Zernitz Marina, Rizzello Carla, Rigoni Marco, Van de Winckel Ann
Centro Studi di Riabilitazione Neurocognitiva, Villa Miari, Vicenza, Italy.
Division of Physical Therapy and Rehabilitation Science, Department of Family Medicine and Community Health, Medical School, University of Minnesota Twin Cities, Minneapolis, MN, United States.
Front Pain Res (Lausanne). 2024 Apr 25;5:1374141. doi: 10.3389/fpain.2024.1374141. eCollection 2024.
Relieving phantom limb pain (PLP) after amputation in patients resistant to conventional therapy remains a challenge. While the causes for PLP are unclear, one model suggests that maladaptive plasticity related to cortical remapping following amputation leads to altered mental body representations (MBR) and contributes to PLP. Cognitive Multisensory Rehabilitation (CMR) has led to reduced pain in other neurologic conditions by restoring MBR. This is the first study using CMR to relieve PLP.
A 26-year-old woman experienced excruciating PLP after amputation of the third proximal part of the leg, performed after several unsuccessful treatments (i.e., epidural stimulator, surgeries, analgesics) for debilitating neuropathic pain in the left foot for six years with foot deformities resulting from herniated discs. The PLP was resistant to pain medication and mirror therapy. PLP rendered donning a prosthesis impossible. The patient received 35 CMR sessions (2×/day during weekdays, October-December 2012). CMR provides multisensory discrimination exercises on the healthy side and multisensory motor imagery exercises of present and past actions in both limbs to restore MBR and reduce PLP.
After CMR, PLP reduced from 6.5-9.5/10 to 0/10 for neuropathic pain with only 4-5.5/10 for muscular pain after exercising on the Numeric Pain Rating Scale. McGill Pain Questionnaire scores reduced from 39/78 to 5/78, and Identity (ID)-Pain scores reduced from 5/5 to 0/5. Her pain medication was reduced by at least 50% after discharge. At 10-month follow-up (9/2013), she no longer took Methadone or Fentanyl. After discharge, receiving CMR as outpatient, she learned to walk with a prosthesis, and gradually did not need crutches anymore to walk independently indoors and outdoors (9/2013). At present (3/2024), she no longer takes pain medication and walks independently with the prosthesis without assistive devices. PLP is under control. She addresses flare-ups with CMR exercises on her own, using multisensory motor imagery, bringing the pain down within 10-15 min.
The case study seems to support the hypothesis that CMR restores MBR which may lead to long-term (12-year) PLP reduction. MBR restoration may be linked to restoring accurate multisensory motor imagery of the remaining and amputated limb regarding present and past actions.
对于传统治疗无效的截肢患者，缓解幻肢痛（PLP）仍然是一项挑战。虽然PLP的病因尚不清楚，但有一种模型认为，截肢后与皮质重新映射相关的适应性不良可塑性会导致心理身体表征（MBR）改变，并促成PLP。认知多感官康复（CMR）通过恢复MBR，已使其他神经系统疾病的疼痛减轻。这是第一项使用CMR缓解PLP的研究。
一名26岁女性在腿部近端三分之一处截肢后经历了极度的PLP，此前针对左脚严重神经性疼痛进行了多次治疗（即硬膜外刺激器、手术、镇痛药）均未成功，该疼痛由椎间盘突出导致足部畸形引起。PLP对止痛药物和镜像疗法均无反应。PLP使得佩戴假肢成为不可能。该患者接受了35次CMR治疗（2012年10月至12月工作日每天2次）。CMR在健康侧提供多感官辨别练习，并对双下肢当前和过去动作进行多感官运动想象练习，以恢复MBR并减轻PLP。
CMR治疗后，在数字疼痛评分量表上，神经性疼痛引起的PLP从6.5 - 9.5/10降至0/10，运动后肌肉疼痛仅为4 - 5.5/10。麦吉尔疼痛问卷评分从39/78降至5/78，身份 - 疼痛评分从5/5降至0/5。出院后她的止痛药物至少减少了50%。在10个月随访（2013年9月）时，她不再服用美沙酮或芬太尼。出院后，作为门诊患者接受CMR治疗，她学会了使用假肢行走，逐渐不再需要拐杖在室内外独立行走（2013年9月）。目前（2024年3月），她不再服用止痛药物，使用假肢独立行走且无需辅助设备。PLP得到控制。她通过自行进行CMR练习应对疼痛发作，运用多感官运动想象，在10 - 15分钟内减轻疼痛。
该病例研究似乎支持以下假设，即CMR恢复MBR，这可能导致长期（12年）PLP减轻。MBR恢复可能与恢复剩余肢体和截肢肢体关于当前和过去动作的准确多感官运动想象有关。
