Journal CME, November 2021: Treatment Recommendations for Phantom Limb Pain in People with Amputations: An Expert Consensus Delphi Study-Treatment Recommendations

Treatment Recommendations - article.pdf

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The study aimed to develop expert consensus and recommendation on effective treatments for Phantom Limb Pain (PLP) using a three-round Delphi method involving 27 clinicians and researchers. PLP is a common and distressing phenomenon affecting approximately 64% of amputees. Traditional pharmacological treatments like amitriptyline, duloxetine, and pregabalin show no significant efficacy beyond placebo.<br /><br />Initially, 37 treatments were proposed, out of which consensus was reached on seven treatments deemed effective. These include graded motor imagery, mirror therapy, cognitive behavioral therapy (CBT), virtual reality training, sensory discrimination training, use of a functional prosthesis, and amitriptyline. Two treatments, citalopram, and dorsal root ganglion pulsed radiofrequency, were considered ineffective due to a lack of supporting scientific evidence.<br /><br />Notably, many of the endorsed treatments are nonpharmacological, reflecting their potential in addressing neuroplastic changes that maintain PLP. Mirror therapy and GMI are particularly highlighted, given their success in addressing maladaptive cortical reorganization. Virtual reality training, offering visual-proprioceptive feedback, also garnered high expert endorsement despite its nascent stage of research.<br /><br />CBT's high endorsement, despite limited direct evidence for PLP, underscores the role of psychological factors and interventions in managing chronic pain. The functional prosthesis showing clinical efficacy aligns with research documenting its role in improving function and pain management through proprioceptive feedback.<br /><br />However, sensory discrimination training reached only a low consensus, possibly due to limited evidence. The study emphasizes the importance of nonpharmacological approaches in PLP management but also highlights an urgent need for rigorous clinical trials to further establish these methods' long-term efficacy.<br /><br />The study concludes that nonpharmacological treatments and amitriptyline may play significant roles in PLP management, emphasizing the impact of neural mechanisms in PLP and suggesting future research areas in psychological treatments and valid sham treatments to determine direct treatment efficacy beyond placebo effects.

Keywords

Phantom Limb Pain

PLP

Delphi method

graded motor imagery

mirror therapy

cognitive behavioral therapy

virtual reality training

functional prosthesis

amitriptyline

nonpharmacological treatments