Acquired limb deficiencies. 4. Troubleshooting
Contents
1. PROBLEMS AND SOLUTIONS IN OPERATING THE PROSTHESIS Successful use of a body powered or a hybrid system re quires a certain amount of strength and range of motion Scapular excursion chest expansion and shoulder and elbow motion can all be used to provide cable tension Physical or occupational therapy may be indicated if the patient lacks the necessary power or limb mobility to operate these types of prostheses If an amputee with adequate strength and range of motion is having difficulty operating the prosthesis an obvious first step is to evaluate the condition of the terminal device and mechan ical joints eg elbow and wrist unit The cable the housing and the fittings should be inspected The most common prob lem is with the housing binding the cable movement Mechan ical wrist units with friction control are adjustable The amount of resistance to supination and pronation can be adjusted with an Allen wrench If the nylon bushings are sufficiently worn or damaged replacement is warranted Heavy duty use may de mand greater torque resistance of a wrist unit to lock the terminal device in a set amount of pronation or supination A quick change wrist unit is preferred for these users HARNESSES AND CABLES The fit of the harness is directly related to the efficiency and operation of the prosthesis The figure of 8 harness is the configuration most commonly used after transradial and trans humeral amputations 2 The harness sh2. letter N Engl J Med 1976 295 678 25 Patterson JF Carbamezepine in the treatment of phantom limb pain South Med 1988 81 1100 2 26 Oille WA Beta adrenergic blockade and phantom limb letter Ann Intern Med 1970 73 1044 5 27 Ahmad 8 Phantom limb and propranolol Br Med J 1979 1 415 28 Marsland AR Weekes JW Atkinson RL Leong MG Phantom limb pain a case for beta blockers Pain 1982 12 295 7 29 Bartusch SL Sanders BJ Alessio JG Jernigan JR Clonazepam for the treatment of lancinating phantom limb pain Clin J Pain 1996 12 59 62 30 Dillingham TR Rehabilitation of the lower limb amputee In Belandres PV Dillingham TR editors Rehabilitation of the injured combatant Vol 1 Washington DC Office of The Surgeon General at TMM Publications 1998 p 136 9 31 Sanders GT Lower limb amputations a guide to rehabilitation Philadelphia Davis 1986 p 415 76 32 Esquenazi A Analysis of prosthetic gait Phys Med Rehabil State Art Rev 1994 8 201 20 33 Sanders GT Lower limb amputations a guide to rehabilitation Philadelphia Davis 1986 p 455 6 Key References Suppliers a Conva Tec PO Box 5254 Princteon NJ 08543 b TEC Interface Systems 820 Sundail Dr Waite Park MN 56387
3. or 12 months It is unlikely that higher doses of medication would have been more effective because the pa tients were rendered pain free by the test doses It is possible that a longer period of pretreatment would have been effective because the earlier trials treated patients from 24 hours to 3 days preoperatively PERIPHERAL STIMULATION Peripheral stimulation in the form of transcutaneous electri cal nerve stimulation TENS vibration and acupuncture have all been used with benefit in PLP Winnem and Amundsen treated 11 amputee patients with disabling PLP with TENS for 2 15 minute sessions twice per day for 5 days TENS treatment was initiated at high frequency 100Hz in the residual limb but was switched to low frequency 2Hz if high frequency stimulation failed to effect relief If TENS remained ineffec tive the procedure was repeated in the intact limb segmentally to the area of pain Two patients achieved complete relief and 5 others experienced very definite improvement Responders experienced 50 reduction in consumption of analgesics Fol low up ranged from 3 to 12 months A study of the effects of TENS on healing the residuum and on PLP in 51 persons about to undergo amputation was performed by Finsen et al This trial compared sham TENS alone sham TENS plus chlorprom azine and genuine low frequency TENS 7 pulses twice per second 100Hz 90pus duration Healing rates were higher in the genuine TENS gro
4. 25 Acquired Limb Deficiencies 4 Troubleshooting Charles Levy MD Phillip R Bryant DO Mary C Spires DO Daniel A Duffy DO ABSTRACT Levy CE Bryant PR Spires MC Duffy DA Acquired limb deficiencies 4 Troubleshooting Arch Phys Med Rehabil 2001 82 Suppl 1 525 30 This self directed learning module offers practical analyses of and solutions for common clinical problems of amputees It is part of the chapter on acquired limb deficiencies in the Self Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation The in formation presented here has been designed to be useful also to other interested professionals including prosthetists physical therapists occupational therapists and nurses Topics covered include the management of typical obstacles encountered in upper limb amputees and the diagnosis and treatment of phan tom and residual limb pain Diagnostic and treatment ap proaches to skin breakdown in the transtibial amputee and to knee instability in the transfemoral amputee are also presented Overall Article Objective To analyze common clinical problems of amputees Key Words Amputation Phantom limb Pain Prostheses and implants Skin care Rehabilitation 2001 by the American Academy of Physical Medicine and Rehabilitation 4 1 Objective To identify and overcome commen obsta cles associated with body powered and upper limb prostheses The early goals i
5. a neuropathic origin and has a modest side effect profile 8 It is however relatively expensive Other agents are used less commonly Capsaicin a natural extract of chili peppers when applied topically causes the release of substance P and other neuropeptides from the termi nals of slow conducting unmyelinated C fibers With repeated dosing substance P becomes depleted Capsaicin has been used effectively to treat residual limb pain as opposed to PLP in 3 patients and it is free of systemic side effects however it can cause unpleasant burning discomfort where topically applied 9 Calcitonin is a peptide hormone involved in the regulation of calcium homeostasis that is secreted by the perifollicular cells of the thyroid gland The mechanism of calcitonin s antinoci ceptive properties is unknown although an increase in beta endorphins and stimulation of serotoninergic neurons may be involved Calcitonin has been effective in PLP in 2 trials 2 22 Adverse effects include nausea vomiting and allergic reac tions Mexiletine is a class 1B antidysrhythmic agent that has also found use in neuropathic pain syndromes eg painful diabetic neuropathy Its mechanism of action is believed re lated to its effect on sodium potassium channels resulting in less peripheral nerve excitability Mexiletine has been effective in an open label trial of 31 amputee patients with PLP The risk of sudden death in patients taking this medication for dys
6. especially in the setting of proximal constric tion vascular insufficiency and excessive distal suction The treatment for open wounds is wound care cessation from wearing the prosthesis and appropriate prosthetic modi fication The patient should not use the prosthesis until the wound has healed except in some instances of minor ulceration or abrasion where the wound can be covered with a padded occlusive dressing such as DuoDERM and prosthetic use can be resumed immediately after modification For closed wounds prosthetic modification is often sufficient Modifica tion can be as simple as adding socks or changing alignment or it may demand liner or socket modification replacement of the socket or other components or a totally new prosthesis In many settings these decisions are best left to the prosthetist However even better results are likely if the physician can add his her insight based on medical knowledge and a sound un derstanding of the biomechanical interplay between user and prosthesis The patient should be observed in the prosthesis while stand ing static analysis and during ambulation dynamic analysis Standard alignment of the patellar tendon bearing prosthesis is designed to maintain balance advance the prosthetic foot in the normal line of progression and preserve comfort and integrity of the skin by preferentially loading the soft tissues and less ening the load over bony prominences For an uncomplica
7. or hybrid prosthetic systeras which require less harnessing Suction suspension can also reduce harnessing needs but re quires close monitoring to maintain an effective fit Roll on liners can cause excessive perspiration If this problem persists topical antiperspirants are usually indicated Resistant perspi ration may be treated with oral medications or electrolysis Residual limbs with significant tissue deficits or split thickness skin grafts are typically not good candidates for suction sus pension systems Roll on liners are often helpful in these cases 4 2 Objective To discuss medicines and physical modal ities in the treatment of phantom limb pain The first step in treating phantom limb pain PLP is accurate diagnosis The cardinal feature of PLP is painful sensation perceived in a body part that has been lost or never developed This should be distinguished from phantom sensation a non painful awareness ie proprioception pressure wetness itch ing tickle of the absent limb and from residual limb pain Phantom sensation is usually not treated pharmacologically Residual limb pain can be due to multiple causes including infection vascular insufficiency necrosis prosthetic fit bone spurs and neuroma formation 4 Optimal treatment of pain arising from an amputation begins in the preoperative and perioperative periods Although not definitively linked with better outcomes compassionate care suggests counseling to h
8. to high and a socket with a too small anteroposterior diameter 3 Careful static and dynamic gait analysis in a person with a lower limb deficiency along with close inspection of the condition and alignment of the residual limb and prosthetic device is essential in identifying and correcting gait deviations Acknowledgment The author is indebted to Sikhar N Banerjee whose chapter on lower extremity amputation in the book Clinical Decision Making in Rehabilitation Basmajian JV Banjaree SN edi tors New York Churchill Livingstone 1996 strongly influenced the concepts discussed in Objective 4 2 References 1 Spires MC Miner L Colwell M Upper extremity amputation and prosthetic rehabilitation In Grabois M Garrison SJ Hart KA Lehmkuhl LD editors Physical medicine and rehabilitation the complete approach Malden MA Blackwell Science 2000 p 549 82 2 Fryer CM Michael JW Upper limb prosthetics body powered components Atlas of limb prosthetics surgical prosthetic and rehabilitation princples St Louis Mosby Year Book 1981 p 107 31 3 Fryer CM Harnessing and controls for body powered devices Atlas of limb prosthetics surgical prosthetic and rehabilitation princples St Louis Mosby Yearbook 1981 p 133 50 4 Thompson HM Pain after amputation is prevention better than cure Br Anaesth 1998 80 415 6 5 Weiss T Miltner WH Adler T Brukner L Taub E Decrease in phanton limb pain associated with pro
9. ate deviations to call attention to the perceived seriousness of the problem Patients should also be watched carefully while they don and doff their prosthesis Errors in technique may be at the root of their problem When the residual limb has been exposed the color shape size texture and distribution of the lesions should be noted along with the condition and shape of the residual limb Scars should be noted Palpation of the limb will disclose the extent of tenderness the presence and quality of edema and the amount of muscle bulk and atrophy Palpation can also reveal areas of tissue adherence to the underlying bone These areas are at greater risk of injury during the normal shearing move ments of the socket on the limb during ambulation A variety of lesions may be seen and can give clues as to the duration and nature of the problem Reactive hyperemia is among the first reactions to excessive shear or pressure In the presence of moisture this may progress to maceration Blis ters represent a more serious mismatch between the user s skin and the shear and pressure of the environment Further pro gression can lead to frank ulceration Tissue can also prolifer ate in response to shear or pressure Lichenification thickened leathery skin can form at areas where repetitive stresses ex ceed skin tolerance Callosities usually form over bony prom inences Verrucose hyperplasia a warty condition of the distal limb can form
10. direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author s or upon any organization with which the author s is are associated Address correspondence to Charles E Levy MD Physical Medicine and Rehabil itation Service North Florida South Georgia Veterans Health System 1601 SW Archer Rd Gainesville FL 32608 0003 9993 01 8203 6658 35 00 0 doi 10 1053 apmr 2001 22225 dial socket is too short or is not flared away from the ulna local discomfort over the ulna results If the proximal trim lines are too distal the socket will slide on the residual limb and create irritation Skillful reshaping of the socket s inner wall usually provides relief Socket modification must redistribute pressure while maintaining a secure fit that can resist slippage and rotatory forces Adding padding or other materials in the area of irritation is not usually indicated because the padding often creates additional pressure Lining the socket with silicone can reduce friction if shear is the culprit Ultimately if a socket cannot be adequately reshaped to relieve areas of excessive pressure socket replacement should be considered Patients with very short transradial amputations can be dif ficult to fit because the proximal trim lines must be placed near the antecubital fossa to offer effective suspension This can interfere with elbow flexion and can cause soft tissue impinge ment and pa
11. elp prepare the prospective amputee for limb loss and aggressive treatment of pain Compression early mobilization and active desensitization of the residual limb should decrease edema and pain and help the new amputee patient regain a sense of personal control over his her body Actual use of a prosthesis has been associated with decreased PLP PREOPERATIVE EPIDURAL TREATMENT Several early studies have shown that the use of an epidural block preceding amputation may diminish or obliterated the occurrence of PLP S This treatment was supported by the observation that limb pain prior to surgery was correlated with the incidence of residual limb pain and PLP after surgery Despite encouraging results these initial studies were limited by small sample sizes insufficient randomization and non blinded assessment of treatment effects In a well constructed placebo controlled trial of peroperative epidural treatment 60 patients scheduled for lower limb amputation were randomized to receive either a continuous infusion of bupivacaine 25 4 7mL hr and morphine 16 28mg hr or an infusion of epidural saline and paracetamol 4 times daily and morphine 4 TROUBLESHOOTING Levy 27 to 6 times daily The treatment regimens started 18 hours before surgery and the infusions were continued during sur gery No statistical differences were found between the treat ment and control groups in regard to phantom pain at 1 week and 3 6
12. ent socket flexion or anterior tilt of the socket on the pylon and 4 excessive anterior tilt of the socket on the pylon If the socket is too large the residual limb can bottom out The patellar tendon bar will migrate proximally and approach or cover the patella in standing When the socket is removed erythema may be evident where the patella has met the patella tendon bar The hamstring tendons may also be pinched The use of putty powder and pressure transducers can all give valuable information about the amount and extent of contact between the residuum and the socket Insufficient anterior tilt can increase distal end bearing be cause the anterior soft tissues are not adequately loaded The lack of anterior tilt becomes evident when the prosthesis is removed and is observed upright with the foot resting on a flat surface Too great an angle of anterior tilt places the ground reaction force far posterior to the knee axis at heel strike This causes knee flexion moment that must be countered by forceful contraction of the quadriceps to prevent further knee instabil ity The distal tibia must ultimately absorb the torque of the rotating socket Other causes of a premature and increased knee flexion moment at initial contact include excessive heel height excessive length of the heel lever arm and excessive dorsiflex ion of the foot No matter which of these is the culprit the result is the same increased anterior distal and posteri
13. in When limited range of motion interferes with prosthetic function a step up hinge system with a split socket will increase available flexion However such a system dou bles the amount of force the amputee must generate to flex the elbow and forearm Discomfort may occur in the medial or lateral forearm which can be attenuated by using a split cable system A forearm lift assist can also aid elbow flexion for those amputees who lack strength or endurance This device is attached medially to the socket and counterbalances the weight of the forearm In some cases a second forearm lift assist is indicated particularly for transhumeral amputees If these ef forts fail the transradial amputee may be successfully fitted as a transhumeral amputee This is often true for the individual whose residual forearm disappears into the antecubital fossa with elbow flexion Suction suspension and other self suspension systems de pend on an intimate interface between the residuum and the socket Volumetric or geometric fluctuations of the residual limb adversely affect fit This is especially true for self sus pending systems which are found more commonly in myo electric systems If increased residual limb volume is due to disuse such as occurs when the prosthesis is not used for a period of days an elasticized stump shrinker or similar device can be used to reduce the limb size The use of elastic bandages ie Ace wraps requires that the patient em
14. ion and maintain its efficiency and comfort The anterior strap prevents displacement of the socket during loading If displacement is still present after the harness and socket have been examined and adjusted the patient may be better served with a heavy duty or shoulder saddle design The shoulder saddle design can be modified with a Bowden Arch Phys Med Rehabil Vol 82 Suppl 1 March 2001 cable and housing placed on the anterior and posterior aspect of the saddle This cable can operate more freely and prevent the saddle harness from becoming displaced with vertical loading When the anterior strap is torn stretched out or not placed properly the amputee will experience excessive rotation If the prosthesis has flexible elbow hinges these too can be stretched out allowing the socket to slide on the residual limb The hinges may need to be replaced or reattached more distally on the socket Some patients have difficulty tolerating harnesses Adding a cross back strap or O rings or changing the type of harness may improve comfort Other options to improve comfort include sleeve suspension roll on liners with locking mechanisms and sockets with flexible liners A transradial amputee may benefit from a Muenster socket or sleeve suspension eg a neoprene sleeve with a figure of 9 harness The figure of 9 harness however is not a good choice for the amputee who does a significant amount of lifting Others benefit from myoelectric
15. n rehabilitation of the upper limb amputee include stabilization of the residual limb volume and shape and fabrication of the prosthesis The new amputee may encounter problems of pain wound healing body image and cosmesis After the prosthesis has been fabricated and fitted the amputee enters the postacute stage in which a new set of problems can interfere with prosthetic use Skin irritation or breakdown and difficulty in operating the prostheses may be due to poor fit inappropriate cable and strap postition of function or compo nent failure SOCKET PROBLEMS AND SOLUTIONS A poorly fitting upper limb prosthetic socket can cause local irritation or discomfort Bony prominences eg the radial and ulnar styloid processes the humeral condyles are particularly vulnerable For instance if the proximal trim line of a transra From the Physical Medicine and Rehabilitation Service and Brain Rehabilitation Research Service North Florida South Georgia Veterans Health System Dept of Orthopaedics and Rehabilitation College of Medicine University of Florida Gaines ville FL Levy Department of Physical Medicine and Rehabilitation Brody School of Medicine East Carolina University Greenville NC Bryant Department of Physical Medicine and Rehabilitation University of Michigan Ann Arbor MI Spires and Rehabilitation Services Field Neuroscience Institute Saginaw MI Duffy Accepted November 1 2000 No commercial party having a
16. om Manage 1991 6 73 83 14 Lundeberg T Relief of pain from a phantom limb by peripheral stimulation J Neuro 1985 232 79 82 15 Xing G Acupuncture treatment of phantom limb pain a report of 9 cases Tradit Chin Med 1998 18 199 201 16 Lotze M Grodd W Birnbaumer N Erb M Huse E Flor H Does use of a myoelectric prosthesis prevent cortical reorganization of phantom limb pain Nat Neurosci 1999 2 501 2 17 Panerai AE Monza G Movilia P Bianchi M Francucci BM Tiengo M A randomized within patient cross over placebo controlled trial on the efficacy and tolerability of the tricyclic antidepressants chlorimipramine and nortriptyline in central pain Acta Neurol Scand 1990 82 34 8 18 Rosenberg JM Harrell C Ristic H Werner RA de Rosayro AM The effect of gabapentin on neuropathic pain Clin J Pain 1997 13 251 5 19 Cannon DT Wu YT Topical capsaicin as an adjuvant analgesic for the treatment of traumatic amputee neurogenic residual limb pain Arch Phys Med Rehabil 1998 79 591 3 20 Wall GC Heyneman CA Calcitonin in phantom limb pain Ann Pharmacother 1999 33 499 501 21 Kessel C Worz R Immediate response of phantom limb pain to calcitonin Pain 1987 30 79 87 22 Jaeger H Maier C Calcitonin in phantom limb pain a double blind study Pain 1992 48 21 7 23 Davis RW Successful treatment of phantom pain Orthopaedics 1993 16 691 5 24 Elliott F Little A Milbrandt W Carbamazepine for phantom limb phenomena
17. or prox imal pressure A foot that is inset too far relative to the socket will place the ground reaction force too far medial to the knee axis Increased pressure will be exerted at the proximal medial and distal lateral portions of the residual limb A pronated foot or a socket with too much lateral tilt will have the same effect Conversely the proximal lateral and distal medial areas will bear the brunt of a foot that is outset too far or supinated or a socket set with too little lateral tilt To summarize the treatment for all of these conditions is modification of the prosthesis addition or sub traction of socks or use of methods to stabilize the volume of the limb The last named treatment may include the application of shrink socks elastic stockinette elastic bandages ie Ace wraps elevation of the limb when it is not in the prosthesis and wearing the prosthesis on a consistent basis Some patients simply possess fragile skin ie burns skin grafts adhesions Gel liners of various thickness may be helpful Urethane liners with multidirectional flow characteris tics ie TEC liner may offer special advantages by distrib uting weight bearing more widely and more equally throughout the residuum 29 Reaction to contact dermatitis runs the gamut from slight erythema to a fulminant reaction with local inflammation vesiculation crusting and serious oozing Although contact dermatitis can be exacerbated by pressure
18. or shear the history and the widespread distribution and character of the lesions are usually sufficient to distinguish this condition from those caused by mechanical forces alone Treatment consists of re moving offending agents which usually means replacing the liner 4 4 Objective To evaluate the potential causes of recur rent knee buckling in a college coach with a trans femoral amputation Gait deviation in lower limb amputees can be caused by intrinsic user related or extrinsic prosthesis related factors or a combination of the 2 An adequate history and physical examination should be performed to detect any musculoskele tal neurologic dermatologic cardiopulmonary vascular or theumatologic factors that may cause weakness or pain disturb sensation or disrupt coordination or motor programming such that gait is impaired The evaluation must also focus on the prosthesis itself and the user prosthesis interface Finally the practitioner must be alert for psychologic factors that might cause rejection or sabotage of the prosthesis Most often the amputee is first encountered in a seated position in the examination room After the history has been obtained the user is observed while doffing the prosthesis Important information regarding the prosthetic fit and the us er s attitude and comfort familiarity and facility with the prosthesis can be gleaned Next the residual limb is inspected for erythema edema rashes ab
19. ould fit snugly flat against the back without compromising the neurovascular bun dle of the sound arm brachial plexopathy mononeuropathy or vascular occlusion may result The axilla loop anchors the control straps of the prosthesis it too should fit securely This becomes increasingly important with shorter residual limbs Irritation within the axilla can be caused by friction from the axilla loop against bare skin A T shirt or some other absorbent garment worn under the harness is recommended Covering the axilla loop with lamb s wool or other soft material or employ ing a wider strap will also reduce chafing If the control attachment strap of the harness is resting too proximally on the thorax the amputee may not be able to achieve sufficient cable excursion to operate the prosthesis This strap should rest midway between the inferior and the superior borders of the scapula with the intersection of the harness straps lateral to the spinous processes toward the sound side When the control strap is located too far distally the amputee must recruit a more forceful shoulder flexion motion to operate the mechanical elbow or terminal device Likewise the efficiency of the har ness and control system may be hampered by too proximal positioning of the posterior intersection of the harness straps ie at or above the C7 spinous process If this is the case refitting the harness or adding a cross back strap will keep the harness in posit
20. ploy the correct wrapping technique to avoid tissue folds or creases and prox imal constriction which can result in vascular congestion Because elasticized stump shrinkers are easier to don they encourage compliance Once the limb volume has restabilized prosthetic wear can be resumed A weight change of 5 to 10lb can result in a change of residual limb volume and alter socket fit Significant change in the volume or shape of the residual limb should alert the clinician to screen for systemic disease ie a neoplasm in the face of unexpected weight loss Although loss of volume can often be corrected by adding stump socks or by padding or lining the socket significant weight gain typically necessitates fabrication of a new socket The choke syndrome proximal soft tissue constriction lead ing to vascular congestion may occur with suction sockets or self suspending systems Relieving the proximal socket to al low vascular return providing auxiliary suspension to decrease the vertical pull on the residual limb and improving the inti Arch Phys Med Rehabil Vol 82 Suppl 1 March 2001 26 TROUBLESHOOTING Levy macy of the socket limb interface are approaches to correct this problem In the transhumeral amputee adding a supra acromial strap attached on the harness in an anteroposterior direction often resolves this problem by minimizing the loss of distal contact from a vertically migrating socket responding to the force of gravity
21. rasions blisters ulcerations and other dermatologic abnormalities This is followed by a palpatory examination to determine the condition of the soft tissue the adherence of scar tissue and the presence of focal or diffuse tenderness The pattern of findings may suggest sys temic or local disease or problems with fit ie bottoming out or incomplete contact Next the examiner asks the user to don the prosthesis noting any errors in technique Static alignment and fit are evaluated while the user stands dynamic alignment and fit are evaluated in the anteroposterior plane and the mediolateral plane while the user ambulates Typically the user is assessed while he she traverses a level surface Depending on the history and the activity of the user he she may be asked to ascend and descend stairs or to run or walk on uneven terrain The specific phase of gait in which the deviation occurs and the nature of the deviation are noted A patient with a poorly fitting prosthesis may actually learn an adaptive gait pattern that allows relatively comfortable and efficient ambulation despite the shortcomings of the prosthesis Careful analysis may reveal such compensatory strategies even if they are subtle One of the most common gait deviations in patients with transfemoral amputations is abrupt or excessive knee flexion during ambulation This may result in dynamic instability with recurrent knee buckling loss of balance and falls 32 The pros
22. rhythmias suggests a cautious approach to its use Carbamazepine is an anticonvulsant with a ring structure that is similar to that of the tricyclic antidepressants Its anal gesic properties are thought to be due to its sodium channel blocking capacity and consequent membrane stabilizing effect Carbamazepine has reportedly been effective in the treatment of lancinating PLP in 6 amputee patients 2425 Hematologic parameters must be monitored because blood dyscrasias are a possible side effect The application of beta blockers in phantom pain is unusual although they are occasionally used in neuropathic pain con ditions such as reflex sympathetic dystrophy and complex regional pain syndrome Complete relief of PLP has been reported in three amputee patients who received propranolol for angina 2627 Two additional persons responded to propran olol and another to metoprolol in a separate study 8 Clonazepam is a benzodiazepine that was initially used to treat petit mal and myoclonic seizures Benzodiazepines en hance the action of gamma aminobutyric acid within the cen tral nervous system Clonazepam increases serotonin synthe sis and serotonin concentrations at synaptic receptor sites It provided relief from shooting and shocking PLP refractory to various narcotic and non narcotic analgesics in a case report of 2 persons with hip disarticulation 4 3 Objective To describe the causes and management of transtibial residual limb
23. rug regimens should be attempted Starting with 1 medication the physician should reduce the doses of each medication in a stepwise manner as tolerated until the minimal effective regimen has been established This will reduce costs and chances of complications A simpler regimen should also improve compliance PHARMACOLOGIC AGENTS FOR THE TREATMENT OF PLP The literature on the definitive pharmacologic treatment of PLP is sparse perhaps because PLP is relatively rare in the general population Therefore clinicians must adapt agents and strategies that are used to treat other neuropathic disorders Amitriptyline and gabapentin can be considered the first line agents in the pharmacologic treatment of PLP Amitriptyline is a tricyclic antidepressant with noradrenergic serotoninergic anticholinergic and antihistaminergic properties It is reason ably well established and effective in treating neuropathic pain Arch Phys Med Rehabil Vol 82 Suppl 1 March 2001 28 TROUBLESHOOTING Levy and fibromyalgia and it is relatively inexpensive Its tendency to cause somnolence can be used to help restore sleep which is often disrupted in pain syndromes Amitriptyline also may help alleviate the commonly associated depression although doses to treat depression are typically higher Alternatives to amitrip tyline include other tricyclics such as nortriptyline and the anticonvulsant carbamazepine Gabapentin is often effective against pain of
24. skin breakdown The first task of the practitioner is to determine the cause of the lesion s Skin problems are most commonly due to pros thetic causes ie a reaction to friction pressure shear undue suction or choking due a poorly fitting socket or malalignment of the prosthesis They can also be caused by a dermatologic reaction to the materials of the interface Less commonly skin lesions can be due to dermatologic or vascular conditions unrelated to the prosthesis To diagnose and treat lesions of the Arch Phys Med Rehabil Vol 82 Supp 1 March 2001 residual limb the clinician must examine the prosthetic history along with a medical history and review of systems The clinician should determine when the problem was first noted any aggravating and relieving factors whether the reaction is related to prosthetic use the amount of time spent in the prosthesis whether there have been any changes in the pros thetic prescription ie change of shoes to a set with a different heel height or changes in kind or level of activity The physical examination often begins before the patient is aware that it has commenced The patient is observed as he she walks into the room This often provides the truest glimpse of the patient s actual gait pattern Later in the examination when patients know they are being observed they may consciously or unconsciously minimize or compensate for deviations to please the examiner or they may exagger
25. sthesis induced increased use of an amputation stump in humans Neurosci Lett 1999 272 131 4 6 Bach S Noreng MF Tjellden NU Phanton limb pain in ampu tees during the fist 12 months following limb amputation after preoperative lumbar epidural blockade Pain 1988 33 297 301 7 Jahangiri M Jayatunga AP Bradley JW Dark CH Prevention of phanton pain after major lower limb amputation by epidural infusion of diamorphine clonidine and bupivacaine Ann R Coll Surg Eng 1994 76 324 6 8 Schug SA Burrell R Payne J Tester P Pre emptive epidural analgesia may prevent phanton limb pain Reg Anesth 1995 20 256 9 Nikolajsen L Ilkjaer S Krgner K Christensen JH Jensen TS The influence of preamputation pain on postamputation stump and phantom pain Pain 1997 72 393 405 10 Nikolajsen L kjaer S Christensen JH Kr ner K Jensen TS Randomised trial of epidural bupivacaine and morphine in pre vention of stump and phantom pain in lower limb amputation Lancet 1997 350 1353 7 11 Winnem MF Amundsen T Treatment of phanton limb pain with TENS letter Pain 1982 12 299 300 Arch Phys Med Rehabil Vol 82 Suppl 1 March 2001 12 Finsen V Persen L Lovlien M Veslegaard EK Simensen M Gasvann AK et al Transcutaneous electrical nerve stimulation after major amputation J Bone Joint Surg Br 1988 70 109 12 13 Katz J Melzack R Auricular transcutaneous electrical nerve stimulation TENS reduces phantom limb pain J Pain Sympt
26. ted transtibial amputee with no significant knee contractures stan dard alignment has been well defined Medial tibial plateau to TROUBLESHOOTING Levy floor length and pelvis to floor length should be equal to those dimensions in the intact lower limb The socket is preposi tioned in 5 of adduction and 5 to 10 of anterior tilt 3 The anterior tilt allows loading of the soft tissues of the anterior surface of the residual limb The foot is slightly inset relative to the socket The patellar tendon bar is located halfway between the tibial tubercle and the distal end of the patella The poste rior brim of the socket should end about an inch below the patellar tendon bar with reliefs made for the hamstring ten dons The socket and liner should fit intimately and the socket should have contours that spare the bony prominences In normal prosthetic walking only a miniscule amount of piston ing should be evident Deviation from proper alignment can cause excessive pres sure and shear in predictable patterns The anterior distal area overlying the end of the tibia is especially vulnerable because of its paucity of soft tissue coverage and its position at the end of the tibial lever arm There are 4 common socket related problems that expose the distal tibia to elevated forces that may lead to breakdown 1 a socket that is too large 2 a socket that is too broad in the anteroposterior plane bell clapper effect 3 insuffici
27. thesis and whose PLP was rated as a mean of 2 33 on a 6 point scale Cortical reorganization was inves tigated with functional magnetic resonance imaging while the subjects performed a lip motor task Those free of PLP showed hemispheric symmetry in lip representation whereas in those with PLP the lip area was displaced toward the hand area in the hemisphere contralateral to the amputated hand Lotze sug gested that use of the prosthesis prevented or blunted maladap tive reorganization responsible for PLP Well controlled ran domized trials must be performed to substantiate such claims PRINCIPLES FOR EFFECTIVE DOSING OF MEDICATIONS IN PLP Adherence to established principles of pain management will yield the best chance of success in PLP 1 The temptation to start more than 1 pharmacologic agent at a time should be avoided Although combinations of medications may ultimately be necessary determining which medicine is responsible for an unpleasant side effect is often impossible if more than 1 medicine is started at a time Further the patient may reject both medications because of an unpleasant interaction when either alone might have been sufficient 2 The regimen should begin with a modest dose the effi cacy and the incidence of unwanted side effects should be monitored If the initial dose is too great the patient may reject the medication because of intolerable side effects Once this occurs the practitioner may have to o
28. thetic knee joint should normally be stable in extension in stance phase from heel contact to foot flat This is accom plished in part by aligning the prosthetic knee axis posterior to the trochanteric knee ankle line thus maintaining the knee in extension Adequate strength and range of motion in hip ex tension are critical in maintaining this alignment Thus weak hip extensors and hip flexion contractures can cause knee instability The prosthetic socket with an insufficient anterior posterior diameter may cause undue and repetitive pressure on the hamstring tendons at the level of the ischial tuberosity This can cause reduced hamstring function with an increased ten Arch Phys Med Rehabil Vol 82 Suppi 1 March 2001 30 TROUBLESHOOTING Levy dency for knee instability during stance phase particularly at heel strike Two prosthetic causes of knee instability are 1 knee axis malalignment in an excessively anterior position relative to the hip and ankle joints and 2 excessive socket flexion If the foot comes to foot flat prematurely the knee axis may cross anterior to the trochanteric knee ankle line again result ing in instability This may be due to an overly firm prosthetic heel or a prosthetic heel inserted in a tight shoe which limits compressibility of the heel Other causes include a plantarflex ion bumper that is too stiff excessive foot dorsiflexion an overly long heel lever arm a change in shoe heel height from low
29. up At 4 weeks there was no difference in PLP At 16 weeks none of the patients receiving real TENS had PLP whereas 4 of 11 receiving sham TENS plus the drug and 7 of 12 receiving sham TENS alone complained of PLP These group differences disappeared by the end of 1 year at which point PLP was judged to be slight and occasional in those affected Auricular TENS has also led to modest im provement in chronic PLP in 11 amputee patients Literature supporting the use of acupuncture and massage is limited by lack of statistical analysis and by nonrandomization 4 5 PROSTHETIC USE Use of a Sauerbach prosthesis and myoelectric prostheses has reduced PLP in upper limb amputee patients 6 Weiss et al5 studied 9 patients who had received a Sauerbach prosthesis and compared them with 12 patients using a cosmetic prosthe sis The Sauerbach prosthesis surgically connects an upper limb muscle directly to the mechanism of the prosthesis Those with the Sauerbach prosthesis experienced a significant drop in PLP compared with those with cosmetic prostheses Limita tions of this study include the nonrandomization of patients the retrospective nature of the study and the fact that the Sauer bach users were patients of one of the investigators Lotze et al S studied 14 unilateral upper limb amputee patients and found that the 5 using myoelectric prostheses had no PLP compared with the 9 who either did not wear a prosthesis or used a cosmetic pros
30. vercome considerable skepticism when trying to reintroduce the medicine at a lesser dose An example is a patient who is started on 25 to 50mg of amitriptyline only to be over come by sedation dry mouth or urinary hesitancy Such patients may become convinced that amitriptyline does not work and begin to question the competence of the physician As a result the physician may have difficulty persuading the patient to try the medicine again at a dose of 10mg which is often well tolerated and effective 3 The dose should be increased in a gentle and deliberate manner until either the medication is completely effective or the benefits of treatment no longer outweigh the un pleasant side effects At a certain point the dose may have to be reduced to reach the most favorable balance between desired and undesired effects If the side effects are intolerable at the lowest dose or the medicine offers no significant treatment effect discontinuation of the medication and initiation of an alternative are appropri ate If the best balance between effect and side effect is reached but relief of symptoms is not satisfactory the first medicine may be maintained while a second is in troduced When additional medications are considered agents with different mechanisms of action are usually preferred to agents with mechanisms similar to those medications that have already been tried 4 Once optimal control has been obtained simplification of multi d
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