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Evidence for the optimal management of acute and chronic phantom pain MEDLINE was searched from 1966 to 1999 for publications in the English language.

Key search terms were: 'randomised controlled trial', 'controlled clinical trial', 'double blind method', 'single blind method', 'placebos', 'research design', 'comparative study', 'evaluation studies', 'follow up studies', 'prospective studies', 'phantom limb', 'phantom limb pain' and 'human'. Previous review articles and references from relevant studies were examined, and experts in the field were contacted for missing or ongoing trials.Specific interventions included in the reviewStudies that examined any intervention for PLP were eligible, including treatments before and during amputation and chronic pain treatments. The participants were aged from 47 to 75 years. The majority of the included patients were undergoing lower limb amputations, mostly below the knee. Other types of amputation included through knee, above knee, hip, elbow, shoulder disarticulation and undefined upper extremity amputation. The reasons for amputation included peripheral vascular disease, diabetes mellitus, trauma, infection, failed embolectomy, chronic deformity, cancer, renal failure, radiation and polio. In the late post operative trials, the time since amputation ranged louis vuitton alma gm amarante from 36 days to 46 years.Outcomes assessed in the reviewStudies that measured PLP as either a primary or secondary outcome were eligible. In the included studies, PLP was assessed as a dichotomous outcome or using a visual analogue scale or the McGill pain questionnaire. Other outcomes assessed in the individual studies were stump pain, phantom sensation and opioid use.Assessment of study qualityValidity was assessed and scored using the criteria of Jadad et al. (see Other Publications of Related Interest), which assess randomisation method, double blinding and withdrawals or drop outs. The validity scores ranged louis vuitton bags real vs fake from 0 to the maximum possible score of 5 points. The adequacy of the sample size in detecting a difference between the treatment groups was also assessed.Methods of synthesisHow were the studies combined?The studies were categorised as pre operative and early pre operative interventions (less than 2 weeks) or late post operative interventions (greater than 2 weeks), and a narrative synthesis was undertaken.How were differences between studies investigated?Differences between the studies with respect to validity and follow up periods were louis vuitton alma epi price discussed in the text of the review.Results of the reviewTwelve studies (375 patients) were included: 6 RCTs (194 patients), one pseudo randomised trial (25 patients), 4 non randomised controlled trials (97 patients), and one trial with cohorts of intervention and control patients (59 patients).Only 3 studies scored the maximum 5 points on the validity scale. Of the remaining studies, one trial scored 4 points, one trial 3 points, 4 trials one point, and 3 trials zero points. Three of the 6 trials reported as randomised included an adequate description of randomisation. Four trials were reported as double blind and 7 trials reported drop outs and withdrawals. Only 2 studies included a sample size calculation. There were no trials examining membrane stabilisers or tricyclic antidepressants.Pre operative and early pre operative interventions (8 trials with 278 patients, including 4 RCTs with 149 patients). Epidural anaesthesia (3 trials, including 1 RCT with a quality score of 5): the trials found different results. The RCT (60 patients entered; drop outs included 4 patients before amputation, 5 patients with re amputations and 20 deaths by 12 months) found no significant difference in PLP between epidural bupivacaine plus morphine versus epidural saline plus morphine louis vuitton shoes official website at one year.Regional nerve block (3 trials, including 1 RCT with a quality score of 5): the small RCT (21 patients) found no significant difference in PLP between an infusion of bupivacaine versus saline at 3 or 6 months.TENS (1 RCT with a quality score of 2): the RCT (51 patients) found no significant difference in PLP between TENS versus sham TENS versus sham TENS plus chlorpromazine at 12 months.Intravenous salmon calcitonin (1 RCT with crossover after 2 hours, with a quality score of 3): the small RCT (21 patients) found that salmon calcitonin versus saline control reduced PLP regardless of the order of infusions. The effect on longer term follow up was not controlled.Late post operative interventions (4 trials with 97 patients, including 2 RCTs with 45 patients).TENS (2 non randomised controlled trials with quality scores of 1 and 0; 52 patients): the 2 trials found different results; one found decreased pain with TENS versus placebo stimulation, while the other had a large drop out rate and found no difference between the treatments. Farabloc (1 RCT with a quality score of 5): more patients in the small crossover RCT (34 patients) found a short term reduction of PLP during the Farabloc intervention than with the control intervention. Evidence on pre emptive epidurals, early regional nerve blocks and mechanical vibratory stimulation provides inconsistent support for these treatments. While experts in the field were contacted for additional trials, restricting the search to English language publications identified in one database may have resulted in the omission of other relevant studies. It was not reported how many of the reviewers selected the studies for inclusion in the review. Validity was formally assessed and scored using validated criteria.

Relevant data were extracted and tabulated, and the methods used to extract the data were described. In addition, the characteristics of the studies were summarised in the text. A narrative review was appropriate given the heterogeneity among the studies.

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