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NMCSD Pain Medicine Research Initiatives   Steven R. Hanling, M.D. Assistant Clinical Professor Department of Anesthesiology/Pain Medicine Uniformed Services University of the Health Sciences Anesthesia Department Naval Medical Center San Diego
TOPICS ,[object Object],[object Object],[object Object],[object Object],[object Object]
Background ,[object Object],[object Object],[object Object],[object Object],[object Object]
Background ,[object Object],[object Object],[object Object],[object Object],[object Object]
Historical Perspective ,[object Object],[object Object],[object Object],[object Object],Fortschr Med. 1990 Feb 10;108(4):62-6. [So-called initial description of phantom pain by Ambroise Par e . "Chose digne d'admiration et quasi incredible": the "douleur  es   parties mortes et amput ee s "]
Historical Perspective ,[object Object],[object Object],[object Object],[object Object],[object Object],Sherman and Sherman. Prevalence and characteristics of chronic phantom limb pain among American veterans.  Results of a trial survey. Am J Phys Med (1983) vol. 62 (5) pp. 227-38
Status Quo ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Ketz. The experience of phantom limb pain in patients with combat-related traumatic amputations.  Archives of physical medicine and rehabilitation (2008) vol. 89 (6) pp. 1127-32 ASA Newsletter March 2007 Vol 71
“ Conventional” PLP Tx’s ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Phantom Limb Pain Mechanisms Flor et al. Phantom limb pain: a case of maladaptive CNS plasticity?. Nat Rev Neurosci (2006) vol. 7 (11) pp. 873-881
Phantom Pain and Cortical Reorg  ,[object Object],[object Object],[object Object],[object Object],Merzenich et al. Somatosensory cortical map changes following digit amputation in adult  monkeys.  J Comp Neurol (1984) vol. 224 (4)  pp . 591-605
PLP Neuroplastic Changes? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Flor et al. Phantom limb pain: a case of maladaptive CNS plasticity?. Nat Rev Neurosci (2006) vol. 7 (11) pp. 873-881
Cortical Reorganization: fMRI Amputee with PLP Amputee, no PL  Control Lotze et al. Phantom movements and pain. An fMRI study in upper limb amputees.  Brain (2001) vol. 124 (Pt 11) pp. 2268-77 as referenced in Flor et al. Phantom limb pain: a case of maladaptive CNS plasticity?. Nat Rev Neurosci (2006) vol. 7 (11) pp. 873-881
“Virtual Reality Box” ,[object Object],[object Object],Ramachandran and Rogers-Ramachandran. Synaesthesia in phantom limbs induced with mirrors. Proc Biol Sci (1996) vol. 263 (1369) pp. 377-86
Mirror Image Therapy Literature Ramachandran and Altschuler. The use of visual feedback, in particular mirror  visual feedback, in restoring brain function. Brain (2009) vol. 132 (Pt 7) pp. 1693-710
Effective PLP Treatment ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Chan et al. Mirror therapy for phantom limb pain. N Engl J Med (2007) vol. 357 (21) pp. 2206-7
Limits of Current Studies ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Methods ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Methods ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Photo courtesy of David H. Peterzell, PhD
Pre-operative Results
Future Research ,[object Object],Qazi et al; Resolving crossings in the corticospinal tract by two-tensor streamline tractogaphy:  Method and clinical assessment using fMRI.  NeuroImage 47 (2009) T98-T106.
Structural/Imaging Outcomes ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Outcomes ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Mirror Therapy Summary ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Pain Medicine & Force Readiness
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Low Back Pain & Readiness Cohen et al. Presentation, diagnoses, mechanisms of injury, and treatment of soldiers injured in Operation Iraqi Freedom: an epidemiological study conducted at two military pain management centers. Anesth Analg (2005) vol. 101 (4) pp. 1098-103, table of contents
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Intradiscal Biacuplasty Non-surgical option for discogenic low back pain
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Intradiscal Biacuplasty Non-surgical option for discogenic low back pain
Comparative Outcomes: Intradiscal Biacuplasty vs. Lumbar Fusion ,[object Object],[object Object],[object Object],[object Object]
Does a cricothyroidotomy simulator enhance procedural proficiency in deployed medical personnel in Afghanistan? The CricSim simulator affords the trainee a 3D stereoscopic view of the patient’s cricothyroid anatomy coupled with a bimanual haptic interface device attached to a desktop PC computer to provide the realistic feel encountered during cricothyroidotomy (1). The CricSim simulator was previously used in Iraq to enhance the training combat medics received in cricothyroidotomy– a low frequency but high-risk lifesaving procedure.  The simulator assessed comfort level with the procedure in 65 medics, showing high realism but moderate ease of use (2). A follow-on study proposed at the level 3 treatment facility in Kandahar, Afghanistan using a refined CricSim simulator will seek to define proficiency as measured by time to perform a cricothyroidotomy and competence in completion of a standardized checklist, while evaluating its deployability and ease of operation in the theater of operations. LCDR C. Cornelissen a , M. Bowyer b , A. Liu b , J. Lopreiato b a Medical and Surgical Simulation Center, NMCSD b National Capital Area Simulation Center, USUHS ,[object Object],[object Object]
NMCSD Pain Medicine Relief, Restoration & Research "The great thing in the world is not so much where we stand, as in what direction we are moving."   - Oliver Wendell Holmes
[object Object],[object Object],[object Object],[object Object],Cortical Effects of SCS
Magnetoencephalography (MEG) Los Alamos National Laboratory Image

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NMRS 2010 Mirror Therapy Brief

  • 1. NMCSD Pain Medicine Research Initiatives Steven R. Hanling, M.D. Assistant Clinical Professor Department of Anesthesiology/Pain Medicine Uniformed Services University of the Health Sciences Anesthesia Department Naval Medical Center San Diego
  • 2.
  • 3.
  • 4.
  • 5.
  • 6.
  • 7.
  • 8.
  • 9. Phantom Limb Pain Mechanisms Flor et al. Phantom limb pain: a case of maladaptive CNS plasticity?. Nat Rev Neurosci (2006) vol. 7 (11) pp. 873-881
  • 10.
  • 11.
  • 12. Cortical Reorganization: fMRI Amputee with PLP Amputee, no PL Control Lotze et al. Phantom movements and pain. An fMRI study in upper limb amputees. Brain (2001) vol. 124 (Pt 11) pp. 2268-77 as referenced in Flor et al. Phantom limb pain: a case of maladaptive CNS plasticity?. Nat Rev Neurosci (2006) vol. 7 (11) pp. 873-881
  • 13.
  • 14. Mirror Image Therapy Literature Ramachandran and Altschuler. The use of visual feedback, in particular mirror visual feedback, in restoring brain function. Brain (2009) vol. 132 (Pt 7) pp. 1693-710
  • 15.
  • 16.
  • 17.
  • 18.
  • 20.
  • 21.
  • 22.
  • 23.
  • 24. Pain Medicine & Force Readiness
  • 25.
  • 26.
  • 27.
  • 28.
  • 29.
  • 30. NMCSD Pain Medicine Relief, Restoration & Research "The great thing in the world is not so much where we stand, as in what direction we are moving."   - Oliver Wendell Holmes
  • 31.
  • 32. Magnetoencephalography (MEG) Los Alamos National Laboratory Image

Hinweis der Redaktion

  1. Nikolajsen 1999 as references
  2. Nikolajsen 1999 as references
  3. Pare not only first wrote about phantom pain but differentiated it into painles phantom limb sensationa nd stump pain as well as described two theories of the pain with 1 being nerve changes locally, or what we would call a neuroma and 2) a central process much as is thought to be the case even today. Fortschr Med. 1990 Feb 10;108(4):62-6. [So-called initial description of phantom pain by Ambroise Par � . "Chose digne d'admiration et quasi incredible": the "douleur 鑚 parties mortes et amput 馥 s "] [Article in German] Keil G .Institut f  Geschichte der Medizin, Universit 舩 W z burg.In his (1552 (1554?) "Harquebusses and other guns" tractate the French surgeon, Ambroise Par � (1510-1590) described the post-amputation syndrome-considered to be the first description of this syndrome--which, on hermaneutic analysis, proves surprisingly complete: Par � differentiated pre-amputation pain ("la douleur 鑚 parties mortes") from post-operative symptoms; he differentiated stump pain from phantom-limb sensations ("faux sentiments"), and he succeeded in distinguishing pain-free exteroceptive sensations--the so-called phantom-limb sensation--from phantom-limb pain proper ("la douleur 鑚 parties amput 馥 s "). He characterised the psychogenic pain syndrome ("se plaigner fort"), described protracted, intermittent and delayed courses, as also exogenous modulating factors which--e.g. the weather ("les causes froides")--exacerbate the situation, or--e.g. massage--can also ameliorate it. Furthermore, he made use of psychological factors to combat pain, and rejected the use of multiple peripheral surgery to treat pain. He proposed two neurological models to explain the etiology of phantom-limb pain, one postulating peripheral changes in stump nerves, the other, involving memory, suggesting a cerebral origin, and locating algogenesis in the brain. 1983 by Sherman & Sherman noted that 61% of amputees with PLP discused the problem with physicians and only 17% offered care with the rest being told they were mentally disturbed. - BJA 2001 review article Remember that many even into WWII still thought of malingering
  4. Good, direct and simple sets historical framework 1983 by Sherman & Sherman noted that 61% of amputees with PLP discused the problem with physicians and only 17% offered care with the rest being told they were mentally disturbed. - BJA 2001 review article Remember that many even into WWII still thought of malingering
  5. Convenience sample of 30 pts used to represent all patients Perceived Effectiveness of Treatment Of the 23 participants who had PLP, 82% (n =2 8) reported talking to their health care providers about the pain, but only 68% (n =1 5) of participants reporting PLP received treatment from their health care providers. Percent treated improved dramatically and is certainly much higher. In this study there was no definition of “treatment by the physician”. My guess is that this meant pharmacologic or injection and does not count those who received multidisciplinary treatments in the form of physical therapy or health psych with modalities such as biofeedback training and/or cognitive behavior therapy. Overall vastly improved
  6. Add PT treatments and reviews Over 60 effective treatments have been described, many have claimed great success but realistically
  7. Add notes from page 111 of nikolajsen article in 2001 BJA.
  8. So the stage was set for imaging studies to find the mechanism behind recontrol of the phantom limbs. Fortunately parallel studies were already being performed on neural plasticity in animal models.. In this study by Merzenich et al, microelectrodes where placed into the somatosensory areas of the brain of Owl Monkeys 2-8 months after unilateral amputation of a digit and it was noted that the cortical area of intact digits grew into areas previously representing amputated digits.
  9. This study prompted a Professor out of the university of heidelberg in Germany to consider if there was a correlation between cortical reorganization and phantom limb pain.
  10. And she thought this coincided well with a study by Lotze et al which used fMRI in UE limb amputees. Possible Mirror Therapy Mechanisms modulated pain pathways in amputated limb by visually perceived movement of amputated limb sprouting new neurons leading to cortical remapping
  11. So in order to give patients back the control he experimentally trialed the use of a virtual reality box. In which he had the patient insert their intact limb and view the mirror image and told the patients to send a motor command to both visually perceived limbs. A new ability to control the phantom limb was observed in 6 of the 10 patients and was a pretty dramatic experience for the patients, some of whom had not moved the phantom limb in 10 years. An example of the results include this quote from patient D.S. who had suffered a brachial plexus avulsion some ten years prior. Consider using figure 3 from Brain 2009 article
  12. And although the literature concerning the use of mirror image therapy is growing, only three randomized controlled trials exist.
  13. Issue include what is the half life of mental visualization….started down ward trend. Perhaps if trial continued this modality would have worked as well.
  14. Summary   BACKGROUND AND OBJECTIVES: The aim of this review was to evaluate the evidence for the treatment of phantom limb pain with mirror therapy. MATERIAL AND METHODS: Randomised controlled studies were identified by a systematic search strategy in the databases "Medline" and "The Cochrane Library". The studies were evaluated using the quality criteria of the JADAD-scale. RESULTS: Three small-sized randomised controlled studies were identified. Unfortunately, these studies lacked methodological quality. One of them found a significant decrease of phantom pain after four weeks of daily mirror therapy sessions. Two other studies could not find a significant difference in the reduction of phantom limb pain between intervention- and control-groups. To date, there is only circumstantial evidence for mirror therapy in phantom pain. Hence, no firm recommendations regarding this treatment option are possible. CONCLUSION: More sufficiently powered randomised controlled studies with high methodological quality are mandatory to investigate the analgesic effect of mirror therapy in phantom limb pain.
  15. We initially started peforming this clinically and then
  16. At four weeks postoperatively, one patient reported no residual limb pain or PLP; two patients described mild stump pain and mild PLP, and one patient reported moderate residual limb pain with brief moderate episodes of PLP. It is notable that all of our patients were at high risk for the development of PLP due to their prolonged courses of limb salvage surgeries and chronic moderate to severe pain and yet experienced minimal PLP.
  17. Although a small sample size, we think further studies are warranted as the likelihood that these results would occur by chance seems minimal given both the high-risk patient population in this report and the high incidence of PLP. Will utiliz
  18. Low back pain was the primary indication for 53% of active duty soldiers medically evacuated from Operation Iraqi Freedom for pain management
  19. Low back pain was the primary indication for 53% of active duty soldiers medically evacuated from Operation Iraqi Freedom for pain management
  20. Low back pain was the primary indication for 53% of active duty soldiers medically evacuated from Operation Iraqi Freedom for pain management
  21. Comparative Outcomes- Intradiscal Biacuplasty Vs Lumbar Fusion
  22. Magnetoencephalography ( MEG ) is an imaging technique used to measure the magnetic fields produced by electrical activity in the brain via extremely sensitive devices such as superconducting quantum interference devices (SQUIDs). These measurements are commonly used in both research and clinical settings. There are many uses for the MEG, including assisting surgeons in localizing a pathology, assisting researchers in determining the function of various parts of the brain, neurofeedback , and others. The Los Alamos system looks like a helmet and contains 155 ultra-sensitive sensors, known as superconducting quantum interference devices, or SQUIDs. Atop the helmet is a unique shield that screens out electrical and magnetic interference and an instrument column immersed in liquid helium that maintains the SQUIDs at minus-450 degrees F.The SQUIDs record the magnetic fields produced by active neurons and display the fields as topographic maps. Computer models are used to calculate the locations and durations of brain activity and project maps of those active neurons on three-dimensional MRI images of the brain."SQUIDs are the most sensitive magnetic field detectors known," said Bob Kraus of Los Alamos' Biophysics Group, MEG principal investigator. "They detect and then convert the weak magnetic fields from neural activity into electrical signals that can be measured more easily."Los Alamos researchers have been working to improve MEG instruments and the computational methods used to analyze MEG data for nearly 15 years. Several Los Alamos concepts are being applied in a clinical setting at the VA Medical Center's Neuroimaging Center.