力研究，了解截肢者认为PLP有意义减轻的标准，以及疼痛强度是否为合理治疗靶点达成共识。
