Potential of Physical Analgesia in the Complex Rehabilitation of Patients with Stump Pain and Phantom Pain After Lower Limb Amputation (A Double-blind Randomised Controlled Trial of Efficacy of Deep Oscillation, Laser Therapy and Paravertebral Infiltrations)

Introduction: Most of amputees feel residual limb (stump) pain, phantom sensations and phantom
pain. Our purpose was to remind the wide public of the impact of rehabilitation (including the modern
physical modalities Deep Oscillation – DO and Laser therapy - LTh) in the pain management of
amputees. According the medical definitions the amputation is ‘’the intentional surgical removal of a
limb or body part; performed for the following reasons: to remove malignant tumors, after severe
trauma, and to remove tissues without adequate blood supply, because of injury to the blood vessel,
hardening of the arteries, arterial embolism, impaired circulation, repeated severe infection that leads
to gangrene, severe frostbite, Raynaud's disease, or Buerger's disease’’.
Aims: Comparative evaluation of drug, physical (including DO and LTh) and combined analgesia in
the complex rehabilitation of patients after trans-femoral amputation suffering from stump pain and
phantom pain. In the current chapter, we tested the hypothesis that some modern preformed
modalities (Deep Oscillation and Laser therapy) in combination with paravertebral infiltrations have
the capacity to provide an analgesic effect, to relieve reactive depression and to ameliorate the quality
of life of amputees.
Materials and Methods: During last years a total of 105 amputees with stump pain and phantom pain
were observed and investigated. The investigation was conducted with consideration for the
protection of patients, as outlined in the Declaration of Helsinki, and was approved by the appropriate
institutional review boards and ethic commissions. All patients gave written informed consent before
undergoing any examination or study procedure.
A simple randomization was used. Patients were sequentially numbered and randomized into five
treatment groups of 21 each one.
All patients received a complex rehabilitation programme including physical therapy and patients’
education. In group 1 we applied too drug therapy – paravertebral infiltrations with steroids, lidocaine
and B vitamins. Patients of group 2 received a complex rehabilitation programme, including DO. In
group 3 we applied drug and physical analgesia techniques (infiltrations and DO). Patients of group 4
received a complex rehabilitation programme, including LaserTh. In group 5 we applied drug and
physical analgesia techniques (infiltrations and LTh).
For statistical evaluation we used t-test (ANOVA) and Wilcoxon rank test (non-parametrical correlation
analysis), performed using SPSS package. The treatment difference was considered as statistically
significant if the P value was < 0.05.
Results: The comparative analysis of results shows a significant improvement of the symptoms of the
patients, concerning: pain relief (visualized by the analysis of results of Visual analogue scale, evaluation of stump tenderness), and depression (scales of Zung and McGill Quality of life
questionnaire). In all cases we detected reduction of pain sensation and depression; amelioration of
the independence in ADL. The drug analgesia in group 1 was fast, but short; the efficacy in
physiotherapy groups 2 & 4 was slow, but stable, and durable. We received best results in combined
groups 3 & 5.
Discussion: The drug therapy is efficient but with short duration. The physical analgesia with DO and
LTh initiates its effect slowly, but the results are stable. Best efficacy was observed in case of
combination of medication with physical modalities – in the beginning due to the steroid injection,
toward the moment of effective «input» of the physical modalities.
Current paper proposes personal opinions on some contemporaneous theories of pain and
therapeutic concepts of analgesia, including physical analgesia. We mentioned principal natural and
preformed physical modalities, with effectiveness in clinical practice. Authors suggest a conception of
mechanisms of physical analgesia, especially in case of application of Deep oscillation and Laser
therapy.
Conclusion: We consider most effective the combination of drug and non-drug analgesia in all
patients after lower limb amputation. We could recommend the complex program for treatment of the
pain in amputees. Pain management is an important part of the rehabilitation algorithms in amputated
patients with stump and phantom limb pain. The efficacy of Deep Oscillation is probably due to a
block of nociceptors. The application of Laser therapy is most effective in cases with trophic
alterations.